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Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

ABSTRACT: OBJECTIVE:To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care. DESIGN:Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting. SETTING:Cardiac surgical unit in New Zealand. PARTICIPANTS:Culturally diverse patients in hospital undergoing heart surgery. MAIN OUTCOMES:A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort. RESULTS:Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment. CONCLUSIONS:These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

SUBMITTER: Wensley C

PROVIDER: S-EPMC7239554 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

Wensley Cynthia C Botti Mari M McKillop Ann A Merry Alan F AF

BMJ open 20200518 5

<h4>Objective</h4>To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care.<h4>Design</h4>Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting.<h4>Setting</h4>Cardi ...[more]

PMID: 32430447

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Project description:BackgroundThere are limited data on the effectiveness of the vaccines against symptomatic coronavirus disease 2019 (Covid-19) currently authorized in the United States with respect to hospitalization, admission to an intensive care unit (ICU), or ambulatory care in an emergency department or urgent care clinic.MethodsWe conducted a study involving adults (≥50 years of age) with Covid-19-like illness who underwent molecular testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We assessed 41,552 admissions to 187 hospitals and 21,522 visits to 221 emergency departments or urgent care clinics during the period from January 1 through June 22, 2021, in multiple states. The patients' vaccination status was documented in electronic health records and immunization registries. We used a test-negative design to estimate vaccine effectiveness by comparing the odds of a positive test for SARS-CoV-2 infection among vaccinated patients with those among unvaccinated patients. Vaccine effectiveness was adjusted with weights based on propensity-for-vaccination scores and according to age, geographic region, calendar time (days from January 1, 2021, to the index date for each medical visit), and local virus circulation.ResultsThe effectiveness of full messenger RNA (mRNA) vaccination (≥14 days after the second dose) was 89% (95% confidence interval [CI], 87 to 91) against laboratory-confirmed SARS-CoV-2 infection leading to hospitalization, 90% (95% CI, 86 to 93) against infection leading to an ICU admission, and 91% (95% CI, 89 to 93) against infection leading to an emergency department or urgent care clinic visit. The effectiveness of full vaccination with respect to a Covid-19-associated hospitalization or emergency department or urgent care clinic visit was similar with the BNT162b2 and mRNA-1273 vaccines and ranged from 81% to 95% among adults 85 years of age or older, persons with chronic medical conditions, and Black or Hispanic adults. The effectiveness of the Ad26.COV2.S vaccine was 68% (95% CI, 50 to 79) against laboratory-confirmed SARS-CoV-2 infection leading to hospitalization and 73% (95% CI, 59 to 82) against infection leading to an emergency department or urgent care clinic visit.ConclusionsCovid-19 vaccines in the United States were highly effective against SARS-CoV-2 infection requiring hospitalization, ICU admission, or an emergency department or urgent care clinic visit. This vaccine effectiveness extended to populations that are disproportionately affected by SARS-CoV-2 infection. (Funded by the Centers for Disease Control and Prevention.).

Project description:Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.Six Veterans Affairs Medical Centers (VAMCs).Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n?=?6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

Project description:BackgroundThere is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings.ObjectiveTo compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs).DesignCluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites.ParticipantsOne hundred thirty-two providers from PCCTs at 47 VAMCs.InterventionsBoth training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers.Main measurementsSeveral processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates.Key resultsEighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement.ConclusionFindings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used.Trial registrationClinicalTrials.gov identifier: NCT02383173.

Project description:Rigorous healthcare design research is critical to inform design decisions that improve human experience. Current limitations in the field include a lack of consistent and valid measures that provide feedback about the role of the built environment in producing desirable outcomes. Research findings about nurses' efficiency, quality of care, and satisfaction related to inpatient unit designs have been mixed, and there was previously no validated instrument available to quantitatively measure nurses' ability to work efficiently and effectively in their environment. The objective of this study was to develop, refine, and validate a survey instrument to measure affordance of the care environment to nurse practice, based on various aspects of their work in inpatient units. The HDR Clinical Activities Related to the Environment (CARE) Scale Inpatient Version was developed using item design, refinement, and reliability and validity testing. Psychometric methods from classical test theory and item response theory, along with statistical analyses involving correlations and factor analysis, and thematic summaries of qualitative data were conducted. The four-phase process included (1) an initial pilot study, (2) a content validation survey, (3) cognitive interviews, and (4) a final pilot study. Results from the first three phases of analysis were combined to inform survey scale revisions before the second pilot survey, such as a reduction in the number and rewording of response options, and refinement of scale items. The updated 9-item scale showed excellent internal consistency and improved response distribution and discrimination. The factor analysis revealed a unidimensional measure of nurse practice, as well as potential subscales related to integration, efficiency, and patient care. Within the healthcare design industry, this scale is much needed to generate quantitative and standardized data and will facilitate greater understanding about the aspects of an inpatient healthcare facility that best support nurses' ability to provide quality patient care.

Project description:AbstractPatient feedback can provide insights to assess and improve the quality of healthcare. This study aimed to develop a measure of surgical inpatient satisfaction and comfort and examine its acceptability, validity, and reliability among discharged surgical patients.This multicenter, descriptive, cross-sectional study was conducted at three tertiary hospitals in Shaanxi Province, China. A random sample of patients admitted to the surgical inpatient departments of the three hospitals between November and December 2018 was recruited. An analysis was conducted on the acceptability, validity, and reliability of a newly developed measure of satisfaction with surgical inpatient services.A total of 1582 out of 1805 (87.6%) eligible patients completed the questionnaire (average time taken = 17.1 ± 10.3 minutes), which indicated high acceptability. Sociodemographic differences between the participants and non-participants were not significant. Using factor analysis, the following 7 dimensions (number of items: 65, variance explained: 68.0%) were identified: medical care (19 items), nursing care (15 items), environment and logistics (11 items), postoperative and hospitalization experiences (11 items), feeling nervous and afraid (4 items), operating room services (3 items), and visiting (2 items). The latent structure of the assessment was examined and validated using exploratory and confirmatory factor analyses, respectively. All item loadings were >0.4. All dimensions demonstrated satisfactory internal consistency (Cronbach's alphas = 0.83-0.96) and test-retest reliability (intra-class correlation coefficients = 0.77-0.96).The Chinese Surgical Inpatient Satisfaction and Comfort Questionnaire has strong psychometric properties and can be used to assess patient satisfaction with public hospital surgical inpatient services in China. A distinguishing feature of this questionnaire is the inclusion of a subscale that assesses comfort as a dimension of patient satisfaction. Such instruments can be used to identify the factors that should be addressed to improve the quality of patient care. Further research is needed to determine the role of assessment in quality improvement.

Project description:IntroductionJob aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries work towards reducing neonatal mortality. However, inpatient vital sign readings are often poorly documented and little attention has been paid to the process of chart design as a method of improving care quality. Poorly designed charts do not meet user needs leading to increased mental effort, duplication, suboptimal documentation and fragmentation. We provide a detailed account of a process of designing a monitoring chart.MethodsWe used a Human-Centred Design (HCD) approach to co-design a newborn monitoring chart between March and May 2019 in three workshops attended by 16-21 participants each (nurses and doctors) drawn from 14 hospitals in Kenya. We used personas, user story mapping during the workshops and observed chart completion to identify challenges with current charts and design requirements. Two new charts were piloted in four hospitals between June 2019 and February 2020 and revised in a cyclical manner.ResultsChallenges were identified regarding the chart design and supply, and how staff used existing charts. Challenges to use included limited staffing, a knowledge deficit among junior staff, poor interprofessional communication, and lack of appropriate and working equipment. We identified a strong preference from participants for one chart to capture vital signs, assessment of the baby, and feed and fluid prescription and monitoring; data that were previously captured on several charts.DiscussionAdopting a Human-Centred Design approach, we designed a new comprehensive newborn monitoring chart that is unlike observation charts in the literature that only focus on vital signs. While the new chart does not address all needs, we believe that once implemented, it can help build a clearer picture of the care given to newborns.ConclusionThe chart was co-designed and piloted with the user and context in mind resulting in a unique monitoring chart that can be adopted in similar settings.

Dataset Information

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

Publications

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

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