Interprofessional Patient-Specific Simulation Preparation to Improve Management of Neonatal High-Acuity Low-Occurrence (HALO) Scenarios.

Fetal compressive intrapericardial teratoma is a rare and life-threatening condition, qualifying as a high-acuity low-occurrence (HALO) event. To prepare for delivery and immediate neonatal management, specialists from pediatric cardiology, cardiac surgery, maternal-fetal-medicine, neonatology, cardiac anesthesia, critical care, clinical perfusion, obstetrical nursing, and operating room nursing convened. An in situ operating room simulation was used to identify and introduce key team members, derive and practice the anticipated clinical management algorithm, position human and equipment resources strategically, and ensure that each specialist team was familiar with the environment and available equipment. As rehearsed in the simulation, the cesarean delivery of the patient and neonatal cardiac surgery was uncomplicated and yielded a favourable clinical outcome. A patient-specific HALO simulation preparation (PSHSP) can facilitate positive clinical outcomes and improve health care team confidence in HALO scenarios such as the birth of newborns anticipated to have cardiorespiratory instabilty.

Social work leadership in a medical school: A coordinated, compassionate COVID-19 response.

The COVID-19 pandemic has exposed the systemic inequities in our health care system and society has called for actions to meet the clinical, psychosocial and educational needs in health care settings and communities. In this paper we describe how an organized Department of Health Social Work in a medical school played a unique role in responding to the challenges of a pandemic with community, clinical, and educational initiatives that were integral to our community's health.

A randomized trial of a multi-level intervention to improve advance care planning and symptom management among low-income and minority employees diagnosed with cancer in outpatient community settings.

INTRODUCTION: Equitable delivery of advance care planning and symptom management among patients is crucial to improving cancer care. Existing interventions to improve the uptake of these services have predominantly occurred in clinic settings and are limited in their effectiveness, particularly among low-income and minority populations. METHODS: The "Lay health worker Educates Engages and Activates Patients to Share (LEAPS)" intervention was developed to improve advance care planning and symptom management among low-income and minority hourly-wage workers with cancer, in two community settings. The intervention provides a lay health worker to all patients newly diagnosed with cancer and aims to educate and activate patients to engage in advance care planning and symptom management with their oncology providers. In this randomized clinical trial, we will evaluate the effect on quality of life (primary outcome) using the validated Functional Assessment of Cancer Therapy - General Survey, at enrollment, 4- and 12- months post-enrollment. We will examine between-group differences on our secondary outcomes of patient activation, patient satisfaction with healthcare decision-making, and symptom burden (at enrollment, 4- and 12-months post-enrollment), and total healthcare use and healthcare costs (at 12-months post-enrollment). DISCUSSION: Multilevel approaches are urgently needed to improve cancer care delivery among low-income and minority patients diagnosed with cancer in community settings. The current study describes the LEAPS intervention, the study design, and baseline characteristics of the community centers participating in the study. ClinicalTrials.gov Registration #NCT03699748.

QuitSMART Utah: an implementation study protocol for a cluster-randomized, multi-level Sequential Multiple Assignment Randomized Trial to increase Reach and Impact of tobacco cessation treatment in Community Health Centers.

BACKGROUND: Tobacco use remains the leading cause of death and disability in the USA and is disproportionately concentrated among low socioeconomic status (SES) populations. Community Health Centers (CHCs) are a key venue for reaching low SES populations with evidence-based tobacco cessation treatment such as Quitlines. Electronic health record (EHR)-based interventions at the point-of-care, text messaging (TM), and phone counseling have the potential to increase Quitline reach and are feasible to implement within CHCs. However, there is a lack of data to inform how, when, and in what combination these strategies should be implemented. The aims of this cluster-randomized trial are to evaluate multi-level implementation strategies to increase the Reach (i.e., proportion of tobacco-using patients who enroll in the Quitline) and Impact (i.e., Reach × Efficacy [efficacy is defined as the proportion of tobacco-using patients who enroll in Quitline treatment that successfully quit]) and to evaluate characteristics of healthcare system, providers, and patients that may influence tobacco-use outcomes. METHODS: This study is a multilevel, three-phase, Sequential Multiple Assignment Randomized Trial (SMART), conducted in CHCs (N = 33 clinics; N = 6000 patients). In the first phase, clinics will be randomized to two different EHR conditions. The second and third phases are patient-level randomizations based on prior treatment response. Patients who enroll in the Quitline receive no further interventions. In phase two, patients who are non-responders (i.e., patients who do not enroll in Quitline) will be randomized to receive either TM or continued-EHR. In phase three, patients in the TM condition who are non-responders will be randomized to receive either continued-TM or TM + phone coaching. DISCUSSION: This project will evaluate scalable, multi-level interventions to directly address strategic national priorities for reducing tobacco use and related disparities by increasing the Reach and Impact of evidence-based tobacco cessation interventions in low SES populations. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT03900767) on April 4th, 2019.

Using an Evidence-Based Approach for Electronic Health Record Downtime Education in Nurse Onboarding.

Electronic health record systems have been widely implemented throughout healthcare settings over the last few years, and nurses rely on these systems to obtain information about patients, make clinical decisions, and deliver safe and appropriate care. Health information technology systems have electronic health record downtime episodes both due to scheduled maintenance and unforeseen circumstances. The ability to deliver safe and effective care during electronic health record downtime episodes is important, yet training on electronic health record downtime is rarely included for nursing staff. This quality improvement project implemented an electronic health record downtime training course and administered it to 50 onboarding nurses within the hospital facility. The participants indicated a positive perception of electronic health record downtime preparedness after the course offering related to ability to find and follow downtime procedures. However, no precourse metrics were obtained, and therefore it is uncertain if this positive perception is a direct result of the electronic health record downtime training course. While initial results are promising, further investigation will need to be conducted to determine training course effectiveness.

Trauma-Informed Care in Pediatrics: A Developmental Perspective in Twelve Cases with Narratives.

INTRODUCTION: The dose-response relationship of adverse childhood experiences (ACEs) with chronic morbidities is recognized as prevalent. However, screening for ACEs and implementing trauma-informed care (TIC) have yet to become a standard of care in pediatrics. OBJECTIVES: To document impactful developmental experiences of implementing TIC and universal screening of ACEs in the pediatric setting, elucidate the relationship between ACEs and their common presentation of developmental and behavioral health problems in pediatric patients, and propose feasible system changes to promote evidence-based professional expertise. METHODS: During pediatric residency training, I implemented routine universal screening of pediatric patients using ACE questionnaires. Research-based trauma-informed practices, such as patient-centered communication regarding adverse health outcomes associated with prevalent ACEs, were used. Clinical vignettes describe 12 cases. RESULTS: Most patients and their families were receptive to counsel on recognizing, preventing, and mitigating the effects of toxic stress resulting from ACEs. Behavior in a patient, and sometimes a parent, was addressed from a developmentally sensitive lens of TIC, and appropriate therapeutic interventions were discussed. Addressing ACEs opened crucial conversations with some patients, which promoted efficacious, developmentally sensitive care. DISCUSSION: Implementing TIC in the pediatric setting, especially in training, is not only feasible but also vital to adequately understand the patient population. Equipped with clinical knowledge and experience in addressing ACEs, practitioners will more readily empower patients and their families to improve health outcomes. CONCLUSION: When pediatric practitioners discover, intervene, and address the adverse effects of ACEs, their care becomes more efficacious and evidence based.

Use and reporting of experience-based codesign studies in the healthcare setting: a systematic review.

BACKGROUND: Experience-based codesign (EBCD) is an approach to health service design that engages patients and healthcare staff in partnership to develop and improve health services or pathways of care. The aim of this systematic review was to examine the use (structure, process and outcomes) and reporting of EBCD in health service improvement activities. METHODS: Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Library) were searched to identify peer-reviewed articles published from database inception to August 2018. Search terms identified peer-reviewed English language qualitative, quantitative and mixed methods studies that underwent independent screening by two authors. Full texts were independently reviewed by two reviewers and data were independently extracted by one reviewer before being checked by a second reviewer. Adherence to the 10 activities embedded within the eight-stage EBCD framework was calculated for each study. RESULTS: We identified 20 studies predominantly from the UK and in acute mental health or cancer services. EBCD fidelity ranged from 40% to 100% with only three studies satisfying 100% fidelity. CONCLUSION: EBCD is used predominantly for quality improvement, but has potential to be used for intervention design projects. There is variation in the use of EBCD, with many studies eliminating or modifying some EBCD stages. Moreover, there is no consistency in reporting. In order to evaluate the effect of modifying EBCD or levels of EBCD fidelity, the outcomes of each EBCD phase (ie, touchpoints and improvement activities) should be reported in a consistent manner. TRIAL REGISTRATION NUMBER: CRD42018105879.

Relato de experiencia del Cesac Nº 13 / Experience report at Cesac Nº 13

Relato de la experiencia en atención y formación de las residentes de Psicopedagogía del Centro de Salud Nº 13, perteneciente al área programática del Hospital General de Agudos P. Piñero, de la Ciudad de Buenos Aires, durante el "Aislamiento Social, Preventivo y Obligatorio" decretado por la pandemia de Covid-19. Durante el año 2020, el equipo de Psicopedagogía de este Centro de Salud debió reorientar sus tareas y actividades, y cooperar con el resto del personal de salud del Centro, así como pensar en nuevas modalidades de capacitación.

Development and Evaluation of a Training Program for Community-Based Participatory Research in Breast Cancer.

This paper describes the development and feasibility of the Community Based Research Infrastructure to Better Science (CRIBS) training. The goal of this training program was to help new or existing community-academic teams to build strong partnerships and successfully develop together fundable research projects focused on breast cancer environmental causes and disparities. A comprehensive mixed-methods participatory approach was utilized to assess the training. Twenty-two community-academic teams applied for the training program; twelve teams were enrolled. All teams completed the training and subsequently submitted research applications for funding. All components of the training received high ratings and positive qualitative comments. Self-rated competency in all of the learning domains increased during the training. Four (33%) of teams were successful in their first attempt to garner research funding, and six (50%) were eventually successful. The evaluation of CRIBS found it to have successfully achieved all four goals of the training: (1) Twelve new CBPR (community-based participatory research) teams, (2) improved knowledge about CBPR and science, (3) twelve submitted grant proposals in the first year, and (4) six (50%) successfully funded research projects.

A complex teamwork intervention in a surgical ward in Norway.

OBJECTIVES: Interprofessional team training has a positive impact on team behavior and patient safety culture. The overall objective of the study was to explore the impact of an interprofessional teamwork intervention in a surgical ward on structure, process and outcome. In this paper, the implementation of the teamwork intervention is reported to expand the understanding of the future evaluation results of this study. RESULTS: The evidence-based Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was implemented in three phases according to the program's implementation plan, which are built on Kotter's organizational change model. In the first phase, a project group with the leaders and researchers was established and information about the project was given to all health care personnel in the ward. The second phase comprised 6 h interprofessional team training for all frontline health care personnel followed by 12 months implementation of TeamSTEPPS tools and strategies. In the third phase, the implementation of the tools and strategies continued, and refresher training was conducted. Trial registration Trial registration number (TRN) is ISRCTN13997367. The study was registered retrospectively with registration date May 30, 2017.

Clostridium Difficile: Reducing Infections Using an Evidence-Based Practice Initiative.

BACKGROUND: Nosocomial Clostridium difficile (C. difficile) infections are adverse incidents that affect immunocompromised hospitalized patients. High-touch surface areas within the patient's environment are frequently overlooked and are a source of microscopic bacterial transmission. OBJECTIVES: This article examines whether the use of a standardized protocol for cleaning high-touch surface areas would reduce the incidence of hospital-acquired C. difficile infection. METHODS: The initiative targeted five high-touch surfaces, and nurses were educated about these findings. Baseline data on the C. difficile infection rate was collected from four specialty medical-surgical oncology units. A pilot period of the Five by Five initiative evaluated C. difficile infection rates after staff cleaning of these high-touch surfaces. FINDINGS: This initiative accounted for a statistically significant reduction in C. difficile infections. The use of a standardized cleaning initiative was effective in reducing C. difficile infections. Nursing staff perceived that the education was easy to remember and supported efficient implementation.

Novice Oncology Nurse Navigator: Core Elements in Establishing Training Needs and Building on Competencies.

BACKGROUND: Oncology nurse navigation opportunities are rapidly expanding as the value of the role is recognized. However, there is a lack of training opportunities focusing on the unique needs of the oncology nurse navigator (ONN). Most navigator training programs provide only general oncology navigation content. OBJECTIVES: The purpose of this article is to evaluate the current state of training for the novice ONN and begin to identify core elements to inform development of a standardized training program. METHODS: Navigator training programs and literature related to the role and development needs of the novice ONN were reviewed. FINDINGS: Training of the novice ONN varies widely, with little evaluation of the most effective way to prepare for the role. It is clear that the learning needs of the ONN are different than those of other types of navigators and oncology nurses.

Training Clinicians with Communication Skills Needed to Match Medical Treatments to Patient Values.

Most clinicians currently in practice did not receive the evidence-based communication skills training they need to provide high-quality communication for seriously ill older adults and their families. Clinician communication skills are a critical factor in achieving a patient and family understanding of their illness that enables them to share in decision making that will result in medical treatments and social supports that are aligned with their goals and values. Research demonstrates that existing clinician competence in communication skills is extremely variable, that most clinicians need specific communication training to have an adequate level of skill, and that evidence-based training is efficacious. A conservative estimate suggests that more than 219,000 physicians and advance practice providers (APPs) (50% of physicians in high-contact subspecialties and 25% of all APPs) could benefit from training. Combining evidence-based clinician training with health system workflow redesign would likely maximize the impact of this training. We conclude with recommendations designed to address gaps in communication skills through effective training and health system changes in the service of enabling all patients with serious illness and their families to receive care aligned with their personal priorities. J Am Geriatr Soc 67:S435-S441, 2019.

Communication skill frameworks: applications in radiation oncology.

Communication is an important part of high-quality care at every step. Communication skills can be learned, practiced, and improved. In this review, we outline the basic frameworks for communication skills training, describe their components, and demonstrate their utility in the context of vignettes. We discuss specific evidence-based roadmaps for approaching the various communication tasks a radiation oncologist might encounter. Each is summarized with an easy to remember mnemonic. These include responding to emotion using NURSE statements, delivering serious news using SPIKES, discussing prognosis using ADAPT, and discussing goals of care using REMAP. To tie it all together, we offer a simplified general approach to all communication tasks with the mnemonic ACE (Assess, Communicate, Empathize).

Research and policy priorities for addressing prenatal exposure to opioids in Alaska.

The current opioid crisis in Alaska and the USA will negatively affect the health and wellbeing of future generations. The increasing number of infants born with neonatal opioid withdrawal syndrome (NOWS) has had a profound impact on families, health care providers and the child welfare system. This manuscript summarises the main themes of a Symposium held in Anchorage, Alaska with health care providers, researchers, elders and public health officials that focused on identifying emerging challenges, trends and potential solutions to address the increasing number of infants and children affected by maternal opioid use. Five areas of importance for research and policy development that would direct improvement in the care of infants with NOWS in Alaska are outlined with the goal of supporting a research agenda on opioid misuse and child health across the circumpolar north. Abbreviations: NOWS - neonatal opioid withdrawal syndrome; NAS - neonatal abstinence syndrome; MAT - medication-assisted treatment; NICU - neonatal intensive care unit; OATs - opioid agonist treatments; OCS - office of children's services; ANTHC - Alaska Native Tribal Health Consortium; OUD - opioid use disorder; SBIRT - screening, brief intervention and referral to treatment; ISPCTN - IDeA States Pediatric Clinical Trials Network; NIH - National Institutes of Health; ANMC - Alaska Native Medical Center; DHSS - Department of Health and Social Services; AAPP - All Alaska Pediatric Partnership.

Empathy Training Through Symptom Burden Simulation.

BACKGROUND:: Providing quality care to hospice and palliative care patients requires the ability to feel and demonstrate empathic behaviors. To acquire a heightened level of empathy, the learner needs to internalize a process of experiencing first-hand real-life symptom burdens common at end of life. Making this happen during new employee orientation is a challenge but with powerful outcomes. OBJECTIVE:: To increase empathy levels in hospice and palliative care staff within the agency. METHODS:: A mandatory class for all new employees and open sessions for existing employees in a hospice and palliative care setting. Subjecting participants to multiple disease process simulations. RESULTS:: All new employees participated in a symptom simulation workshop during their orientation. CONCLUSIONS:: Ninety-eight percent of the new employees found their experience in the workshop to dramatically positively affect their empathy levels and consequently formulate compassionate responses to patient situations based on their experiences of feeling empathy during the training.

Cost-effectiveness of strategies to improve delivery of brief interventions for heavy drinking in primary care: results from the ODHIN trial.

BACKGROUND: Screening and brief interventions (SBIs) for heavy drinking are an effective and cost-effective approach to reducing alcohol-related harm, yet delivery rates remain low. This study uses trial data to estimate the cost-effectiveness of alternative strategies to increase SBI delivery. METHODS: Data from a large cluster-randomized trial were combined with the Sheffield Alcohol Policy Model, a policy appraisal tool, to estimate the cost-effectiveness of eight strategies to increase SBI delivery in primary care in England, Poland and the Netherlands: care as usual (control), training and support (TS), financial reimbursement (FR), referral of patients to an online brief intervention (eBI) and all combinations of TS, FR and eBI. cost-effectiveness was assessed from a healthcare perspective by comparing health benefits (measured in Quality-Adjusted Life Years) with total implementation costs and downstream healthcare savings for each strategy over a 30-year horizon and calculating Incremental cost-effectiveness ratios (ICERs). RESULTS: All trialled strategies were cost-effective compared to control. TS combined with FR was the most cost-effective approach in England (more effective and less costly than control) and Poland (ICER €4632 vs. next-best strategy). This combination is not cost-effective in the Netherlands, where TS alone is the most cost-effective approach (ICER €3386 vs. next-best strategy). CONCLUSIONS: Structured TS, financial incentives and access to online interventions are all estimated to be cost-effective methods of improving delivery of alcohol brief interventions. TS and FR together may be the most cost-effective approach, however this is sensitive to country characteristics and alternative BI effect assumptions. TRIAL REGISTRATION: ClinicalTrials.gov trial identifier: NCT01501552.

Defining the radiation oncologist's role in palliative care and radiotherapy.

Radiation oncologists play an important role in the palliative care of advanced cancer patients. The article discusses the various clinical indications of palliative radiation therapy, which include the control of bone pain, acute treatment of cord compression, the control of thoracic and gastrointestinal symptoms. The importance of survival estimates for individualization of radiation therapy regime is elaborated. Besides prescription of radiation treatment, radiation oncologists should also function as primary palliative care providers by assessing and initial management of symptoms and other sources of distress, making prompt referrals to specialists for complex symptom management and contributing to the multidisciplinary palliative care team. Additionally, communication skills, including prognostic disclosure and goals of care discussions, should also be a core competency of radiation oncologists.