Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.

STUDY AIM: This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach. BACKGROUND: Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described. METHODS: We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements. RESULTS: We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC. CONCLUSION: This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study. APPLICATION: We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Exposing Undergraduate Nursing Students to Older Adults: A Qualitative Analysis.

ABSTRACT: Care of the older adult can be complex and influenced by ageism. The purpose of this pilot study was to expose nursing students to older adults earlier in the undergraduate curriculum. This study examined the experiences of student participation in caring for older adults. Qualitative analysis of student logs was conducted. Themes that emerged included age-related changes, environmental considerations, psychosocial needs and changes, consideration of gerontology as a career choice, and existing bias. Early experiences are vital in the curriculum and provide enhanced engagement in gerontology.

Self-reported symptom causes of mobility difficulty contributing to fear of falling in older adults.

BACKGROUND: Self-reported symptom causes of mobility difficulty that contribute to  fear of falling (FOF) in older adults has not been fully explored as an area for intervention. AIMS: Identify the prevalence of self-reported symptoms causing mobility difficulties and to examine the difference in FOF by symptom category. METHODS: Conduct a secondary data analysis of a population-based cohort of community-dwelling older adults, ≥ 70 years, enrolled in the MOBILIZE Boston study. The analysis included 242 older adults reported difficulty walking » mile (0.4 km) and/or climbing one flight of stairs. Participants identified the main symptom cause of the mobility difficulty from a list of 32 symptoms, grouped into five categories. FOF was measured using the Tinetti Falls Efficacy Scale. RESULTS: Pain was the primary symptom causing mobility difficulty (38%), followed by endurance (21%), weakness (13%), balance (9%), and other (3%). Although a greater proportion of participants who identified balance as the primary symptom category had significantly higher FOF compared to others, there was a greater number overall who reported pain as their main symptom who also had FOF. Therefore, pain contributed to a higher relative burden of FOF in the population than did balance symptoms. DISCUSSION: Various symptoms affect mobility and are associated with FOF, a known fall risk factor. Many older adults identify pain as the main cause of their mobility difficulty and report FOF. CONCLUSIONS: Improving pain symptoms for older adults may improve mobility and reduce fear of falling, potentially averting further decline in mobility and independence.

Surviving COVID-19 After Hospital Discharge: Symptom, Functional, and Adverse Outcomes of Home Health Recipients.

BACKGROUND: Little is known about recovery from coronavirus disease 2019 (COVID-19) after hospital discharge. OBJECTIVE: To describe the home health recovery of patients with COVID-19 and risk factors associated with rehospitalization or death. DESIGN: Retrospective observational cohort. SETTING: New York City. PARTICIPANTS: 1409 patients with COVID-19 admitted to home health care (HHC) between 1 April and 15 June 2020 after hospitalization. MEASUREMENTS: Covariates and outcomes were obtained from the mandated OASIS (Outcome and Assessment Information Set). Cox proportional hazards models were used to estimate the hazard ratio (HR) of risk factors associated with rehospitalization or death. RESULTS: After an average of 32 days in HHC, 94% of patients were discharged and most achieved statistically significant improvements in symptoms and function. Activity-of-daily-living dependencies decreased from an average of 6 (95% CI, 5.9 to 6.1) to 1.2 (CI, 1.1 to 1.3). Risk for rehospitalization or death was higher for male patients (HR, 1.45 [CI, 1.04 to 2.03]); White patients (HR, 1.74 [CI, 1.22 to 2.47]); and patients with heart failure (HR, 2.12 [CI, 1.41 to 3.19]), diabetes with complications (HR, 1.71 [CI, 1.17 to 2.52]), 2 or more emergency department visits in the past 6 months (HR, 1.78 [CI, 1.21 to 2.62]), pain daily or all the time (HR, 1.46 [CI, 1.05 to 2.05]), cognitive impairment (HR, 1.49 [CI, 1.04 to 2.13]), or functional dependencies (HR, 1.09 [CI, 1.00 to 1.20]). Eleven patients (1%) died, 137 (10%) were rehospitalized, and 23 (2%) remain on service. LIMITATIONS: Care was provided by 1 home health agency. Information on rehospitalization and death after HHC discharge is not available. CONCLUSION: Symptom burden and functional dependence were common at the time of HHC admission but improved for most patients. Comorbid conditions of heart failure and diabetes, as well as characteristics present at admission, identified patients at greatest risk for an adverse event. PRIMARY FUNDING SOURCE: No direct funding.

Improving transitions and outcomes of sepsis survivors (I-TRANSFER): a type 1 hybrid protocol.

BACKGROUND: This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal.  METHODS: Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions and Outcomes of Sepsis Survivors (I-TRANSFER) intervention compared to usual care on 30-day rehospitalization and emergency department use among sepsis survivors receiving HHC. The study design includes a baseline period with no intervention, a six-month start-up period followed by a one-year intervention period in partnership with five dyads of acute and HHC sites. In addition to the usual care/control periods from the dyad sites, additional survivors from national data will serve as control observations for comparison, weighted to produce covariate balance. The hypotheses will be tested using generalized mixed models with covariates guided by the Andersen Behavioral Model of Health Services. We will produce insights and generalizable knowledge regarding the context, processes, strategies, and determinants of I-TRANSFER implementation. DISCUSSION: As the largest HHC study of its kind and the first to transform this novel evidence through implementation science, this study has the potential to produce new knowledge about the impact of timely attention in HHC to alleviate symptoms and support sepsis survivor's recovery at home. If effective, the impact of this intervention could be widespread, improving the quality of life and health outcomes for a growing, vulnerable population of sepsis survivors. A national advisory group will assist with widespread results dissemination.

Parkinson's Disease Medication Administration During a Care Transition: The Impact of Interprofessional Team Simulation on Student Competency, Comfort, and Knowledge.

AIM: This study investigated the impact of an interprofessional mock code on students' comfort and competency related to Parkinson's disease (PD) medication administration during care transitions. BACKGROUD: Patients with PD are at increased risk for medication errors during hospitalization. Individualization of PD medication creates vulnerability during care transitions. METHOD: Four interprofessional groups took part in this study: baccalaureate degree senior nursing students (n = 113), master's level nurse anesthesia students (n = 35), doctor of osteopathic medicine fourth-year students (n = 32), and doctor of clinical psychology fourth-year students (n = 22). Groups participated in an unfolding case study simulation involving a mock code with a focus on the omission of time-sensitive PD medication. Pre- and postsimulation test results were compared. RESULTS: Findings indicated an increased understanding among three of the four groups relating to medication timing during care transitions. CONCLUSION: All groups improved with respect to perceived comfort and competency.

Patients' and caregivers' perspectives in determining discharge readiness from home health.

There are no national, empirically derived clinical decision support tools to assist the interprofessional home health team in determining readiness for discharge from skilled home health. Eliciting patient and family caregiver perspectives around readiness for home health discharge is integral to developing tools that address their needs in this decision-making process. The purpose of this study was to describe the factors home health patients and their family caregivers perceive as critical when determining readiness for discharge from services. A qualitative descriptive study was conducted among skilled home health recipients and their family caregivers who were either recently discharged or recertified for additional care from two different Medicare-certified skilled home health agencies. Nine themes emerged: self-care ability, functional status, status of condition(s) and symptoms, presence of a caregiver, support for the caregiver, connection to community resources/support, safety needs of the home environment addressed, adherence to the prescribed regimen, and care coordination.

Diagnostic Sensitivity of the Dynamic Appraisal of Situational Aggression to Predict Violence and Aggression by Behavioral Health Patients in the Emergency Department.

INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is an assessment tool that has been validated to predict violent or aggressive behavior in psychiatric inpatient settings. Its validity has not been established for use in the emergency department. METHODS: The DASA was implemented within the electronic health record of an academic medical center with inpatient psychiatric services. A retrospective analysis was conducted using Spearman rank-correlation coefficients to compare a final risk score with the subsequent occurrence of violence or aggression, defined as the use of hard leather physical restraints or the administration of intramuscular sedative medication. A receiver operating characteristic curve was used to summarize the predictive accuracy of the tool to assess aggression in behavioral health patients in the emergency department. RESULTS: A total of 3,433 scores were analyzed, representing 1,548 patients. The DASA had predictive validity with increasing scores comparing all tested cutoff scores against incidence of violence and aggression. The area under the curve comparing scores of 0 versus more than 0 was 0.79. The median time to subsequent aggression was 110 minutes. DISCUSSION: The DASA has predictive validity for use in evaluating behavioral health patients in the ED setting in an urban academic medical center. The tool is capable of predicting violence or aggression within a time frame conducive to the implementation of noninvasive measures. The DASA should be tested in other ED settings to further establish its predictive validity.

Medication Safety of Patients With Parkinson's Disease During Care Transitions: Educating Nursing Students.

The purpose of this study was to increase awareness and educate undergraduate nursing students and clinical faculty regarding the importance of missed or omitted Parkinson's disease medications during care transitions. To improve quality and safety among this vulnerable population, an innovative, simulated unfolding case study focusing on incomplete medication reconciliation and omission of time-sensitive medications was conducted. Second-degree BSN students (n = 94) and clinical faculty (n = 7) participated in the study. Pretest/posttest results were compared. Findings indicated increased understanding among students and faculty regarding the impact of medication reconciliation and the timely administration of Parkinson's disease medication.

Transitional Care Experience in Home Health: Exposing Students to Care Transitions Through Scenarios and Simulation.

Chronically ill older adults are at risk for avoidable adverse events especially during care transitions, the transfer to one care setting or one level of care to another. Because of the expected increase in the older adult population, increased demand for transitional care is anticipated. Despite the consistent call for expanded competencies in care transitions, nursing education has not incorporated these concepts into nursing curricula. To fill this gap, Villanova University developed patient care scenarios and simulations incorporating standardized patients to demonstrate the needs, risks, and potential complications associated with transitioning patients from acute care to home.

Regulation of Chemokine Signal Integration by Activator of G-Protein Signaling 4 (AGS4).

Activator of G-protein signaling 4 (AGS4)/G-protein signaling modulator 3 (Gpsm3) contains three G-protein regulatory (GPR) motifs, each of which can bind Gαi-GDP free of Gßγ We previously demonstrated that the AGS4-Gαi interaction is regulated by seven transmembrane-spanning receptors (7-TMR), which may reflect direct coupling of the GPR-Gαi module to the receptor analogous to canonical Gαßγ heterotrimer. We have demonstrated that the AGS4-Gαi complex is regulated by chemokine receptors in an agonist-dependent manner that is receptor-proximal. As an initial approach to investigate the functional role(s) of this regulated interaction in vivo, we analyzed leukocytes, in which AGS4/Gpsm3 is predominantly expressed, from AGS4/Gpsm3-null mice. Loss of AGS4/Gpsm3 resulted in mild but significant neutropenia and leukocytosis. Dendritic cells, T lymphocytes, and neutrophils from AGS4/Gpsm3-null mice also exhibited significant defects in chemoattractant-directed chemotaxis and extracellular signal-regulated kinase activation. An in vivo peritonitis model revealed a dramatic reduction in the ability of AGS4/Gpsm3-null neutrophils to migrate to primary sites of inflammation. Taken together, these data suggest that AGS4/Gpsm3 is required for proper chemokine signal processing in leukocytes and provide further evidence for the importance of the GPR-Gαi module in the regulation of leukocyte function.

Use, maintenance and dose effects of cognitive speed of processing training in Parkinson's disease.

INTRODUCTION: Recent research indicated that cognitive speed of processing training (SPT) improved Useful Field of View (UFOV) among individuals with Parkinson's disease (PD). The effects of SPT in PD have not been further examined. The objectives of the current study were to investigate use, maintenance and dose effects of SPT among individuals with PD. METHODS: Participants who were randomized to SPT or a delayed control group completed the UFOV at a six-month follow-up visit. Use of SPT was monitored across the six-month study period. Regression explored factors affecting SPT use. Mixed effect models were conducted to examine the durability of training gains among those randomized to SPT (n = 44), and training dose effects among the entire sample (n = 87). RESULTS: The majority of participants chose to continue to use SPT (52%). Those randomized to SPT maintained improvements in UFOV performance. A significant dose effect of SPT was evident such that more hours of training were associated with greater UFOV performance improvements. The cognitive benefits derived from SPT in PD may be maintained for up to three months. CONCLUSION: Future research should determine how long gains endure and explore if such training gains transfer.

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults.

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.

Health Care Provider Mobility Counseling Provision to Older Adults: A Rural/Urban Comparison.

The current study examined rural-urban differences in health care provider (HCP) perceptions, attitudes, and practices related to driving safety/cessation-related anticipatory guidance provision to older adults. A cross-sectional survey was conducted with HCPs in several north central states. Exploratory factor analysis was used to examine dimensions of HCP perceptions and attitudes related to mobility counseling. Binary logistic regression analyses were conducted to determine if HCP rurality was significantly predictive of HPC provision of mobility counseling by age. Rural HCPs were less likely than urban HCPs to provide mobility counseling to their patients aged 75 or older. Rural HCPs were less likely to refer patients to a driving fitness evaluation resource if they had questions related to driving issues, and were less likely to perceive there were adequate resources to help with driving issues. Rural-urban differences in HCP mobility counseling provision may contribute to potential health disparities between urban and rural patients. Both rural and urban HCPs need training about older driver issues, so they may educate their patients about driving safety/cessation. Future research should examine the association between rural-urban differences in HCP mobility counseling provision and rural older adult overrepresentation in motor vehicle injuries and fatalities statistics.

Engaging Graduate-Level Distance Learners in Research: A Collaborative Investigation of Rural Aging.

Online educational programs pose challenges to nonresidential graduate students for whom research is a key professional development experience. In this article, the authors share their pedagogical approach to engaging graduate-level online distance learners in research. Five students enrolled in an online master's degree program participated in a directed research course designed to facilitate a semester-long, collaborative, hands-on research experience in gerontology. As such, students recruited participants and conducted phone interviews for a multisite study examining aging in place in rural areas. Several strategies were used to facilitate student engagement and learning, including: regular meetings with faculty mentors, creation of a research team across institutions, interactive training, and technological tools to aid in communication. The authors discuss the process of implementing the project, challenges that arose, strategies for dealing with these issues, and a pedagogical framework that could be used to guide future endeavors of this type.

Defective chemokine signal integration in leukocytes lacking activator of G protein signaling 3 (AGS3).

Activator of G-protein signaling 3 (AGS3, gene name G-protein signaling modulator-1, Gpsm1), an accessory protein for G-protein signaling, has functional roles in the kidney and CNS. Here we show that AGS3 is expressed in spleen, thymus, and bone marrow-derived dendritic cells, and is up-regulated upon leukocyte activation. We explored the role of AGS3 in immune cell function by characterizing chemokine receptor signaling in leukocytes from mice lacking AGS3. No obvious differences in lymphocyte subsets were observed. Interestingly, however, AGS3-null B and T lymphocytes and bone marrow-derived dendritic cells exhibited significant chemotactic defects as well as reductions in chemokine-stimulated calcium mobilization and altered ERK and Akt activation. These studies indicate a role for AGS3 in the regulation of G-protein signaling in the immune system, providing unexpected venues for the potential development of therapeutic agents that modulate immune function by targeting these regulatory mechanisms.

The impact of home health length of stay and number of skilled nursing visits on hospitalization among Medicare-reimbursed skilled home health beneficiaries.

The implementation of the Home Health Prospective Payment System in 2000 led to a dramatic reduction in home health length of stay and number of skilled nursing visits among Medicare beneficiaries. While policy leaders have focused on the rising costs of home health care, its potential underutilization, and the relationship between service use and patient outcomes including hospitalization rates have not been rigorously examined. A secondary analysis of five Medicare-owned assessment and claims data sets for the year 2009 was conducted among two independently randomly selected samples of Medicare-reimbursed home health recipients (each n = 31,485) to examine the relationship between home health length of stay or number of skilled nursing visits and hospitalization rates within 90 days of discharge from home health. Patients who had a home health length of stay of at least 22 days or received at least four skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits. Additional study is needed to clarify the best way to structure home health services and determine readiness for discharge to reduce hospitalization among this chronically ill population. In the mean time, the findings of this study suggest that home health providers should consider the benefits of at least four SNV and/or a home health LOS of 22 days or longer.

EDD enhances cell survival and cisplatin resistance and is a therapeutic target for epithelial ovarian cancer.

The E3 ubiquitin ligase EDD is overexpressed in recurrent, platinum-resistant ovarian cancers, suggesting a role in tumor survival and/or platinum resistance. EDD knockdown by small interfering RNA (siRNA) induced apoptosis in A2780ip2, OVCAR5 and ES-2 ovarian cancer cells, correlating with loss of the prosurvival protein myeloid cell leukemia sequence 1 (Mcl-1) through a glycogen synthase kinase 3 beta-independent mechanism. SiRNA to EDD or Mcl-1 induced comparable levels of apoptosis in A2780ip2 and ES-2 cells. Stable overexpression of Mcl-1 protected cells from apoptosis following EDD knockdown, accompanied by a loss of endogenous, but not exogenous, Mcl-1 protein, suggesting that EDD regulated Mcl-1 synthesis. Indeed, EDD knockdown induced a 1.87-fold decrease in Mcl-1 messenger RNA and EDD transfection enhanced murine Mcl-1 promoter-driven luciferase expression 5-fold. To separate EDD survival and potential cisplatin resistance functions, we generated EDD shRNA stable cell lines that could survive initial EDD knockdown and showed that these cells were 4- to 21-fold more sensitive to cisplatin. Moreover, transient EDD overexpression in COS-7 cells was sufficient to promote cisplatin resistance 2.4-fold, dependent upon its E3 ligase activity. In vivo, mouse intraperitoneal ES-2 and A2780ip2 xenograft experiments showed that mice treated with EDD siRNA by nanoliposomal delivery [1,2-dioleoyl-sn-glycero-3-phophatidylcholine (DOPC)] and cisplatin had significantly less tumor burden than those treated with control siRNA/DOPC alone (ES-2, 77.9% reduction, P = 0.004; A2780ip2, 75.9% reduction, P = 0.042) or control siRNA/DOPC with cisplatin in ES-2 (64.4% reduction, P = 0.035), with a trend in A2780ip2 (60.3% reduction, P = 0.168). These results identify EDD as a dual regulator of cell survival and cisplatin resistance and suggest that EDD is a therapeutic target for ovarian cancer.

Experience and knowledge of pain management in patients receiving outpatient cancer treatment: what do older adults really know about their cancer pain?

OBJECTIVE: An individual's ability to effectively manage their cancer pain is influenced by knowledge and perceptions regarding the pain experience. While significance of the physician's knowledge of cancer pain management has been reported, much less is known how a patient's knowledge may influence their ability to optimally manage their pain. The purpose of this study is to determine the influence health and social factors have on the knowledge and experience of cancer pain among older adults. DESIGN: A prospective cross-sectional study of older Black and White patients presenting for outpatient cancer treatment. METHODS: Participants were surveyed on questions assessing pain severity, knowledge and experience of pain, self-efficacy for pain treatment, satisfaction with pain treatment, and additional social, health, and demographic characteristics. A series of hierarchical regression models were specified to examine predictors of cancer pain knowledge and experience. RESULTS: Education, race, and trust were significant predictors of pain knowledge, whereas self-efficacy for pain, pain interference, and pain severity were indicators of the experience of cancer pain. CONCLUSIONS: Knowledge and experience of (cancer) pain are contingent upon a myriad of social and clinical factors that are not exclusive but rather coexisting determinants of health. Understanding older adults' knowledge of pain may begin to diminish the imparities in the diagnosis and treatment of pain among this growing diverse population of older adults. It may similarly allow for programs to be tailored to fit the specific needs of the patient in the treatment and management of their cancer pain.