Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study.

OBJECTIVES: Studies comprehensively assessing interventions to improve team communication and to engage patients and care partners in ICUs are lacking. This study examines the effectiveness of a patient-centered care and engagement program in the medical ICU. DESIGN: Prospective intervention study. SETTING: Medical ICUs at large tertiary care center. PATIENTS: Two thousand one hundred five patient admissions (1,030 before and 1,075 during the intervention) from July 2013 to May 2014 and July 2014 to May 2015. INTERVENTIONS: Structured patient-centered care and engagement training program and web-based technology including ICU safety checklist, tools to develop shared care plan, and messaging platform. Patient and care partner access to online portal to view health information, participate in the care plan, and communicate with providers. MEASUREMENTS AND MAIN RESULTS: Primary outcome was aggregate adverse event rate. Secondary outcomes included patient and care partner satisfaction, care plan concordance, and resource utilization. We included 2,105 patient admissions, (1,030 baseline and 1,075 during intervention periods). The aggregate rate of adverse events fell 29%, from 59.0 per 1,000 patient days (95% CI, 51.8-67.2) to 41.9 per 1,000 patient days (95% CI, 36.3-48.3; p < 0.001), during the intervention period. Satisfaction improved markedly from an overall hospital rating of 71.8 (95% CI, 61.1-82.6) to 93.3 (95% CI, 88.2-98.4; p < 0.001) for patients and from 84.3 (95% CI, 81.3-87.3) to 90.0 (95% CI, 88.1-91.9; p < 0.001) for care partners. No change in care plan concordance or resource utilization. CONCLUSIONS: Implementation of a structured team communication and patient engagement program in the ICU was associated with a reduction in adverse events and improved patient and care partner satisfaction.

Acute care patient portals: a qualitative study of stakeholder perspectives on current practices.

OBJECTIVE: To describe current practices and stakeholder perspectives of patient portals in the acute care setting. We aimed to: (1) identify key features, (2) recognize challenges, (3) understand current practices for design, configuration, and use, and (4) propose new directions for investigation and innovation. MATERIALS AND METHODS: Mixed methods including surveys, interviews, focus groups, and site visits with stakeholders at leading academic medical centers. Thematic analyses to inform development of an explanatory model and recommendations. RESULTS: Site surveys were administered to 5 institutions. Thirty interviews/focus groups were conducted at 4 site visits that included a total of 84 participants. Ten themes regarding content and functionality, engagement and culture, and access and security were identified, from which an explanatory model of current practices was developed. Key features included clinical data, messaging, glossary, patient education, patient personalization and family engagement tools, and tiered displays. Four actionable recommendations were identified by group consensus. DISCUSSION: Design, development, and implementation of acute care patient portals should consider: (1) providing a single integrated experience across care settings, (2) humanizing the patient-clinician relationship via personalization tools, (3) providing equitable access, and (4) creating a clear organizational mission and strategy to achieve outcomes of interest. CONCLUSION: Portals should provide a single integrated experience across the inpatient and ambulatory settings. Core functionality includes tools that facilitate communication, personalize the patient, and deliver education to advance safe, coordinated, and dignified patient-centered care. Our findings can be used to inform a "road map" for future work related to acute care patient portals.

A web-based and mobile patient-centered ''microblog'' messaging platform to improve care team communication in acute care.

Communication in acute care settings is fragmented and occurs asynchronously via a variety of electronic modalities. Providers are often not on the same page with regard to the plan of care. We designed and developed a secure, patient-centered "microblog" messaging platform that identifies care team members by synchronizing with the electronic health record, and directs providers to a single forum where they can communicate about the plan of care. The system was used for 35% of patients admitted to a medical intensive care unit over a 6-month period. Major themes in messages included care coordination (49%), clinical summarization (29%), and care team collaboration (27%). Message transparency and persistence were seen as useful features by 83% and 62% of respondents, respectively. Availability of alternative messaging tools and variable use by non-unit providers were seen as main barriers to adoption by 83% and 62% of respondents, respectively. This approach has much potential to improve communication across settings once barriers are addressed.

How often are hospitalized patients and providers on the same page with regard to the patient's primary recovery goal for hospitalization?

BACKGROUND: To deliver high-quality, patient-centered care during hospitalization, healthcare providers must correctly identify the patient's primary recovery goal. OBJECTIVE: To determine the degree of concordance between patients and key hospital providers. DESIGN: A validated questionnaire administered to a random sample of hospitalized patients alongside their nurse and physician provider. Goals included: "be cured," "live longer," "improve/maintain health," "be comfortable," "accomplish a particular life goal," or "other." SETTING: Major academic hospital in Boston, Massachusetts. PARTICIPANTS: Adult patients admitted for more than 48 hours from November 2013 to May 2014 were eligible. When a patient was incapacitated, a legal proxy was interviewed. The nurse and physician provider were then interviewed within 24 hours. MEASUREMENTS: Frequencies of responses for each recovery goal and the rate of concordance among the patient, nurse, and physician provider were measured. The frequency of responses across groups were compared using adjusted χ(2) analyses. Inter-rater agreement was measured using 2-way Kappa tests. RESULTS: All 3 participants were interviewed in 109 of the 181 (60.2%) patients approached (or with proxy available). Significant differences in selected goals were observed across respondent groups (P < 0.001). Patients frequently chose "be cured" (46.8%). Nurses and physician providers frequently selected "improve or maintain health" (38.5% and 46.8%, respectively). All 3 participants selected the same goal in 22 cases (20.2%). Inter-rater agreement was poor to slight for all pairs (kappa 0.09 [-0.03-0.19], 0.19 [0.08-0.30], and 0.20 [0.08-0.32] for patient-physician, patient-nurse, and nurse-physician, respectively). CONCLUSIONS: We observed poor to slight concordance among hospitalized patients and key medical team members with regard to the patient's primary recovery goal. Journal of Hospital Medicine 2016;11:615-619. © 2016 Society of Hospital Medicine.

A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: a preliminary evaluation.

We implemented a web-based, patient-centered toolkit that engages patients/caregivers in the hospital plan of care by facilitating education and patient-provider communication. Of the 585 eligible patients approached on medical intensive care and oncology units, 239 were enrolled (119 patients, 120 caregivers). The most common reason for not approaching the patient was our inability to identify a health care proxy when a patient was incapacitated. Significantly more caregivers were enrolled in medical intensive care units compared with oncology units (75% vs 32%; P < .01). Of the 239 patient/caregivers, 158 (66%) and 97 (41%) inputted a daily and overall goal, respectively. Use of educational content was highest for medications and test results and infrequent for problems. The most common clinical theme identified in 291 messages sent by 158 patients/caregivers was health concerns, needs, preferences, or questions (19%, 55 of 291). The average system usability scores and satisfaction ratings of a sample of surveyed enrollees were favorable. From analysis of feedback, we identified barriers to adoption and outlined strategies to promote use.

Strategies for Managing Mobile Devices for Use by Hospitalized Inpatients.

Despite the potential advantages, implementation of mobile devices and ongoing management pose challenges in the hospital environment. Our team implemented the PROSPECT (Promoting Respect and Ongoing Safety through Patient-centeredness, Engagement, Communication and Technology) project at Brigham and Women's Hospital. The goal of PROSPECT is to transform the hospital environment by providing a suite of e-tools to facilitate teamwork among nurses, physicians, patients and to engage patients and care partners in their plan of care. In this paper, we describe the device-related decisions and challenges faced including device and accessory selection, integration, information and device security, infection control, user access, and ongoing operation and maintenance. We relate the strategies that we used for managing mobile devices and lessons learned based on our experiences.

Clinical Workflow Observations to Identify Opportunities for Nurse, Physicians and Patients to Share a Patient-centered Plan of Care.

Patient- and Family-Centered Care (PFCC) is essential for high quality care in the critical and acute-specialty care hospital setting. Effective PFCC requires clinicians to form an integrated interprofessional team to collaboratively engage with the patient/family and contribute to a shared patient-centered plan of care. We conducted observations on a critical care and specialty unit to understand the plan of care activities and workflow documentation requirements for nurses and physicians to inform the development of a shared patient-centered plan of care to support patient engagement. We identified siloed plan of care documentation, with workflow opportunities to converge the nurses plan of care with the physician planned To-do lists and quality and safety checklists. Integration of nurses and physicians plan of care activities into a shared plan of care is a feasible and valuable step toward interprofessional teams that effectively engage patients in plan of care activities.

Participatory Design and Development of a Patient-centered Toolkit to Engage Hospitalized Patients and Care Partners in their Plan of Care.

Patient engagement has been identified as a key strategy for improving patient outcomes. In this paper, we describe the development and pilot testing of a web-based patient centered toolkit (PCTK) prototype to improve access to health information and to engage hospitalized patients and caregivers in the plan of care. Individual and group interviews were used to identify plan of care functional and workflow requirements and user interface design enhancements. Qualitative methods within a participatory design approach supported the development of a PCTK prototype that will be implemented on intensive care and oncology units to engage patients and professional care team members developing their plan of care during an acute hospitalization.