Swallowing Assessment in Post-Comatose Patients: A Feasibility Study on the SWADOC Tool.

Background: After a severe brain injury and a coma, patients may develop disorders of consciousness (DoC), frequently accompanied by severe dysphagia. The evaluation and therapy of swallowing are therefore essential aspects of their management. Objectives: This study aims to evaluate the SWallowing Assessment in Disorders of Consciousness (SWADOC) tool in the assessment of swallowing in post-comatose patients. Here, we validate its quantitative items, describe preliminary results and identify limitations. Methods: Fourteen post-comatose patients were repeatedly evaluated with the Simplified Evaluation of CONsciousness Disorders (SECONDs) and with the SWADOC. Results: The internal consistency of the oral and pharyngeal subscales of the SWADOC was good. The test-retest reliability showed that all items, all subscores and the total score were stable except for two items (endo-buccal secretions and bronchial congestion). A comparison to the Facial Oral Tract Therapy Swallowing Assessment of Saliva (F.O.T.T-SAS) confirmed that scoring with the SWADOC offers a greater potential for quantitative observations in assessing swallowing abilities among patients with DoC. The SECONDs scores and SWADOC total scores showed a significant positive correlation (τ = 0.78, p < 0.001). Conclusions: This study provides preliminary but encouraging results on the psychometric properties of the SWADOC tool. It shows that this tool is relevant and feasible as a bedside assessment of dysphagia in patients with DoC.

Promoting Innovation in State and Territorial Maternal and Child Health Policymaking.

INTRODUCTION: The Association of Maternal & Child Health Programs (AMCHP) and the Association of State and Territorial Health Officials (ASTHO) launched the PRISM (Promoting Innovation in State and Territorial MCH Policymaking) Learning Community, funded by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). The goal of PRISM was to build state and territorial health agency program and policy-making capacity to address substance use and mental health in the maternal and child health (MCH) population. Expanding access to care and treatment for perinatal substance use disorders (SUD) emerged as the issue of greatest need for state teams. METHODS: The PRISM Learning Community consisted of three major components: (1) intensive capacity building for cross-agency state teams, which involved action planning, peer-to-peer learning, and technical assistance; (2) programming to inform the MCH field broadly about innovations in perinatal SUD policy and practice; and (3) a program evaluation involving pre-, mid-, and post-assessments and follow-up key informant interviews with state teams. This manuscript is not based on clinical study or patient data, therefore IRB approval was not required. RESULTS: States reported that their knowledge of perinatal SUDs increased and their cross-agency partnerships were strengthened as a result of their participation in PRISM. States identified four key priorities for their continued work: to improve multisector collaborations, to institute equitable SUD screening practices for pregnant people, to strengthen the perinatal behavioral health workforce, and to enhance Medicaid coverage for perinatal SUD prevention and treatment services. The need to respond to urgent demands of COVID-19 and the stigma associated with perinatal SUDs were the most significant barriers to advancing state action plan goals. DISCUSSION: Since 2018, the PRISM project has supported nine jurisdictions across two cohorts. Participation in PRISM advanced state policies and programs to improve perinatal SUD care through capacity building, technical assistance, and virtual programming. Findings and lessons learned from PRISM may inform the activities of other states seeking to address perinatal substance use disorders.

Insights from the national maternal and Child Health Workforce Development Center on Title V Teams' collaborative readiness and goal accomplishment.

PURPOSE: State Title V programs collaborate with diverse partners to improve maternal and child health. Since 2014, the National Maternal and Child Health Workforce Development Center has trained Title V leaders in facilitating system change. This article describes aspects of initial collaborative readiness differentiating state and jurisdiction teams that later reported meeting their goals to greater or lesser degrees. DESCRIPTION: We used quantitative data from initial team leader reports to characterize readiness to collaborate with external partners, and their responses twelve months later to a prompt about how fully they had accomplished their goals. In addition, we coded excerpts from team leader accounts six and twelve months into their work with the Center, and retrospective coach perspectives, to identify collaborative readiness patterns. ASSESSMENT: Teams whose leaders reported higher goal accomplishment twelve months after beginning work with the Center had initially reported higher levels of collaboration with key partners. Our analyses suggest that such teams were also better able to use their cohort experience with the Center to improve collaboration, including information sharing with external stakeholders. Challenges working with Medicaid were reported both by teams with more and less goal accomplishment. CONCLUSIONS: Title V teams with lower levels of initial collaborative readiness may benefit from additional support in skill development, connections to key partners, and convening power. Given the crucial and increasing role of Medicaid in maternal and child health systems, more attention may be warranted to supporting all Title V programs in partnering with this funder.

Influence of clinical context on interpretation and use of an advance care planning policy: a qualitative study.

BACKGROUND: Advance care planning is a process through which people share their values, goals and preferences regarding future medical treatments with the purpose of aligning care received with patient wishes. The objective of this study was to explore perspectives from patients and clinicians in 4 clinical settings to understand how context influences interpretation and application of advance care planning processes. METHODS: This study used a qualitative interpretive descriptive design. Patient and clinician participants were recruited across 4 clinical outpatient settings (cancer, heart failure, renal failure and supportive living) in Calgary and Edmonton. Data were collected between 2014 and 2015 by means of recorded one-on-one semistructured interviews. We analyzed the data using thematic analysis in 2016-2017. RESULTS: Thirty-four patients and 34 clinicians participated in interviews. Themes common to all 4 contexts were lack of shared understanding between patients and clinicians, and a lack of consistent clinical process related to advance care planning. Advance care planning understanding and process varied substantially between contexts. This variation seemed to be driven by differences in perceptions around disease burden and the nature of the physician-patient relationship. INTERPRETATION: Provision of a system-wide policy and procedural framework alone was not found to be sufficient to form a standardized approach to advance care planning, as considerable variability existed in advance care planning process between and within clinical settings. Quality-improvement methods that consider local processes, gaps and barriers can help in developing a consistent, comprehensive process.

Serious Illness Conversation-Evaluation Exercise: A Novel Assessment Tool for Residents Leading Serious Illness Conversations.

Background/Objectives: The serious illness conversation (SIC) is an evidence-based framework for conversations with patients about a serious illness diagnosis. The objective of our study was to develop and validate a novel tool, the SIC-evaluation exercise (SIC-Ex), to facilitate assessment of resident-led conversations with oncology patients. Design: We developed the SIC-Ex based on SIC and on the Royal College of Canada Medical Oncology milestones. Seven resident trainees and 10 evaluators were recruited. Each trainee conducted an SIC with a patient, which was videotaped. The evaluators watched the videos and evaluated each trainee by using the novel SIC-Ex and the reference Calgary-Cambridge guide (CCG) at months zero and three. We used Kane's validity framework to assess validity. Results: Intra-class correlation using average SIC-Ex scores showed a moderate level of inter-evaluator agreement (range 0.523-0.822). Most evaluators rated a particular resident similar to the group average, except for one to two evaluator outliers in each domain. Test-retest reliability showed a moderate level of consistency among SIC-Ex scores at months zero and three. Global rating at zero and three months showed fair to good/very good inter-evaluator correlation. Pearson correlation coefficients comparing total SIC-Ex and CCG scores were high for most evaluators. Self-scores by trainees did not correlate well with scores by evaluators. Conclusions: SIC-Ex is the first assessment tool that provides evidence for incorporating the SIG guide framework for evaluation of resident competence. SIC-Ex is conceptually related to, but more specific than, CCG in evaluating serious illness conversation skills.

How to increase public participation in advance care planning: findings from a World Café to elicit community group perspectives.

BACKGROUND: In 2014, Alberta, Canada broke new ground in having the first provincial healthcare policy and procedure for advance care planning (ACP), the process of communicating and documenting a person's future healthcare preferences. However, to date public participation and awareness of ACP remains limited. The aim of this initiative was to elicit community group perspectives on how to help people learn about and participate in ACP. METHODS: Targeted invitations were sent to over 300 community groups in Alberta (e.g. health/disease, seniors/retirement, social/service, legal, faith-based, funeral planning, financial, and others). Sixty-seven participants from 47 community groups attended a "World Café". Participants moved between tables at fixed time intervals, and in small groups discussed three separate ACP-related questions. Written comments were captured by participants and facilitators. Each comment was coded according to Michie et al.'s Theoretical Domains Framework, and mapped to the Capability, Opportunity and Motivation behavior change system (COM-B) in order to identify candidate intervention strategies. RESULTS: Of 800 written comments, 76% mapped to the Opportunity: Physical COM-B component of behavior, reflecting a need for access to ACP resources. The most common intervention functions identified pertained to Education, Environmental Restructuring, Training, and Enablement. We synthesized the intervention functions and qualitative comments into eight recommendations for engaging people in ACP. These pertain to access to informational resources, group education and facilitation, health system processes, use of stories, marketing, integration into life events, inclusion of business partners, and harmonization of terminology. CONCLUSIONS: There was broad support for the role of community groups in promoting ACP. Eight recommendations for engaging the public in ACP were generated and have been shared with stakeholders.

'Not yet' and 'Just ask': barriers and facilitators to advance care planning--a qualitative descriptive study of the perspectives of seriously ill, older patients and their families.

OBJECTIVES: To explore seriously ill, older hospitalised patients' and their family members' perspectives on the barriers and facilitators of advance care planning (ACP). METHODS: We used qualitative descriptive study methodology to analyse data from an interviewer administered, questionnaire-based, Canadian multicentre, prospective study of this population. RESULTS: Three main categories described these barriers and facilitators: (1) person (beliefs, attitudes, experiences, health status), (2) access (to doctors and healthcare providers, information, tools and infrastructure to communicate ACP preferences) and (3) the interaction with the doctor (who and how initiated, location, timing, quality of communication, relationship with doctor). CONCLUSIONS: Based on the findings, we suggest strategies for both healthcare systems and individual healthcare providers to improve the quality and quantity of ACP with this population. These include assessing readiness for participation in ACP and personalising relevance of ACP to each individual, routinely offering scheduled family meetings for exploring a person's own goals and sharing information, ensuring systems and policies are in place to access previous ACP documentation and ensuring doctors' education includes ACP communication skills.

Facilitated advance care planning: what is the patient experience?

There is little known about the patient experience of participating in facilitated advance care planning (ACP). We conducted a grounded theory study with facilitated ACP participants who had endstage renal disease. A theoretical model "a positive thing: peace of mind" emerged. This model contained three major categories: a) witnessing illness in self and others; b) "I don't want to live like that", a perception of poor quality of life associated with living with cognitive or physical impairments. These preexisting ideas interacted with c) the process, which contained the patient's experience of all of the interactions encountered in facilitated ACP. The relationship between the three categories left participants comfortable that they had addressed their concerns about living in a burdensome state for themselves or their families. The literature review supported prior illness experiences and self-perceived burden as important in advance decision making. The implications of these findings are discussed.

Cerebral microhemorrhages predict new disabling or fatal strokes in patients with acute ischemic stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Cerebral microhemorrhages (MHs) are common among patients presenting with acute ischemic stroke and may predict both subsequent ischemic and hemorrhagic strokes. METHODS: We prospectively studied patients with and without MHs presenting within 12 hours of their ischemic stroke or transient ischemic attack (TIA). A magnetic resonance (MR) scan was performed within 24 hours of symptom(s) onset. The primary outcome was disabling or fatal stroke at 18 months. RESULTS: An MR scan was done in 236 patients with acute ischemic stroke or TIA. Forty-five (19.1%) patients had an MH on a baseline MR scan. Patients with MHs were 2.8x (10.8% versus 4.0%; P=0.036) more likely to have a subsequent disabling or fatal stroke than patients without an MH. The risk of symptomatic intracerebral hemorrhage was not statistically significant among MH and non-MH patients (3.3% versus 0.8%; P=0.31). CONCLUSIONS: The presence of cerebral MH(s) in patients with acute ischemic stroke or TIA predicts recurrent disabling and fatal strokes. This risk is mainly assumed by recurrent ischemic strokes.