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Information sharing between intensive care and primary care after an episode of critical illness; A mixed methods analysis.

ABSTRACT: INTRODUCTION:Poor quality communication between hospital doctors and GPs at the time of hospital discharge is associated with adverse patient outcomes. This may be more marked after an episode of critical illness, the complications of which can persist long after hospital discharge. AIMS:1. to evaluate information sharing between ICU staff and GPs after a critical illness 2. to identify factors influencing the flow and utilisation of this information. METHODS:Parallel mixed methods observational study in an Irish setting, with equal emphasis on quantitative and qualitative data. Descriptive analysis was performed on quantitative data derived from GP and ICU consultant questionnaires. Qualitative data came from semi-structured interviews with GPs and consultants, and were analysed using directed content analysis. Mixing of data occurred at the stage of interpretation. RESULTS:GPs rarely received information about an episode of critical illness directly from ICU staff, with most coming from patients and relatives. Information received from hospital sources was frequently brief and incomplete. Common communication barriers reported by consultants were insufficient time, low perceived importance and difficulty establishing GP contact. When provided information, GPs seldom actioned specific interventions, citing insufficient guidance in hospital correspondence and poor knowledge about critical illness complications and their management. A majority of all respondents thought that improved information sharing would benefit patients. Cultural influences on practice were identified in qualitative data. A priori qualitative themes were: (1) perceived benefits of information sharing, (2) factors influencing current practice and (3) strategies for optimal information sharing. Emergent themes were: (4) the central role of the GP in patient care, (5) the concept of the "whole patient journey" and (6) a culture of expectation around a GP's knowledge of hospital care. CONCLUSIONS:Practical and cultural factors contribute to suboptimal information sharing between ICU and primary care doctors around an episode of critical illness in ICU. We propose a three-milestone strategy to improve the flow and utilisation of information when patients are admitted, discharged or die within the ICU.

SUBMITTER: Zilahi G

PROVIDER: S-EPMC6394993 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundSparse relative effectiveness evidence is a frequent problem in Health Technology Assessment (HTA). Where evidence directly pertaining to the decision problem is sparse, it may be feasible to expand the evidence-base to include studies that relate to the decision problem only indirectly: for instance, when there is no evidence on a comparator, evidence on other treatments of the same molecular class could be used; similarly, a decision on children may borrow-strength from evidence on adults. Usually, in HTA, such indirect evidence is either included by ignoring any differences ('lumping') or not included at all ('splitting'). However, a range of more sophisticated methods exists, primarily in the biostatistics literature. The objective of this study is to identify and classify the breadth of the available information-sharing methods.MethodsForwards and backwards citation-mining techniques were used on a set of seminal papers on the topic of information-sharing. Papers were included if they specified (network) meta-analytic methods for combining information from distinct populations, interventions, outcomes or study-designs.ResultsOverall, 89 papers were included. A plethora of evidence synthesis methods have been used for information-sharing. Most papers (n=79) described methods that shared information on relative treatment effects. Amongst these, there was a strong emphasis on methods for information-sharing across multiple outcomes (n=42) and treatments (n=25), with fewer papers focusing on study-designs (n=23) or populations (n=8). We categorise and discuss the methods under four 'core' relationships of information-sharing: functional, exchangeability-based, prior-based and multivariate relationships, and explain the assumptions made within each of these core approaches.ConclusionsThis study highlights the range of information-sharing methods available. These methods often impose more moderate assumptions than lumping or splitting. Hence, the degree of information-sharing that they impose could potentially be considered more appropriate. Our identification of four 'core' methods of information-sharing allows for an improved understanding of the assumptions underpinning the different methods. Further research is required to understand how the methods differ in terms of the strength of sharing they impose and the implications of this for health care decisions.

Project description:Operating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process.The Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment: We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants' impressions about the current process. Adaptation and implementation: We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process' feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units.Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process.The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability.The HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients.ClinicalTrials.gov identifier: NCT02267174. Date of registration October 16, 2014.

Project description:INTRODUCTION:Patients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance is required. Performance scorecards are used by institutions for the purposes of driving quality improvement. There is no widely accepted or standardised scorecard that has been used for overall CCM performance. We aim to improve quality of care, patient safety and patient/family experience in CCM practice through the utilisation of a standardised, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics. METHODS AND ANALYSIS:This will be a mixed-methods, controlled before and after study to assess the impact of a CCM-specific quality scorecard. Scorecard metrics were developed through expert consensus and existing literature. The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation are collected daily from bedside flow sheets. Preintervention baseline data will be collected for 6 months for each participant. After this, each participant will receive their scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics following the provision of scorecard feedback to subjects. A cost analysis will also be performed, with the purpose of comparing total ICU costs prior to implementation of the scorecard with total ICU costs following implementation of the scorecard. The qualitative portion will include interviews with participants following the intervention phase. Interviews will be analysed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement. ETHICS AND DISSEMINATION:This protocol has been approved by the local research ethics board. Publication of results is anticipated in 2019. If this intervention is found to improve patient- and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilisation of such a scorecard as a quality standard in CCM.

Project description:OBJECTIVES:To describe the frequency of co-occurring newly acquired cognitive impairment, disability in activities of daily livings, and depression among survivors of a critical illness and to evaluate predictors of being free of post-intensive care syndrome problems. DESIGN:Prospective cohort study. SETTING:Medical and surgical ICUs from five U.S. centers. PATIENTS:Patients with respiratory failure or shock, excluding those with preexisting cognitive impairment or disability in activities of daily livings. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:At 3 and 12 months after hospital discharge, we assessed patients for cognitive impairment, disability, and depression. We categorized patients into eight groups reflecting combinations of cognitive, disability, and mental health problems. Using multivariable logistic regression, we modeled the association between age, education, frailty, durations of mechanical ventilation, delirium, and severe sepsis with the odds of being post-intensive care syndrome free. We analyzed 406 patients with a median age of 61 years and an Acute Physiology and Chronic Health Evaluation II of 23. At 3 and 12 months, one or more post-intensive care syndrome problems were present in 64% and 56%, respectively. Nevertheless, co-occurring post-intensive care syndrome problems (i.e., in two or more domains) were present in 25% at 3 months and 21% at 12 months. Post-intensive care syndrome problems in all three domains were present in only 6% at 3 months and 4% at 12 months. More years of education was associated with greater odds of being post-intensive care syndrome free (p < 0.001 at 3 and 12 mo). More severe frailty was associated with lower odds of being post-intensive care syndrome free (p = 0.005 at 3 mo and p = 0.048 at 12 mo). CONCLUSIONS:In this multicenter cohort study, one or more post-intensive care syndrome problems were present in the majority of survivors, but co-occurring problems were present in only one out of four. Education was protective from post-intensive care syndrome problems and frailty predictive of the development of post-intensive care syndrome problems. Future studies are needed to understand better the heterogeneous subtypes of post-intensive care syndrome and to identify modifiable risk factors.

Project description:BackgroundAntimicrobial resistance is an important global health issue. In Germany, the national agenda supports various interventions to convert habits of antibiotic use. In the CHANGE-3 (Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care) study, digital tools were applied for information delivery: tablet computers in primary care practices, e-learning platforms for medical professionals, and a public website to promote awareness and health literacy among primary care physicians, their teams, and their patients.ObjectiveThis study is embedded in the process evaluation of the CHANGE-3 study. The aim of this study was to evaluate the acceptance and uptake of digital devices for the delivery of health-related information to enhance awareness and change habits of antibiotic use in primary care in Germany.MethodsThis study used a convergent-parallel mixed-methods design. Audio-recorded semistructured telephone interviews were conducted with physicians, nonphysician health professionals, and patients in the CHANGE-3 program. Pseudonymized verbatim transcripts were coded using thematic analysis. In-depth analysis was performed based on the inductive category of information provision via digital information tools. Identified themes were related to the main postulates of Diffusion of Innovations theory (DIT) to provide an explanatory frame. In addition, data generated through a structured survey with physicians and nonphysician health professionals in the program were analyzed descriptively and integrated with the qualitative data to explore the complementarity of the findings.ResultsFindings regarding the acceptance and uptake of digital devices were related to three postulates of DIT: innovation characteristics, communication channels, and unanticipated consequences. Participants considered the provided digital educative solutions to be supportive for promoting health literacy regarding conversion of habits of antibiotic use. However, health care professionals found it challenging to integrate these solutions into existing routines in primary care and to align them with their professional values. Low technology affinity was a major barrier to the use of digital information in primary care. Patients welcomed the general idea of introducing health-related information in digital formats; however, they expressed concerns about device-related hygiene and the appropriateness of the digital tools for older patients.ConclusionsPatients and medical professionals in German primary care are reluctant to use digital devices for information and education. Using a Diffusion of Innovations approach can support assessment of existing barriers and provide information about setting-specific preconditions that are necessary for future tailoring of implementation strategies.Trial registrationInternational Standard Randomized Controlled Trial Number (ISRCTN) 15061174; http://www.isrctn.com/ISRCTN15061174.

Project description:BackgroundImmersive virtual reality (VR) is a promising therapy to improve the experience of patients with critical illness and may help avoid postdischarge functional impairments. However, the determinants of interest and usability may vary locally and reports of uptake in the literature are variable.ObjectiveThe aim of this mixed methods feasibility study was to assess the acceptability and potential utility of immersive VR in critically ill patients at a single institution.MethodsAdults without delirium who were admitted to 1 of 2 intensive care units were offered the opportunity to participate in 5-15 minutes of immersive VR delivered by a VR headset. Patient vital signs, heart rate variability, mood, and pain were assessed before and after the VR experience. Pre-post comparisons were performed using paired 2-sided t tests. A semistructured interview was administered after the VR experience. Patient descriptions of the experience, issues, and potential uses were summarized with thematic analysis.ResultsOf the 35 patients offered the chance to participate, 20 (57%) agreed to partake in the immersive VR experience, with no difference in participation rate by age. Improvements were observed in overall mood (mean difference 1.8 points, 95% CI 0.6-3.0; P=.002), anxiety (difference of 1.7 points, 95% CI 0.8-2.7; P=.001), and pain (difference of 1.3 points, 95% CI 0.5-2.1; P=.003) assessed on 1-10 scales. The heart rate changed by a mean of -1.1 (95% CI -0.3 to -1.9; P=.008) beats per minute (bpm) from a baseline of 86.1 (SD 11.8) bpm and heart rate variability, assessed by the stress index (SI), changed by a mean of -5.0 (95% CI -1.5 to -8.5; P=.004) seconds-2 from a baseline SI of 40.0 (SD 23) seconds-2. Patients commented on the potential for the therapy to address pain, lessen anxiety, and facilitate calmness. Technical challenges were minimal and there were no adverse effects observed.ConclusionsPatient acceptance of immersive VR was high in a mostly medical intensive care population with little prior VR experience. Patients commented on the potential of immersive VR to ameliorate cognitive and emotional symptoms. Investigators can consider integrating minimally modified commercial VR headsets into the existing intensive care unit workflow to further assess VR's efficacy for a variety of endpoints.

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Information sharing between intensive care and primary care after an episode of critical illness; A mixed methods analysis.

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