Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes.

BACKGROUND: Collaboration between primary and secondary care (PSCC) is important to provide patient-centered care. Postgraduate training programmes should provide training to learn PSCC. With a design based research (DBR) approach design principles can be formulated for designing effective interventions in specific contexts. The aim of this study is to determine design principles for interventions aimed to learn PSCC in postgraduate training programmes. METHODS: DBR is characterised by multi-method studies. We started with a literature review on learning collaboration between healthcare professionals from different disciplines within the same profession (intraprofessional) to extract preliminary design principles. These were used to inform and feed group discussions among stakeholders: trainees, supervisors and educationalists in primary and secondary care. Discussions were audiotaped, transcribed and analysed using thematic analysis to formulate design principles. RESULTS: Eight articles were included in the review. We identified four preliminary principles to consider in the design of interventions: participatory design, work process involvement, personalised education and role models. We conducted three group discussions with in total eighteen participants. We formulated three design principles specific for learning PSCC in postgraduate training programmes: (1) The importance of interaction, being able to engage in a learning dialogue. (2) Facilitate that the learning dialogue concerns collaboration. (3) Create a workplace that facilitates engagement in a learning dialogue. In the last design principle we distinguished five subcategories: intervention emphasises the urge for PSCC and is based on daily practice, the presence of role models, the work context creates time for learning PSCC, learning PSCC is formalised in curricula and the presence of a safe learning environment. CONCLUSION: This article describes design principles for interventions in postgraduate training programmes with the aim to learn PSCC. Interaction is key in learning PSCC. This interaction should concern collaborative issues. Furthermore, it is essential to include the workplace in the intervention and make adjacent changes in the workplace when implementing interventions. The knowledge gathered in this study can be used to design interventions for learning PSCC. Evaluation of these interventions is needed to acquire more knowledge and adjust design principles when necessary.

Interprofessional simulation of acute care for nursing and medical students: interprofessional competencies and transfer to the workplace.

BACKGROUND: Teamwork and communication are essential tools for doctors, nurses and other team members in the management of critically ill patients. Early interprofessional education during study, using acute care simulation, may improve teamwork and communication between interprofessional team members on the long run. METHODS: A comparative sequential quantitative-qualitative study was used to understand interprofessional learning outcomes in nursing and medical students after simulation of acute care. Students were assigned to a uni- or interprofessional training. Questionnaires were used to measure short and long term differences in interprofessional collaboration and communication between the intervention and control group for nursing and medical students respectively. Semi-structured focus groups were conducted to gain a better understanding of IPE in acute simulation. RESULTS: One hundred and ninety-one students participated in this study (131 medical, 60 nursing students). No differences were found between the intervention and control group in overall ICCAS scores for both medical and nursing students (p = 0.181 and p = 0.441). There were no differences in ICS scores between the intervention and control group. Focus groups revealed growing competence in interprofessional communication and collaboration for both medical and nursing students. CONCLUSIONS: Interprofessional simulation training did show measurable growth of interprofessional competencies, but so did uniprofessional training. Both medical and nursing students reported increased awareness of perspective and expertise of own and other profession. Furthermore, they reported growing competence in interprofessional communication and collaboration in transfer to their workplace.

[Observing a resident doing a consultation with a patient: goal determines form]. / Hoe observeer je een aios die een consult doet?

Observation of residents by supervisors is a highly recommended, but underused educational tool in postgraduate medical education. Observation can be performed indirectly (using video recordings of residents performing clinical tasks) or directly (supervisor is present when the resident performs the task). The choice of the observation method depends on aim and context of the observation. In general practice, patients tend to involve the supervisor when the resident performs the consultation. They value such participatory direct observation because they know the supervisor and appreciate their input. For specific residents' learning aims (e.g. consultation efficiency), it may be more useful if the supervisor takes a "fly on the wall" approach. Supervisors wishing to take a "fly on the wall" approach to direct observation need to inform the patient about their role and position themselves outside the patient's field of view. Indirect observation by reviewing video-recorded consultations is an alternative for this purpose.

Competencies to promote collaboration between primary and secondary care doctors: an integrative review.

BACKGROUND: In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising 'seamless' care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface. METHODS: We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach. RESULTS: We identified six themes regarding collaborative competencies: 'patient-centred care: a common concern', 'roles and responsibilities', 'mutual knowledge and understanding', 'collaborative attitude and respect', 'communication' and 'leadership'. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration. CONCLUSIONS: This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.

Professional Care Networks of Frail Older People: An Explorative Survey Study from the Patient Perspective.

BACKGROUND: Frail older people living in the community require multidisciplinary care. Despite the fact that patient participation is high on the public agenda, studies into multidisciplinary care mainly focus on the viewpoints of professionals. Little is known about frail older patients' experiences with care delivered by multidisciplinary teams and their perception of collaboration between professional and informal caregivers. OBJECTIVE: To gain more insight into the experiences of frail older patients with integrated multidisciplinary care by mapping the care networks of this patient group and their perception of the interconnection between professional and informal caregivers. METHODS: Survey study to facilitate a care network analysis. Due to the vulnerable health status of the respondents, questionnaires were completed during interviews. Analysis was performed using an iterative process, using both visual and metric techniques. PARTICIPANTS: 44 older persons, considered 'frail' by their general practitioner. SETTING: Four general practices in The Netherlands. RESULTS: The networks of the participants consisted of an average of 15 actors connected by 54 ties. General practitioners were the most common actors in the networks, and were well connected to medical specialists and in-home care providers. The participants did not always perceive a connection between their general practitioner and their informal caregiver. The network analyses resulted in the identification of three subtypes: simple star (n = 16), complex star (n = 16), and sub-group networks (n = 12). CONCLUSIONS: Our findings indicate that the elderly often do not experience the integration of multidisciplinary care as such. This is a real opportunity for MTs to improve their care and to make the patients' experiences better in line with what they are aiming: allowing patients to live at home as healthy and independently as possible for as long as possible. We showed that informal caregivers often form communication bridges between patients and professionals. Having a better knowledge of the patient perspective enables the gaps in professional care networks of frail older people to be filled and facilitates the anticipation of crisis situations.

Preventing acute kidney injury in high-risk patients by temporarily discontinuing medication - an observational study in general practice.

BACKGROUND: Elderly, patients with chronic kidney disease (CKD) and patients with heart failure who continue using renin-angiotensin-aldosterone-system (RAAS) inhibitors, diuretics, or non-steroidal-anti-inflammatory drugs (NSAIDs) during times of fluid loss have a high risk of developing complications like acute kidney injury (AKI). The aim of this study was to assess how often advice to discontinue high-risk medication was offered to high-risk patients consulting the general practitioner (GP) with increased fluid loss. Furthermore, we assessed the number and nature of the complications that occurred after GP consultation. METHODS: We performed a cross-sectional study with patients from seven Dutch general practices participating in the Family Medicine Network between 1 and 6-2013 and 1-7-2018. We included patients who used RAAS-inhibitors, diuretics, or NSAIDs, and had at least one of the following risk factors: age ≥ 70 years, CKD, or heart failure. From this population, we selected patients with a 'dehydration-risk' episode (vomiting, diarrhoea, fever, chills, or gastrointestinal infection). We manually checked their electronic patient files and assessed the percentage of episodes in which advice to discontinue the high-risk medication was offered and whether a complication occurred in 3 months after the 'dehydration-risk' episode. RESULTS: We included 3607 high-risk patients from a total of 44.675 patients (8.1%). We found that patients were advised to discontinue the high-risk medication in 38 (4.6%) of 816 'dehydration-risk' episodes. In 59 of 816 episodes (7.1%) complications (mainly AKI) occurred. CONCLUSIONS: Dutch GPs do not frequently advise high-risk patients to discontinue high-risk medication during 'dehydration-risk' episodes. Complications occur frequently. Timely discontinuation of high-risk medication needs attention.

[Acute renal failure due to RAAS-inhibitors combined with dehydration]. / Acute nierinsufficiëntie bij combinatie RAAS-remmer en dehydratie.

Two men (61 and 81 years old) with mild impaired kidney function developed acute renal failure due to dehydration combined with the use of inhibitors of the renin-angiotensin-aldosterone system (RAAS). After rehydration, correction of hyperkalaemia and stopping RAAS-inhibition and diuretics, they recovered completely. Many patients using RAAS-inhibitors have impaired renal function. In the case of dehydration due to gastroenteritis or prolonged fever they risk developing acute renal failure. The high risk groups are elderly patients, patients with atherosclerosis or heart failure and those with co-medication of diuretics or NSAIDs. The underlying mechanism is that the normal pathways to protect kidney perfusion in case of hypovolaemia are blocked by the use of RAAS-inhibitors or NSAIDs. In the case of dehydration in patients with chronic kidney disease using RAAS-inhibitors, serum creatinine and potassium levels should be monitored. Temporary discontinuation of RAAS-inhibitors or diuretics is often necessary.