Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care.

BACKGROUND: Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions. OBJECTIVE: We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients. DESIGN: Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination. PARTICIPANTS: Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network. INTERVENTION: Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients. KEY MEASURES: Program evaluation metrics included estimated hospital days saved and program acceptance by care team members. KEY RESULTS: During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment. CONCLUSIONS: Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.

Cross-Sectional Prevalence of SARS-CoV-2 Among Skilled Nursing Facility Employees and Residents Across Facilities in Seattle.

BACKGROUND: Skilled nursing facilities (SNFs) are high-risk settings for SARS-CoV-2 transmission. Infection rates among employees are infrequently described. OBJECTIVE: To describe SARS-CoV-2 rates among SNF employees and residents during a non-outbreak time period, we measured cross-sectional SARS-CoV-2 prevalence across multiple sites in the Seattle area. DESIGN: SARS-CoV-2 testing was performed for SNF employees and residents using quantitative real-time reverse transcription polymerase chain reaction. A subset of employees completed a sociodemographic and symptom questionnaire. PARTICIPANTS: Between March 29 and May 13, 2020, we tested 1583 employees and 1208 residents at 16 SNFs for SARS-CoV-2. MAIN MEASURE: SARS-CoV-2 testing results and symptom report among employees and residents. KEY RESULTS: Eleven of the 16 SNFs had one or more resident or employee test positive. Overall, 46 (2.9%) employees had positive or inconclusive testing for SARS-CoV-2, and among those who completed surveys, most were asymptomatic and involved in direct patient care. The majority of employees tested were female (934, 73%), and most employees were Asian (392, 30%), Black (360, 28%), or white (360, 28%). Among the 1208 residents tested, 110 (9.1%) had positive or inconclusive results. There was no association between the presence of positive residents and positive employees within a SNF (p = 0.62, McNemar's test). CONCLUSIONS: In the largest study of SNFs to date, SARS-CoV-2 infections were detected among both employees and residents. Employees testing positive were often asymptomatic and involved in direct patient care. Surveillance testing is needed for SNF employees and residents during the pandemic response.

Western Washington State COVID-19 Experience: Keys to Flattening the Curve and Effective Health System Response.

BACKGROUND: Washington State experienced the first major outbreak of COVID-19 in the US and despite a significant number of cases, has seen a relatively low death rate per million population compared with other states with major outbreaks, and has seen a substantial decrease in the projections for healthcare use, that is, "flattening the curve." This consensus report seeks to identify the key factors contributing to the effective health system disaster response in western WA. METHODS: A multidisciplinary, expert panel including individuals and organizations who were integral to managing the public health and emergency healthcare system response were engaged in a consensus process to identify the key themes and lessons learned and develop recommendations for ongoing management of the COVID-19 pandemic. RESULTS: Six key themes were identified, including early communication and coordination among stakeholders; regional coordination of the healthcare system response; rapid development and access to viral testing; proactive management of long-term care and skilled nursing facilities; proactive management of vulnerable populations; and effective physical distancing in the community. CONCLUSIONS: Based on the lessons learned in each of the areas identified by the panel, 11 recommendations are provided to support the healthcare system disaster response in managing future outbreaks.

Recommendations for Preoperative Management of Frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

Frailty is an age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resiliency and increased vulnerability to stressors. It has proven to be an excellent predictor of unfavorable health outcomes in the older surgical population. There is agreement in recommending that a frailty evaluation should be part of the preoperative assessment in the elderly. However, the consensus is still building with regards to how it should affect perioperative care. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in the fields of gerontology, anesthesiology and preoperative assessment to outline practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. These recommendations summarize evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.

Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities.

INTRODUCTION: Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission. METHODS: Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions. RESULTS: The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement. DISCUSSION: Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.

To Feed or Not to Feed? A Case Report and Ethical Analysis of Withholding Food and Drink in a Patient With Advanced Dementia.

It is well established that competent patients have the right to refuse artificial nutrition and hydration. There is less clarity regarding withholding nutrition in patients who lack decision-making capacity but who are still physically able to eat and drink. This case highlights the ethical dilemma of withholding food and drink in a patient with advanced dementia.

Aneuploidy and chromosome breakage in swim-up versus unprocessed semen from twenty healthy men.

Toxicological and epidemiological studies have investigated several factors that are believed to induce cytogenetic damage in human sperm cells in an effort to estimate heritable risk to future generations. Most of these studies have not differentiated damage based on cell fertility or motility. In the clinical setting, intracytoplasmic sperm injection (ICSI) bypasses the natural process of sperm selection. Although practitioners attempt to select motile sperm for ICSI, the sperm may not always demonstrate motility, maturity, or even viability. Knowing whether cytogenetic damage differs in motile versus unselected sperm would improve our ability to estimate heritable risk and lead to improved ICSI procedures, and would expand the body of toxicology and epidemiology research. We divided semen samples from 20 healthy donors and compared aneuploidy and chromosome breakage in sperm cells gathered directly from the ejaculate (unprocessed semen) with cells enriched for motility using the swim-up assay. Sperm fluorescence in situ hybridization was used to detect aneuploidy for chromosomes 13, 18, 21, X, and Y. Tandem labeling probes were used to detect breakage in the 1cen-1q12 region of chromosome 1. The occurrence of disomy 18-18 and XY18 was significantly lower in specimens enriched for motility (P = .004 and P = .001, respectively). Sperm that carried duplication errors and diploid sperm were also seen less frequently in semen analyzed by the swim-up assay (P < .008). Chromosome 1 breakage did not differ between swim up-assayed and unprocessed specimens. Findings suggest that unprocessed semen may overestimate heritable aneuploidy risk in sperm biomarker studies, and may be biologically relevant to ICSI in disomy categories 18-18 and XY18, demonstrating 1.4-fold to 1.8-fold differences.

Suicide in later life: failed treatment or rational choice?

Suicide is the deliberate act of causing death by self-directed injurious behavior with intent to die. Assisted dying, also known as assisted suicide, involves others to help hasten death. Physician-assisted dying specifically refers to the participation of a physician in facilitating one's death by providing a lethal means. Any decision to actively end a life has profound emotional and psychological effects on survivors. The article discusses the effects that older adults' deaths through suicide, assisted dying, and physician-assisted dying have on survivors and the implications for clinical practice.