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3.
Qual Manag Health Care ; 29(4): 226-231, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32991540

RESUMO

BACKGROUND AND OBJECTIVES: Inability to obtain timely medications is a patient safety concern that can lead to delayed or incomplete treatment of illness. While there are many patient and system factors contributing to postdischarge medication nonadherence, availability and insurance-related barriers are preventable. PURPOSE: To implement a systematic process ensuring review of discharge prescriptions to ensure availability and resolve insurance barriers before patient discharge. METHODS: A prospective single-arm quality improvement intervention study to identify and address insurance-related prescription barriers using nonclinical staff. Intervention was pilot tested with sequential spread across general medicine resident teams. The primary outcome was successful obtainment of postdischarge prescriptions confirmed by phone calls to patients or their pharmacies. RESULTS: From April to August 2015, 59 of 161 patients included in the improvement process (36.6%) had one or more insurance or availability-related barriers with their prescriptions, totaling 89 issues. Forty-three of the 59 patients (72.9%) responded to postdischarge phone calls, 39 of whom (39/43, 90.7%) successfully filled their prescriptions on the first pharmacy visit. CONCLUSIONS: In our study, we preemptively identified that over a third of patients discharged would have encountered barriers filling their prescriptions. This interdisciplinary quality improvement project using nonclinical team members removed barriers for over 90% of our patients to ensure continuation of medical therapy without disruption and a safer postdischarge plan.

4.
Complement Ther Med ; 46: 109-115, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31519266

RESUMO

OBJECTIVE: To determine whether utilizing beginner, video-guided tai chi and qigong classes as an adjunct to physical therapy to enhance mobilization among hospitalized patients is feasible and acceptable. DESIGN: Single-arm feasibility study over a 15½-week period. SETTING: Three medical-surgical units at one hospital. INTERVENTIONS: Small-group video-guided beginner-level tai chi and qigong classes supervised by physical therapists occurred three times a week. MAIN OUTCOME MEASURES: The primary outcome was weekly class attendance. Secondary outcomes included patient and staff satisfaction, collected by surveys and semi-structured interviews. Process measures included class duration. Balancing measures included falls. RESULTS: One-hundred and fifty-seven patients were referred for recruitment, 45 gave informed consent, and 38 patients attended at least one class. The number of weekly class attendees increased during the study period. Based on first-class experience, 68% (26/38) of patients reported enjoying the class "quite a bit" or "extremely," 66% (25/38) of patients reported feeling "more mobile" afterward, and 76% (29/38) of patients agreed that the class made them more comfortable going home. Average class duration was 29 minutes. Zero falls occurred during or immediately following class. CONCLUSIONS: Video-guided tai chi and qigong classes are feasible and well-received at our hospital. Future studies of the impact on preserving mobility and function or reducing length of stay are of interest.


Assuntos
Pacientes Internados/educação , Tai Ji/educação , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Satisfação Pessoal , Qigong , Qualidade de Vida
5.
BMJ Open Qual ; 8(4): e000730, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31922034

RESUMO

Background: Unintended shocks from implantable cardioverter defibrillators (ICDs) are often distressing to patients and family members, particularly at the end of life. Unfortunately, a large proportion of ICDs remain active at the time of death among do not resuscitate (DNR) and comfort care patients. Methods: We designed standardised teaching sessions for providers and implemented a novel decision tool in the electronic medical record (EMR) to improve the frequency of discussions surrounding ICD deactivation over a 6-month period. The intended population was patients on inpatient medicine and cardiology services made DNR and/or comfort care. These rates were compared with retrospective data from 6 months prior to our interventions. Results: After our interventions, the rates of discussions regarding deactivation of ICDs improved from 50% to 93% in comfort care patients and from 32% to 70% in DNR patients. The rates of deactivated ICDs improved from 45% to 73% in comfort care patients and from 29% to 40% in DNR patients. Conclusion: Standardised education of healthcare providers and decision support tools and reminders in the EMR system are effective ways to increase awareness, discussion and deactivation of ICDs in comfort care and DNR patients.


Assuntos
Tomada de Decisões , Desfibriladores Implantáveis , Pessoal de Saúde/educação , Assistência Terminal , Suspensão de Tratamento , Morte , Humanos , Conforto do Paciente , Melhoria de Qualidade , Ordens quanto à Conduta (Ética Médica) , Estudos Retrospectivos
6.
Jt Comm J Qual Patient Saf ; 45(3): 207-216, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30482662

RESUMO

BACKGROUND: Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. METHODS: A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5). RESULTS: Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team. CONCLUSION: Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.


Assuntos
Antibacterianos/administração & dosagem , Gestão de Antimicrobianos/organização & administração , Médicos Hospitalares/organização & administração , Farmacêuticos/organização & administração , Melhoria de Qualidade/organização & administração , Centros Médicos Acadêmicos/organização & administração , Antibacterianos/uso terapêutico , Hospitais Urbanos/organização & administração , Humanos , Capacitação em Serviço/organização & administração , Tempo de Internação , Readmissão do Paciente
7.
Curr Diab Rep ; 18(8): 54, 2018 06 21.
Artigo em Inglês | MEDLINE | ID: mdl-29931547

RESUMO

PURPOSE OF REVIEW: Patients with diabetes are known to have higher 30-day readmission rates compared to the general inpatient population. A number of strategies have been shown to be effective in lowering readmission rates. RECENT FINDINGS: A review of the current literature revealed several strategies that have been associated with a decreased risk of readmission in high-risk patients with diabetes. These strategies include inpatient diabetes survival skills education and medication reconciliation prior to discharge to send the patient home with the "right" medications. Other key strategies include scheduling a follow-up phone call soon after discharge and an office visit to adjust the diabetes regimen. The authors identified the most successful strategies to reduce readmissions as well as some institutional barriers to following a transitional care program. Recent studies have identified risk factors in the diabetes population that are associated with an increased risk of readmission as well as interventions to lower this risk. A standardized transitional care program that focuses on providing interventions while reducing barriers to implementation can contribute to a decreased risk of readmission.


Assuntos
Diabetes Mellitus/epidemiologia , Equipe de Assistência ao Paciente , Readmissão do Paciente , Prescrições de Medicamentos/estatística & dados numéricos , Humanos , Fatores de Risco
8.
Pain Med ; 19(6): 1132-1139, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-28108642

RESUMO

Objective: To determine the role that smartphones may play in supporting older adults with chronic noncancer pain (CNCP) in order to improve pain management in this expanding population. Design: Qualitative study. Setting: One academically affiliated primary care practice serving older adults with CNCP in New York City. Subjects: Thirteen older adults (age 65-85 years) with CNCP on chronic opioid therapy, that is, continuous use of opioids for at least six months. Methods: One researcher conducted one-on-one telephone interviews with participants, and two researchers analyzed the transcribed data using descriptive analysis. A nurse and a physician researcher iteratively critiqued and approved the results. Results: Participants provided opinions as to the effects that smartphones may have on medication management and communications with their providers. Smartphones can benefit older adults by supporting interactions with the health care system such as more effective scheduling and coordinating prescribing practices with local pharmacies. Participants expressed difficulties with isolation due to CNCP and posited that smartphones could provide a means for social support. Specifically, smartphones should support older adult needs to effectively communicate pain experiences with personal contacts and caregivers, as well as health care providers. Based on these results, we provide suggestions that can inform future smartphone interventions for older adults with CNCP. Conclusion: Smartphones that focus on supporting medication management, enhancing communication with providers, and facilitating connectedness within social networks to reduce feelings of isolation may help to improve CNCP outcomes in older adults.


Assuntos
Dor Crônica , Conhecimentos, Atitudes e Prática em Saúde , Manejo da Dor/métodos , Smartphone , Telemedicina , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pesquisa Qualitativa
9.
Healthc (Amst) ; 5(1-2): 17-22, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28668198

RESUMO

BACKGROUND: In 2012, the American Board of Internal Medicine (ABIM) Foundation launched a campaign called Choosing Wisely which was intended to start a national dialogue on services that are not medically necessary. More research is needed on the in-depth reasons why doctors overuse low-value services, their views on Choosing Wisely specifically, and ways to help them change their practice patterns. METHODS: We performed a qualitative study of focus groups with physicians to explore their views on the problem of overuse of low-value services, the reasons why they overuse, and ways that they think could be effective at curbing overuse. Participants were attendings in the fields of emergency medicine, internal medicine, hospital medicine, and cardiology. RESULTS: All physicians felt that overuse of low-value services was a significant problem. Physicians frequently cited that patient expectations drove the use of low-value services and lack of time was the most cited reason why behavior change was difficult. Facilitators that could promote behavior change included decision support through the electronic medical record, motivation to maintain their reputation among their colleagues, internal motivation to be a good doctor, objective data showing their rates of overuse, alignment of institutional goals, and forums to discuss evidence and new research. CONCLUSIONS AND IMPLICATIONS: In focus groups with physicians, we found that physicians perceived that overuse of low-value services was a problem. Participants cited many barriers to behavior change. Methods that help address patient expectations, physician time, and social norms may help physicians reduce their use of low-value services.


Assuntos
Docentes de Medicina/psicologia , Médicos/psicologia , Avaliação de Programas e Projetos de Saúde/métodos , Procedimentos Desnecessários/normas , Feminino , Grupos Focais , Humanos , Masculino , Sobremedicalização/economia , Sobremedicalização/prevenção & controle , Pesquisa Qualitativa , Estados Unidos
10.
J Hosp Med ; 8(11): 619-26, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24124032

RESUMO

BACKGROUND: Reducing hospital readmissions depends on ensuring safe care transitions, which requires a better understanding of the challenges experienced by key stakeholders. OBJECTIVE: Develop a descriptive framework illustrating the interconnected roles of patients, providers, and caregivers in relation to readmissions. DESIGN: Multimethod qualitative study with 4 focus groups and 43 semistructured interviews. Multiple perspectives were included to increase the trustworthiness (internal validity) and transferability (external validity) of the results. Data were analyzed using grounded theory to generate themes associated with readmission. SETTING/PATIENTS: General medicine patients with same-site 30-day readmissions, their family members, and multiple care providers at a large urban academic medical center. RESULTS: A keynote generated from the multiperspective responses was that care transitions were optimized by a well-coordinated multidiscipline support system, described as the Patient Care Circle. In addition, issues pertaining to readmissions were identified and classified into 5 main themes emphasizing the necessity of a coordinated support network: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability, and (5) medications. CONCLUSION: A well-coordinated collaborative Patient Care Circle is fundamental to ensuring safe care transitions.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/normas , Navegação de Pacientes/normas , Readmissão do Paciente/normas , Centros Médicos Acadêmicos/normas , Centros Médicos Acadêmicos/estatística & dados numéricos , Adulto , Idoso , Atitude do Pessoal de Saúde , Continuidade da Assistência ao Paciente/normas , Feminino , Grupos Focais , Hospitais Urbanos/normas , Hospitais Urbanos/estatística & dados numéricos , Humanos , Comunicação Interdisciplinar , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Equipe de Assistência ao Paciente/organização & administração , Navegação de Pacientes/métodos , Navegação de Pacientes/organização & administração , Readmissão do Paciente/estatística & dados numéricos , Pacientes/psicologia , Pacientes/estatística & dados numéricos , Pesquisa Qualitativa , Índice de Gravidade de Doença
11.
Acad Med ; 88(11): 1685-8, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24072112

RESUMO

PROBLEM: Academic medical centers face unique challenges to ensuring patient safety after a hospital discharge, including those related to providing patient follow-up care in practices staffed by residents who are not comfortable managing care transitions. APPROACH: In 2011, the authors designed a quality improvement program for early postdischarge follow-up (bridge visits) at a resident primary care outpatient practice, using existing resources. The authors added a unique appointment template to the outpatient electronic health record to guide residents during the visit. Residents completed both postvisit and postprogram surveys regarding their experience with the program, and patients completed postvisit phone surveys regarding their satisfaction with the program. OUTCOMES: Fifty-eight residents completed postvisit surveys, of which 31.0% (18/58) reported problems with medication reconciliation and 25.9% (15/58) with adherence to discharge medications. Of those residents who completed postprogram surveys, almost half (18/38; 47.4%) agreed that their experience changed the way they discharge patients. Nearly all patients who responded to the postvisit phone surveys reported that the program reinforced their discharge and medication instructions (44/46; 95.7%); 81.8% (18/22) of patients with established providers did not mind seeing an interim physician for expedited postdischarge care. NEXT STEPS: An early postdischarge program at a resident outpatient primary care practice is valuable both in ensuring patient safety and as a model to promote experiential learning in medical education. Findings from this study will be used to develop a formal curriculum in care transitions for all residents.


Assuntos
Ambulatório Hospitalar/organização & administração , Alta do Paciente , Centros Médicos Acadêmicos , Adulto , Feminino , Humanos , Internato e Residência , Masculino , Ambulatório Hospitalar/normas , Satisfação do Paciente , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade
12.
Ann Allergy Asthma Immunol ; 97(3): 365-9, 2006 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-17042143

RESUMO

BACKGROUND: Interest in complementary and alternative medicine (CAM) is increasing. Use of CAM in food-allergic patients has not previously been evaluated. OBJECTIVES: To determine the prevalence of CAM use, the types of CAM modalities used, and opinions about CAM in food-allergic patients. METHODS: A questionnaire was distributed to attendees at a patient conference in 2002 and to patients at pediatric food allergy clinics in 2005. RESULTS: Surveys were completed by 380 families. Respondents were mainly white, parents of children with multiple food allergies, and from the tri-state (New York, New Jersey, Connecticut) area. Diagnostic modalities considered unproven or disproven (such as serum IgG4, electrodermal skin testing, and kinesiology) were used by 22% of respondents; CAM therapies were used by 18%. Participants used several types of CAM practitioners, the most common being chiropractors, homeopaths, and acupuncturists. Only 49% of patients using CAM disclosed this to their physicians. Efficacy ratings for CAM were poor. Regarding participants' opinions, an herbal therapy of equal efficacy, safety, and cost was preferred to a pharmaceutical drug (37% vs 12%; P = .001), but most participants (51%) had no preference or were unsure. CONCLUSION: Unproven or disproven diagnostic methods and CAM treatments were used by approximately 1 in 5 respondents. Those using CAM noted poor efficacy, but if given a choice, many would prefer herbal therapies to pharmaceutical drugs. Education regarding reliable testing for food allergy and further research on CAM therapies are warranted.


Assuntos
Terapias Complementares/estatística & dados numéricos , Hipersensibilidade Alimentar/diagnóstico , Hipersensibilidade Alimentar/terapia , Humanos , Pais , Prevalência , Inquéritos e Questionários
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