Engaging patients in designing a transmural allied health pathway: A qualitative exploration of hospital-to-home transitions.

INTRODUCTION: The transition from hospital to home is often suboptimal, resulting in patients not receiving the necessary allied healthcare after discharge. This may, in turn, lead to delayed recovery, a higher number of readmissions, more emergency department visits and an increase in mortality and healthcare costs. This study aimed to gain insight into patients' experiences, perceptions, and needs regarding hospital-to-home transition, focusing on allied healthcare as a first step towards the development of a transitional integrated allied healthcare pathway for patients with complex care needs after hospital discharge. METHODS: We conducted semistructured interviews with patients. Participants were recruited from universities and general hospitals in the Amsterdam region between May and July 2023. They were eligible if they (1) were discharged from the hospital minimally 3 and maximally 12 months after admission to an oncologic surgery department, internal medicine department, intensive care unit, or trauma centre, (2) received hospital-based care from at least one allied healthcare provider, who visited the patient at least twice during hospital admission, (3) spoke Dutch or English and (4) were 18 years or older. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis of the interview data. RESULTS: Nineteen patients were interviewed. Three themes emerged from the analysis. 'Allied healthcare support during transition' depicts patients' positive experiences when they felt supported by allied health professionals during the hospital-to-home transition. 'Patient and family involvement' illustrates how much patients value the involvement of their family members during discharge planning. 'Information recall and processing' portrays the challenges of understanding and remembering overwhelming amounts of information, sometimes unclear and provided at the wrong moment. Overall, patients' experiences of transitional care were positive when they were involved in the discharge process. Negative experiences occurred when their preferences for postdischarge communication were ignored. CONCLUSIONS: This study suggests that allied health professionals need to continuously collaborate and communicate with each other to provide patients and their families with the personalized support they need. To provide high-quality and person-centred care, it is essential to consider how, when, and what information to provide to patients and their families to allow them to contribute to their recovery actively. PATIENT OR PUBLIC CONTRIBUTION: The interview guide for this manuscript was developed with the assistance of patients, who reviewed it and provided us with feedback. Furthermore, patients provided us with their valuable lived experiences by participating in the interviews conducted for this study.

Inspiratory muscle training for mechanically ventilated patients in the intensive care unit: Obstacles and facilitators for implementation. A mixed method quality improvement study.

BACKGROUND: Mechanically ventilated patients are at risk of developing inspiratory muscle weakness (IMW), which is associated with failure to wean and poor outcomes. Inspiratory muscle training (IMT) is a recommended intervention during and after extubation but has not been widely adopted in Dutch intensive care units (ICUs). OBJECTIVES: The objective of this study was to explore the potential, barriers, and facilitators for implementing IMT as treatment modality for mechanically ventilated patients. METHODS: This mixed-method, proof-of-concept study was conducted in a large academic hospital in the Netherlands. An evidence-based protocol for assessing IMW and training was applied to patients ventilated for ≥24 h in the ICU during an 8-month period in 2021. Quantitative data on completed measurements and interventions during and after ICU-stay were collected retrospectively and were analysed descriptively. Qualitative data were collected through semistructured interviews with physiotherapists executing the new protocol. Interview data were transcribed and thematically analysed. FINDINGS: Of the 301 screened patients, 11.6% (n = 35) met the inclusion criteria. Measurements were possible in 94.3% of the participants, and IMW was found in 78.8% of the participants. Ninety-six percent started training in the ICU, and 88.5% continued training after transfer to the ward. Follow-up measurements were achieved in 73.1% of the patients with respiratory muscle weakness. Twelve therapists were interviewed, of whom 41.7% regularly worked in the ICU. When exploring reasons for protocol deviation, three themes emerged: "professional barriers", "external factors", and "patient barriers". CONCLUSIONS: Implementation of measurements of and interventions for IMW showed to be challenging in this single centre study. Clinicians' willingness to change their handling was related to beliefs regarding usefulness, effectiveness, and availability of time and material. We recommend that hospitals aiming to implement IMT during or after ventilator weaning consider these professional and organisational barriers for implementation of novel, evidence-based interventions into daily clinical practice.

Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: Results of an international Delphi study.

For older adults, acute hospitalization is a high-risk event with poor health outcomes, including functional decline. In absence of practical guidelines and high quality randomized controlled trials, this Delphi study was conducted. The aim of this study was to obtain consensus on an exercise intervention program, a core outcome set (COS) and handover information to prevent functional decline or restore physical function in acutely hospitalized older patients transitioning from hospital to home. An internal panel of experts in the field of exercise interventions for acutely hospitalized older adults were invited to join the study. In the Delphi study, relevant topics were recognized, statements were formulated and ranked on a 9-point Likert scale in two additional rounds. To reaching consensus, a score of 7-9 was classified as essential. Results were expressed as median and semi-interquartile range (SIQR), and consensus threshold was set at SIQR≤0.5. Fifteen international experts from eight countries participated in the panel. The response rate was 93%, 93% and 80% for the three rounds respectively. After three rounds, consensus was reached on 167 of the 185 (90.3%) statements, of which ninety-five (51.4%) were ranked as essential (median Likert-score ≥7.0, SIQR ≤0.5). This Delphi study provides starting points for developing an exercise intervention, a COS and handover information. The results of this Delphi study can assist physical therapists to provide a tailored exercise intervention for older patients with complex care needs after hospital discharge, to prevent functional decline and/or restore physical function.

Telerehabilitation Delivery in Canada and the Netherlands: Results of a Survey Study.

BACKGROUND: Following the onset of the COVID-19 pandemic, telerehabilitation (TR) has been expanding to address the challenges and risks of in-person delivery. It is likely that a level of TR delivery will continue after the pandemic because of its advantages, such as reducing geographical barriers to service. Many pandemic-related TR initiatives were put in place quickly. Therefore, we have little understanding of current TR delivery, barriers and facilitators, and how therapists anticipate integrating TR into current practice. Knowing this information will allow the incorporation of competencies specifically related to the use and provision of TR into professional profiles and entry-to-practice education, thereby promoting high-quality TR care. OBJECTIVE: This study aimed to obtain a descriptive overview of current TR practice among rehabilitation therapists in Canada and the Netherlands and identify perceived barriers to and facilitators of practice. METHODS: A web-based cross-sectional survey was conducted with occupational, physical, and respiratory therapists and dietitians in Canada (in French and English) and the Netherlands (in Dutch and English) between November 2021 and March 2022. Recruitment was conducted through advertisements on social media platforms and email invitations facilitated by regulatory and professional bodies. The survey included demographic and practice setting information; whether respondents delivered TR, and if so, components of delivery; confidence and satisfaction ratings with delivery; and barriers to and facilitators of use. TR satisfaction and uptake were measured using the Telehealth Usability Questionnaire and modified Technology Acceptance Model. Data were first summarized descriptively, and then, comparisons were conducted between professions. RESULTS: Overall, 723 survey responses were received, mostly from Canada (n=666, 92.1%) and occupational therapists (n=434, 60%). Only 28.1% (203/723) reported receiving specific training in TR, with 1.2% (9/723) indicating that it was part of their professional education. Approximately 19.5% (139/712) reported not using TR at all, whereas most participants (366/712, 51.4%) had been using this approach for 1 to 2 years. Services delivered were primarily teleconsultation and teletreatment with individuals. Respondents offering TR were moderately satisfied with their service delivery and found it to be effective; 90.1% (498/553) indicated that they were likely to continue offering TR after the pandemic. Technology access, confidence, and setup were rated the highest as facilitators, whereas technology issues and the clinical need for physical contact were the most common barriers. CONCLUSIONS: Professional practice and experience with TR were similar in both countries, suggesting the potential for common strategic approaches. The high prevalence of current practice and strong indicators of TR uptake suggest that therapists are likely to continue TR delivery after the pandemic; however, most therapists (461/712, 64.7%) felt ill prepared for practice, and the need to target TR competencies during professional and postprofessional education is critical. Future studies should explore best practice for preparatory and continuing education.

Feasibility of a home-based interdisciplinary rehabilitation program for patients with Post-Intensive Care Syndrome: the REACH study.

BACKGROUND: Survivors of critical illness experience long-term functional challenges, which are complex, heterogeneous, and multifactorial in nature. Although the importance of rehabilitation interventions after intensive care unit (ICU) discharge is universally recognized, evidence on feasibility and effectiveness of home-based rehabilitation programs is scarce and ambiguous. This study investigates the feasibility of an interdisciplinary rehabilitation program designed for patients with Post-Intensive Care Syndrome (PICS) who are discharged home. METHODS: A mixed method, non-randomized, prospective pilot feasibility study was performed with a 6-month follow-up, comparing the intervention (REACH) with usual care. REACH was provided by trained professionals and included a patient-centered, interdisciplinary approach starting directly after hospital discharge. Primary outcomes were patient safety, satisfaction, adherence, referral need and health care usage. Secondary outcomes, measured at 3 timepoints, were functional exercise capacity, self-perceived health status, health-related quality of life (HRQoL), return to work and psychotrauma. Risk of undernutrition was assessed at baseline. RESULTS: 43 patients with a median mechanical ventilation duration of 8 (IQR:10) days, were included in the study and 79.1% completed 6-month follow-up. 19 patients received the intervention, 23 received usual care. Groups were similar for gender distribution and ICU length of stay. No adverse events occurred. REACH participants showed higher satisfaction with treatment and reported more allied health professional visits, while the usual care group reported more visits to medical specialists. Qualitative analysis identified positive experiences among REACH-professionals related to providing state-of-the-art interventions and sharing knowledge and expertise within an interprofessional network. Similar recovery was seen between groups on all secondary outcomes, but neither group reached reference values for HRQoL at 6 months. Larger return to work rates were seen in the REACH group. Prevalence of undernutrition at hospital discharge was high in both groups (> 80%), warranting the need for careful tuning of physical therapy and nutritional interventions. CONCLUSIONS: This study shows that providing early, home-based rehabilitation interventions for patients with PICS-related symptoms is feasible and perceived positively by patients and professionals. When provided in an interdisciplinary collaborative network state of the art, person-centered interventions can be tailored to individual needs potentially increasing patient satisfaction, adherence, and efficacy. Registered in the Dutch Trial register: NL7792: https://www.trialregister.nl/trial/7792 , registered 7-06-2019.

Preparing undergraduate students for clinical work in a complex environment: evaluation of an e-learning module on physiotherapy in the intensive care unit.

BACKGROUND: Intensive Care Units (ICUs) are daunting environments for physiotherapy (PT) students performing clinical rotations. To prepare students for this environment, a newly developed, evidence-based e-learning module was designed and implemented in the undergraduate curriculum. The aim of this study was to investigate whether e-learning is a feasible method in preparing PT students for clinical work in complex ICU environments, as perceived by students and experts. METHODS: A mixed methods proof of concept study was undertaken. Participants were final-year students of an international curriculum, and experts from didactic and clinical fields. An e-learning module consisting of 7 separate chapters based on the latest scientific evidence and clinical expertise was developed, piloted and incorporated into the undergraduate curriculum as a compulsory course to be completed prior to clinical ICU rotations. Data were collected through 3 focus group meetings and 5 semi-structured interviews; these meetings and interviews were audio recorded, transcribed verbatim and analyzed. RESULTS: The study sample comprised of 14 students and 5 experts. Thematic analysis revealed three themes: expected competencies of PT students in ICU, feeling prepared for ICU clinical work and dealing with local variety. The e-learning module enabled students to anticipate clinical situations and PT tasks in the ICU. Higher level clinical reasoning skills, handling of lines and wires and dealing with out-of-textbook situations could not be achieved with the e-learning module alone. CONCLUSIONS: An e-learning module can sufficiently prepare PT students for their clinical tasks in the ICU, as long as it is integrated with, or closely connected to, the students' clinical placement.

Physiotherapy treatment approaches for survivors of critical illness: a proposal from a Delphi study.

Purpose: The aim of this study was to develop practical recommendations for physiotherapy for survivors of critical illness after hospital discharge. Methods: A modified Delphi consensus study was performed. A scoping literature review formed the basis for three Delphi rounds. The first round was used to gather input from the panel to finalize the survey for the next two rounds in which the panel was asked to rank each of the statements on an ordinal scale with the objective to reach consensus. Consensus was defined as a SIQR of ≤ 0.5. Ten Dutch panelists participated in this study: three primary care physiotherapists, four intensive care physiotherapists, one occupational therapist, one ICU-nurse and one former ICU-patient. All involved professionals have treated survivors of critical illness. Our study was performed in parallel with an international Delphi study with hospital-based health-care professionals and researchers. Results: After three Delphi rounds, consensus was reached on 95.5% of the statements. This resulted in practical recommendations for physiotherapy for critical illness survivors in the primary care setting. The panel agreed that the handover should include information on 14 items. Physiotherapy treatment goals should be directed toward improvement of aerobic capacity, physical functioning, activities in daily living, muscle strength, respiratory and pulmonary function, fatigue, pain, and health-related quality of life. Physiotherapy measurements and interventions to improve these outcomes are suggested. Conclusion: This study adds to the knowledge on post-ICU physiotherapy with practical recommendations supporting clinical decision-making in the treatment of survivors of critical illness after hospital discharge.

Survivors of Critical Illness and Their Relatives. A Qualitative Study on Hospital Discharge Experience.

Rationale: To target rehabilitation needs of survivors of critical illness and their relatives in a timely and adequate manner, a thorough needs assessment is recommended when hospital discharge planning is initiated. In light of existing evidence on physical and psychological consequences of critical illness for patients and family, it is currently unclear if current hospital discharge procedures suffice to meet the needs of this group.Objectives: To explore hospital discharge experience and to identify perceived barriers and enablers for a positive transition experience from hospital to home or rehabilitation facility as perceived by survivors of critical illness and their families.Methods: We performed a grounded theory study with semi-structured interviews among a group of survivors of critical illness and their relatives (n = 35) discharged from 16 hospitals across the Netherlands. Interviews were audio recorded and transcribed verbatim. Using constant comparative methods, initial and focused coding was applied to the data, which were further labeled into major categories and subcategories, ultimately leading to the identification of key concepts. Triangulation was applied through several reflexivity meetings at different stages of the study.Results: Twenty-two former intensive care unit patients and 13 relatives were interviewed. The mean age was 53 (standard deviation ± 11.2) and 60% were female. Median intensive care unit and hospital length of stay were 14 days (interquartile range, 9.75-24.5) and 35 days (interquartile range, 21.75-57.25), respectively. Thematic analyses led to identification of seven key concepts, representing barriers and enablers to a positive transition experience. "Existing in a fragmented reality," "being overlooked," and "feeling disqualified" were identified barriers and "feeling empowered," "encountering empathic and expert professionals," "managing recovery expectations," and "family engagement" were identified as enablers for a positive perceived transition experience.Conclusions: Findings of this study suggest that current hospital discharge practice for survivors of critical illness is driven by speed and efficiency, rather than by individual needs assessments, despite advocacies for patient- and family-centered care. Discharge strategies should be customized to facilitate adequate and comprehensive assessment of aftercare needs, conducted at the right time and within the right context, encouraging empowerment and a positive perceived transition from hospital to home.