Patient, caregiver and professional views on preventable emergency admissions of older patients, a multi-method study in three Dutch hospitals.

BACKGROUND: Older adults are too often hospitalized from the emergency department (ED) without needing hospital care. Knowledge about rates and causes of these preventable emergency admissions (PEAs) is limited. This study aimed to assess the proportion of PEAs, the level of agreement on perceived preventability between physicians and patients, and to explore their underlying causes as perceived by patients, their relatives, and the admitting physician. METHODS: A multi-center multi-method study at the ED of one academic and two regional hospitals in the Netherlands was performed. All patients aged > 70 years and hospitalized from the ED were consecutively sampled during a six-week period. Quantitative data regarding patient and clinical characteristics and perceived preventability of the admission were prospectively collected from the electronical medical record and analyzed using descriptive statistics. Agreement on preventability between patient, caregivers and physicians was assessed by using the Cohen's kappa. Underlying causes of a PEA were subsequently collected by semi-structured interviews with patients and caregivers. Physician's perceived causes of a PEA were collected by telephone interviews and by open-ended questions sent by email. Thematic content analysis was used to analyze the interview transcripts and email narratives. RESULTS: Out of 773 admissions, 56 (7.2%) were deemed preventable by patients or their caregivers. Admitting physicians regarded 75 (9.7%) admissions as preventable. The level of agreement between these two groups was low with a Cohen's kappa score of 0.10 (p = 0.003). Perceived causes for PEAs related to six themes: (1) insufficient support at home, (2) suboptimal care in the community setting, (3) errors in hospital care, (4) time of presentation to ED and availability of resources, (5) delayed help seeking behavior, and (6) errors made by patients. CONCLUSIONS: Our findings contribute to the existing evidence that a substantial part (almost one out of ten) of the older adults visiting the ED is perceived as unnecessary hospital care by patients, caregivers and health care providers. Findings also provide valuable insight into the causes for PEAs from a patient perspective. Further research is needed to understand why the perspectives of those responsible for hospital admission and those being admitted vary considerably.

Putting measurement on a diet: development of a core set of indicators for quality improvement in the ICU using a Delphi method.

BACKGROUND: The number and efficacy of indicators used to monitor and improve the quality of care in Intensive Care Units (ICU) is debatable. This study aimed to select a consensus-based core set of indicators for effective quality improvement in the ICU. METHODS: A Delphi study with a panel of intensivists, ICU nurses, and former ICU patients or relatives (n = 34) from general, teaching, and academic hospitals. Panelists completed a questionnaire in which they scored 69 preselected quality indicators on relevance using a nine-point Likert scale. Indicators were categorized using the rated relevance score into: 'accepted, 'equivocal' and 'excluded'. Questionnaire results were discussed in focus groups to reach consensus on the final set. RESULTS: Response rates for the questionnaire and focus groups were 100 and 68%, respectively. Consensus was reached on a final set of 17 quality indicators including patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). Other quality indicators relate to the organization and outcome of ICU care, including safety culture, ICU standardized mortality ratio, and the process indicator 'learning from and improving after serious incidents'. CONCLUSIONS: ICU clinicians and former patients and relatives developed a consensus-based core set of ICU quality indicators that is relatively short but comprehensive and particularly tailored to end-users needs.

Preparing tomorrow's medical specialists for participating in oncological multidisciplinary team meetings: perceived barriers, facilitators and training needs.

INTRODUCTION: The optimal treatment plan for patients with cancer is discussed in multidisciplinary team meetings (MDTMs). Effective meetings require all participants to have collaboration and communication competences. Participating residents (defined as qualified doctors in training to become a specialist) are expected to develop these competences by observing their supervisors. However, the current generation of medical specialists is not trained to work in multidisciplinary teams; currently, training mainly focuses on medical competences. This study aims to identify barriers and facilitators among residents with respect to learning how to participate competently in MDTMs, and to identify additional training needs regarding their future role in MDTMs, as perceived by residents and specialists. METHODS: Semi-structured interviews were conducted with Dutch residents and medical specialists participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' demographic and professional characteristics (e.g. sex, specialty, training duration, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis. RESULTS: Nineteen residents and 16 specialists were interviewed. Three themes emerged: 1) awareness of the educational function of MDTMs among specialists and residents; 2) characteristics of MDTMs (e.g. time constraints, MDTM regulations) and 3) team dynamics and behaviour. Learning to participate in MDTMs is facilitated by: specialists and residents acknowledging the educational function of MDTMs beyond their medical content, and supervisors fulfilling their teaching role and setting conditions that enable residents to take a participative role (e.g. being well prepared, sitting in the inner circle, having assigned responsibilities). Barriers to residents' MDTM participation were insufficient guidance by their supervisors, time constraints, regulations hindering their active participation, a hierarchical structure of relations, unfamiliarity with the team and personal characteristics of residents (e.g. lack of confidence and shyness). Interviewees indicated a need for additional training (e.g. simulations) for residents, especially to enhance behavioural and communication skills. CONCLUSION: Current practice with regard to preparing residents for their future role in MDTMs is hampered by a variety of factors. Most importantly, more awareness of the educational purposes of MDTMs among both residents and medical specialists would allow residents to participate in and learn from oncological MDTMs. Future studies should focus on collaboration competences.

Teach-back of discharge instructions in the emergency department: a pre-post pilot evaluation.

OBJECTIVES: With the 'teach-back' method, patients or carers repeat back what they understand, so that professionals can confirm comprehension and correct misunderstandings. The effectiveness of teach-back has been underexamined, particularly for older patients discharged from the emergency department (ED). We aimed to determine whether teach-back would reduce ED revisits and whether it would increase patients' retention of discharge instructions, improve self-management at home and increase satisfaction with the provision of instructions. METHODS: A nonrandomised pre-post pilot evaluation in the ED of one Dutch academic hospital including patients discharged from the ED receiving standard discharge care (pre) and teach-back (post). Primary outcomes were ED-revisits within 7 days and within 8-30 days postdischarge. Secondary outcomes for a subsample of older adults were retention of instructions, self-management 72 hours after discharge and satisfaction with the provision of discharge instructions. RESULTS: A total of 648 patients were included, 154 were older adults. ED revisits within 7 days and within 8-30 days were lower in the teach-back group compared with those receiving standard discharge care: adjusted odds ratios (AORs) of 0.23 (95% CI 0.05 to 1.07) and 0.42 (95% CI 0.14 to 1.33), respectively. Participants in the teach-back group had an increased likelihood of full knowledge retention on information related to their ED diagnosis and treatment (AOR 2.19; 95% CI 1.01 to 4.75; p=0.048), medication (AOR 14.89; 95% CI 4.12 to 53.85; p>0.001) and follow-up appointments (AOR 3.86; 95% CI 1.33 to 10.19; p=0.012). Use of teach-back was not significantly associated with improved self-management and higher satisfaction with discharge instructions. Discharge conversations were generally shorter for participants receiving teach-back. CONCLUSIONS: Discharging patients from the ED with a relatively simple and feasible teach-back method can contribute to safer and better transitional care from the ED to home.

Dutch emergency physicians insufficiently educated in geriatric emergency medicine: results of a nationwide survey.

BACKGROUND: Emergency physicians (EPs) provide care to older adults with complex health problems. Treating these patients is challenging for many EPs, which might originate from modest geriatric education. OBJECTIVE: Our aim was to assess EPs' self-perceived needs regarding geriatric emergency medicine (GEM) education, factors determining these needs and the utilization of this education. Our secondary aim was to assess emergency department (ED) managers' view and support for GEM education. METHODS: All EPs and ED managers in the Netherlands received a survey by e-mail. The questionnaires focused on EPs' needs in GEM education, EPs' utilization of GEM education and managerial support for GEM education. We used descriptive statistics to analyse needs, utilization of- and support for GEM education. Regression analyses were used to identify factors associated with EPs' need for GEM education. RESULTS: EPs reported to need better training in diagnosing, treating and communicating with older adults. Seventy percent of EPs reported no GEM education program in their hospital, and 83% reported no utilization of GEM education outside their hospital. EPs working in EDs with a possibility for geriatric consultation, and EPs aware of actual GEM education programs, had lower educational needs. Of responding managers, 86.2% reported the care for older adults as an important topic; lack of finances and time were obstacles to provide GEM education for EPs. CONCLUSION: EPs in the Netherlands feel insufficiently educated to treat older adults. ED managers largely recognize this educational challenge. This nationwide survey underlines the need to prioritize GEM education for EPs.

Holding the frontline: a cross-sectional survey of emergency department staff well-being and psychological distress in the course of the COVID-19 outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak has been associated with stress and challenges for healthcare professionals, especially for those working in the front-line of treating COVID-19 patients. This study aimed to: 1) assess changes in well-being and perceived stress symptoms of Dutch emergency department (ED) staff in the course of the first COVID-19 wave, and 2) assess and explore stressors experienced by ED staff since the COVID-19 outbreak. METHODS: We conducted a cross-sectional study. An online questionnaire was administered during June-July 2020 to physicians, nurses and non-clinical staff of four EDs in the Netherlands. Well-being and stress symptoms (i.e., cognitive, emotional and physical) were scored for the periods pre, during and after the first COVID-19 wave using the World Health Organization Well-Being Index (WHO-5) and a 10-point Likert scale. Stressors were assessed and explored by rating experiences with specific situations (i.e., frequency and intensity of distress) and in free-text narratives. Quantitative data were analyzed with descriptive statistics and generalized estimating equations (GEE). Narratives were analyzed thematically. RESULTS: In total, 192 questionnaires were returned (39% response). Compared to pre-COVID-19, the mean WHO-5 index score (range: 0-100) decreased significantly with 14.1 points (p < 0.001) during the peak of the first wave and 3.7 points (< 0.001) after the first wave. Mean self-perceived stress symptom levels almost doubled during the peak of the first wave (≤0.005). Half of the respondents reported experiencing more moral distress in the ED since the COVID-19 outbreak. High levels of distress were primarily found in situations where the staff was unable to provide or facilitate necessary emotional support to a patient or family. Analysis of 51 free-texts revealed witnessing suffering, high work pressure, fear of contamination, inability to provide comfort and support, rapidly changing protocols regarding COVID-19 care and personal protection, and shortage of protection equipment as important stressors. CONCLUSIONS: The first COVID-19 wave took its toll on ED staff. Actions to limit drop-out and illness among staff resulting from psychological distress are vital to secure acute care for (non-)COVID-19 patients during future infection waves.

Delayed emergency healthcare seeking behaviour by Dutch emergency department visitors during the first COVID-19 wave: a mixed methods retrospective observational study.

BACKGROUND: Emergency department (ED) visits due to non-coronavirus disease 2019 (COVID-19) conditions have drastically decreased since the outbreak of the COVID-19 pandemic. This study aimed to identify the magnitude, characteristics and underlying motivations of ED visitors with delayed healthcare seeking behaviour during the first wave of the pandemic. METHODS: Between March 9 and July 92,020, adults visiting the ED of an academic hospital in the East of the Netherlands received an online questionnaire to collect self-reported data on delay in seeking emergency care and subsequent motivations for this delay. Telephone interviews were held with a subsample of respondents to better understand the motivations for delay as described in the questionnaire. Quantitative data were analysed using descriptive statistics. Qualitative data were thematically analysed. RESULTS: One thousand three hundred thirty-eight questionnaires were returned (34.0% response). One in five respondents reported a delay in seeking emergency care. Almost half of these respondents (n = 126; 45.4%) reported that the pandemic influenced the delay. Respondents reporting delay were mainly older adults (mean 61.6; ±13.1 years), referred to the ED by the general practitioner (GP; 35.1%) or a medical specialist (34.7%), visiting the ED with cardiac problems (39.7%). The estimated median time of delay in receiving ED care was 3 days (inter quartile range  8 days). Respectively 46 (16.5%) and 26 (9.4%) respondents reported that their complaints would be either less severe or preventable if they had sought for emergency care earlier. Delayed care seeking behaviour was frequently motivated by: fear of contamination, not wanting to burden professionals, perceiving own complaints less urgent relative to COVID-19 patients, limited access to services, and by stay home instructions from referring professionals. CONCLUSIONS: A relatively large proportion of ED visitors reported delay in seeking emergency care during the first wave. Delay was often driven by misperceptions of the accessibility of services and the legitimacy for seeking emergency care. Public messaging and close collaboration between the ED and referring professionals could help reduce delayed care for acute needs during future COVID-19 infection waves.

Effects of a geriatric education program for emergency physicians: a mixed-methods study.

Emergency physicians (EPs) often regard care for older adults as complex, while they lack sufficient geriatric skills. This study evaluates the effect of a geriatric education program on EPs' geriatric knowledge, attitude and medical practice when treating older adults. A mixed-methods study was performed on EPs from two Dutch hospitals. Effects were measured by pre-post tests of EPs' (n = 21) knowledge of geriatric syndromes and attitudes toward older adults, and by a retrospective pre-post analysis of 100 records of patients aged 70 years or more. Six EPs were purposively sampled and interviewed after completion of the education program. The program significantly improved EPs' geriatric knowledge. EPs indicated that the program improved their ability and attentiveness to recognize frailty and geriatric syndromes. The program also significantly improved EPs' attention for the older patient's social history and circumstances (P = 0.04) but did not have a significant effect on medical decision making. EPs valued especially the case-based teaching and indicated that the interactive setting helped them to better understand and retain knowledge. Combined quantitative and qualitative data suggest that EPs benefit from geriatric emergency teaching. Future enhancement and evaluation of the geriatric education program is needed to confirm benefits to clinical practice and patient outcomes.

Continuous Monitoring of Vital Signs in the General Ward Using Wearable Devices: Randomized Controlled Trial.

BACKGROUND: Wearable devices can be used for continuous patient monitoring in the general ward, increasing patient safety. Little is known about the experiences and expectations of patients and health care professionals regarding continuous monitoring with these devices. OBJECTIVE: This study aimed to identify positive and negative effects as well as barriers and facilitators for the use of two wearable devices: ViSi Mobile (VM) and HealthPatch (HP). METHODS: In this randomized controlled trial, 90 patients admitted to the internal medicine and surgical wards of a university hospital in the Netherlands were randomly assigned to continuous vital sign monitoring using VM or HP and a control group. Users' experiences and expectations were addressed using semistructured interviews. Nurses, physician assistants, and medical doctors were also interviewed. Interviews were analyzed using thematic content analysis. Psychological distress was assessed using the State Trait Anxiety Inventory and the Pain Catastrophizing Scale. The System Usability Scale was used to assess the usability of both devices. RESULTS: A total of 60 patients, 20 nurses, 3 physician assistants, and 6 medical doctors were interviewed. We identified 47 positive and 30 negative effects and 19 facilitators and 36 barriers for the use of VM and HP. Frequently mentioned topics included earlier identification of clinical deterioration, increased feelings of safety, and VM lines and electrodes. No differences related to psychological distress and usability were found between randomization groups or devices. CONCLUSIONS: Both devices were well received by most patients and health care professionals, and the majority of them encouraged the idea of monitoring vital signs continuously in the general ward. This comprehensive overview of barriers and facilitators of using wireless devices may serve as a guide for future researchers, developers, and health care institutions that consider implementing continuous monitoring in the ward. TRIAL REGISTRATION: Clinicaltrials.gov NCT02933307; http://clinicaltrials.gov/ct2/show/NCT02933307.

Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review.

BACKGROUND: The growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions. METHODS: Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects. RESULTS: Of the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician. CONCLUSION: Inter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention's effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures. TRIAL REGISTRATION: The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).

Prevention of and dealing with poor performance: an interview study about how professional associations aim to support healthcare professionals.

OBJECTIVE: To explore how professional associations of nine healthcare professions aim to support professionals to prevent and deal with poor performance. DESIGN: Qualitative interview study. SETTING: The Netherlands. PARTICIPANTS: Representatives of professional associations for dentists, general practitioners, medical specialists, midwives, nurses, pharmacists, physiotherapists, psychologists and psychotherapists. INTERVENTIONS: During nine face-to-face semi-structured interviews we asked how associations aim to support professionals in prevention of and dealing with poor performance. Following the first interview, we monitored new initiatives in support over a 2.5-year period, after which we conducted a second interview. Interviews were analysed using thematic analysis. MAIN OUTCOME MEASURES: Available policy and support regarding poor performance. RESULTS: Three themes emerged from our data (i.e. elaborating on professional performance, performance insight and dealing with poor performance) for which we identified a total of 10 categories of support. Support concerned professional codes, guidelines and codes of conduct, quality registers, individual performance assessment, peer consultation, practice evaluation, helpdesk and expert counselling, a protocol for dealing with poor performance, a place for support and to report poor performance, and internal disciplinary procedures. CONCLUSIONS: This study provides an overview of support given to nine healthcare professions by their associations regarding poor performance, and identifies gaps that associations could follow up on, such as clarifying what to do when confronted with a poorly performing colleague, supporting professionals that poorly perform, and developing methods for individual performance assessment to gain performance insight. A next step would be to evaluate the use and effect of different types of support.

Improving patient discharge and reducing hospital readmissions by using Intervention Mapping.

BACKGROUND: There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge. METHODS: The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance. RESULTS: Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change. CONCLUSIONS: This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

Can quality from a care ethical perspective be assessed? A review.

BACKGROUND: Ethics-of-care theories contain important notions regarding the quality of care; however, until now, concrete translations of the insights into instruments are lacking. This may be a result of the completely different type of epistemology, theories and concepts used in the field of quality of care research. OBJECTIVES: Both the fields of 'ethics of care' and 'quality of care' aim for improvement of care; therefore; insights could possibly meet by focusing on the following question: How could ethics-of-care theories contribute to better quality in care at a measurement level? This study reviews existing instruments with the aim of bridging this gap and examines the evidence of their psychometric properties, feasibility and responsiveness. RESEARCH DESIGN: A systematic search of the literature was undertaken using multiple electronic databases covering January 1990 through May 2012. METHOD AND FINDINGS: Of the 3427 unique references identified, 55 studies describing 40 instruments were selected. Using a conceptual framework, an attempt was made to distinguish between related concepts and to group available instruments measuring different types of concepts. A total of 13 instruments that reflect essential aspects of ethics-of-care theory were studied in greater detail, and a quality assessment was conducted. CONCLUSION: Three promising qualitative instruments were found, which follow the logic of the patient and take their specific context into account.

Improving patient care transitions from the intensive care unit to the ward by learning from everyday practice. A multicenter qualitative study.

OBJECTIVE: To explore and describe the everyday practices (Work-As-Done) that hinder and facilitate patient care transitions from the intensive care unit (ICU) to the ward. RESEARCH METHOD/DESIGN: Multiple qualitative case studies in the ICU and various specialized wards of three Dutch hospitals. Adult patients planned to be transferred were purposively sampled on a variety of characteristics along with their relative (if present), and the ICU and ward nurses who were involved in the transition process. Data were collected by using multiple sources (i.e., observations, semi-structured interviews and a qualitative survey) and then systematically analyzed using the thematic analysis approach until saturation was reached. FINDINGS: Twenty-six cases were studied. For each case, the actual transfer was observed. Sixteen patients, five relatives and 36 nurses were interviewed. Two patients completed the survey. Fifteen themes emerged from the data, showing that the quality of transitions is influenced by the extent to which nurses anticipate to patient-specific needs (e.g., providing timely and adequate information, orientation, mental support and aftercare) and to the needs of the counterpart to continue care (e.g., by preparing handovers) besides following standard procedures. Data also show that procedures sometimes interfere with what works best in practice (e.g., communication via a liaison service instead of direct communication between ICU and ward nurses). CONCLUSIONS: Subtle, non-technical nursing skills play an important role in comforting patients and in the coordination of care when patients are transferred from the ICU to the ward. IMPLICATIONS FOR CLINICAL PRACTICE: These Work-As-Done findings and their underlying narratives, that are often overlooked when focusing on quality improvement, can be used as material to reflect on own practice and raise awareness for its impact on patients. They may stimulate healthcare staff in crafting interventions for optimizing the transition process.

Consensus-based indicators for evaluating and improving the quality of regional collaborative networks of intensive care units: Results of a nationwide Delphi study.

PURPOSE: To select a consensus-based set of relevant and feasible indicators for monitoring and improving the quality of regional ICU network collaboratives. METHODS: A three-round Delphi study was conducted in the Netherlands between April and July 2022. A multidisciplinary expert panel prioritized potentially relevant and feasible indicators in two questionnaire rounds with two consensus meetings between both rounds. The RAND/UCLA appropriateness method was used to categorize indicators and synthesize results. A core set of highest ranked indicators with consensus-based levels of relevance and feasibility were finally tested in two ICU networks to assess their measurability. RESULTS: Twenty-four indicators were deemed as relevant and feasible. Seven indicators were selected for the core set measuring the standardized mortality rate in the region (n = 1) and evaluating the presence, content and/or follow-up of a formal plan describing network structures and policy agreements (n = 3), a long-term network vision statement (n = 1), and network meetings to reflect on and learn from outcome data (n = 2). The practice tests led to minor reformulations. CONCLUSIONS: This study generated relevant and feasible indicators for monitoring and improving the quality of ICU network collaboratives based on the collective opinion of various experts. The indicators may help to effectively govern such networks.

Reducing administrative burden by implementing a core set of quality indicators in the ICU: a multicentre longitudinal intervention study.

BACKGROUND: The number of quality indicators for which clinicians need to record data is increasing. For many indicators, there are concerns about their efficacy. This study aimed to determine whether working with only a consensus-based core set of quality indicators in the intensive care unit (ICU) reduces the time spent on documenting performance data and administrative burden of ICU professionals, and if this is associated with more joy in work without impacting the quality of ICU care. METHODS: Between May 2021 and June 2023, ICU clinicians of seven hospitals in the Netherlands were instructed to only document data for a core set of quality indicators. Time spent on documentation, administrative burden and joy in work were collected at three time points with validated questionnaires. Longitudinal data on standardised mortality rates (SMR) and ICU readmission rates were gathered from the Dutch National Intensive Care registry. Longitudinal effects and differences in outcomes between ICUs and between nurses and physicians were statistically tested. RESULTS: A total of 390 (60%), 291 (47%) and 236 (40%) questionnaires returned at T0, T1 and T2. At T2, the overall median time spent on documentation per day was halved by 30 min (p<0.01) and respondents reported fewer unnecessary and unreasonable administrative tasks (p<0.01). Almost one-third still experienced unnecessary administrative tasks. No significant changes over time were found in joy in work, SMR and ICU readmission. CONCLUSIONS: Implementing a core set of quality indicators reduces the time ICU clinicians spend on documentation and administrative burden without negatively affecting SMR or ICU readmission rates. Time savings can be invested in patient care and improving joy in work in the ICU.

Organizational culture: an important context for addressing and improving hospital to community patient discharge.

BACKGROUND: Organizational culture is seen as having a growing impact on quality and safety of health care, but its impact on hospital to community patient discharge is relatively unknown. OBJECTIVES: To explore aspects of organizational culture to develop a deeper understanding of the discharge process. RESEARCH DESIGN: A qualitative study of stakeholders in the discharge process. Grounded Theory was used to analyze the data. SUBJECTS: In 5 European Union countries, 192 individual and 25 focus group interviews were conducted with patients and relatives, hospital physicians, hospital nurses, general practitioners, and community nurses. RESULTS: Three themes emerged representing aspects of organizational culture: a fragmented hospital to primary care interface, undervaluing administrative tasks relative to clinical tasks in the discharge process, and lack of reflection on the discharge process or process improvement. Nine categories were identified: inward focus of hospital care providers, lack of awareness to needs, skills, and work patterns of the professional counterpart, lack of a collaborative attitude, relationship between hospital and primary care providers, providing care in a "here and now" situation, administrative work considered to be burdensome, negative attitude toward feedback, handovers at discharge ruled by habits, and appreciating and integrating new practices. CONCLUSIONS: On the basis of the data, we hypothesize that the extent to which hospital care providers value handovers and the outreach to community care providers is critical to effective hospital discharge. Community care providers often are insufficiently informed about patient outcomes. Ongoing challenges with patient discharge often remain unspoken with opportunities for improvement overlooked. Interventions that address organizational culture as a key factor in discharge improvement efforts are needed.

Quality and safety of hospital discharge: a study on experiences and perceptions of patients, relatives and care providers.

OBJECTIVE: To identify barriers experienced and perceived at discharge by physicians, nurses, patients and relatives. DESIGN: We developed questionnaires based on focus group interviews with hospital and community care providers, and individual interviews with patients and relatives. A survey was conducted among patients, relatives and related nurses and physicians from hospital and community care. SETTING: One university hospital and the related community care area in the Netherlands. PARTICIPANTS: Thirty health-care providers and eight patients and/or relatives participated in focus group and individual interviews. Questionnaires were returned by 344 health-care providers and 206 patients and relatives. RESULTS: Information from the hospital to community care is often incomplete, unclear and delayed. Especially hospital physicians (52%) and general practitioners (GPs; 63%) experience the quality of information exchanged from the hospital to the GP as poor. Coordination of care is often frustrated by a lack of care provider knowledge and collaboration. Hospital physicians (47%) and GPs (71%) feel that hospital physicians are often not sufficiently aware of the patient's home situation. Respectively, 59 and 81% experience that the GP is often not clearly informed about expected tasks and responsibilities at discharge. CONCLUSIONS: This is the first study that provides a clear picture of the experiences and perceptions of stakeholders regarding handovers at hospital discharge. Lack of knowledge, understanding and interest between hospital and community care providers are important causes for ineffective and unsafe discharge. The study suggests that improvement efforts should be focused more on these aspects, as primary conditions for improving hospital discharge.

Improving patient handovers from hospital to primary care: a systematic review.

BACKGROUND: Evidence shows that suboptimum handovers at hospital discharge lead to increased rehospitalizations and decreased quality of health care. PURPOSE: To systematically review interventions that aim to improve patient discharge from hospital to primary care. DATA SOURCES: PubMed, CINAHL, PsycInfo, the Cochrane Library, and EMBASE were searched for studies published between January 1990 and March 2011. STUDY SELECTION: Randomized, controlled trials of interventions that aimed to improve handovers between hospital and primary care providers at hospital discharge. DATA EXTRACTION: Two reviewers independently abstracted data on study objectives, setting and design, intervention characteristics, and outcomes. Studies were categorized according to methodological quality, sample size, intervention characteristics, outcome, statistical significance, and direction of effects. DATA SYNTHESIS: Of the 36 included studies, 25 (69.4%) had statistically significant effects in favor of the intervention group and 34 (94.4%) described multicomponent interventions. Effective interventions included medication reconciliation; electronic tools to facilitate quick, clear, and structured summary generation; discharge planning; shared involvement in follow-up by hospital and community care providers; use of electronic discharge notifications; and Web-based access to discharge information for general practitioners. Statistically significant effects were mostly found in reducing hospital use (for example, rehospitalizations), improvement of continuity of care (for example, accurate discharge information), and improvement of patient status after discharge (for example, satisfaction). LIMITATIONS: Heterogeneity of the interventions and study characteristics made meta-analysis impossible. Most studies had diffuse aims and poor descriptions of the specific intervention components. CONCLUSION: Many interventions have positive effects on patient care. However, given the complexity of interventions and outcome measures, the literature does not permit firm conclusions about which interventions have these effects. PRIMARY FUNDING SOURCE: The European Union, the Framework Programme of the European Commission.

Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review.

OBJECTIVE: Suboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults. DESIGN: Systematic review. MEASUREMENTS: We searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest. RESULTS: From the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low. CONCLUSIONS: Comprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes. PROSPERO REGISTRATION NUMBER: CRD42021237345.