An innovative approach for coordinating multiple sedated procedures in medically complex pediatric patients.

Children and youth with special health care needs often undergo a higher frequency of sedated procedures, increasing their risk for complications, prolonged hospitalizations, as well as increased time and cost burdens. By consolidating multiple procedures requiring anesthetic sedation, the risk and cost can be reduced for both families and health care systems. In this paper, we discuss an innovative model to coordinate procedures across internal and external providers to improve quality of care for this vulnerable patient population. Although preliminary, our findings suggest this approach may be beneficial to both the patient, family, and health system.

Implementing a social work care coordination model for children and youth with special health care needs in a rural-urban health system.

This retrospective chart review examined care coordination among pediatric patients with varying levels of medical complexity who received care in a rural-urban health system. Care coordination utilization across patient acuity levels was examined for meaningful differences in frequency and duration of care coordination services. Results indicated that patients with more severe medical complexity had increased frequency and duration of care coordination services, as well as different patterns of care coordination activity utilization. This model of pediatric outpatient care coordination provides a flexible and highly targeted approach for stratification of care and services based on the needs of the individual patient.

Masked pregnancy-associated hypertension as a predictor of adverse outcomes.

BACKGROUND: Masked hypertension has been described in nonpregnant populations as elevated blood pressure in the home setting that is not reproduced on clinical assessment. Patients with masked hypertension have a greater risk of cardiovascular morbidity than patients who have blood pressures within normal range or those with white coat hypertension. OBJECTIVE: This study aimed to determine whether masked pregnancy-associated hypertension detected on Connected Maternity Online Monitoring, a remote home blood pressure monitoring system, is associated with higher rates of hypertensive disorders of pregnancy during delivery admission and maternal and neonatal morbidities. STUDY DESIGN: This was a retrospective cohort study of all patients on Connected Maternity Online Monitoring who delivered at 6 hospitals in a single healthcare system between October 2016 and December 2020. Patients were classified as having either normal blood pressure or masked pregnancy-associated hypertension. Masked pregnancy-associated hypertension was defined as remotely detected systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg after 20 weeks of gestation on 2 occasions before diagnosis in a clinical setting. The chi-square test and Student t test were used for demographic and outcomes comparisons. Logistic regression was used to adjust outcomes by race, insurance, and body mass index. RESULTS: A total of 2430 deliveries were included in our analysis, including 165 deliveries that met the criteria for masked pregnancy-associated hypertension. Clinically established pregnancy-associated hypertension, defined at the time of delivery, was more common in the masked pregnancy-associated hypertension group than in the normotensive group (66% vs 10%; adjusted odds ratio, 17.2; 95% confidence interval, 11.91-24.81). Patients with masked pregnancy-associated hypertension had higher rates of preeclampsia with severe features on delivery admission than normotensive patients (28% vs 2%; adjusted odds ratio, 23.35; 95% confidence interval, 14.25-38.26). Preterm delivery (16% vs 7%; adjusted odds ratio, 2.47; 95% confidence interval, 1.55-3.94), cesarean delivery(38% vs 26%; adjusted odds ratio, 1.58; 95% confidence interval, 1.13-2.23), small for gestational age (11% vs 5%; adjusted odds ratio, 2.27; 95% confidence interval, 1.31-3.94), and neonatal intensive care unit admission (8% vs 4%; adjusted odds ratio, 2.20; 95% confidence interval, 1.18-4.09) were more common among patients with masked pregnancy-associated hypertension than among normotensive patients. CONCLUSION: With more outcomes research, remote blood pressure monitoring may prove to be an important tool in identifying pregnancies at risk of complications related to masked hypertension.

Health-care utilization for sinusitis after pneumococcal vaccination in patients with low antibody titers.

BACKGROUND: Pneumococcal antibody deficiency has been the subject of limited study in chronic rhinosinusitis (CRS) and has not been studied in recurrent acute rhinosinusitis (RARS). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is considered for patients with nonprotective Streptococcus pneumoniae titers. We hypothesized that both RARS and CRS patients with deficient S pneumoniae titers and subsequent PPSV23 vaccination would have reduced health-care encounters for sinusitis and fewer prescriptions for antibiotics or steroids. METHODS: A retrospective cohort study was performed of patient encounters between January 2011 and December 2019. All patients included were ≥18 and ≤65 years old with a diagnosis of CRS or RARS and pneumococcal titer data. Patients with immunodeficiency and comorbid conditions requiring PPSV23 vaccination before 65 years of age were excluded. RESULTS: A total of 938 patients were included in the study. Nonprotective antibody titers were present in 75.8% of CRS and 74.8% of RARS patients. A total of 306 patients with deficient antibody titers received the PPSV23 vaccine. Eighty-nine percent of CRS and 90.1% of RARS patients had protective responses. Among the 217 patients with continuous data from 2 years before through 2 years after PPSV23 vaccination, a decrease in the number of encounter diagnoses of CRS (p < 0.0001) and RARS (p = 0.0006) was observed. Decreases in the frequency of antibiotic (p = 0.002) and corticosteroid (p = 0.04) prescriptions were also appreciated. CONCLUSION: Most patients with CRS and RARS have nonprotective antibody titers. PPSV23 administration significantly decreases health-care utilization.

Pediatric care coordination and risk tiering: Moving beyond claims data.

PURPOSE: The goal of this study was to evaluate the performance of a pediatric stratification tool that incorporates health and non-medical determinants to identify children and youth with special health care needs (CYSHCN) patients according to increasing levels of complexity and compare this method to existing tools for pediatric populations. METHODS: This retrospective cohort study examined pediatric patients aged 0 to 21 years who received care at our institution between 2012 and 2015. We used the St. Luke's Children's Acuity Tool (SLCAT) to evaluate mean differences in dollars billed, number of encounters, and number of problems on the problem list and compared the SLCAT to the Pediatric Chronic Conditions Classification System version2 (CCCv2). RESULTS: Results indicate that the SLCAT assigned pediatric patients into levels reflective of resource utilization and found that children with highly complex chronic conditions had significantly higher utilization than those with mild and/or moderate complex conditions. The SLCAT found 515 patients not identified by the CCCv2. Nearly half of those patients had a mental/behavioral health diagnosis. CONCLUSIONS: The findings of this study provide evidence that a tiered classification model that incorporates all aspects of a child's care may result in more accurate identification of CYSHCN. This would allow for primary care provider and care coordination teams to match patients and families with the appropriate amount and type of care coordination services.

The Lunch Conference Diet: Fostering Resident Engagement in Culinary Medicine Through a Curriculum Centered on Changes to Provided Conference Food.

BACKGROUND: Despite the burden of chronic disease attributable to lifestyle, most internal medicine residents do not receive adequate training in nutrition and nutrition counseling. METHODS: We held a culinary medicine workshop in September 2018, followed by didactic sessions throughout the academic year. Changes were made to lunch conference food to more closely follow the Mediterranean diet and to encourage healthy eating. With a modified NUTCOMP (Nutrition Competence Questionnaire) instrument, we assesses residents' perceived competence with nutrition counseling before and after the curriculum. RESULTS: Twenty-six of 30 residents completed the pre-curriculum and post-curriculum surveys (not the same 26). The mean NUTCOMP score increased from 3.5 to 4.0 (P < .0001), indicating an increased perceived competence with nutritional counseling. Residents felt that nutritional counseling was important before and after the curriculum (4.2 to 4.3, P = .48). Conference food was more nutritious at the end of the intervention (Mediterranean diet score range 1-4 to 4-7) and residents enjoyed the food more. CONCLUSIONS: An innovative, multimodal nutrition curriculum centered on changes to catered lunch conference food improved resident's confidence with nutritional counseling. This could feasibly be integrated into other residency programs with supportive leadership and adequate training.

Interprofessional grant writing seminar for early career faculty in a small, isolated teaching center.

Small, isolated teaching centers have difficulty mentoring interprofessional junior faculty in research methods and grant writing. Peer mentoring programs for grant writing at larger institutions have been successful. In this short report, we describe our program that leveraged mentor experience using four framing seminars followed by project refinement in three-person peer groups and monthly mentored works in progress meetings. In its first year, ten faculty from medicine, psychology, and pharmacy completed the program and successfully obtained six funded grants. Five of the projects transitioned from single profession applications to interprofessional applications as participants connected and profession-specific expertise was identified. Refinements for future cohorts are discussed.

Development and Psychometric Testing of the Nurses' Confidence Scale: Unique Families.

OBJECTIVE: To develop and evaluate an instrument designed to measure the confidence of nurses in their ability to provide neutral, compassionate care to unique families in perinatal settings: the Nurses' Confidence Scale: Unique Families. DESIGN: Prospective instrument development and psychometric study. SETTING: Health system in the U.S. Mountain West region. PARTICIPANTS: Convenience sample of 62 perinatal/neonatal nurses. METHODS: We developed a two-part scale to measure the confidence of nurses in their ability to care for complex/nontraditional families, termed unique families. Part A was focused on nursing care behaviors for any unique family; Part B was focused on providing care to seven specific unique family populations. Five experts in perinatal nursing or adoption evaluated the scale's content validity. To test the psychometric properties of the scale, we used item analysis, reliability analysis, and exploratory factor analysis. RESULTS: The content validity index was 0.82. The Cronbach's alpha coefficient estimate of internal consistency for Part A was .92. Principal component analysis resulted in two factors that explained 64% of the total variance: skills and resources (Cronbach's alpha coefficient = .89) and awareness and sensitivity (Cronbach's alpha coefficient = .87). Part B had a Cronbach's alpha coefficient of .90. Parts A and B showed a strong positive relationship with one another (r = .77). The general self-efficacy measure was strongly and positively correlated with Part A (r = .81) and moderately and positively correlated with Part B (r = .48). CONCLUSION: The Nurses' Confidence Scale: Unique Families is a new tool with which to measure the confidence of perinatal/neonatal nurses in providing sensitive, specific care to complex/nontraditional families. Results of our psychometric evaluation supported initial acceptable reliability and validity of the scale.

Clinical Care Coordination in Medically Complex Pediatric Cases: Results From the National Survey of Children With Special Health Care Needs.

This study uses a secondary analysis of the 2009-2010 National Survey of Children with Special Health Care Needs (NS-CSHCN) to describe care coordination (CC) for children with medical complexity (CMC). Chi-square test, t test, and multivariate logistic regression statistical tests are used to determine the relationships and differences between sources of CC and factors associated with receiving clinic-based CC for CMC and their family. Among CMC, 66.47% received no CC support and 25.73% received clinic-based CC. In multivariate models, families reporting dissatisfaction with communication between health care providers or reporting family-centered care were less likely to receive clinic-based CC. Families were more likely to receive clinic-based CC if they had younger children, lower household income, and greater school absenteeism. Clinic-based CC is associated with improved communication between health providers but must become more family-centered and minimize student absenteeism for the CMC population.

Evaluation of Food Insecurity in Adults and Children With Cystic Fibrosis: Community Case Study.

Advances in the care and treatment of cystic fibrosis (CF) have led to improved mortality rates; therefore, considerably more individuals with CF are living into adulthood. With an increased number of CF patients advancing into adulthood, there is the need for more research that surrounds the aging adult CF patient. It is important to conduct research and collect results on the aging CF population to help better prepare the CF patient, who is dealing with the heavy treatment and financial burden of their disease, build autonomy and increase their quality of life. Of note, research has found that social, behavioral, and physical factors influence the ability of those with CF to follow dietary recommendations. A primary treatment goal in CF is a high calorie, high protein, and high fat diet. A socio-economic factor that has not been adequately investigated with regards to dietary compliance of individuals with CF is food insecurity. The aim of this community case study was to document the experiences and estimate the prevalence of food insecurity among CF patients residing in Idaho. The correlation between food insecurity and health outcomes (lung function and body mass index) was also examined. Participants included adult patients and parents of pediatric patients with CF. Food insecurity rates among CF patients of all ages were found to be significantly higher than that seen in the overall community; however, no specific correlation between food insecurity and body mass index (BMI) or lung function emerged. This case study highlights the need for continued research around food access issues in this patient population. The data resulting from this study shows the value of CF advocacy organizations promoting efforts to build resources and provide education around food insecurity issues.

NO SToPS: Assessment of a Supportive Care Program to Reduce Treatment Breaks in Patients With Head and Neck Cancer.

NO SToPS is an interprofessional supportive care program implemented in 2008 for patients with head and neck cancer undergoing chemoradiation. The goals of the program are to reduce radiation treatment breaks and hospitalizations related to toxicity from this difficult treatment. Breaks lead to lower locoregional control and survival rates in this population. This article describes the effect of the NO SToPS program.

Successful adherence and retention to daily monitoring of physical activity: Lessons learned.

Research utilizing repeated-measures such as daily assessments with self-report and/or objective measures [e.g., physical activity (PA) monitors] are important in understanding health behaviors and informing practice and policy. However, studies that utilize daily assessment often encounter issues with attrition and non-compliance. The current research yielded high levels of retention and adherence with both self-report and objective daily measures. The purpose of this paper is to highlight and discuss strategies utilized in maximizing retention, minimizing missing data, and some lessons learned from the research experience. Fifty community participants took part in a 4-week study utilizing both daily self-report questionnaires and daily use of PA monitors (Fitbit One™). This study focused on typical daily PA and was not an intervention study (e.g., participants were not randomized nor asked to change their PA behavior). Participants completed the study in two waves (wave 1 n = 10, wave 2 n = 40). The research team utilized several retention strategies including automating the data collection process, a prorated incentive structure, having a dedicated and responsive study staff, and utilizing the 2-wave process to optimize data collection during the 2nd wave. The study had 100% retention and generally positive anonymous feedback post-study. Overall, participants completed the vast majority of daily surveys (97%) and wore their Fitbits (for at least part of the day) on almost all days (99.57%) of the study, although there were individual differences. The strategies discussed and lessons learned may be useful to other researchers using daily measurements for whom adherence and retention are important issues. Future research employing these strategies in different populations, with different measurements, and for longer durations is warranted to determine generalizability.

Evaluation of a Designated Family Bonding Time to Decrease Interruptions and Increase Exclusive Breastfeeding.

OBJECTIVE: The purpose of this quality improvement project was to plan and implement a daily family bonding time on our mother/baby care unit and evaluate its effect on interruptions, mothers' perceptions of interruptions, and exclusive breastfeeding rates. DESIGN: A separate sample pre-/postintervention design conducted in three phases. SETTING/LOCAL PROBLEM: Healthy breastfeeding newborns had double the odds of receiving supplementation before discharge if they stayed more than 1 night or were born at night. Night nurses suggested implementing a daily quiet time as a strategy for limiting interruptions. PARTICIPANTS: A convenience sample of 60 postpartum women. INTERVENTION/MEASURES: During Phases 1 and 3, data were collected on interruptions (number, duration, and by whom), women's perceptions of interruptions, and exclusive breastfeeding rates. Family bonding time was launched in Phase 2 during the hours of 2 p.m. to 4 p.m. Women were encouraged to rest with their newborns in their rooms; interruptions were limited to those that were urgent, medically necessary, or requested by the women. RESULTS: Outcome data were analyzed using descriptive statistics, a repeated-measures analysis of variance, t test, and chi-square test. Analysis of interruptions by the unit nursing staff indicated a decrease in interruptions between 2 p.m. and 4 p.m. that could be attributed to family bonding time (F(1, 58) = 7.50, p = .008). Analysis of interruptions by other hospital staff and visitors indicated a significant interaction of time with interruptions; interruptions decreased in both phases between 2 p.m. and 4 p.m. (F(3, 174) = 4.83, p = .0029; F(3, 174) = 2.95, p = .034). Exclusive breastfeeding rates increased significantly (χ2(4) = 21.27, p = .0003); there were no significant differences in women's perceptions of interruptions. CONCLUSION: New mothers experience many interruptions during their hospital stays, particularly when visitors arrive in large groups and stay more than 60 minutes. Documenting sources of interruptions before launching family bonding time helps identify hospital staff who need to be informed. Addressing their concerns before implementation can facilitate project sustainability.

Impact of a complex chronic care patient case conference on quality and utilization.

There is need for effective venues to allow teams to coordinate care for high-risk or high-need patients. In addition, health systems need to assess the impact of such approaches on outcomes related to chronic health conditions and patient utilization. We evaluate the clinical impact of a novel case conference involving colocated trainees and supervisors in an interprofessional academic primary care clinic. The study utilized a prospective cohort with control group. Intervention patients (N = 104) were matched with controls (N = 104) from the same provider's panel using propensity scores based on age, gender, risk predictors, and prior utilization patterns. Clinical outcomes and subsequent utilization patterns were compared prior to and up to 6 months following the conference. In terms of utilization, intervention patients demonstrated increased visits with primary care team members (p = .0002) compared with controls, without a corresponding increase in the number of primary care providers' visits. There was a trend towards decreased urgent care and emergency visits (p = .07) and a significant decrease in the rate of hospitalizations (p = .04). Patients with poorly-controlled hypertension saw significant decreases in mean systolic blood pressure from 167 to 146 mm Hg. However, there were no differences between the intervention and control groups. Intervention patients with diabetes demonstrated a nonsignificant trend towards decreased hemoglobin A1c from 9.8 to 9.4, when compared with controls. Interprofessional case conferences have potential to improve care coordination and may be associated with improved disease management, decreased unplanned care, and overall reduced hospitalizations.

Interprofessional case conference: impact on learner outcomes.

Transition to interprofessional team-based care is a quickly progressing healthcare model and requires changes in medical training approaches. The Department of Veteran Affairs (VA) has taken a lead role in creating such training experiences, one of which is the establishment of multiple Centers of Excellence in Primary Care Education (CoEPCE). These sites are tasked with developing teaching innovations to better facilitate interprofessional team-based care. The patient-aligned care team interprofessional care update (PACT-ICU) is an interprofessional workplace learning activity with the goals of simultaneously addressing educational and patient care needs. Participants of the PACT-ICU included trainees and faculty of a variety of medical disciplines (e.g., internal medicine, psychology, and pharmacy) involved in a training primary care clinic. Two medically complex patients were presented at each PACT-ICU conference with the purpose of creating a plan of care that maintained an interprofessional team-based approach. Following implementation of the PACT-ICU conference intervention, two primary outcomes were assessed. First, self-assessment of PACT-ICU attendee learner outcomes was measured using a brief questionnaire surveying knowledge gain as it related to increase in knowledge of other professions' capabilities, roles, and responsibilities. Secondly, trainee provider behavior change was evaluated by measuring number of "within PACT" consults before and after participating in PACT-ICU. There was a significant positive change in self-assessed knowledge along with an indication of trainee behavioral change, as measured by electronic medical record consult patterns. This study demonstrates that interprofessional case conferences involving trainees and staff from multiple professions can increase awareness of other professions roles in patient care as well as facilitate interprofessional collaboration.

Interprofessional Care Conferences for High-Risk Primary Care Patients.

PROBLEM: As health care systems convert to team-based care, the need to improve interprofessional education is tremendous. In addition to formal instruction, trainees need authentic team-based workplace learning experiences. APPROACH: The authors designed the PACT-ICU (Patient-Aligned Care Team Interprofessional Care Update) conference to provide team-based care to high-risk patients while teaching trainees principles of interprofessionalism and modeling relevant behaviors. Trainees, supervisors, and affiliated support staff from the fields of internal medicine, nurse practitioner, pharmacy, psychology, and nursing all participate in this conference. During the conference, each participant focuses on the narrative of the patient's illness from his/her own professional perspective. A multifaceted care plan with specific action items is the product of the conference. To evaluate this workplace learning opportunity, the authors recorded patient characteristics, plus trainees' participation and satisfaction. OUTCOMES: Over the first 16 months (2013-2014) of the PACT-ICU, 33 trainees presented 79 patients. Each trainee presented two or three times each academic year. Patients were 90% male; their mean age was 64.5 years (SD 9.3, range 28-92), and their mean calculated 90-day risk of death or hospitalization was 22% (SD 14%, range 1%-45%).Overall, all surveyed trainees (n = 32; 97% response rate) expressed satisfaction, reporting that the conference was "helpful" or "very helpful" in developing treatment plans. NEXT STEPS: Further assessment of change in trainee behavior related to interprofessional team care, patient-level outcomes (e.g., quality of care and utilization), and factors facilitating dissemination of the model to other academic clinic settings is necessary.

The value of a genetic counselor: improving identification of cancer genetic counseling patients with chart review.

Advances in genetics are changing cancer care and requiring institutions to maximize the unique skills of genetics professionals. The identification of genetic syndromes is vital for prevention and management of families with high cancer risks. Despite this, high risk individuals who qualify are often not referred. Genetic counselors could review oncology charts to improve identification. A genetics assessment tool developed by NCI Community Cancer Centers Program was used to perform self-assessment of the genetics program. A weekly report of all new oncology patients was provided to a genetic counselor for chart review. In 2010, 58 % of all eligible patients (n = 152) were offered a genetics evaluation. In 2011 this improved to 70 % (n = 167), which was a statistically significant difference, X (2)(1) = 5.13, p = 0.02. By cancer site, ovarian cancer referrals also showed statistically significant improvement, X (2)(1) = 6.36, p = 0.01. Breast and colon referrals were improved but not significant. Over 10 months, 129 patients were identified through the chart review program. Three were confirmed to have a genetic mutation for a hereditary cancer syndrome. An average week included review of 73 charts for 10 medical oncologists, 4 radiation oncologists, and 4 pediatric oncologists which generated 60-80 min of work for the genetic counselor. This program improved patient identification and quality, and allowed physicians to become more aware of opportunities for genetic counseling and more patients to receive genetic counseling and testing.

A multisite, multistakeholder validation of the Accreditation Council for Graduate Medical Education competencies.

PURPOSE: The Accreditation Council for Graduate Medical Education's (ACGME's) six-competency framework has not been validated across multiple stakeholders and sites. The objective of this study was to perform a multisite validation with five stakeholder groups. METHOD: This was a cross-sectional, observational study carried out from October to December, 2011, in the internal medicine residency continuity clinics of eight internal medicine residency programs in the Pacific Northwest, including a VA, two academic medical centers, a military medical center, and four private hospitals. The authors performed a cultural consensus analysis (CCA) and a convergent-discriminant analysis using previously developed statements based on internal medicine milestones related to the six competencies. Ten participants were included from each of five stakeholder groups: patients, nurses, residents, faculty members, and administrators from each training site (total: 400 participants). RESULTS: Moderate to high agreement and coherence for all groups were observed (CCA eigenvalue ratios ranging from 2.16 to 3.20); however, high differences in ranking order were seen between groups in four of the CCA statements, which may suggest between-group tension in these areas. Analyses revealed excellent construct validity (Zcontrast score of 5.323, P < .0001) for the six-competency framework. Average Spearman correlation between same-node statements was 0.012, and between different-node statements it was -0.096. CONCLUSIONS: The ACGME's six-competency framework has reasonable face and construct validity across multiple stakeholders and sites. Stakeholders appear to share a single mental model of competence in this learning environment. Data patterns suggest possible improvements to the competency-milestone framework.

Cancer deaths and occupational exposure in a group of plutonium workers.

An exploratory epidemiological study was conducted for 319 deceased nuclear workers who had intakes of transuranic radionuclides and histories of employment during the time period from 1943 to 1995. The workers were employed at various facilities throughout the United States, including the Department of Energy defense facilities and uranium mining and milling sites. The majority of individuals were involved in documented radiological incidents during their careers. All had voluntarily agreed to donate their organs or whole body to the United States Transuranium and Uranium Registries. External and internal dose assessments were performed using occupational exposure histories and postmortem concentrations of transuranic radionuclides in critical organs. Statistical data analyses were performed to investigate the potential relationship between radiation exposure and causes of death within this population due to cancers of the lungs, liver, and all sites combined while controlling for the effects of other confounders. No association was found between radiation exposure and death due to cancer (α = 0.05). However, statistically significant associations were found between death due to any type of cancer and smoking (yes or no) (odds ratio = 5.41; 95% CI: 1.42 to 20.67) and rate of cigarette smoking (packs per day) (odds ratio = 2.70; 95% CI: 1.37 to 5.30).