Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study.

Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework-what matters, medications, mentation, mobility-has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients' goals of care and 2) use of the worksheet was feasible in the ED. Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January-June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients' underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

Using a human-factors engineering approach to evaluate environmental cleaning in Veterans' Affairs acute and long-term care facilities: A qualitative analysis.

BACKGROUND: Environmental cleaning is important in the interruption of pathogen transmission. Although prevention initiatives have targeted environmental cleaning, practice variations exist and compliance is low. Evaluation of human factors influencing variations in cleaning practices can be valuable in developing interventions to standardized practices. We conducted a work-system analysis using a human-factors engineering (HFE) framework to identify barriers and facilitators to environmental cleaning practices in acute and long-term care settings within the Veterans' Affairs health system. METHODS: We conducted a qualitative study with key stakeholders at 3 VA facilities. We analyzed transcripts for thematic content and mapped themes to the HFE framework. RESULTS: Staffing consistency was felt to improve cleaning practices and teamwork. We found that many environmental management service (EMS) staff were veterans who were motivated to serve fellow veterans, especially to prevent infections. However, hiring veterans comes with regulatory hurdles that affect staffing. Sites reported some form of monitoring their cleaning process, but there was variation in method and frequency. The EMS workload was affected by whether rooms were occupied by patients or were semiprivate rooms; both were reportedly more difficult to clean. Room design and surface finishes were identified as important to cleaning efficiency. CONCLUSION: HFE work analysis identified barriers and facilitators to environmental cleaning. These findings highlight intervention entry points that may facilitate standardized work practices. There is a need to develop task-specific procedures such as cleaning occupied beds and semiprivate rooms. Future research should evaluate interventions that address these determinants of environmental cleaning.

Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework.

Background: We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting. Methods: A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework. Results: A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry. Conclusions: Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.

A mixed-methods evaluation of why an implementation trial failed to engage veterans with posttraumatic stress disorder in trauma-focused psychotherapy.

An effectiveness trial found that telemedicine collaborative care for posttraumatic stress disorder (PTSD) significantly increased engagement in trauma-focused psychotherapy (TFP) and improved PTSD symptoms. However, in a subsequent implementation trial, very few veterans enrolled in collaborative care initiated TFP. We conducted a mixed-methods evaluation to determine why veterans did not initiate TFP in the implementation trial. After conducting chart reviews of 1,071 veterans with PTSD enrolled in collaborative care, patients were categorized into four mutually exclusive TFP groups: TFP not discussed; TFP discussed, declined; TFP discussed, did not decline; and TFP initiated. We conducted semistructured interviews with 43 unique patients and 58 unique providers (i.e., care managers and mental health specialists). Almost half (48.6%) of the veterans had no documentation of discussing TFP with their care manager; another 28.9% discussed it but declined. Most veterans (77.1%) had an encounter with a mental health specialist, 36.8% of whom never discussed TFP, and 35.7% of whom discussed it but declined. Providers reported that many veterans were not able, willing, or ready to engage in TFP and that non-trauma-focused therapies were better aligned with their treatment goals. Veterans gave numerous reasons for not initiating TFP, including having bad prior experiences with TFP and wanting to avoid thinking about past traumatic experiences. Commonly cited reasons for noninitiation were providers never discussing TFP with veterans and veterans declining TFP after discussing it with their provider. Interventions, such as shared decision-making tools, may be needed to engage providers and patients in informed discussions about TFP.

Nephrotoxin Exposure and Acute Kidney Injury in Adults.

BACKGROUND: Rates of nephrotoxic AKI are not well described in adults due to lack of a clear definition, debate over which drugs should be considered nephrotoxins, and illness-related confounding. Nephrotoxic Injury Negated by Just-in Time Action (NINJA), a program that reduces rates of nephrotoxic AKI in pediatric populations, may be able to address these concerns, but whether NINJA can be effectively applied to adults remains unclear. METHODS: In this retrospective cohort study conducted at the University of Iowa Hospital, we included adult patients admitted to a general hospital floor for ≥48 hours during 2019. The NINJA algorithm screened charts for high nephrotoxin exposure and AKI. After propensity score matching, Cox proportional hazard modeling was used to evaluate the relationship between nephrotoxic exposure and all-stage AKI, stage 2-3 AKI, or death. Additional analyses evaluated the most frequent nephrotoxins used in this population. RESULTS: Of 11,311 patients, 1527 (16%) had ≥1 day of high nephrotoxin exposure. Patients with nephrotoxic exposures subsequently developed AKI in 29% of cases, and 22% of all inpatient AKI events met nephrotoxic AKI criteria. Common nephrotoxins were vancomycin, iodinated contrast dye, piperacillin-tazobactam, acyclovir, and lisinopril. After propensity score matching, Cox proportional hazard models for high nephrotoxin exposure were significantly associated with all AKI (hazard ratio [HR] 1.43, 1.19-1.72, P<0.001), stage 2-3 AKI (HR 1.78, 1.18-2.67, P=0.006), and mortality (HR 2.12, 1.09-4.11, P=0.03). CONCLUSIONS: Nephrotoxin exposure in adults is common and is significantly associated with AKI development, including stage 2-3 AKI.

Risk Factors for Death Among Veterans Following Acute Kidney Injury.

BACKGROUND: Acute kidney injury is prevalent among hospitalized veterans, and associated with increased risk of death following discharge. However, risk factors for death following acute kidney injury have not been well defined. We developed a mortality prediction model using Veterans Health Administration data. METHODS: This retrospective cohort study included inpatients from 2013 through 2018 with a creatinine increase of ≥0.3 mg/dL. We evaluated 45 variables for inclusion in our final model, with a primary outcome of 1-year mortality. Bootstrap sampling with replacement was used to identify variables selected in >60% of models using stepwise selection. Best sub-sets regression using Akaike information criteria was used to identify the best-fitting parsimonious model. RESULTS: A total of 182,683 patients were included, and 38,940 (21.3%) died within 1 year of discharge. The 10-variable model to predict mortality included age, chronic lung disease, cancer within 5 years, unexplained weight loss, dementia, congestive heart failure, hematocrit, blood urea nitrogen, bilirubin, and albumin. Notably, acute kidney injury stage, chronic kidney disease, discharge creatinine, and proteinuria were not selected for inclusion. C-statistics in the primary validation cohorts were 0.77 for the final parsimonious model, compared with 0.52 for acute kidney injury stage alone. CONCLUSION: We identified risk factors for long-term mortality following acute kidney injury. Our 10-variable model did not include traditional renal variables, suggesting that non-kidney factors contribute to the risk of death more than measures of kidney disease in this population, a finding that may have implications for post-acute kidney injury care.

A valued voice: A qualitative analysis of parental decision-making preferences in emergent paediatric surgery.

INTRODUCTION: Shared decision-making, with an emphasis on patient autonomy, is often advised in healthcare decision-making. However, this may be difficult to implement in emergent settings. We have previously demonstrated that when considering emergent operations for their children, parents prefer surgeon guidance as opposed to shared decision-making. Here, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. METHODS: Parents of paediatric patients who underwent surgery over the past 5 years at a University-based, tertiary children's hospital for cancer, an emergent operation while in the neonatal intensive care unit (NICU) or extracorporeal membrane oxygenation (ECMO) were invited to complete a 60-min semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Thematic content analysis was performed via deductive and inductive analysis. An iterative approach to thematic sampling/data analysis was used. RESULTS: Thematic saturation was achieved after 12 interviews (4 cancer, 5 NICU and 3 ECMO). Five common themes were identified: (1) recommendations from surgeons are valuable; (2) 'lifesaving mode': parents felt there were no decisions to be made; (3) effective ways of obtaining information about treatment; (4) shared decision-making as a 'dialogue' or 'discussion' and (5) parents as a 'valued voice' to advocate for their children. CONCLUSIONS: When engaging in decision-making regarding emergent surgical procedures for their children, parents value a surgeon's recommendation. Parents felt that discussion or dialogue with surgeons defined shared decision-making, and they believed that the opportunity to ask questions gave them a 'valued voice', even when they felt there were no decisions to be made. PATIENT OR PUBLIC CONTRIBUTION: For this study, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. Parents thus provided all the data for the study.

Association of interactions between Tele-critical care and bedside with length of stay and mortality.

INTRODUCTION: Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization. METHODS: We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes. RESULTS: Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay. DISCUSSION: Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.

Reporting Outcomes of Pediatric Intensive Care Unit Patients to Referring Physicians via an Electronic Health Record-Based Feedback System.

BACKGROUND: Many critically ill children are initially evaluated in front-line settings by clinicians with variable pediatric training before they are transferred to a pediatric intensive care unit (PICU). Because clinicians learn from past performance, communicating outcomes of patients back to front-line clinicians who provide pediatric emergency care could be valuable; however, referring clinicians do not consistently receive this important feedback. OBJECTIVES: Our aim was to determine the feasibility, usability, and clinical relevance of a semiautomated electronic health record (EHR)-supported system developed at a single institution to deliver timely and relevant PICU patient outcome feedback to referring emergency department (ED) physicians. METHODS: Guided by the Health Information Technology Safety Framework, we iteratively designed, implemented, and evaluated a semiautomated electronic feedback system leveraging the EHR in one institution. After conducting interviews and focus groups with stakeholders to understand the PICU-ED health care work system, we designed the EHR-supported feedback system by translating stakeholder, organizational, and usability objectives into feedback process and report requirements. Over 6 months, we completed three cycles of implementation and evaluation, wherein we analyzed EHR access logs, reviewed feedback reports sent, performed usability testing, and conducted physician interviews to determine the system's feasibility, usability, and clinical relevance. RESULTS: The EHR-supported feedback process is feasible with timely delivery and receipt of feedback reports. Usability testing revealed excellent Systems Usability Scale scores. According to physicians, the process was well-integrated into their clinical workflows and conferred minimal additional workload. Physicians also indicated that delivering and receiving consistent feedback was relevant to their clinical practice. CONCLUSION: An EHR-supported system to deliver timely and relevant PICU patient outcome feedback to referring ED physicians was feasible, usable, and important to physicians. Future work is needed to evaluate impact on clinical practice and patient outcomes and to investigate applicability to other clinical settings involved in similar care transitions.

Deploying a telemedicine collaborative care intervention for posttraumatic stress disorder in the U.S. Department of Veterans Affairs: A stepped wedge evaluation of an adaptive implementation strategy.

OBJECTIVE: To address barriers to trauma-focused psychotherapy for veterans with posttraumatic stress disorder (PTSD), we compared two implementation strategies to promote the deployment of telemedicine collaborative care. METHOD: We conducted a Hybrid Type III Effectiveness Implementation trial at six VA medical centers and their 12 affiliated Community Based Outpatient Clinics. The trial used a stepped wedge design and an adaptive implementation strategy that started with standard implementation, followed by enhanced implementation for VA medical centers that did not achieve the performance benchmark. Implementation outcomes for the 544 veterans sampled from the larger population targeted by the intervention were assessed from chart review (care management enrollment and receipt of trauma-focused psychotherapy) and telephone survey (perceived access and PTSD symptoms) after each implementation phase. The primary outcome was enrollment in care management. RESULTS: There was no significant difference between standard implementation and enhanced implementation on any of the implementation outcomes. 41.6% of sampled veterans had a care manager encounter, but only 6.0% engaged in trauma-focused psychotherapy. CONCLUSIONS: While telemedicine collaborative care was shown to be effective at engaging veterans in trauma-focused psychotherapy in a randomized controlled trial, neither standard nor enhanced implementation strategies were sufficient to support successful deployment into routine care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02737098.

Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA.

Background: Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Methods: Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Results: Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Conclusions: Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.

Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review.

BACKGROUND: Delirium is an acute disorder of attention and cognition that is common, serious, costly, under-recognized, and potentially fatal. Delirium is particularly problematic in the emergency department (ED) care of medically complex older adults, who are being seen in greater numbers. OBJECTIVE: This evidence-based narrative review focuses on the key components of delirium screening, prevention, and treatment. DISCUSSION: The recognition of delirium requires a systematic approach rather than a clinical gestalt alone. Several delirium assessment tools with high sensitivity and specificity, such as delirium triage screen and brief Confusion Assessment Method, can be used in the ED. The prevention of delirium requires environmental modification and unique geriatric care strategies tailored to the ED. The key approaches to treatment include the removal of the precipitating etiology, re-orientation, hydration, and early mobilization. Treatment of delirium requires a multifaceted and comprehensive care plan, as there is limited evidence for significant benefit with pharmacological agents. CONCLUSION: Older ED patients are at high risk for current or subsequent development of delirium, and a focused screening, prevention, and intervention for those who are at risk for delirium and its associated complications are the important next steps.

Comparing brief, covert, directly observed hand hygiene compliance monitoring to standard methods: A multicenter cohort study.

Hand hygiene compliance is subject to the Hawthorne effect, which may be attenuated by covert observers and brief observation periods. This study demonstrated that hand hygiene compliance rates were between 8% and 29% greater when reported by infection prevention programs than when reported by covert observers over brief observation periods.

An automated computerized critical illness severity scoring system derived from APACHE III: modified APACHE.

PURPOSE: To evaluate the performance of an automated computerized ICU severity scoring derived from the APACHE III. MATERIALS AND METHODS: Within a retrospective cohort of patients admitted to Veterans Health Administration ICUs between 2009 and 2015, we created an automated illness severity score(modified APACHE or mAPACHE), that we extracted from the electronic health records, using the same scoring as the APACHE III excluding the Glasgow Coma Scale, urine output, arterial blood gas components of APACHE III. We assessed the mAPACHE discrimination by using the area under the curve(AUC), and calibration by using the Hosmer-Lemeshow test and calculating the difference between observed and expected mortality across equal-sized risk deciles for death. RESULTS: The ICU and 30-day mortality was 5.07% of 7.82%, respectively (n = 490,955 patients). The AUC of mAPACHE for ICU and 30-day mortality was 0.771 and 0.786, respectively. The Hosmer-Lemeshow test was significant for both ICU and 30-day mortality (p < .001). The absolute difference between observed and expected mortality did not exceed ±1.53% across equal-sized deciles of risk for death. The AUC for ICU mortality was >0.7 in all admission diagnosis categories except in endocrine, respiratory, and sepsis. The AUC for 30-day mortality was >0.7 in every category. CONCLUSION: mAPACHE has adequate performance to predict mortality.

ICU Telemedicine Reduces Interhospital ICU Transfers in the Veterans Health Administration.

BACKGROUND: The effect of ICU telemedicine on transfers is not well studied. This study tests the hypothesis that ICU telemedicine decreases ICU patient interhospital transfers. METHODS: Data were retrieved for patients admitted to 306 Veterans Affairs ICUs in 117 acute care facilities between 2011 and 2015. Telemedicine was provided to 52 ICUs in 23 acute care facilities by two support centers located in Minneapolis and Cincinnati. We compared interhospital transfer rates in ICU telemedicine-affiliated hospitals with transfer rates of facilities with no telemedicine program. We used generalized linear mixed multivariable models to assess the association of ICU telemedicine with transfer rates and 30-day mortality. RESULTS: A total of 553,523 admissions to Veterans Affairs ICUs (97,256 to telemedicine hospitals; 456,267 to non-telemedicine hospitals) were analyzed. Transfers decreased from 3.46% to 1.99% in the telemedicine hospitals and from 2.03% to 1.68% in the non-telemedicine facilities between pre- and post-telemedicine implementation periods (P < .001). After adjusting for demographics, illness severity, admission diagnosis, and facility, ICU telemedicine was associated with overall reduced transfers with a relative risk (RR) of 0.79 (95% CI, 0.71-0.87; P < .001); this reduction occurred in patients with moderate (RR, 0.77; 95% CI, 0.61-0.98; P =.034), moderate to high (RR, 0.79; 95% CI, 0.63-0.98; P =.035), and high illness severity (RR, 0.73; 95% CI, 0.60-0.90; P =.003) and in nonsurgical patients (RR, 0.82; 95% CI, 0.73-0.92; P =.001). Transfers decreased in patients admitted with GI (RR, 0.55; 95% CI, 0.41-0.74, P < .001) and respiratory admission diagnoses (RR, 0.52; 95% CI, 0.38-0.71; P < .001). ICU telemedicine was not associated with an increase in 30-day mortality. CONCLUSIONS: ICU telemedicine was associated with a decrease in interhospital ICU transfers.

Using electronic medical record notes to measure ICU telemedicine utilization.

Given the complexity of high-acuity health care, designing an effective clinical note template can be beneficial to both document patient care and clarify how telemedicine is used. We characterized documented interactions via a standardized note template between bedside intensive care unit (ICU) providers and teleintensivists in 2 Veterans Health Administration ICU telemedicine support centers. All ICUs linked to support centers and providing care from October 2012 through September 2014 were considered. Interactions were assessed based on initiation site, bedside initiator, contact type, and patient care change. Of 14 511 ICU admissions with teleintensivist access, teleintensivist interaction was documented in 21.6% (N = 3136). In particular, contacts were primarily initiated by bedside staff (74.4%), use increased over time, and of contacts resulting in changes in patient care, most were initiated by a bedside nurse (84.3%). Given this variation, future research necessitates inclusion of utilization in evaluation of Tele-ICU and patient outcomes.

Feasibility of monitoring compliance to the My 5 Moments and Entry/Exit hand hygiene methods in US hospitals.

We compared the ability to observe hand hygiene opportunities using the World Health Organization My 5 Moments method to the Entry/Exit method. Under covert direct observation, Entry/Exit method opportunities were observed at all times. My 5 Moments were observable in 32.3% of episodes, with a lower rate in wards versus intensive care units (28.0% vs 39.4%; P < .01). In US hospitals, the Entry/Exit method appears to be more feasible for directly observed hand hygiene compliance monitoring due to line-of-sight issues and other barriers.