Uptake and Scalability of a Peritoneal Dialysis Virtual Care Solution: Qualitative Study.

BACKGROUND: Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. OBJECTIVE: In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients' outcomes and experiences. METHODS: This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders-6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers-participated in this study. RESULTS: The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case. CONCLUSIONS: Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.

Improving safety and efficiency in care: multi-stakeholders' perceptions associated with a peritoneal dialysis virtual care solution.

BACKGROUND: Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home. METHODS: A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach. RESULTS: The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies. DISCUSSION: Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers. CONCLUSION: The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management.

Engaging Nurses in Optimizing Antimicrobial Use in ICUs: A Qualitative Study.

Antimicrobial stewardship programs (ASPs) have predominately involved infectious diseases physicians and pharmacists with little attention to the nurses. To achieve optimal success of ASPs, engagement of nurses to actively participate in initiatives, strategies, and solutions to combat antibiotic resistance across the health care spectrum is required. In this context, the experiences of local ASP teams engaging nurses in appropriate antimicrobial use were explored to inform future strategies to enhance their involvement in ASPs.

Using Local Data to Improve Care and Collaborative Practice: Insights From a Qualitative Study.

A qualitative study was undertaken to explore the experiences and perceptions of project leaders, clinicians, managers, and mentors associated with the implementation of a strategy aimed at enhancing clinicians' ability to use data to guide quality improvement projects. Our study findings elucidated the value and benefits including (1) using data to understand local context and move forward and (2) improving care and engaging in collaborative professional practice.

Adult Patient Perspectives on Care for Type 1 and Type 2 Diabetes Across the Institute of Medicine's 6 Domains of Quality.

OBJECTIVES: To gather patient perspectives on quality of care provided in diabetes clinics within the framework of the Institute of Medicine's 6 domains of quality. METHODS: A qualitative study including semi-structured interviews was conducted at 5 academic hospital sites. Transcripts were analyzed using a direct content approach for themes and subthemes with saturation of themes achieved. Purposive sampling was conducted at 5 diabetes clinics (n=47 interviews). RESULTS: The median age of participants was 50 years with a mean duration of diabetes of 14 years; 53% of participants were male, 57% had type 2 diabetes and 81% were using insulin. Patients ranked safety as the most important Institute of Medicine domain, followed by the domains effective, patient-centred, timely, equitable and efficient. Their expectations spanned the first 4 Institute of Medicine domains. They expressed a desire for a knowledgeable, caring, available and communicative team that assist with self-management and overall control of diabetes (effective, patient-centred and timely). They wanted to avoid diabetes complications, including hypoglycemia (safe and effective). They wanted to share in care planning and achieve personalized goals (patient-centred). Efficient and equitable care were not prioritized as highly, but many patients expressed concerns about the costs of medications and insulin supplies. CONCLUSION: Patients' views of high-quality diabetes care include all 6 domains of quality with a stronger emphasis on safe, effective and patient-centred care. Future evaluation of diabetes programs should incorporate a comprehensive and patient-informed approach to consideration of what constitutes high-quality care.

Collaborative Care Transitions Symposium: Insights from Participants.

BACKGROUND/PURPOSE: There are promising signs that interprofessional collaborative practice is associated with quality care transitions and improved access to patient-centred healthcare. A one-day symposium was held to increase awareness and capacity to deliver quality collaborative care transitions to interprofessional health disciplines and service users. METHOD: A mixed methods study was used that included a pre-post survey design and interviews to examine the impact of the symposium on knowledge, attitudes and practice change towards care transitions and collaborative practice with symposium participants. DISCUSSION: Our survey results revealed a statistically significant increase in only a few of the scores towards care transitions and collaborative practice among post-survey respondents. Three key themes emerged from the qualitative analysis, including: (1) engaging the patient at the heart of interprofessional collaboration and co-design of care transitions; (2) having time to reach out, share and learn from each other; and (3) reflecting, reinforcing and revising practice. CONCLUSION: Further efforts that engage inter-organizational learning by exchanging knowledge and evaluating these forums are warranted.

Exploring the utility and scalability of a telehomecare intervention for patients with chronic kidney disease undergoing peritoneal dialysis-a study protocol.

BACKGROUND: Chronic Kidney Disease (CKD) is a pressing global health concern that is placing increased strain on health care resources. CKD patients regularly receive peritoneal dialysis as a common CKD treatment. An emerging technological solution is telehomecare as way to support patients receiving PD in their homes. This study protocol outlines a mixed methods evaluation exploring a telehomecare developed to enhance CKD patients' outcomes and experiences. The study aims to assess the usability, acceptability and scalability of this virtual care application. METHODS: A realist evaluation using an embedded case study design will be used to understand the usability, acceptability and scalability of a telehomecare application for patients with CKD undergoing PD. The realist evaluation that is further described in this paper is part of a larger evaluation of the eQ Connect™ intervention that includes a randomized, parallel-arm control trial aimed at determining if utilizing eQ Connect improves selected clinical outcomes for PD patients (CONNECT Trial). DISCUSSION: Potential implications of this study include elucidating which components of the intervention are most effective and under what conditions with a focus on the contextual influences. Collectively, our multi-method design will yield knowledge around how best to implement, sustain and spread the telehomecare application that will be useful to guide the development, implementation and evaluation of future virtual care applications aimed at improving the quality of care outcomes and experiences of patients. TRIAL REGISTRATION: NCT02670512 . Registered: January 18, 2016.

Provider perspectives on treatment decision-making in nephrotic syndrome.

BACKGROUND: Managing patients with nephrotic syndrome (NS) remains difficult for the practicing nephrologist. This often young patient population is faced with a debilitating, relapsing and remitting disease with non-specific treatment options that are often poorly tolerated. Clinicians managing these complex patients must attempt to apply disease-specific evidence while considering the individual patient's clinical and personal situation. METHODS: We conducted qualitative interviews to ascertain the provider perspectives of NS, treatment options and factors that influence recommendations for disease management, and administered a survey to assess both facilitators and barriers to the implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. RESULTS: When making treatment recommendations, providers considered characteristics of various treatments such as efficacy, side effects and evaluation of risk versus benefit, taking into account how the specific treatment fit with the individual patient. Time constraints and the complexity of explaining the intricacies of NS were noted as significant barriers to care. Although the availability of guidelines was deemed a facilitator to care, the value of the KDIGO guidelines was limited by the perception of poor quality of evidence. CONCLUSIONS: The complexity of NS and the scarcity of robust evidence to support treatment recommendations are common challenges reported by nephrologists. Future development and use of shared learning platforms may support the integration of best available evidence, patient/family preferences and exchange of information at a pace that is unconstrained by the outpatient clinic schedule.

Learning to live with nephrotic syndrome: experiences of adult patients and parents of children with nephrotic syndrome.

Background: People living with nephrotic syndrome (NS) need to develop an in-depth understanding of their condition in order to participate in treatment decisions, develop self-management skills and integrate illness into daily life. However, the learning needs of adult patients and parents of children with NS are unknown. We therefore explored patient and parent perspectives on learning needs related to NS as part of a larger study to develop a shared learning tool for NS. Methods: Qualitative data were collected using semistructured focus groups and individual interviews with adult patients (n = 22) and parents of children with NS (n = 25). Results: The complexity of NS and its treatment made decision making challenging, as patients/parents often had to assimilate information about a condition that is poorly understood. Specific informational needs related to understanding the diagnosis and treatment approaches as well as learning to manage NS were identified. Difficulty in getting accurate information often made learning challenging. The importance of learning to monitor their condition, including understanding triggers that might precipitate a relapse, was highlighted, underscoring the need for individualized approaches to ensure unique learning needs are addressed. Conclusions: Our findings reveal some of the unique concerns of people with NS given its uncertain course and the limited information available specific to NS. These results suggest the need for shared communication between the patient/parents and providers to elicit the patient's/parents' understanding of NS and to support them in meeting their unique learning needs.

The Experience of Surrogate Decision Makers on Being Approached for Consent for Patient Participation in Research. A Multicenter Study.

RATIONALE: Recruitment in critical care research differs from other contexts in important ways: patients lack decision-making capacity, uncertainty exists regarding patient prognosis, and critical illnesses are often associated with appreciable morbidity and mortality. OBJECTIVES: We aimed to describe the experiences of surrogate decision makers (SDMs) in being approached for consent for critically ill patients to participate in research. METHODS: A multicenter, qualitative study involving semistructured interviews with 26 SDMs, who provided or declined surrogate consent for research participation, at 5 Canadian centers nested within a multicenter observational study of research recruitment practices. Transcripts were reviewed by three qualitative researchers, and data were analyzed using grounded theory and a narrative critical analysis. MEASUREMENTS AND MAIN RESULTS: SDMs were guided by an overarching desire for the patient to live. Surrogate research decision-making involved three sequential stages: (1) being approached; (2) reflecting on participation; and (3) making a decision. In stage 1, SDMs identified factors (their expectations, how they were approached, the attributes of the person approaching, and study risks and benefits) that characterized their consent encounter and affirmed a preference to be approached in person. If SDMs perceived the risk of participation to be too high or felt patients may not benefit from participation, they did not contemplate further. In stage 2, SDMs who knew the patient's wishes or had a deeper understanding of research prioritized the patient's wishes and the perceived benefits of participation. Without this information, SDMs prioritized obtaining more and better care for the patient, considered what was in their mutual best interests, and valued healthcare professional's knowledge. Trust in healthcare professionals was essential to proceeding further. In stage 3, SDMs considered six factors in rendering decisions. CONCLUSIONS: SDMs engaged in three sequential stages and considered six factors in making surrogate decisions for research participation. Surrogates' assessments of the risks and benefits of participation and their trust in healthcare professionals were critical factors in research decision-making. By conceptualizing surrogate decision-making for research in stages, future research can develop and test procedures to enhance the surrogate research decision-making process.

Contextualizing learning to improve care using collaborative communities of practices.

BACKGROUND: The use of interorganizational, collaborative approaches to build capacity in quality improvement (QI) in health care is showing promise as a useful model for scaling up and accelerating the implementation of interventions that bridge the "know-do" gap to improve clinical care and provider outcomes. Fundamental to a collaborative approach is interorganizational learning whereby organizations acquire, share, and combine knowledge with other organizations and have the opportunity to learn from their respective successes and challenges in improvement areas. This learning approach aims to create the conditions for collaborative, reflective, and innovative experiential systems that enable collective discussions regarding daily practice issues and finding solutions for improvement. METHODS: The concepts associated with interorganizational learning and deliberate learning activities within a collaborative 'Communities-of-practice'(CoP) approach formed the foundation of the of an interactive QI knowledge translation initiative entitled PERFORM KT. Nine teams participated including seven teams from two acute care hospitals, one from a long term care center, and one from a mental health sciences center. Six monthly CoP learning sessions were held and teams, with the support of an assigned mentor, implemented a QI project and monitored their results which were presented at an end of project symposium. 47 individuals participated in either a focus group or a personal interview. Interviews were transcribed and analyzed using an iterative content analysis. RESULTS: Four key themes emerged from the narrative dataset around experiences and perceptions associated with the PERFORM KT initiative: 1) being successful and taking it to other levels by being systematic, structured, and mentored; 2) taking it outside the comfort zone by being exposed to new concepts and learning together; 3) hearing feedback, exchanging stories, and getting new ideas; and 4) having a pragmatic and accommodating approach to apply new learnings in local contexts. CONCLUSIONS: Study findings offer insights into collaborative, inter-organizational CoP learning approaches to build QI capabilities amongst clinicians, staff, and managers. In particular, our study delineates the need to contextualize QI learning by using deliberate learning activities to balance systematic and structured approaches alongside pragmatic and accommodating approaches with expert mentors.

Engaging Patients to Meet Their Fundamental Needs: Key to Safe and Quality Care.

This paper highlights the relationship between the Fundamentals of Care Framework, patient safety and quality improvement by describing a more holistic view of patient engagement across the healthcare system. By creating reliable and resilient healthcare organizations that enhance nurses' capacity to engage in relational care and vigilance, healthcare agencies can effectively achieve safety and quality aims. Integral to this is the nurse-patient relationship, whereby nurses know patient preferences for care and recognize when patients are deteriorating to prevent harm within the context of care environments.

Enabling Role of Manager in Engaging Clinicians and Staff in Quality Improvement: Being Present and Flexible.

Managers are uniquely placed to facilitate quality improvement (QI), yet little empirical evidence exists about their influence in engaging clinicians in QI. To address this gap, a qualitative study was undertaken and revealed 2 themes: balancing being present with letting frontline staff lead their QI projects, and leveraging flexibility in scheduling with protected time. Efforts are needed to enable managers to engage clinicians and staff in local QI efforts.

A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success.

BACKGROUND: Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. "Antimicrobial stewardship" is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs. OBJECTIVE: To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians' attitudes toward and behaviours related to antimicrobial prescribing. METHODS: In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013. RESULTS: The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards' credibility and their ability to influence the uptake of effective antimicrobial use. CONCLUSIONS: Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.

CONTEXTE: L'utilisation inappropriée d'antimicrobiens est liée au développement et à la propagation de pathogènes résistants aux médicaments, en plus d'être associée à une augmentation de la morbidité, de la mortalité, de la durée du séjour à l'hôpital et des coûts des soins de santé. « Gérance des antimicrobiens ¼ est le terme générique désignant une stratégie d'application des connaissances fondée sur des données probantes qui comporte des activités exhaustives d'amélioration de la qualité pour : optimiser l'utilisation des antimicrobiens, améliorer les résultats thérapeutiques, freiner l'émergence de la résistance aux antimicrobiens, diminuer les infections nosocomiales (notamment par Clostridium difficile) et réduire les coûts des soins de santé. OBJECTIFS: Évaluer les perceptions et l'expérience des chefs des programmes de gérance des antimicrobiens par rapport à l'attitude et aux habitudes des cliniciens quant à la prescription d'antimicrobiens. MÉTHODES: Dans la présente étude qualitative, des entrevues semi-structurées ont été réalisées auprès de 6 responsables de la gérance des antimicrobiens (2 médecins et 4 pharmaciens) dans 3 centres hospitaliers universitaires entre juin et août 2013. RÉSULTATS: Les entrevues ont permis de dégager trois thèmes clés : obtenir le concours des bonnes personnes, établir des relations collégiales et démontrer un bilan convaincant le plus rapidement possible. Les résultats de l'étude ont permis d'expliquer le rôle joué par les chefs de programme et autres responsables de la gérance des antimicrobiens ainsi que les mécanismes qu'ils ont utilisés pour influencer les autres cliniciens à entreprendre une utilisation réellement efficace des antimicrobiens. Les résultats ont aussi mis en évidence les méthodes employées par des membres de l'équipe de gérance des antimicrobiens pour adapter leurs stratégies en fonction du contexte local et des parties prenantes des services participants; pour obtenir davantage de crédibilité en démontrant les effets du programme sur les résultats cliniques et les coûts; et pour amener les hauts dirigeants à soutenir le programme et à y investir, ce qui augmente la crédibilité des responsables de la gérance des antimicrobiens et accroît leur capacité à influencer l'adoption d'une utilisation réellement efficace des antimicrobiens. CONCLUSIONS: Ensemble, ces résultats aident à mieux comprendre les méthodes et mécanismes d'influence employés par les responsables de la gérance des antimicrobiens pour faire en sorte que les cliniciens fassent un meilleur usage des antimicrobiens, ce qui permettra ensuite de guider la mise en œuvre d'une future gérance des antimicrobiens et de stratégies relatives au changement organisationnel dans les hôpitaux.

Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus.

BACKGROUND: The primary objective of this mechanistic open-label, stratified clinical trial was to determine the effect of 8 weeks' sodium glucose cotransporter 2 inhibition with empagliflozin 25 mg QD on renal hyperfiltration in subjects with type 1 diabetes mellitus (T1D). METHODS AND RESULTS: Inulin (glomerular filtration rate; GFR) and paraaminohippurate (effective renal plasma flow) clearances were measured in individuals stratified based on having hyperfiltration (T1D-H, GFR ≥ 135 mL/min/1.73m(2), n=27) or normal GFR (T1D-N, GFR 90-134 mL/min/1.73m(2), n=13) at baseline. Renal function and circulating levels of renin-angiotensin-aldosterone system mediators and NO were measured under clamped euglycemic (4-6 mmol/L) and hyperglycemic (9-11 mmol/L) conditions at baseline and end of treatment. During clamped euglycemia, hyperfiltration was attenuated by -33 mL/min/1.73m(2) with empagliflozin in T1D-H, (GFR 172±23-139±25 mL/min/1.73 m(2), P<0.01). This effect was accompanied by declines in plasma NO and effective renal plasma flow and an increase in renal vascular resistance (all P<0.01). Similar significant effects on GFR and renal function parameters were observed during clamped hyperglycemia. In T1D-N, GFR, other renal function parameters, and plasma NO were not altered by empagliflozin. Empagliflozin reduced hemoglobin A1c significantly in both groups, despite lower insulin doses in each group (P≤0.04). CONCLUSIONS: In conclusion, short-term treatment with the sodium glucose cotransporter 2 inhibitor empagliflozin attenuated renal hyperfiltration in subjects with T1D, likely by affecting tubular-glomerular feedback mechanisms. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01392560.

Building knowledge for safer care: nursing research advancing practice.

Organizational and professional efforts to support nurses engaging in research projects that advance patient safety practices are needed. In this context, the purpose of this article is to provide a description of the design, implementation, and evaluation of a research capacity strategy designed for clinical nurses and the lessons learned. Participating nurses evolved from research novices to key champions in advancing nursing practice, patient safety, and quality improvement.

Leveraging safer nursing care by conceptualizing near misses as recovery processes.

The purpose of this study was to elicit perceptions and experiences of nurses associated with a recovery process (near miss) intervention (wound care management). From the content analysis of interview data involving 12 registered nurses, 2 key themes emerged. Both themes illuminated the links among pattern recognition, alignment of care processes and practice guidelines, and nurses' accountability for safe pressure ulcer care.