Digital home care interventions and quality of primary care for older adults: a scoping review.

BACKGROUND: Population aging is forcing the transformation of health care. Long-term care in the home is complex and involves complex communication with primary care services. In this scenario, the expansion of digital health has the potential to improve access to home-based primary care; however, the use of technologies can increase inequalities in access to health for an important part of the population. The aim of this study was to identify and map the uses and types of digital health interventions and their impacts on the quality of home-based primary care for older adults. METHODS: This is a broad and systematized scoping review with rigorous synthesis of knowledge directed by the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The quantitative data were analyzed through descriptive statistics, and the qualitative data were analyzed through basic qualitative content analysis, considering the organizational, relational, interpersonal and technical dimensions of care. The preliminary results were subjected to consultation with stakeholders to identify strengths and limitations, as well as potential forms of socialization. RESULTS: The mapping showed the distribution of publications in 18 countries and in the Sub-Saharan Africa region. Older adults have benefited from the use of different digital health strategies; however, this review also addresses limitations and challenges, such as the need for digital literacy and technological infrastructure. In addition to the impacts of technologies on the quality of health care. CONCLUSIONS: The review gathered priority themes for the equitable implementation of digital health, such as access to home caregivers and digital tools, importance of digital literacy and involvement of patients and their caregivers in health decisions and design of technologies, which must be prioritized to overcome limitations and challenges, focusing on improving quality of life, shorter hospitalization time and autonomy of older adults.

The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review.

BACKGROUND: The central component in impactful healthcare decisions is evidence. Understanding how nurse leaders use evidence in their own managerial decision making is still limited. This mixed methods systematic review aimed to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurse leaders and their performance, organizational, and clinical outcomes. METHODS: We included articles using any type of research design. We referred nurses, nurse managers or other nursing staff working in a healthcare context when they attempt to influence the behavior of individuals or a group in an organization using an evidence-based approach. Seven databases were searched until 11 November 2021. JBI Critical Appraisal Checklist for Quasi-experimental studies, JBI Critical Appraisal Checklist for Case Series, Mixed Methods Appraisal Tool were used to evaluate the Risk of bias in quasi-experimental studies, case series, mixed methods studies, respectively. The JBI approach to mixed methods systematic reviews was followed, and a parallel-results convergent approach to synthesis and integration was adopted. RESULTS: Thirty-one publications were eligible for the analysis: case series (n = 27), mixed methods studies (n = 3) and quasi-experimental studies (n = 1). All studies were included regardless of methodological quality. Leadership problems were related to the implementation of knowledge into practice, the quality of nursing care and the resource availability. Organizational data was used in 27 studies to understand leadership problems, scientific evidence from literature was sought in 26 studies, and stakeholders' views were explored in 24 studies. Perceived and measured effects of evidence-based leadership focused on nurses' performance, organizational outcomes, and clinical outcomes. Economic data were not available. CONCLUSIONS: This is the first systematic review to examine how evidence is used to solve leadership problems and to describe its measured and perceived effects from different sites. Although a variety of perceptions and effects were identified on nurses' performance as well as on organizational and clinical outcomes, available knowledge concerning evidence-based leadership is currently insufficient. Therefore, more high-quality research and clinical trial designs are still needed. TRAIL REGISTRATION: The study was registered (PROSPERO CRD42021259624).

Measuring the quality of skin cancer management in primary care: A scoping review.

Skin cancer is a growing global problem and a significant health and economic burden. Despite the practical necessity for skin cancer to be managed in primary care settings, little is known about how quality of care is or should be measured in this setting. This scoping review aimed to capture the breadth and range of contemporary evidence related to the measurement of quality in skin cancer management in primary care settings. Six databases were searched for relevant texts reporting on quality measurement in primary care skin cancer management. Data from 46 texts published since 2011 were extracted, and quality measures were catalogued according to the three domains of the Donabedian model of healthcare quality (structure, process and outcome). Quality measures within each domain were inductively analysed into 13 key emergent groups. These represented what were deemed to be the most relevant components of skin cancer management as related to structure, process or outcomes measurement. Four groups related to the structural elements of care provision (e.g. diagnostic tools and equipment), five related to the process of care delivery (e.g. diagnostic processes) and four related to the outcomes of care (e.g. poor treatment outcomes). A broad range of quality measures have been documented, based predominantly on articles using retrospective cohort designs; systematic reviews and randomised controlled trials were limited.

Intra- and Extra-Hospitalization Monitoring of Vital Signs-Two Sides of the Same Coin: Perspectives from LIMS and Greenline-HT Study Operators.

BACKGROUND: In recent years, due to the epidemiological transition, the burden of very complex patients in hospital wards has increased. Telemedicine usage appears to be a potential high-impact factor in helping with patient management, allowing hospital personnel to assess conditions in out-of-hospital scenarios. METHODS: To investigate the management of chronic patients during both hospitalization for disease and discharge, randomized studies (LIMS and Greenline-HT) are ongoing in the Internal Medicine Unit at ASL Roma 6 Castelli Hospital. The study endpoints are clinical outcomes (from a patient's perspective). In this perspective paper, the main findings of these studies, from the operators' point of view, are reported. Operator opinions were collected from structured and unstructured surveys conducted among the staff involved, and their main themes are reported in a narrative manner. RESULTS: Telemonitoring appears to be linked to a reduction in side-events and side-effects, which represent some of most commons risk factors for re-hospitalization and for delayed discharge during hospitalization. The main perceived advantages are increased patient safety and the quick response in case of emergency. The main disadvantages are believed to be related to low patient compliance and an infrastructural lack of optimization. CONCLUSIONS: The evidence of wireless monitoring studies, combined with the analysis of activity data, suggests the need for a model of patient management that envisages an increase in the territory of structures capable of offering patients subacute care (the possibility of antibiotic treatments, blood transfusions, infusion support, and pain therapy) for the timely management of chronic patients in the terminal phase, for which treatment in acute wards must be guaranteed only for a limited time for the management of the acute phase of their diseases.

The Roadmap for Implementing Value-Based Healthcare in European University Hospitals-Consensus Report and Recommendations.

OBJECTIVES: Value-based healthcare (VBHC) aims at improving patient outcomes while optimizing the use of hospitals' resources among medical personnel, administrations, and support services through an evidence-based, collaborative approach. In this article, we present a blueprint for the implementation of VBHC in hospitals, based on our experience as members of the European University Hospital Alliance. METHODS: The European University Hospital Alliance is a consortium of 9 large hospitals in Europe and aims at increasing the quality and efficiency of care to ultimately drive better outcomes for patients. RESULTS: The blueprint describes how to prepare hospitals for VBHC implementation; analyzes gaps, barriers, and facilitators; and explores the most effective ways to turn patient pathways into a process that results in high-value care. Using a patient-centric approach, we identified 4 core minimum components that must be established as cornerstones and 7 organizational enablers to waive the barriers to implementation and ensure sustainability. CONCLUSION: The blueprint guides through pathway implementation and establishment of key performance indicators in 6 phases, which hospitals can tailor to their current status on their way to implement VBHC.

Implementing multidisciplinary tumor boards in oncology: a narrative review.

The healthcare industry compares unfavorably with other ultra-safe industries such as aviation and nuclear power plants, which address complexity by reducing the vulnerability of a single person and promoting teams and strong systems. A multidisciplinary tumor board (MTB) is an evidence-based organizational approach to implementing a more effective concept in oncology practice. Studies addressing the correlation between MTBs and cancer outcomes show promising results, and other potential benefits are also addressed. The objectives of this article are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs effectiveness and address challenges to the implementation and maintenance of MTBs. In this commentary-type narrative review, the authors present their opinions and, whenever possible, substantiate recommendations by citing supportive literature.

Lay abstract Compared with other ultra-safe industries such as aviation and nuclear power plants, the healthcare industry operates with lower safety standards. Multidisciplinary tumor boards (MTBs) are regular meetings of various specialist doctors and other health professionals involved in cancer care to discuss cases of patients with cancer. MTBs are considered valuable tools to promote the quality of care in oncology by reducing the vulnerability of a single person and promoting teams and strong systems. Studies have shown that MTBs correlate with better treatment results, and other potential benefits are also addressed. The objectives of this paper are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs and address challenges to the implementation and maintenance of MTBs. The authors substantiate their views with literature citations where possible.

Cross-sectional study on the role of public awareness in preventing the spread of COVID-19 outbreak in India.

BACKGROUND: WHO has recommended personal hygiene (respiratory hygiene, using face masks, washing hands with warm water and soap, use of alcohol-based hand sanitizers, avoid touching mouth, eyes & nose, cleanliness), social distancing and careful handling of purchased products as an effective preventive measure for COVID-19 disease. The growing pandemic of COVID-19 disease requires social distancing and personal hygiene measures to protect public health. But this message is not clear and well understood among people. The aim of this study is to determine the awareness, knowledge and attitude about COVID-19 and relate the behaviour of Indian society, especially when the country is restarting all its economic activities, after the complete lockdown. METHOD: The present paper is based on an extensive survey among 21 406 adult participants of various sections of Indian society with different age groups between 18 and 80 years to introspect the level of public awareness with respect to cause, spread, prevention and treatment of disease caused by spread of COVID-19 viral outbreak, which will be automatically reflected in the societal behavioural response of rigorous precautionary measures. CONCLUSIONS: There is a need to extend the knowledge base among individuals to enhance their active participation in the prevention mechanisms with respect to the spread of the pandemic. There is a need to elaborate the Indian socio-cultural aspects, so that society starts appreciating and voluntarily following social distancing. This should improve the adaptability of people with livelihood resilience to let them protect themselves not only from the present pandemic but also from all other unforeseen infections, and to provide care to patients.

Balancing adaptation and innovation for resilience in healthcare - a metasynthesis of narratives.

BACKGROUND: Adaptation and innovation are both described as instrumental for resilience in healthcare. However, the relatedness between these dimensions of resilience in healthcare has not yet been studied. This study seeks to develop a conceptual understanding of adaptation and innovation as a basis for resilience in healthcare. The overall aim of this study is therefore to explore how adaptation and innovation can be described and understood across different healthcare settings. To this end, the overall aim will be investigated by identifying what constitutes adaptation and innovation in healthcare, the mechanisms involved, and what type of responses adaptation and innovation are associated with. METHODS: The method used to develop understanding across a variety of healthcare contexts, was to first conduct a narrative inquiry of a comprehensive dataset from various empirical settings (e.g., maternity, transitional care, telecare), that were later analysed in accordance with grounded theory. Narrative inquiry provided a contextually informed synthesis of the phenomenon, while the use of grounded theory methodology allowed for cross-contextual comparison of adaptation and innovation in terms of resilience in healthcare. RESULTS: The results identified an imbalance between adaptation and innovation. If short-term adaptations are used too extensively, they may mask system deficiencies and furthermore leave the organization vulnerable, by relying too much on the efforts of a few individuals. Hence, short-term adaptations may end up a barrier for resilience in healthcare. Long-term adaptations and innovation of products, processes and practices proved to be of a lower priority, but had the potential of addressing the flaws of the system by proactively re-organizing and re-designing routines and practices. CONCLUSIONS: This study develops a new conceptual account of adaptation and innovation as a basis for resilience in healthcare. Findings emerging from this study indicate that a balance between adaptation and innovation should be sought when seeking resilience in healthcare. Adaptations can furthermore be divided into short-term and long-term adaptations, creating the need to balance between these different types of adaptations. Short-term adaptations that adopt the pattern of firefighting can risk generating complex and unintended outcomes, but where no significant changes are made to organization of the system. Long-term adaptations, on the other hand, introduce re-organization of the system based on feedback, and therefore can provide a proactive response to system deficiencies. We propose a pattern of adaptation in resilience in healthcare: from short-term adjustments, to long-term reorganizations, to innovations.

Improving postoperative mobilisation rates in patients undergoing elective major hepatopancreatobiliary surgery.

BACKGROUND: Early mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives. OBJECTIVES: The primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months. METHODS: We report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan-Do-Study-Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay. RESULTS: Mobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay. CONCLUSION: Multidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

Completeness and quality of text paging for subspecialty consult requests.

It is unclear whether previously developed frameworks for effective consultation apply to requests initiated by alphanumeric text page. We assessed a random sample of 210 text paged consult requests for communication of previously described 'essential elements' for effective consultation: reason for consult, level of urgency and requester contact information. Overall page quality was evaluated on a 5-point Likert scale. Over 90% of text paged consult requests included contact information and reason for consult; 14% indicated level of urgency. In ordinal logistic regression, reason for consult was most strongly associated with quality (OR 22.4; 95% CI 8.1 to 61.7), followed by callback number (OR 6.2; 95% CI 0.8 to 49.5), caller's name (OR 5.0; 95% CI 1.9 to 13.1) and level of urgency (OR 3.3; 95% CI 1.6 to 6.7). Results suggest that text paged consult requests often include most informational elements, and that urgency, often missing, may not be as 'essential' for text pages as it was once thought to be.

Antibiotic prescriptions by medical interns in Hong Kong: influence of the hospital settings and prescription culture.

BACKGROUND: Inappropriate antibiotic prescribing practices predispose to resistance emergence. Despite the inclusion of the topic in medical school curricula worldwide, it is uncertain whether newly graduated medical interns have confidence in proper antibiotic prescription. OBJECTIVES: This study aimed to explore the antibiotic prescribing behaviours of the medical interns in Hong Kong and their barriers to appropriate antibiotic prescription. METHODS: Two focus groups were conducted among medical interns with training experiences in different public hospitals. Their prescribing behaviours and barriers were further examined with a questionnaire survey just before completion of internship. RESULTS: Focus group interviews identified a variety of hospital workplace cultures, including inappropriate empirical prescriptions and dosages, interns' passive roles in prescribing antibiotics and varied guidelines between different departments. Defensive medicine and lack of clinical experience were other barriers encountered. The interns believed that the incorrect practice learnt would perpetuate in their minds and affect their future practice. The top barriers reported by the survey respondents were adaptation to prescription culture of different hospitals (93.5%), lack of experience in antibiotic prescription (88.3%), inadequate knowledge in the choice of antibiotics (85.7%) and compliance with the seniors' instructions (80.6%). However, some focus group participants perceived weaker barriers in paediatric departments which provided close monitoring of antibiotic use. CONCLUSIONS: Inadequate knowledge and low confidence in antibiotic prescription led to the passive role of medical interns in antibiotic prescription, predisposing to future inappropriate practice. Inconsistent guidelines and prescription cultures between different hospitals and departments might further exacerbate their barriers.

Value configurations for balancing standardization and customization in chronic care: a qualitative study.

BACKGROUND: Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations - shop, chain, and network - has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions. METHODS: A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach. RESULTS: Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process. CONCLUSIONS: The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors.

PURPOSE: To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade. STUDY DESIGN: We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative. RESULTS: We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005). CONCLUSIONS: Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

Patient safety culture in Polish Primary Healthcare Centers.

OBJECTIVE: To examine patient safety culture in primary healthcare centers in Poland. DESIGN: A cross-sectional survey conducted in 2017 using the questionnaire based on the 'Medical Office Survey on Patient Safety Culture' from Agency for Healthcare Research and Quality (AHRQ). SETTING: Three hundred thirty-seventy primary healthcare centers in Poland. PARTICIPANTS: Family physician practices in Poland selected from the population of 5400 using systematic random sampling. The response rate was 62%. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The survey includes 38 items that measured 10 dimensions of patient safety culture and questions referring to information exchange with other settings, quality issues and overall ratings on quality and safety. Mean percent positive scores on all items in each composite were calculated according to user's guide. RESULTS: Individual domains of patient safety culture had better scores among younger respondents and respondents with job seniority at their clinic under 10 years. Patient safety culture scores correlated with size and location (urban or rural) of studied centers, as well as with respondents' gender. The most highly ranked domains were: organizational learning (87.05% of positive scores), teamwork (84.91%), overall perception of patient safety and quality (84.77%) and leadership support for patient safety (84.30%) while the lowest ranked ones were: patient care tracking and follow-up (65.11%), work pressure and pace (57.77%). Other domains such as communication openness (80.96%), staff training (78.90%), office processes and standardization (71.92%) and communication about error (69.80%) ranked between. CONCLUSIONS: Patient safety culture in primary healthcare centers in Poland was evaluated positively.

Futility and appropriateness: challenging words, important concepts.

The provision of healthcare is being challenged by a 'perfect storm' of forces including an increasing population with multiple comorbidities, high expectations and resource limitations, and in the background, the pre-eminence of the 'curative medical model'. Non-beneficial (futile) treatments are wasteful and costly. They have a negative impact on quality of life especially in the last year of life. Among professionals, frequent encounters with futility cause moral distress and demoralisation. The factors that drive non-beneficial treatments include personal biases, patient-related pressures and institutional imperatives. Breaking loose from the perceived necessity to deliver non-beneficial treatment is a major challenge. Curative intent should give way to appropriateness such that curative and palliative interventions are valued equally. Goals of treatment should be shaped by illness trajectory, the risk of harms as well as potential benefits and patient preferences. This strategy should be reflected in professional training and the design of acute services.

Physician alert: the legal risks associated with 'on-call' duties in the USA.

On-call physicians encounter a diverse aggregate of interfaces with sundry persons concerning patient care that may surface potential legal peril. The duties and obligations of an on-call physician, who must act as a fiduciary to all patients, create a myriad of circumstances where there is a risk of falling prey to legal ambiguities. The understanding of the doctor-patient relationship, the obligations of physicians under the Emergency Medical Treatment and Labor Act, the meaning of medical informed consent and the elements of negligence will help physicians avoid the legal risk associated with the various encounters of being on call. After introducing the legal concepts, we will explore the interactions that may put physicians at legal risk and outline how to mitigate that risk. Being on call is time consuming and arduous. While on call, physicians have a duty to act morally and ethically in the best interest of the patients.