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ObjectivesWith 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.MethodsA 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.ResultsA 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.ConclusionsDischarging 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.

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.

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 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.

BackgroundWearable 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.ObjectiveThis 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).MethodsIn 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.ResultsA 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.ConclusionsBoth 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 RegistrationClinicaltrials.gov NCT02933307; http://clinicaltrials.gov/ct2/show/NCT02933307.

BackgroundThe 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.MethodsSix 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.ResultsOf 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.ConclusionInter-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 registrationThe protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).

Contains fulltext : 215444.pdf (Publisher’s version ) (Open Access) OBJECTIVES: To evaluate geriatric education programs for emergency department (ED) professionals based on: content and teaching methods and learning outcome effects and factors promoting or hindering program implementation. DESIGN: Systematic review. SETTING: ED. PARTICIPANTS: Physicians, nurses, and medical residents working in the ED. METHODS AND MEASUREMENT: Five major biomedical databases were searched for (quasi) experimental studies, published between 1990 and April 2018, evaluating geriatric education programs for ED professionals. Data were synthesized around study quality, learning participants, teaching content and methods, and Kirkpatrick learning outcomes. RESULTS: Nine before-after studies were included. Learners were mostly ED residents and, to a smaller extent, ED nurses and physicians. Study quality was moderate, with the lowest scores on sampling and instrument validity. Programs varied from a 1-day workshop to a 2-year curriculum, mostly combining didactic lectures with active and experiential learning formats. Topics commonly addressed included managing: geriatric syndromes, trauma and falls, medication, atypical presentations, and care transitions. Statistically significant improvements were mostly found in learners' knowledge acquisition (six studies). Significant improvements were also found in single studies on: self-reported geriatric screening, documentation of geriatric care, and appropriate urinary catheter placement. Factors promoting program implementation included: solving competing educational demands and busy work schedules, embedding the program in preexisting curricula, and close collaboration between emergency and geriatric medicine faculties. CONCLUSIONS: Various geriatric education programs improve the geriatric knowledge of ED professionals and seem to positively impact their clinical practice. However, more program evaluations with larger study samples, and use of valid and reliable outcome measures, are needed to provide robust evidence on the effectiveness of such programs. J Am Geriatr Soc, 1-8, 2019. J Am Geriatr Soc 67:2402-2409, 2019.

ObjectiveTo explore associations among twenty formal and informal, societal and individual-level factors and quality of life (QOL) among people living with congestive heart failure (CHF) in two settings with different healthcare and social care systems and sociocultural contexts.Setting and participantsWe recruited 367 adult patients with CHF from a single heart failure clinic within two countries with different national social to healthcare spending ratios: Minneapolis, Minnesota, United States (US), and Nijmegen, Netherlands (NL).DesignCross-sectional survey study. We adapted the Social Quality Model (SQM) to organize twenty diverse factors into four categories: Living Conditions (formal-societal: e.g., housing, education), Social Embeddedness (informal-societal: e.g., social support, trust), Societal Embeddedness (formal-individual: e.g., access to care, legal aid), and Self-Regulation (informal-individual: e.g., physical health, resilience). We developed a survey comprising validated instruments to assess each factor. We administered the survey in-person or by mail between March 2017 and August 2018.OutcomesWe used Cantril's Self-Anchoring Scale to assess overall QOL. We used backwards stepwise regression to identify factors within each SQM category that were independently associated with QOL among US and NL participants (pResults367 CHF patients from the US (32%) and NL (68%) participated. Among US participants, financial status, receiving legal aid or housing assistance, and resilience were associated with QOL, and together explained 49% of the variance in QOL; among NL participants, financial status, perceived physical health, independence in activities of daily living, and resilience were associated with QOL, and explained 53% of the variance in QOL.ConclusionsFour formal and informal factors explained approximately half of the variance in QOL among patients with CHF in the US and NL.

IntroductionThe USA lags behind other high-income countries in many health indicators. Outcome differences are associated with differences in the relative spending between healthcare and social services at the national level. The impact of the ratio and delivery of social and healthcare services on the individual patient’s health is however unknown. ‘Reframing Healthcare Services through the Lens of Co-Production’ (RheLaunCh) will be a cross-Atlantic comparative study of the mechanisms by which healthcare and social service delivery may impact patient health with chronic conditions. Insight into these mechanisms is needed to better and cost-effectively organise healthcare and social services.MethodsWe designed a mixed methods study to compare the socioeconomic background, needs of and service delivery to patients with congestive heart failure and chronic obstructive pulmonary disease in the USA and the Netherlands. We will conduct: (1) a literature scan to compare national and regional healthcare and social service systems; (2) a retrospective database study to compare patient’s socioeconomic and clinical characteristics and the service use and spending at the national, regional and hospital level; (3) a survey to compare patient perceived quality of life, receipt and experience of service delivery and ability of these services to meet patient needs; and (4) multiple case studies to understand what patients need to better govern their quality of life and how needs are met by services.Ethics and disseminationEthics approval was granted by the ethics committee of the Radboud University Medical Center (2016–2423) in the Netherlands and by the Human Subjects Research Committee of the Hennepin Health Care System, Inc. (HSR #16–4230) in the USA. Multiple approaches will be used for dissemination of results, including (inter)national research presentations and peer-reviewed publications. A website will be established to support the development of a community of practice.

Background: Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at risk. Objective: Our aim was to demonstrate how process mapping can illustrate current handover practices between ambulatory and inpatient care settings, identify existing barriers and facilitators to effective transitions of care, and highlight potential areas for quality

Item does not contain fulltext BACKGROUND: Much of the research on improving patient handovers has focused on enhancing communication within the hospital system, but there have been relatively few efforts aimed at addressing the challenges at the interface between the hospital and the primary care setting. METHODS: A qualitative thematic analysis using a clinical microsystems lens applied to 28 semi-structured key stakeholder interviews in the Netherlands. Data were organised into seven 'virtual' clinical microsystem datasets composed of patients, hospital-based physicians, hospital-based nurses and community-based general practitioners. RESULTS: Five themes that contributed to effective or ineffective handovers emerged from our analysis: (1) lack of adequate information; (2) healthcare professionals' availability and opportunity for personal contact; (3) feedback, teaching and protocols related to handovers; (4) information technology facilitated communication solutions; and (5) the role and responsibility of patients. Our analysis suggests that each healthcare professional attempted to provide the best care possible, but did this largely in isolation, and without the benefit of the knowledge and expertise of the other members of the microsystem. CONCLUSIONS: The microsystem approach offers an innovative organisational construct and approach to assess the gaps in 'hospital to community' patient handovers, by viewing the hospital to the community interface as a clinical microsystem continuum. Our application of the microsystem approach confirms and extends earlier findings about the impact of barriers on the continuity and safety of patient transitions and their impact on the quality of patient care.

Background: Patient safety experts have postulated that increasing patient participation in communications during patient handovers will improve the quality of patient transitions, and that this may reduce hospital readmissions. Choosing strategies that enhance patient safety through improved handovers requires better understanding of patient experiences and preferences for participation. Objective: The aim of this paper is to explore the patients' experiences and perspectives related to the handovers between their primary care providers and the inpatient hospital. Methods: A qualitative secondary analysis was performed, based on individual and focus group patient interviews with 90 patients in five European countries. Results: The analysis revealed three themes: patient positioning in the handover process; prerequisites for patient participation and patient preferences for the handover process. Patients' participation ranged from being the key actor, to sharing the responsibility with healthcare professional(s), to being passive participants. For active participation patients required both personal and social resources as well as prerequisites such as information and respect. Some patients preferred to be the key actor in charge; others preferred their healthcare professionals to be the key actors in the handover. Conclusions: Patients' participation is related to the healthcare system, the activity of healthcare professionals' and patients' capacity for participation. Patients prefer a handover process where the responsibility is clear and unambiguous. Healthcare organisations need a clear and well-considered system of responsibility for handover processes, that takes into account the individual patient's need of clarity, and support in relation to his/hers own recourses.

Contains fulltext : 172783.pdf (Publisher’s version ) (Open Access) OBJECTIVES: To systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility. DESIGN: A systematic review of the literature. METHODS: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews and PsychInfo were searched for studies published between January 1990 and July 2014. We included studies evaluating interventions relevant for higher management to oversee and manage patient safety, in prehospital emergency medical service (EMS) organisations and hospital-based emergency departments (EDs). Two reviewers independently selected candidate studies, extracted data and assessed study quality. Studies were categorised according to study quality, setting, sample, intervention characteristics and findings. RESULTS: Of the 18 included studies, 13 (72%) were non-experimental. Nine studies (50%) reported data on the reliability and/or validity of the intervention. Eight studies (44%) reported on the feasibility of the intervention. Only 4 studies (22%) reported statistically significant effects. The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively. CONCLUSIONS: Characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in EMS organisations and EDs. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base.

Contains fulltext : 172502.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. DESIGN: Systematic review of systematic reviews. DATA SOURCES: PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. STUDY SELECTION: English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. RESULTS: Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design. CONCLUSIONS: The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.

Objective: While internal audits are widely used, insight into the essential components of the internal audit to govern patient safety is limited. The aim of this study is to explore factors that hinder and stimulate internal audits as an effective patient safety governance tool for hospital boards.Methods: A qualitative interview study in six Dutch hospitals. Interviews (n = 43) were held with auditees, quality officers, boards of directors and boards of supervisors. Data were collected and analysed using Grounded Theory.Results: Barriers and facilitators were classified into 14 categories from which four themes emerged: (1) board positioning of audits, (2) organisation and content of audits, (3) competences and composition of audit team, and (4) cultural factors and attitudes towards auditing.Conclusions: We found two themes consisting of factors related to the audit itself (organisation and content of audits, and competences and composition of audit team) and two themes consisting of contextual factors (board positioning of audits, and cultural factors and attitudes towards auditing). These may contribute to support for auditing and to the generation of reliable audit results, which subsequently could result in effective audits for governance of patient safety. Hospital boards and executives can optimise the patient safety auditing system in their hospitals by increasing active leadership engagement, by promoting audits as an opportunity for staff to learn from safety problems (rather than a mandatory examination instrument) and by providing vital resources for a smooth audit process, such as a medical specialist in the audit team.

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. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-389) contains supplementary material, which is available to authorized users.

Background: Advocates for quality and safety havecalled for healthcare that is patient-centred anddecision-making that involves patients.Objective: The aim of the paper is to explore thebarriers and facilitators to patient-centred care in thehospital discharge process.Methods: A qualitative study using purposive samplingof 192 individual interviews and 26 focus groupinterviews was conducted in five European Unioncountries with patients and/or family members,hospital physicians and nurses, and community generalpractitioners and nurses. A modified Grounded Theoryapproach was used to analyse the data.Results: The barriers and facilitators were classified into15 categories from which four themes emerged:(1) healthcare providers do not sufficiently prioritisedischarge consultations with patients and family membersdue to time restraints and competing care obligations;(2) discharge communication varied from instructingpatients and family members to shared decision-making;(3) patients often feel unprepared for discharge, andpostdischarge care is not tailored to individual patientneeds and preferences; and (4) pressure on availablehospital beds and community resources affect thedischarge process.Conclusions: Our findings suggest that involvement ofpatients and families in the preparations for discharge isdetermined by the extent towhich care providers arewillingand able to accommodate patients’ and families’ capabilities,needs and preferences. Future interventions should bedirected at healthcare providers’ attitudes and theirorganisation’s leadership, with afocus on improvingcommunication among care providers, patients and families,and between hospital and community care providers.

Item does not contain fulltext 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.