The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents.

BACKGROUND: Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood. OBJECTIVES: We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care. METHODS: B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health. IMPLICATIONS: If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Acute Care Patient Portal Intervention: Portal Use and Patient Activation.

BACKGROUND: Patient-facing health information technology (HIT) tools, such as patient portals, are recognized as a potential mechanism to facilitate patient engagement and patient-centered care, yet the use of these tools remains limited in the hospital setting. Although research in this area is growing, it is unclear how the use of acute care patient portals might affect outcomes, such as patient activation. OBJECTIVE: The aim of this study was to describe the use of an acute care patient portal and investigate its association with patient and care partner activation in the hospital setting. METHODS: We implemented an acute care patient portal on 6 acute care units over an 18-month period. We investigated the characteristics of the users (patients and their care partners) of the patient portal, as well as their use of the portal. This included the number of visits to each page, the number of days used, the length of the user's access period, and the average percent of days used during the access period. Patient and care partner activation was assessed using the short form of the patient activation measure (PAM-13) and the caregiver patient activation measure (CG-PAM). Comparisons of the activation scores were performed using propensity weighting and robust weighted linear regression. RESULTS: Of the 2974 randomly sampled patients, 59.01% (1755/2974) agreed to use the acute care patient portal. Acute care patient portal enrollees were younger, less sick, less likely to have Medicare as their insurer, and more likely to use the Partners Healthcare enterprise ambulatory patient portal (Patient Gateway). The most used features of the acute care patient portal were the laboratory test results, care team information, and medication list. Most users accessed the portal between 1 to 4 days during their hospitalization, and the average number of days used (logged in at least once per day) was 1.8 days. On average, users accessed the portal 42.69% of the hospital days during which it was available. There was significant association with patient activation on the neurology service (P<.001) and medicine service (P=.01), after the introduction of HIT tools and the acute care patient portal, but not on the oncology service. CONCLUSIONS: Portal users most often accessed the portal to view their clinical information, though portal usage was limited to only the first few days of enrollment. We found an association between the use of the portal and HIT tools with improved levels of patient activation. These tools may help facilitate patient engagement and improve outcomes when fully utilized by patients and care partners. Future study should leverage usage metrics to describe portal use and assess the impact of HIT tools on specific outcome measures in the hospital setting.

Assessing the Effectiveness of Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall Prevention Toolkit: An Implementation Science Study.

BACKGROUND: Patient falls are a major problem in hospitals. The development of a Patient-Centered Fall Prevention Toolkit, Fall TIPS (Tailoring Interventions for Patient Safety), reduced falls by 25% in acute care hospitals by leveraging health information technology to complete the 3-step fall prevention process-(1) conduct fall risk assessments; (2) develop tailored fall prevention plans with the evidence-based interventions; and (3) consistently implement the plan. We learned that Fall TIPS was most effective when patients and family were engaged in all 3 steps of the fall prevention process. Over the past decade, our team developed 3 Fall TIPS modalities-the original electronic health record (EHR) version, a laminated paper version that uses color to provide clinical decision support linking patient-specific risk factors to the interventions, and a bedside display version that automatically populates the bedside monitor with the patients' fall prevention plan based on the clinical documentation in the EHR. However, the relative effectiveness of each Fall TIPS modality for engaging patients and family in the 3-step fall prevention process remains unknown. OBJECTIVE: This study aims to examine if the Fall TIPS modality impacts patient engagement in the 3-step fall prevention process and thus Fall TIPS efficacy. METHODS: To assess patient engagement in the 3-step fall prevention process, we conducted random audits with the question, "Does the patient/family member know their fall prevention plan?" In addition, audits were conducted to measure adherence, defined by the presence of the Fall TIPS poster at the bedside. Champions from 3 hospitals reported data from April to June 2017 on 6 neurology and 7 medical units. Peer-to-peer feedback to reiterate the best practice for patient engagement was central to data collection. RESULTS: Overall, 1209 audits were submitted for the patient engagement measure and 1401 for the presence of the Fall TIPS poster at the bedside. All units reached 80% adherence for both measures. While some units maintained high levels of patient engagement and adherence with the poster protocol, others showed improvement over time, reaching clinically significant adherence (>80%) by the final month of data collection. CONCLUSIONS: Each Fall TIPS modality effectively facilitates patient engagement in the 3-step fall prevention process, suggesting all 3 can be used to integrate evidence-based fall prevention practices into the clinical workflow. The 3 Fall TIPS modalities may prove an effective strategy for the spread, allowing diverse institutions to choose the modality that fits with the organizational culture and health information technology infrastructure.

Development and Validation of a Fall Prevention Knowledge Test.

Falls are a serious, persistent problem in hospitals. Ensuring that all hospital staff have adequate knowledge of how to prevent falls is the first step in prevention. We identified validated fall prevention knowledge tests (FPKTs) and planned to conduct a systematic literature review. When the review identified a lack of FPKTs, we developed and evaluated a FPKT, confirmed its conceptual framework, identified the content domain, drafted test items, devised the format, selected items for empirical examination, and conducted a psychometric evaluation. We randomly divided a 209-subject data set into test and validation samples to make item reduction decisions and examine reliability and validity. The typical respondent was a white, 42-year old female nurse with a bachelor's degree and 7 years' experience. Subjects were confident in their ability to prevent falls, rating themselves an 8 on a self-efficacy scale of 1 (not at all) to 10 (very). The 11-item FPKT scale (range 0-11) attained a tetrachoric coefficient of 0.73, confirming initial reliability. FPKT mean scores obtained before and after fall prevention education improved from 5.1 ± 1.8 to 6.6 ± 1.7. Statistically significant differences (paired t-test = 12.4, p < .001) confirmed validity. A robust way to assess nurses' knowledge of fall prevention is needed to inform effective educational programs. Addressing gaps in validated FPKTs provides an opportunity to inform and evaluate effective fall prevention programs. J Am Geriatr Soc 67:133-138, 2019.

Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a Patient-Centered Fall Prevention Toolkit.

BACKGROUND: Patient falls during an acute hospitalization cause injury, reduced mobility, and increased costs. The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient's fall risk assessment with evidence-based interventions. Strategies were needed to integrate this evidence into clinical practice. METHODS: The Institute for Healthcare Improvement's Framework for Spread is the conceptual model for pilot implementation of Fall TIPS at Brigham and Women's Hospital (BWH; Boston) and Montefiore Medical Center (MMC; Bronx, New York). The key to translating the evidence into practice was engaging stakeholders by leveraging existing shared governance structures, identifying unit champions, holding training sessions for all staff, and implementing auditing to assess and provide feedback on protocol adherence and patient outcomes. RESULTS: BWH unit compliance with using Fall TIPS averaged 82%, the mean fall rate decreased from 3.28 to 2.80 falls per 1,000 patient-days from January through June 2015 versus 2016, and the mean fall with injury rate for these periods decreased from 1.00 to 0.54 per 1,000 patient-days. At MMC, compliance averaged 91%, but the mean fall rate increased marginally from 3.04 to 3.10, while the mean fall with injury rate decreased from 0.47 to 0.31 per 1,000 patient-days. Patient knowledge survey results show improvement in knowledge of the risks for falls and the ways to prevent falls. CONCLUSION: Engaging hospital and clinical leadership is critical in translating evidence-based care into clinical practice. Barriers to adoption of the protocol have been addressed and detailed to provide guidance for spread to other institutions.

Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver.

A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15-22.].

Novel Helicobacter pylori therapeutic targets: the unusual suspects.

Understanding the current status of the discovery and development of anti-Helicobacter therapies requires an overview of the searches for therapeutic targets performed to date. A summary is given of the very substantial body of work conducted in the quest to find Helicobacter pylori genes that could be suitable candidates for therapeutic intervention. The products of most of these genes perform metabolic functions, and others have roles in growth, cell motility and colonization. The genes identified as potential targets have been organized into three categories according to their degree of characterization. A short description and evaluation is provided of the main candidates in each category. Investigations of potential therapeutic targets have generated a wealth of information about the physiology and genetics of H. pylori, and its interactions with the host, but have yielded little by way of new therapies.

Bioinformatic analysis of Helicobacter pylori XGPRTase: a potential therapeutic target.

BACKGROUND: Xanthine-guanine phosphoribosyltransferase (XGPRTase) is an enzyme of purine nucleotide salvage synthesis. The gpt gene of Helicobacter pylori has been annotated as encoding an XGPRTase and proposed as essential for survival of the bacterium in vitro. The aims of this work were to investigate the structure of H. pylori XGPRTase and to compare the key features of the enzyme to other phosphoribosyltransferases employing computational, modelling, and bioinformatic tools. MATERIALS AND METHODS: XGPRTase activity was measured in the cytosolic fraction of H. pylori by (31)P-nuclear magnetic resonance spectroscopy, and also in recombinant XGPRTase produced by a cell-free expression system. Bioinformatics was employed to analyze the phylogeny of XGPRTase, and a structural model of the XGPRTase was built using threading techniques. The observed interactions of purine phosphoribosyltransferases with immucillin-GP were used to study the theoretical interactions of H. pylori XGPRTase with this transition-state analog. RESULTS: It was demonstrated that the gpt gene of H. pylori encodes a functional XGPRTase enzyme. Analyses of the XGPRTase sequence showed that the enzyme is significantly divergent from equivalent mammalian enzymes. Modelling served to identify specific features of the enzyme and key residues involved in catalysis. CONCLUSIONS: The H. pylori XGPRTase is structurally similar to other phosphoribosyltransferase enzymes, but there were significant differences between the hood domain of H. pylori XGPRTase and other purine salvage phosphoribosyltransferases. Significant differences were found between the interactions of the H. pylori and human enzymes with a purine phosphoribosyltransferase inhibitor.