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Implementation of a Standardized Initial Assessment for Demand Management in Outpatient Emergency Care in Germany: Early Qualitative Process Evaluation.

ABSTRACT: BACKGROUND:Inadequate assessment of the severity and urgency of medical problems is one of the factors contributing to unnecessary emergency department (ED) visits. The implementation of a software-based instrument for standardized initial assessment-Standardisierte medizinische Ersteinschätzung in Deutschland (SmED) (Standardized medical Initial Assessment in Germany in English)-aims to support health care professionals and steer patients toward the right health care provider. This study aimed to explore the implementation process of SmED from a user perspective. OBJECTIVE:This study aims to evaluate the overall perception of SmED by health care professionals using the software, to examine to what extent SmED influences the workload and work routines of health care professionals, and to determine which factors are associated with the use of SmED. METHODS:An early qualitative process evaluation on the basis of interviews was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Participants were 30 health care professionals who work with SmED either at the joint central contact points of the outpatient emergency care service and the EDs of hospitals (ie, the Joint Counter; Gemeinsamer Tresen in German) or at the initial telephone contact points of the outpatient emergency care service (phone number 116117). Matrix-based framework analysis was applied to analyze the interview data. RESULTS:Health care professionals perceived that workload increased initially, due to additional time needed per patient. When using SmED more frequently and over a longer time period, its use became more routine and the time needed per call, per patient, decreased. SmED was perceived to support decision making regarding urgency for medical treatment, but not all types of patients were eligible. Technical problems, lack of integration with other software, and lack of practicability during peak times affected the implementation of SmED. CONCLUSIONS:Initial experiences with SmED were positive, in general, but also highlighted organizational issues that need to be addressed to enhance sustainability. TRIAL REGISTRATION:German Clinical Trials Register DRKS00017014; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017014.

SUBMITTER: Roth C

PROVIDER: S-EPMC7501577 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Implementation of a Standardized Initial Assessment for Demand Management in Outpatient Emergency Care in Germany: Early Qualitative Process Evaluation.

Roth Catharina C Breckner Amanda A Paulus Jan J Wensing Michel M

JMIR formative research 20200904 9

<h4>Background</h4>Inadequate assessment of the severity and urgency of medical problems is one of the factors contributing to unnecessary emergency department (ED) visits. The implementation of a software-based instrument for standardized initial assessment-Standardisierte medizinische Ersteinschätzung in Deutschland (SmED) (Standardized medical Initial Assessment in Germany in English)-aims to support health care professionals and steer patients toward the right health care provider. This stud ...[more]

PMID: 32663159

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Project description:BackgroundInadequate assessment of the severity and urgency of health problems is one of the factors contributing to unnecessary emergency department visits. A software-based instrument for standardized initial assessment (SmED) aims to support healthcare professionals and steer patients to the appropriate source of care. The aim of this study was to evaluate the implementation process of SmED based on the point of view of users in order to facilitate sustainable implementation.MethodsA quantitative process evaluation on the basis of a paper-based questionnaire was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Healthcare professionals who worked with SmED either at the joint contact points of the outpatient emergency care service and the emergency departments of hospitals ("Joint Counter", German "Gemeinsamer Tresen") or at the initial telephone contact points of the outpatient emergency care service (116117) were invited to participate in the survey.Results200 users of SmED completed the questionnaire comprising the five scales: Intervention effectiveness/efficacy, Interprofessional context/occupational Interest, Individual Context, Organisational Framework Conditions, and Medical Context. Several individual characteristics were related to the implementation process of SmED. Female and younger healthcare professionals and participants with less than five years of professional experience tended to evaluate the implementation process as more positive. Factors related to the Individual Context and to the Medical Context were associated with the reported use of SmED (p = 0.004 and 0.041, respectively).ConclusionThe involvement of healthcare professionals, particularly more experienced professionals, in the implementation of SmED may help to facilitate sustainable implementation. In addition, training of potential user prior and during the implementation process and the adaption of Organisational Context factors are crucial. Trial registration The study was registered at the German Clinical Trials Register prior to the start of the study (DRKS00017014).

Project description:BackgroundThe number of people with complex nursing and care needs living in their own homes is increasing. The implementation of Case and Care Management has shown to have a positive effect on unmet care needs. Research on and implementation of Case and Care Management in the community setting in Austria is limited. This study aimed to understand the changes and challenges of changing care needs by mobile nurses and to evaluate the need for Case Management in mobile care organizations by investigating the evolution of mobile care nurses'task profiles and the challenges in working in a dynamic field with changing target groups and complexifying care needs.MethodsA qualitative study with reductive-interpretative data analysis consisting of semi-structured focus groups was conducted. Community care nurses, head nurses, and managers of community mobile care units as well as discharge managers of a community hospital (n = 24) participated in nine qualitative, semi-structured focus groups. The recorded focus groups were transcribed and analyzed using qualitative content analysis.ResultsThe analysis revealed three main categories: the complexity of the case, innerinstitutional frameworks, and interinstitutional collaboration, which influence the perception of need for further development in the direction of Case and Care Management. Feelings of overwhelmedness among nurses were predominantly tied to cases that presented with issues beyond healthcare such as legal, financial, or social that necessitated communication and collaboration across multiple care providers.ConclusionsCare institutions need to adapt to changing and increasingly complex care needs that necessitate cooperation between organizations within and across the health and social sectors. A key facilitator for care coordination and the adequate service provision for complex care needs are multidisciplinary institutional networks, which often remain informal, leaving nurses in the role of petitioner without equal footing. Embedding Case and Care Management in the community has the potential to fill this gap and facilitate flexible, timely, and coordinated care across multiple care providers.

Project description:ObjectivesTo examine context-specific delivery factors, facilitators and barriers to implementation of the Diabetes Community Exercise and Education Programme (DCEP) for adults with type 2 diabetes (T2D) using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.DesignA qualitative evaluation embedded within the DCEP pragmatic randomised controlled trial. Data collected via focus groups and interviews and analysed thematically.SettingCommunity-based in two cities (Dunedin and Invercargill) in the lower south island of New Zealand.ParticipantsSeventeen adults diagnosed with T2D attending DCEP and 14 healthcare professionals involved in DCEP delivery.InterventionDCEP is a twice weekly session of exercise and education over 12 weeks, followed by a twice weekly ongoing exercise class.ResultsWhile our reach target was met (sample size, ethnic representation), the randomisation process potentially deterred Māori and Pasifika from participating. The reach of DCEP may be extended through the use of several strategies: promotion of self-referral, primary healthcare organisation ownership and community champions. DCEP was considered effective based on perceived benefit. The social and welcoming environment created relationships and connections. People felt comfortable attending DCEP and empowered to learn. Key to implementation and adoption was the building of trusting relationships with local health providers and communities. This takes time and care and cannot be rushed. Training of staff and optimising communication needed further attention. To maintain DCEP, delivery close to where people live and a generic approach catering for people with multiple chronic conditions may be required.ConclusionsFor success, lifestyle programmes such as DCEP, need time and diligence to build and maintain networks and trust. Beyond frontline delivery staff and target populations, relationships should extend to local healthcare organisations and communities. Access and ongoing attendance are enabled by healthcare professionals practicing in a nuanced person-centred manner; this, plus high staff turnover, necessitates ongoing training.Trial registration numberACTRN12617001624370.

Project description:BackgroundImplementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children.MethodsWe conducted a scoping review using Arksey and O'Malley's framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies.ResultsWe included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%).ConclusionsStudies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that 'dissemination' is the most common strategy used, and 'capacity building and scale-up' are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.

Project description:BackgroundPatient numbers in emergency departments are on the rise. The DEMAND intervention aims to improve the efficacy of emergency services by computer-assisted structured initial assessment assigning patients to emergency departments or primary care practices. The aims of our study were to evaluate patient satisfaction with this intervention and to analyse if reduced patient satisfaction is predicted by sociodemographic data, health status or health literacy.MethodsWe conducted a cross-sectional patient survey in emergency departments and co-located primary care practices. Each intervention site was planned to participate for two observation periods, each with a duration of one full week. Study participants were recruited by the local staff. The patients filled out a written questionnaire during their waiting time. Patient satisfaction was assessed by agreement to four statements on a four point Likert scale. Predictors of patient satisfaction were identified by multilevel, multivariable logistic regression models adjusted for random effects at the intervention site level.ResultsThe sample included 677 patients from 10 intervention sites. The patients had a mean age of 38.9 years and 59.0% were women. Between 67.5% and 55.0% were fully satisfied with aspects of the intervention. The most criticised aspect was that the staff showed too little interest in the patients' personal situation. Full satisfaction ("clearly yes" to all items) was reported by 44.2%. Reduced patient satisfaction (at least one item rated as "rather yes", "rather no", "clearly no") was predicted by lower age (odds ratio 0.79 for ten years difference, 95% confidence interval 0.67/0.95, p = 0.009), presenting with infections (3.08,1.18/8.05,p = 0.022) or injuries (3.46,1.01/11.82,p = 0.048), a higher natural logarithm of the symptom duration (1.23,1.07/1.30,p = 0.003) and a lower health literacy (0.71 for four points difference, 0.53/0.94,p = 0.019).ConclusionsThe patients were for the most part satisfied with the intervention. Assessment procedures should be evaluated a) regarding if all relevant patient-related aspects are included; and whether patient information can be improved b) for patients with strong opinions about cause, consequences and treatment options for their health problem; and c) for patients who have problems in the handling of information relevant to health and healthcare.Trial registrationGerman Clinical Trials Register ( https://www.drks.de/drks_web/setLocale_EN.do ) no. DRKS00017014.

Project description:BackgroundCOVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care's potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal.ObjectiveThis study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations.MethodsWe conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT.ResultsA total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group.ConclusionsAs further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient.

Project description:BACKGROUND:Insufficient communication and coordination is one of the most problematic issues in German health care delivery leading to detrimental effects on health care outcomes. As a consequence interprofessional continuing education (CIPE) is gathering momentum in German health policy and health care practice aiming to enhance service quality and patient safety. Nevertheless, there is limited evidence on the course of implementation and the perceived effectiveness/acceptance of CIPE in German health care. This paper describes the objectives and formal characteristics of CIPE trainings and maps important determinants influencing the success of CIPE implementation from the perspective of providers offering CIPE trainings for German health care professionals. METHODS:Forty-nine training institutions offering CIPE for health care professionals were identified by a structured web search including the websites of German medical education associations and public/private training institutions. Directors and managers of the identified institutions were invited to participate in a semi-structured interview. The interview guideline was developed using the SPSS method by Helferich and colleges. Interviews were analyzed using the summarizing content analysis developed by Mayring resulting in a paradigm that contextualizes hindering factors regarding the implementation of CIPE in the German health care system. RESULTS:Overall, 19 of the identified institutions agreed to participate with one director/manager per institution resulting in a response rate of almost 38.8%. The included institutions offer n?=?85 CIPE trainings for health care professionals. Trainings offered mainly address the enhancement of domain, social and personal competencies of the participating health care professionals and follow three main objectives comprising better care of severely ill patients, improvement of patient safety by sustained risk management as well as a more patient centered care. Implementation of CIPE in Germany is influenced by various hindering factors mostly coming from systemic (missing incentives), behavioral (hierarchy problems) and methodological (limited quality assurance) factors. CONCLUSION:CIPE is an evolving concept in the German health care system. There are various difficulties that impede a successful implementation of CIPE and might be mitigated by specific health policy interventions such as mandatory CIPE participation of health care professionals and comprehensive pre-license interprofessional education.

Dataset Information

Implementation of a Standardized Initial Assessment for Demand Management in Outpatient Emergency Care in Germany: Early Qualitative Process Evaluation.

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Implementation of a Standardized Initial Assessment for Demand Management in Outpatient Emergency Care in Germany: Early Qualitative Process Evaluation.

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