Consensus-based indicators for evaluating and improving the quality of regional collaborative networks of intensive care units: Results of a nationwide Delphi study.

PURPOSE: To select a consensus-based set of relevant and feasible indicators for monitoring and improving the quality of regional ICU network collaboratives. METHODS: A three-round Delphi study was conducted in the Netherlands between April and July 2022. A multidisciplinary expert panel prioritized potentially relevant and feasible indicators in two questionnaire rounds with two consensus meetings between both rounds. The RAND/UCLA appropriateness method was used to categorize indicators and synthesize results. A core set of highest ranked indicators with consensus-based levels of relevance and feasibility were finally tested in two ICU networks to assess their measurability. RESULTS: Twenty-four indicators were deemed as relevant and feasible. Seven indicators were selected for the core set measuring the standardized mortality rate in the region (n = 1) and evaluating the presence, content and/or follow-up of a formal plan describing network structures and policy agreements (n = 3), a long-term network vision statement (n = 1), and network meetings to reflect on and learn from outcome data (n = 2). The practice tests led to minor reformulations. CONCLUSIONS: This study generated relevant and feasible indicators for monitoring and improving the quality of ICU network collaboratives based on the collective opinion of various experts. The indicators may help to effectively govern such networks.

Pros and cons of streamlining and use of computerised clinical decision support systems to future-proof oncological multidisciplinary team meetings.

Introduction: Nowadays nearly every patient with cancer is discussed in a multidisciplinary team meeting (MDTM) to determine an optimal treatment plan. The growth in the number of patients to be discussed is unsustainable. Streamlining and use of computerised clinical decision support systems (CCDSSs) are two major ways to restructure MDTMs. Streamlining is the process of selecting the patients who need to be discussed and in which type of MDTM. Using CCDSSs, patient data is automatically loaded into the minutes and a guideline-based treatment proposal is generated. We aimed to identify the pros and cons of streamlining and CCDSSs. Methods: Semi-structured interviews were conducted with Dutch MDTM participants. With purposive sampling we maximised variation in participants' characteristics. Interview data were thematically analysed. Results: Thirty-five interviews were analysed. All interviewees agreed on the need to change the current MDTM workflow. Streamlining suggestions were thematised based on standard and complex cases and the location of the MDTM (i.e. local, regional or nationwide). Interviewees suggested easing the pressure on MDTMs by discussing standard cases briefly, not at all, or outside the MDTM with only two to three specialists. Complex cases should be discussed in tumour-type-specific regional MDTMs and highly complex cases by regional/nationwide expert teams. Categorizing patients as standard or complex was found to be the greatest challenge of streamlining. CCDSSs were recognised as promising, although none of the interviewees had made use of them. The assumed advantage was their capacity to generate protocolised treatment proposals based on automatically uploaded patient data, to unify treatment proposals and to facilitate research. However, they were thought to limit the freedom to deviate from the treatment advice. Conclusion: To make oncological MDTMs sustainable, methods of streamlining should be developed and introduced. Physicians still have doubts about the value of CCDSSs.

Time spent on documenting quality indicator data and associations between the perceived burden of documenting these data and joy in work among professionals in intensive care units in the Netherlands: a multicentre cross-sectional survey.

OBJECTIVES: The number of indicators used to monitor and improve the quality of care is debatable and may influence professionals' joy in work. We aimed to assess intensive care unit (ICU) professionals' perceived burden of documenting quality indicator data and its association with joy in work. DESIGN: Cross-sectional survey. SETTING: ICUs of eight hospitals in the Netherlands. PARTICIPANTS: Health professionals (ie, medical specialists, residents and nurses) working in the ICU. MEASUREMENTS: The survey included reported time spent on documenting quality indicator data and validated measures for documentation burden (ie, such documentation being unreasonable and unnecessary) and elements of joy in work (ie, intrinsic and extrinsic motivation, autonomy, relatedness and competence). Multivariable regression analysis was performed for each element of joy in work as a separate outcome. RESULTS: In total, 448 ICU professionals responded to the survey (65% response rate). The overall median time spent on documenting quality data per working day is 60 min (IQR 30-90). Nurses spend more time documenting these data than physicians (medians of 60 min vs 35 min, p<0.01). Most professionals (n=259, 66%) often perceive such documentation tasks as unnecessary and a minority (n=71, 18%) perceive them as unreasonable. No associations between documentation burden and measures of joy in work were found, except for the negative association between unnecessary documentations and sense of autonomy (ß=-0.11, 95% CI -0.21 to -0.01, p=0.03). CONCLUSIONS: Dutch ICU professionals spend substantial time on documenting quality indicator data they often regard as unnecessary. Despite the lacking necessity, documentation burden had limited impact on joy in work. Future research should focus on which aspects of work are affected by documentation burden and whether diminishing the burden improves joy in work.

Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review.

OBJECTIVE: Suboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults. DESIGN: Systematic review. MEASUREMENTS: We searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest. RESULTS: From the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low. CONCLUSIONS: Comprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes. PROSPERO REGISTRATION NUMBER: CRD42021237345.

Facilitators and barriers to conducting an efficient, competent and high-quality oncological multidisciplinary team meeting.

BACKGROUND: Optimal oncological care nowadays requires discussing every patient in a multidisciplinary team meeting (MDTM). The number of patients to be discussed is rising rapidly due to the increasing incidence and prevalence of cancer and the emergence of new multidisciplinary treatment options. This puts MDTMs under considerable time pressure. The aim of this study is therefore to identify the facilitators and barriers with regard to performing an efficient, competent and high-quality MDTM. METHODS: Semistructured interviews were conducted with Dutch medical specialists and residents participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' professional and demographic characteristics (eg, sex, medical specialist vs resident, specialty, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis. RESULTS: Sixteen medical specialists and 19 residents were interviewed. All interviewees agreed that attending and preparing MDTMs is time-consuming and indicated the need for optimal execution in order to ensure that MDTMs remain feasible in the near future. Four themes emerged that are relevant to achieving an optimal MDTM: (1) organisational aspects; (2) participants' responsibilities and requirements; (3) competences, behaviour and team dynamics and (4) meeting content. Good organisation, a sound structure and functioning information and communication technology facilitate high-quality MDTMs. Multidisciplinary collaboration and adequate communication are essential competences for participants; a lack thereof and the existence of a hierarchy are hindering factors. CONCLUSION: Conducting an efficient, competent and high-quality oncological MDTM is facilitated and hindered by many factors. Being aware of these factors provides opportunities for optimising MDTMs, which are under pressure due to the increase in the number of patients to discuss.

[Preoperative geriatric screening in care path 'AAA']. / Preoperatieve geriatrische screening in zorgpad 'AAA'.

AIM: Determining the added value of preoperative geriatric screening (POGS) in the care path 'Infrarenal abdominal aortic aneurysm'. DESIGN: Retrospective observational study in a university hospital. METHOD: For patients (>60 years) with non-acute aortic pathology, data on preoperative screening (including frailty measures) and treatment was automatically generated from medical records for the period 2018-2021 (42 months). Data has been analysed with descriptive and test statistics. Completeness of the data was checked manually by reading the medical files for the period 2020-2021 (24 months). RESULTS: A total of 343 cases were included; POGS was performed in 90 patients (26%). In 84.2% of the cases the vascular surgeon adhered to the geriatrician's advice. In the other cases, the treatment is less (10.5%) or more (5.3%) intrusive than the POGS advice; the patient's preference seems to be particular decisive here. The geriatric advice is most consistent with the measures from the Clinical Frailty Scale. From the manual data collection, we learned that about 20% of the POGS were missing. CONCLUSION: Introducing geriatric screening in the care pathway is likely to lead to a more considered choice by healthcare professionals as well as patients. The added value seems embraced by geriatricians and vascular surgeons as the adherence to the geriatric advice is strong. A cardiovascular nurse can use the Clinical Frailty Scale to select the patients that really need a geriatric advice. The advice is to include POGS in the care path 'Infrarenal abdominal aortic aneurysm' and possibly also in other care paths.

Putting measurement on a diet: development of a core set of indicators for quality improvement in the ICU using a Delphi method.

BACKGROUND: The number and efficacy of indicators used to monitor and improve the quality of care in Intensive Care Units (ICU) is debatable. This study aimed to select a consensus-based core set of indicators for effective quality improvement in the ICU. METHODS: A Delphi study with a panel of intensivists, ICU nurses, and former ICU patients or relatives (n = 34) from general, teaching, and academic hospitals. Panelists completed a questionnaire in which they scored 69 preselected quality indicators on relevance using a nine-point Likert scale. Indicators were categorized using the rated relevance score into: 'accepted, 'equivocal' and 'excluded'. Questionnaire results were discussed in focus groups to reach consensus on the final set. RESULTS: Response rates for the questionnaire and focus groups were 100 and 68%, respectively. Consensus was reached on a final set of 17 quality indicators including patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). Other quality indicators relate to the organization and outcome of ICU care, including safety culture, ICU standardized mortality ratio, and the process indicator 'learning from and improving after serious incidents'. CONCLUSIONS: ICU clinicians and former patients and relatives developed a consensus-based core set of ICU quality indicators that is relatively short but comprehensive and particularly tailored to end-users needs.

Preparing tomorrow's medical specialists for participating in oncological multidisciplinary team meetings: perceived barriers, facilitators and training needs.

INTRODUCTION: The optimal treatment plan for patients with cancer is discussed in multidisciplinary team meetings (MDTMs). Effective meetings require all participants to have collaboration and communication competences. Participating residents (defined as qualified doctors in training to become a specialist) are expected to develop these competences by observing their supervisors. However, the current generation of medical specialists is not trained to work in multidisciplinary teams; currently, training mainly focuses on medical competences. This study aims to identify barriers and facilitators among residents with respect to learning how to participate competently in MDTMs, and to identify additional training needs regarding their future role in MDTMs, as perceived by residents and specialists. METHODS: Semi-structured interviews were conducted with Dutch residents and medical specialists participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' demographic and professional characteristics (e.g. sex, specialty, training duration, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis. RESULTS: Nineteen residents and 16 specialists were interviewed. Three themes emerged: 1) awareness of the educational function of MDTMs among specialists and residents; 2) characteristics of MDTMs (e.g. time constraints, MDTM regulations) and 3) team dynamics and behaviour. Learning to participate in MDTMs is facilitated by: specialists and residents acknowledging the educational function of MDTMs beyond their medical content, and supervisors fulfilling their teaching role and setting conditions that enable residents to take a participative role (e.g. being well prepared, sitting in the inner circle, having assigned responsibilities). Barriers to residents' MDTM participation were insufficient guidance by their supervisors, time constraints, regulations hindering their active participation, a hierarchical structure of relations, unfamiliarity with the team and personal characteristics of residents (e.g. lack of confidence and shyness). Interviewees indicated a need for additional training (e.g. simulations) for residents, especially to enhance behavioural and communication skills. CONCLUSION: Current practice with regard to preparing residents for their future role in MDTMs is hampered by a variety of factors. Most importantly, more awareness of the educational purposes of MDTMs among both residents and medical specialists would allow residents to participate in and learn from oncological MDTMs. Future studies should focus on collaboration competences.

Teach-back of discharge instructions in the emergency department: a pre-post pilot evaluation.

OBJECTIVES: With the 'teach-back' method, patients or carers repeat back what they understand, so that professionals can confirm comprehension and correct misunderstandings. The effectiveness of teach-back has been underexamined, particularly for older patients discharged from the emergency department (ED). We aimed to determine whether teach-back would reduce ED revisits and whether it would increase patients' retention of discharge instructions, improve self-management at home and increase satisfaction with the provision of instructions. METHODS: A nonrandomised pre-post pilot evaluation in the ED of one Dutch academic hospital including patients discharged from the ED receiving standard discharge care (pre) and teach-back (post). Primary outcomes were ED-revisits within 7 days and within 8-30 days postdischarge. Secondary outcomes for a subsample of older adults were retention of instructions, self-management 72 hours after discharge and satisfaction with the provision of discharge instructions. RESULTS: A total of 648 patients were included, 154 were older adults. ED revisits within 7 days and within 8-30 days were lower in the teach-back group compared with those receiving standard discharge care: adjusted odds ratios (AORs) of 0.23 (95% CI 0.05 to 1.07) and 0.42 (95% CI 0.14 to 1.33), respectively. Participants in the teach-back group had an increased likelihood of full knowledge retention on information related to their ED diagnosis and treatment (AOR 2.19; 95% CI 1.01 to 4.75; p=0.048), medication (AOR 14.89; 95% CI 4.12 to 53.85; p>0.001) and follow-up appointments (AOR 3.86; 95% CI 1.33 to 10.19; p=0.012). Use of teach-back was not significantly associated with improved self-management and higher satisfaction with discharge instructions. Discharge conversations were generally shorter for participants receiving teach-back. CONCLUSIONS: Discharging patients from the ED with a relatively simple and feasible teach-back method can contribute to safer and better transitional care from the ED to home.

A systematic review of instruments to measure health literacy of patients in emergency departments.

OBJECTIVES: Knowledge of patient's health literacy (HL) in the emergency department (ED) can facilitate care delivery and reduce poor health outcomes. This systematic review investigates HL measurement instruments used in the ED and their psychometric properties, accuracy in detecting limited HL, and feasibility. METHODS: We searched in five biomedical databases for studies published between 1990 and January 2021, evaluating HL measurement instruments tested in the ED on internal consistency, criterion validity, diagnostic accuracy, or feasibility. Reviewers screened studies for relevance and assessed methodologic quality with published criteria. Data were synthesized around study and instrument characteristics and outcomes of interest. RESULTS: Of the 2,376 references screened, seven met our inclusion criteria. Studied instruments varied in objective (n = 5) and subjective (n = 6) measurement of HL skills, and in HL constructs measured. The Brief Health Literacy Screen (BHLS) and the Subjective Numeracy Scale demonstrate acceptable and good internal consistency across studies. None of the instruments perform consistently well on criterion validity. The Rapid Estimate of Adult Literacy in Medicine-Revised and the Newest Vital Sign, both objective tests with short administration times, demonstrate good accuracy in one study with high risk of bias. The BHLS, a short subjective measure, shows moderate accuracy across studies including one with low risk of bias. CONCLUSIONS: Several short instruments seem valid in measuring HL and accurate in detecting limited HL among ED patients, each with its practical advantages and disadvantages and specific measurement of HL. Additional research is necessary to develop a robust evidence base supporting these instruments.

The updated national research agenda 2021-2026 for prehospital emergency medical services in the Netherlands: a Delphi study.

BACKGROUND: In 2015, a national research agenda was established for Dutch prehospital EMS to underpin the evidence base of care delivery and inform policymakers and funders. The continuously increasing demand for ambulance care and the reorientation towards the role of EMS in recent years may have changed research priorities. Therefore, this study aimed to update the Dutch national EMS research agenda. METHODS: A three-round online Delphi survey was used to explore and discuss different viewpoints and to reach consensus on research priorities (i.e., themes and special interest groups, e.g. patient types who require specific research attention). A multidisciplinary expert panel (n = 62) was recruited in the field of prehospital EMS and delegates of relevant professional organizations and stakeholders participated. In round one, fifty-nine research themes and six special interest groups (derived from several resources) were rated on importance on a 5-point scale by the panel members. In round two, the panel selected their priority themes and special interest groups (yes/no), and those with a positive difference score were further assessed in round three. In this final round, appropriateness of the remaining themes and agreement within the panel was taken into account, following the RAND/UCLA appropriateness method, which resulted in the final list of research priorities. RESULTS: The survey response per round varied between 94 and 100 percent. In round one, a reduction from 59 to 25 themes and the selection of three special interest groups was realized. Round two resulted in the prioritization of six themes and one special interest group ('Vulnerable elderly'). Round three showed an adequate level of agreement regarding all six themes: 'Registration and (digital) exchange of patient data in the chain of emergency care'; 'Mobile care consultation/Non conveyance'; 'Care coordination'; 'Cooperation with professional partners within the care domain'; 'Care differentiation' and 'Triage and urgency classification'. CONCLUSIONS: The updated Dutch national EMS research agenda builds further on the previous version and introduces new EMS research priorities that correspond with the future challenges prehospital EMS care is faced with. This agenda will guide researchers, policymakers and funding bodies in prioritizing future research projects.

Dutch emergency physicians insufficiently educated in geriatric emergency medicine: results of a nationwide survey.

BACKGROUND: Emergency physicians (EPs) provide care to older adults with complex health problems. Treating these patients is challenging for many EPs, which might originate from modest geriatric education. OBJECTIVE: Our aim was to assess EPs' self-perceived needs regarding geriatric emergency medicine (GEM) education, factors determining these needs and the utilization of this education. Our secondary aim was to assess emergency department (ED) managers' view and support for GEM education. METHODS: All EPs and ED managers in the Netherlands received a survey by e-mail. The questionnaires focused on EPs' needs in GEM education, EPs' utilization of GEM education and managerial support for GEM education. We used descriptive statistics to analyse needs, utilization of- and support for GEM education. Regression analyses were used to identify factors associated with EPs' need for GEM education. RESULTS: EPs reported to need better training in diagnosing, treating and communicating with older adults. Seventy percent of EPs reported no GEM education program in their hospital, and 83% reported no utilization of GEM education outside their hospital. EPs working in EDs with a possibility for geriatric consultation, and EPs aware of actual GEM education programs, had lower educational needs. Of responding managers, 86.2% reported the care for older adults as an important topic; lack of finances and time were obstacles to provide GEM education for EPs. CONCLUSION: EPs in the Netherlands feel insufficiently educated to treat older adults. ED managers largely recognize this educational challenge. This nationwide survey underlines the need to prioritize GEM education for EPs.

Holding the frontline: a cross-sectional survey of emergency department staff well-being and psychological distress in the course of the COVID-19 outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak has been associated with stress and challenges for healthcare professionals, especially for those working in the front-line of treating COVID-19 patients. This study aimed to: 1) assess changes in well-being and perceived stress symptoms of Dutch emergency department (ED) staff in the course of the first COVID-19 wave, and 2) assess and explore stressors experienced by ED staff since the COVID-19 outbreak. METHODS: We conducted a cross-sectional study. An online questionnaire was administered during June-July 2020 to physicians, nurses and non-clinical staff of four EDs in the Netherlands. Well-being and stress symptoms (i.e., cognitive, emotional and physical) were scored for the periods pre, during and after the first COVID-19 wave using the World Health Organization Well-Being Index (WHO-5) and a 10-point Likert scale. Stressors were assessed and explored by rating experiences with specific situations (i.e., frequency and intensity of distress) and in free-text narratives. Quantitative data were analyzed with descriptive statistics and generalized estimating equations (GEE). Narratives were analyzed thematically. RESULTS: In total, 192 questionnaires were returned (39% response). Compared to pre-COVID-19, the mean WHO-5 index score (range: 0-100) decreased significantly with 14.1 points (p < 0.001) during the peak of the first wave and 3.7 points (< 0.001) after the first wave. Mean self-perceived stress symptom levels almost doubled during the peak of the first wave (≤0.005). Half of the respondents reported experiencing more moral distress in the ED since the COVID-19 outbreak. High levels of distress were primarily found in situations where the staff was unable to provide or facilitate necessary emotional support to a patient or family. Analysis of 51 free-texts revealed witnessing suffering, high work pressure, fear of contamination, inability to provide comfort and support, rapidly changing protocols regarding COVID-19 care and personal protection, and shortage of protection equipment as important stressors. CONCLUSIONS: The first COVID-19 wave took its toll on ED staff. Actions to limit drop-out and illness among staff resulting from psychological distress are vital to secure acute care for (non-)COVID-19 patients during future infection waves.

Delayed emergency healthcare seeking behaviour by Dutch emergency department visitors during the first COVID-19 wave: a mixed methods retrospective observational study.

BACKGROUND: Emergency department (ED) visits due to non-coronavirus disease 2019 (COVID-19) conditions have drastically decreased since the outbreak of the COVID-19 pandemic. This study aimed to identify the magnitude, characteristics and underlying motivations of ED visitors with delayed healthcare seeking behaviour during the first wave of the pandemic. METHODS: Between March 9 and July 92,020, adults visiting the ED of an academic hospital in the East of the Netherlands received an online questionnaire to collect self-reported data on delay in seeking emergency care and subsequent motivations for this delay. Telephone interviews were held with a subsample of respondents to better understand the motivations for delay as described in the questionnaire. Quantitative data were analysed using descriptive statistics. Qualitative data were thematically analysed. RESULTS: One thousand three hundred thirty-eight questionnaires were returned (34.0% response). One in five respondents reported a delay in seeking emergency care. Almost half of these respondents (n = 126; 45.4%) reported that the pandemic influenced the delay. Respondents reporting delay were mainly older adults (mean 61.6; ±13.1 years), referred to the ED by the general practitioner (GP; 35.1%) or a medical specialist (34.7%), visiting the ED with cardiac problems (39.7%). The estimated median time of delay in receiving ED care was 3 days (inter quartile range  8 days). Respectively 46 (16.5%) and 26 (9.4%) respondents reported that their complaints would be either less severe or preventable if they had sought for emergency care earlier. Delayed care seeking behaviour was frequently motivated by: fear of contamination, not wanting to burden professionals, perceiving own complaints less urgent relative to COVID-19 patients, limited access to services, and by stay home instructions from referring professionals. CONCLUSIONS: A relatively large proportion of ED visitors reported delay in seeking emergency care during the first wave. Delay was often driven by misperceptions of the accessibility of services and the legitimacy for seeking emergency care. Public messaging and close collaboration between the ED and referring professionals could help reduce delayed care for acute needs during future COVID-19 infection waves.

Continuous Monitoring of Vital Signs in the General Ward Using Wearable Devices: Randomized Controlled Trial.

BACKGROUND: Wearable devices can be used for continuous patient monitoring in the general ward, increasing patient safety. Little is known about the experiences and expectations of patients and health care professionals regarding continuous monitoring with these devices. OBJECTIVE: This study aimed to identify positive and negative effects as well as barriers and facilitators for the use of two wearable devices: ViSi Mobile (VM) and HealthPatch (HP). METHODS: In this randomized controlled trial, 90 patients admitted to the internal medicine and surgical wards of a university hospital in the Netherlands were randomly assigned to continuous vital sign monitoring using VM or HP and a control group. Users' experiences and expectations were addressed using semistructured interviews. Nurses, physician assistants, and medical doctors were also interviewed. Interviews were analyzed using thematic content analysis. Psychological distress was assessed using the State Trait Anxiety Inventory and the Pain Catastrophizing Scale. The System Usability Scale was used to assess the usability of both devices. RESULTS: A total of 60 patients, 20 nurses, 3 physician assistants, and 6 medical doctors were interviewed. We identified 47 positive and 30 negative effects and 19 facilitators and 36 barriers for the use of VM and HP. Frequently mentioned topics included earlier identification of clinical deterioration, increased feelings of safety, and VM lines and electrodes. No differences related to psychological distress and usability were found between randomization groups or devices. CONCLUSIONS: Both devices were well received by most patients and health care professionals, and the majority of them encouraged the idea of monitoring vital signs continuously in the general ward. This comprehensive overview of barriers and facilitators of using wireless devices may serve as a guide for future researchers, developers, and health care institutions that consider implementing continuous monitoring in the ward. TRIAL REGISTRATION: Clinicaltrials.gov NCT02933307; http://clinicaltrials.gov/ct2/show/NCT02933307.

Effects of a geriatric education program for emergency physicians: a mixed-methods study.

Emergency physicians (EPs) often regard care for older adults as complex, while they lack sufficient geriatric skills. This study evaluates the effect of a geriatric education program on EPs' geriatric knowledge, attitude and medical practice when treating older adults. A mixed-methods study was performed on EPs from two Dutch hospitals. Effects were measured by pre-post tests of EPs' (n = 21) knowledge of geriatric syndromes and attitudes toward older adults, and by a retrospective pre-post analysis of 100 records of patients aged 70 years or more. Six EPs were purposively sampled and interviewed after completion of the education program. The program significantly improved EPs' geriatric knowledge. EPs indicated that the program improved their ability and attentiveness to recognize frailty and geriatric syndromes. The program also significantly improved EPs' attention for the older patient's social history and circumstances (P = 0.04) but did not have a significant effect on medical decision making. EPs valued especially the case-based teaching and indicated that the interactive setting helped them to better understand and retain knowledge. Combined quantitative and qualitative data suggest that EPs benefit from geriatric emergency teaching. Future enhancement and evaluation of the geriatric education program is needed to confirm benefits to clinical practice and patient outcomes.

An international comparison of factors affecting quality of life among patients with congestive heart failure: A cross-sectional study.

OBJECTIVE: To explore associations among twenty formal and informal, societal and individual-level factors and quality of life (QOL) among people living with congestive heart failure (CHF) in two settings with different healthcare and social care systems and sociocultural contexts. SETTING AND PARTICIPANTS: We recruited 367 adult patients with CHF from a single heart failure clinic within two countries with different national social to healthcare spending ratios: Minneapolis, Minnesota, United States (US), and Nijmegen, Netherlands (NL). DESIGN: Cross-sectional survey study. We adapted the Social Quality Model (SQM) to organize twenty diverse factors into four categories: Living Conditions (formal-societal: e.g., housing, education), Social Embeddedness (informal-societal: e.g., social support, trust), Societal Embeddedness (formal-individual: e.g., access to care, legal aid), and Self-Regulation (informal-individual: e.g., physical health, resilience). We developed a survey comprising validated instruments to assess each factor. We administered the survey in-person or by mail between March 2017 and August 2018. OUTCOMES: We used Cantril's Self-Anchoring Scale to assess overall QOL. We used backwards stepwise regression to identify factors within each SQM category that were independently associated with QOL among US and NL participants (p<0.05). We then identified factors independently associated with QOL across all categories (p<0.05). RESULTS: 367 CHF patients from the US (32%) and NL (68%) participated. Among US participants, financial status, receiving legal aid or housing assistance, and resilience were associated with QOL, and together explained 49% of the variance in QOL; among NL participants, financial status, perceived physical health, independence in activities of daily living, and resilience were associated with QOL, and explained 53% of the variance in QOL. CONCLUSIONS: Four formal and informal factors explained approximately half of the variance in QOL among patients with CHF in the US and NL.

Environmental Needs, Barriers, and Facilitators for Optimal Healing in the Postoperative Process: A Qualitative Study of Patients' Lived Experiences and Perceptions.

OBJECTIVES: Gaining an understanding of postoperative patients' environmental needs, barriers, and facilitators for optimal healing. BACKGROUND: An optimal hospital environment (the "healing environment") can enhance patients' postoperative recovery and shorten length of stay. However, insights lack into patients' lived environmental needs for optimal healing after surgery and how these needs are being met. METHOD: A qualitative study was conducted between August 2016 and August 2017 with 21 patients who underwent elective major abdominal surgery in a Dutch university hospital. Data were collected through context-mapping exercises and interviews to capture patients' lived experiences and explore the meaning of these experiences. Data were systematically analyzed according to the principles of thematic content analysis. RESULTS: Three themes were identified. First, participants want a sense of control over their treatment, ambient features, privacy, nutrition, and help requests. Participants described the need for positive distractions: personalizing the room, connecting with the external environment, and the ability to undertake activities. Finally, participants expressed the importance of functional, practical, and emotional support from professionals, peers, and relatives. According to participants, the hospital environment often does not meet their healing needs while being hospitalized. CONCLUSION: The hospital environment often does not meet patients' needs. Needs fulfillment can be improved by practical adjustments to the physical and interpersonal environment and considering patient's individual preferences and changing needs during recovery. Patient narratives, pictures, and drawings are valuable sources for hospital managers in their efforts to design evidence-based environments that anticipate to patient-specific needs for achieving early recovery.

Preventable emergency admissions of older adults: an observational mixed-method study of rates, associative factors and underlying causes in two Dutch hospitals.

OBJECTIVE: Older adults are hospitalised from the emergency department (ED) without potentially needing hospital care. Knowledge about rates, associative factors and causes of these preventable emergency admissions (PEAs) is limited. This study aimed to determine the rates, associative factors and causes for PEAs of older adults. DESIGN: A mixed-method observational study. SETTING: The EDs of two Dutch hospitals. PARTICIPANTS: 492 patients aged >70 years and hospitalised from the ED. MEASUREMENTS: Quantitative data were retrospectively extracted from the electronical medical record over a 1-month period. Admissions were classified (non)preventable based on a standardised approach. Univariate and multivariate multilevel logistic regression analyses were performed to identify possible associations between PEAs and demographic, clinical and care process factors. Qualitative data were prospectively collected by email and telephone interviews and analysed thematically to explore hospital physician's perceived causes for the identified PEAs. RESULTS: Of the 492 included cases, 86 (17.5%) were classified as PEA. Patients with a higher age (adjusted OR 1.04, 95% CI 1.01 to 1.08; p=0.04), a low urgency classification (adjusted OR 1.89, 95% CI 1.14 to 3.15; p=0.01), and attending the ED in the weekend (adjusted OR 2.02, 95% CI 1.22 to 3.37; p<0.01) were associated with an increased likelihood of a PEA. 49 physicians were interviewed by telephone and email. Perceived causes for PEAs were related to patient's attitudes (eg, postponement of medical care at home), provider's attitudes (eg, deciding for admission after family pressure), health system deficiencies (eg, limited access to community services during out-of-hours and delayed access to inpatient diagnostic resources) and poor communication between primary care and hospital professionals about patient treatment preferences. CONCLUSIONS: Our findings contribute to existing evidence that many emergency admissions of older adults are preventable, thereby indicating a possible source of unnecessary expensive, and potentially harmful, hospital care.