Health Service and Functional Measures of Benefit of a Medical Home in Children with Autism.

OBJECTIVES: A medical home is a model of patient-centered, comprehensive care recommended by the American Academy of Pediatrics for all children. The aims of this study were (1) to determine if the presence of a medical home is associated with improved health service outcomes of children with autism, and (2) to determine if the presence of a medical home is associated with improved key functional outcomes in children with autism. METHODS: This study used data from the 2016-2017 National Survey of Children's Health. We used a medical home construct of 14 survey questions as the main independent variable in logistic regression models estimating cross-sectional association, and also evaluated the interaction between medical home and demographic and household characteristics, including race, income, household composition, and autism severity in regression for outcomes. RESULTS: Overall, the presence of a medical home was associated with increased parent reporting of shared health care decision-making, receipt of preventive pediatric care, and reduced frustration in accessing services. Some functional outcomes were also positively associated with the presences of a medical home in children with parent-reported mild autism symptoms; children who had a medical home visited the ED less often than children without a medical home. This did not persist for children with moderate or severe parent-rated autism. CONCLUSIONS FOR PRACTICE: Based on parent-reported, cross-sectional data from a large, nationally representative sample of families with a child with autism, the presence of a medical home was positively associated with some improved health services and functional outcomes.

Unintentional Pediatric Poisoning Exposures in an Emergency Department: A Comparison of Poison Control Center Referrals and Caregiver Self-Referred Visits.

OBJECTIVES: The purpose of this study is to describe the demographics and clinical characteristics of patients referred to a pediatric emergency department (ED) for unintentional poisoning exposures by a poison control center (PCC) compared with patients/caregivers who self-refer. METHODS: The electronic data warehouse at a pediatric hospital was queried from October 1, 2014, to September 30, 2015, for unintentional poisoning-related ED visits and subsequent inpatient admissions. Eligible patients aged 18 years and younger were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes for pharmaceuticals, non-pharmaceuticalchemicals, fumes/vapors, foreign bodies, adverse food reactions, food poisoning, and bites/stings. Referral classification (PCC referral vs self-refer) was determined by PCC and hospital medical records.Descriptive statistics were used to characterize the patient demographics and ED visits by referral classification and age group. Simple and multiple logistic regression models examined the individual and combined impact of demographic and clinical characteristics on self-referral. RESULTS: Of the 705 patients identified, 84.4% presented as caregiver/self-referred compared with PCC-referred. As compared with those who self-referred, a higher percentage of patients who contacted the PCC before ED presentation were white (93.9% [89.4-98.2%] vs 83.8% [80.7-86.7%]) and had commercial insurance (62.7% [51.5-69.5%] vs 53.0% [48.9-57.0%]). Pharmaceutical (71.9%) and chemical (14.0%) exposures were the most common exposure types for PCC-referred patients whereas foreign bodies (54.3%) were the most common for self-referred patients. The largest predictors of self-referral were age, insurance, and exposure type. CONCLUSIONS: Among patients presenting at 1 pediatric ED, disparities with PCC utilization exist among age groups, racial identification, and poison exposure type. Educational outreach interventions are needed to ensure optimal use of the PCC services by patients, caregivers, and health care professionals.

Patients' experiences in Australian hospitals: a systematic review of evidence.

Objective Patients are uniquely positioned to provide insightful comments about their care. Currently, a lack of comparable patient experience data prevents the emergence of a detailed picture of patients' experiences in Australian hospitals. The present study addresses this gap by identifying factors reported in primary research as relating to positive and negative experiences of patients in Australian hospitals. Methods Evidence from Australian qualitative studies of patients of all ages reporting their experiences in any hospital or day procedure centre was synthesised. A range of text words, synonyms and subject headings was developed and used to undertake a systematic search of seven electronic databases from January 1995 to July 2015 and the grey literature. Two reviewers independently screened the titles, abstracts or executive summaries and applied the inclusion criteria. Data were synthesised in a meta-narrative. Results Thirty-nine publications were included: 33 articles from database searches and six from the grey literature. Quality improvement researchers produced the dominant narrative and the nursing perspective was strong. Six themes emerged: 'Reciprocal communication and information sharing', 'Interpersonal skills and professionalism', 'The care environment', 'Emotional support', 'Discharge planning and process' and 'Correct treatment and physical outcomes'. Conclusion Tangible opportunities to enhance the patient experience are apparent. Small changes to the way that the health system operates and is resourced and the way that health professionals engage with patients could substantially improve care. Examples include inviting patients and carers to contribute to decision making and discussions about their treatment options and care preferences. What is known about the topic? Patient experience is identified as a key component of an optimal health system, along with improving the health of populations and reducing the per capita costs of care. The use of patient experience data has been associated with improved clinical effectiveness and patient safety. What does this paper add? Patient experience data are currently not routinely captured and difficulties exist as to where this information is available. These data are gathered using a variety of different methods that prohibit the development of a national picture. As a step towards overcoming this barrier, the present study identifies the common elements of healthcare experience reported by patients in Australia as being positive or negative. What are the implications for practitioners? Ensuring that patients and carers are active partners in their care is at the centre of a positive patient experience. Health professionals should provide patients with opportunities to make decisions about their care and ask questions, and to provide clear information before, during and after hospitalisation to enhance patients' experiences in Australian hospitals.

Point-of-Care Ultrasound to Assess Anuria in Children.

Anuria in children may arise from a host of causes and is a frequent concern in the emergency department. This review focuses on differentiating common causes of obstructive and nonobstructive anuria and the role of point-of-care ultrasound in this evaluation. We discuss some indications and basic techniques for bedside ultrasound imaging of the urinary system.

Strengthening the capacity of nursing leaders through multifaceted professional development initiatives: A mixed method evaluation of the 'Take The Lead' program.

BACKGROUND: Effective nursing leadership is necessary for the delivery of safe, high quality healthcare. Yet experience and research tells us that nursing leaders are commonly unprepared for their roles. Take The Lead (TTL), a large-scale, multifaceted professional development program was initiated in New South Wales, Australia, to strengthen the capacity of Nursing/Midwifery Unit Managers (N/MUMs). The aim of this study was to examine the effects of TTL on job performance, nursing leadership and patient experience. METHODS: Nursing/Midwifery Unit Managers (n = 30) and managers of N/MUMs (n = 30) who had completed the TTL program were interviewed between August and December 2010. The semi-structured interviews included a combination of open-ended questions and questions that required respondents to rate statements using a Likert scale. Data from the open-ended questions were thematically analysed to identify and categorise key concepts. The responses to the Likert items were analysed via descriptive statistics. RESULTS: Nursing/Midwifery Unit Managers' participation in TTL engendered improvements in job performance and leadership skills, as well as some improvement in patients' experiences of care. The program facilitated role clarification and helped foster peer-support and learning networks, which were perceived to provide ongoing professional and personal benefits to participants. CONCLUSIONS: Our study revealed a consensus about the beneficial outcomes of TTL among those involved with the program. It supports the significant and ongoing value of widely implemented, multifaceted nursing leadership development programs and demonstrates that participants value their informal interactions as highly as they do the formal content. These findings have implications for delivery mode of similar professional development programs.

The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip.

Children presenting with hip pain or a limp are a diagnostic challenge for the clinician. The differential diagnosis is extensive, and the workup can be broad. This review focuses on differentiating between transient synovitis and septic arthritis of the hip. The role of bedside ultrasound in the clinical evaluation of these patients is addressed, including the technique and appropriate indications for bedside ultrasound of the hip in the emergency department.

Utilization of a pediatric observation unit for toxicologic ingestions.

OBJECTIVES: The objectives of this study were to evaluate the efficacy and utilization of an observation unit (OU) for admission of pediatric patients after a toxicologic ingestion; compare the characteristics and outcomes of patients admitted to the pediatric OU, inpatient (IP) service, and intensive care unit (ICU) after ingestions using retrospective chart review; and attempt to identify factors associated with unplanned IP admission after an OU admission. METHODS: This was a retrospective chart review of children seen in the emergency department (ED) after potentially toxic suspected ingestions and then admitted to the OU, IP service, or ICU from June 2003 to September 2007. RESULTS: One thousand twenty-three children were seen in the ED for ingestions: 18% were admitted to the OU, 15% to the IP service service, and 6% to the ICU. Observation unit patients had less mental status changes reported and were less frequently given medications while in the ED. Eighty-one percent of OU patients were admitted with poison center recommendation. Ninety-four percent of OU patients were discharged within 24 hours, and less than half of IP service/ICU patients were discharged that quickly. No significant associations were found between specific historical and physical examination or laboratory characteristics in the ED and the need for unplanned IP admission. CONCLUSIONS: Observation unit patients admitted after ingestions were young, typically ingested substances found in the home, and required observation according to poison center recommendations. Ninety-four percent were able to be discharged home within 24 hours even after ingesting some of the most concerning substances such as central nervous system depressants, cardiac/antihypertension medications, hypoglycemics, and opiates. All OU patients did well without any adverse events reported. Many patients requiring prolonged observation after an ingestion, and who do not require ICU care, may be appropriate for OU management. This study suggests a potential underutilization of observation units in this setting.

Professional conceptualisation and accomplishment of patient safety in mental healthcare: an ethnographic approach.

BACKGROUND: This study seeks to broaden current understandings of what patient safety means in mental healthcare and how it is accomplished. We propose a qualitative observational study of how safety is produced or not produced in the complex context of everyday professional mental health practice. Such an approach intentionally contrasts with much patient safety research which assumes that safety is achieved and improved through top-down policy directives. We seek instead to understand and articulate the connections and dynamic interactions between people, materials, and organisational, legal, moral, professional and historical safety imperatives as they come together at particular times and places to perform safe or unsafe practice. As such we advocate an understanding of patient safety 'from the ground up'. METHODS/DESIGN: The proposed project employs a six-phase data collection framework in two mental health settings: an inpatient unit and a community team. The first four phases comprise multiple modes of focussed, unobtrusive observation of professionals at work, to enable us to trace the conceptualisation and enactment of safety as revealed in dialogue and narrative, use of artefacts and space, bodily activity and patterns of movement, and in the accomplishment of specific work tasks. An interview phase and a social network analysis phase will subsequently be conducted to offer comparative perspectives on the observational data. This multi-modal and holistic approach to studying patient safety will complement existing research, which is dominated by instrumentalist approaches to discovering factors contributing to error, or developing interventions to prevent or manage adverse events. DISCUSSION: This ethnographic research framework, informed by the principles of practice theories and in particular actor-network ideas, provides a tool to aid the understanding of patient safety in mental healthcare. The approach is novel in that it seeks to articulate an 'anatomy of patient safety' as it actually occurs, in terms of the networks of elements coalescing to enable the conceptual and material performance of safety in mental health settings. By looking at how patient safety happens or does not happen, this study will enable us to better understand how we might in future productively tackle its improvement.

How and why are communities of practice established in the healthcare sector? A systematic review of the literature.

BACKGROUND: Communities of Practice (CoPs) are promoted in the healthcare sector as a means of generating and sharing knowledge and improving organisational performance. However CoPs vary considerably in the way they are structured and operate in the sector. If CoPs are to be cultivated to benefit healthcare organisations, there is a need to examine and understand their application to date. To this end, a systematic review of the literature on CoPs was conducted, to examine how and why CoPs have been established and whether they have been shown to improve healthcare practice. METHODS: Peer-reviewed empirical research papers on CoPs in the healthcare sector were identified by searching electronic health-databases. Information on the purpose of establishing CoPs, their composition, methods by which members communicate and share information or knowledge, and research methods used to examine effectiveness was extracted and reviewed. Also examined was evidence of whether or not CoPs led to a change in healthcare practice. RESULTS: Thirty-one primary research papers and two systematic reviews were identified and reviewed in detail. There was a trend from descriptive to evaluative research. The focus of CoPs in earlier publications was on learning and exchanging information and knowledge, whereas in more recently published research, CoPs were used more as a tool to improve clinical practice and to facilitate the implementation of evidence-based practice. Means by which members communicated with each other varied, but in none of the primary research studies was the method of communication examined in terms of the CoP achieving its objectives. Researchers are increasing their efforts to assess the effectiveness of CoPs in healthcare, however the interventions have been complex and multifaceted, making it difficult to directly attribute the change to the CoP. CONCLUSIONS: In keeping with Wenger and colleagues' description, CoPs in the healthcare sector vary in form and purpose. While researchers are increasing their efforts to examine the impact of CoPs in healthcare, cultivating CoPs to improve healthcare performance requires a greater understanding of how to establish and support CoPs to maximise their potential to improve healthcare.

The development, design, testing, refinement, simulation and application of an evaluation framework for communities of practice and social-professional networks.

BACKGROUND: Communities of practice and social-professional networks are generally considered to enhance workplace experience and enable organizational success. However, despite the remarkable growth in interest in the role of collaborating structures in a range of industries, there is a paucity of empirical research to support this view. Nor is there a convincing model for their systematic evaluation, despite the significant potential benefits in answering the core question: how well do groups of professionals work together and how could they be organised to work together more effectively? This research project will produce a rigorous evaluation methodology and deliver supporting tools for the benefit of researchers, policymakers, practitioners and consumers within the health system and other sectors. Given the prevalence and importance of communities of practice and social networks, and the extent of investments in them, this project represents a scientific innovation of national and international significance. METHODS AND DESIGN: Working in four conceptual phases the project will employ a combination of qualitative and quantitative methods to develop, design, field-test, refine and finalise an evaluation framework. Once available the framework will be used to evaluate simulated, and then later existing, health care communities of practice and social-professional networks to assess their effectiveness in achieving desired outcomes. Peak stakeholder groups have agreed to involve a wide range of members and participant organisations, and will facilitate access to various policy, managerial and clinical networks. DISCUSSION: Given its scope and size, the project represents a valuable opportunity to achieve breakthroughs at two levels; firstly, by introducing novel and innovative aims and methods into the social research process and, secondly, through the resulting evaluation framework and tools. We anticipate valuable outcomes in the improved understanding of organisational performance and delivery of care. The project's wider appeal lies in transferring this understanding to other health jurisdictions and to other industries and sectors, both nationally and internationally. This means not merely publishing the results, but contextually interpreting them, and translating them to advance the knowledge base and enable widespread institutional and organisational application.

In search of meaning: values in modern clinical behavior analysis.

Skinner described behavior analysis as the field of values and purpose. However, he defined these concepts in terms of a history of reinforcement and failed to specify whether and how human and nonhuman values might differ. Human values have been seen as theoretically central within a number of nonbehavioral traditions in psychology, including humanism and positive psychology. However, these approaches have failed to provide explanations of the behavior-environment relations involved in valuing that might allow prediction and influence with respect to this phenomenon. Modern clinical behavior analysis in the form of acceptance and commitment therapy (ACT), however, succeeds in providing a functional definition of human values that meets this latter criterion. ACT is rooted in behavior analysis and relational frame theory (RFT) and defines values in terms of verbally established motivation. ACT empirical research into values has begun to blossom in recent years, and ACT-RFT researchers are currently investigating the concept at the most basic empirical level as well as in the applied clinical arena, heralding new interest in and insight into values within clinical behavioral psychology.

Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation.

BACKGROUND: Previous research has shown that interdisciplinary ward rounds have the potential to improve team functioning and patient outcomes. DESIGN: A convergent parallel multimethod approach to evaluate a hospital interdisciplinary ward round intervention and ward restructure. SETTING: An acute medical unit in a large tertiary care hospital in regional Australia. PARTICIPANTS: Thirty-two clinicians and inpatients aged 15 years and above, with acute episode of care, discharged during the year prior and the year of the intervention. INTERVENTION: A daily structured interdisciplinary bedside round combined with a ward restructure. MEASUREMENTS: Qualitative measures included contextual factors and measures of change and experiences of clinicians. Quantitative measures included length of stay (LOS), monthly "calls for clinical review," and cost of care delivery. RESULTS: Clinicians reported improved teamwork, communication, and understanding between and within the clinical professions, and between clinicians and patients, after the intervention implementation. There was no statistically significant difference between the intervention and control wards in the change in LOS over time (Wald ?2 = 1.05; degrees of freedom [df] = 1; P = .31), but a statistically significant interaction for cost of stay, with a drop in cost over time, was observed in the intervention group, and an increase was observed in the control wards (Wald ?2 = 6.34; df = 1; P = .012). The medical wards and control wards differed significantly in how the number of monthly "calls for clinical review" changed from prestructured interdisciplinary bedside round (SIBR) to during SIBR (F (1,44) = 12.18; P = .001). CONCLUSIONS: Multimethod evaluations are necessary to provide insight into the contextual factors that contribute to a successful intervention and improved clinical outcomes.

The case for mindfulness-based approaches in the cultivation of empathy: does nonjudgmental, present-moment awareness increase capacity for perspective-taking and empathic concern?

Empathic responding, most notably perspective-taking and empathic concern, has important implications for interpersonal functioning. While empathy training approaches have received some support for a variety of populations, few extant interventions have targeted empathic responding in couples. Mindfulness- and acceptance-based behavioral approaches, for couples as a unit and/or for individual family members/partners, are proposed as an adjunct to empathy training interventions. Preliminary findings suggest that the viability of these interventions for increasing empathic responding should be further investigated, and specific suggestions for this line of research are offered.

Technology meets tradition: The perceived impact of the introduction of information and communication technology on ward rounds in the intensive care unit.

BACKGROUND: Public policy in many health systems is currently dominated by the quest to find ways to 'do more with less'-to achieve better outcomes at a reduced cost. The success or failure of initiatives in support of this quest are often understood in terms of an adversarial dynamic or struggle between the professional logics of medicine and of management. Here, we use the case of the introduction of information and communication technology (ICT) to a well-established ritual of medical autonomy (the medical ward round) to articulate a more nuanced explanation of how and why new ways of working with technology are accepted and adopted (or not). METHODS: The study was conducted across four intensive care units (ICUs) in major teaching hospitals in Sydney, Australia. Using interviews, we examined 48 doctors' perceptions of the impact of ICT on ward round practice. We applied the concept of institutional logics to frame our analysis. Interview transcripts were analysed using a hybrid of deductive and inductive thematic analysis. RESULTS: The doctors displayed a complex engagement with the technology that belies simplistic characterisations of medical rejection of managerial encroachment. In fact, they selectively welcomed into the ward round aspects of the technology which reinforced the doctor's place in the healthcare hierarchy and which augmented their role as scientists. At the same time, they guarded against allowing managerial logic embedded in ICT to de-emphasise their embodied subjectivity in relation to the patient as a person rather than as a collection of parameters. CONCLUSION: ICT can force the disruption of some aspects of existing routines, even where these are long-established rituals. Resistance arose when the new technology did not fit with the 'logic of care'. Incorporation of the logic of care into the design and customisation of clinical information systems is a challenge and potentially counterproductive, because it could attempt to apply a technological fix to what is essentially a social problem. However, there are significant opportunities to ensure that new technologies do not obstruct doctors' roles as carers nor disrupt the embodied relationship they need to have with patients.

Health system frameworks and performance indicators in eight countries: A comparative international analysis.

OBJECTIVES: Performance indicators are a popular mechanism for measuring the quality of healthcare to facilitate both quality improvement and systems management. Few studies make comparative assessments of different countries' performance indicator frameworks. This study identifies and compares frameworks and performance indicators used in selected Organisation for Economic Co-operation and Development health systems to measure and report on the performance of healthcare organisations and local health systems. Countries involved are Australia, Canada, Denmark, England, the Netherlands, New Zealand, Scotland and the United States. METHODS: Identification of comparable international indicators and analyses of their characteristics and of their broader national frameworks and contexts were undertaken. Two dimensions of indicators - that they are nationally consistent (used across the country rather than just regionally) and locally relevant (measured and reported publicly at a local level, for example, a health service) - were deemed important. RESULTS: The most commonly used domains in performance frameworks were safety, effectiveness and access. The search found 401 indicators that fulfilled the 'nationally consistent and locally relevant' criteria. Of these, 45 indicators are reported in more than one country. Cardiovascular, surgery and mental health were the most frequently reported disease groups. CONCLUSION: These comparative data inform researchers and policymakers internationally when designing health performance frameworks and indicator sets.

A preliminary test of the role of experiential avoidance in post-event functioning.

Experiential avoidance is the unwillingness to experience unwanted thoughts, emotions, or bodily sensations and an individual's attempts to alter, avoid, or escape those experiences. The aim of the current studies was to broaden previous research indicating that experiential avoidance often leads to the development and maintenance of psychological distress. Results indicated that experiential avoidance is significantly correlated with psychological distress and post-traumatic symptomatology over and above other measures of psychological functioning. Limitations and implications for treatment and prevention of psychological distress are discussed.

The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation.

PURPOSE: With increasing concerns about radiation exposure, we questioned whether a structured program of FAST might decrease CT use. METHODS: All pediatric trauma surgeons in our level 1 pediatric trauma center underwent formal FAST training. Children with potential abdominal trauma and no prior imaging were prospectively evaluated from 10/2/09 to 7/31/11. After physical exam and FAST, the surgeon declared whether the CT could be eliminated. RESULTS: Of 536 children who arrived without imaging, 183 had potential abdominal trauma. FAST was performed in 128 cases and recorded completely in 88. In 48% (42/88) the surgeon would have elected to cancel the CT based on the FAST and physical exam. One of the 42 cases had a positive FAST and required emergent laparotomy; the others were negative. The sensitivity of FAST for injuries requiring operation or blood transfusion was 87.5%. The sensitivity, specificity, PPV, and NPV in detecting pathologic free fluid were 50%, 85%, 53.8%, and 87.9%. CONCLUSIONS: True positive FAST exams are uncommon and would rarely direct management. While the negative FAST would have potentially reduced CT use due to practitioner reassurance, this reassurance may be unwarranted given the test's sensitivity.