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BACKGROUND Hypertension is a major contributor of various adverse health outcomes. Although prior studies have shown benefits of home blood pressure monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a blood pressure monitor integrated into the electronic health record is superior to a non-integrated blood pressure monitor. OBJECTIVE In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to non-integrated blood pressure monitors for hypertension improvement. METHODS This is a 12-month randomized, comparative effectiveness study conducted at three large academic health centers across California. The three sites will enroll a total of 660 participants (approximately n=220 per site) with 330 in the integrated blood pressure monitor arm and 330 in the non-integrated blood pressure control arm. The primary outcome of this study will be absolute difference in systolic blood pressure in mmHg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment into the study. Participants will use their assigned blood pressure monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the UCLA Value-Based Care Research Consortium. A pre-study and post-study questionnaire will be conducted to further evaluate participant perspectives regarding their blood pressure monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS The study will start enrolling participants in the second quarter of 2023 and complete by first half 2024. Results will be published by end of 2024. CONCLUSIONS This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home blood pressure monitor improves patients’ hypertension better than a hypertension intervention with a non-integrated blood pressure monitor. The outcomes of this study may help health system decision-makers determine whether to invest in integrated blood pressure monitors for vulnerable patient populations. CLINICALTRIAL The ClinicalTrials.gov ID for this study is "NCT05390502." It was registered 05/20/2022. Protocol ID is 22000036.

The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy. We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system. The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation. There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99). After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.

Nurses face workplace stressors that contribute to job dissatisfaction, burnout, and turnover, impacting not only patient safety but the nurses' physical and emotional well-being. At the 2018 American Academy of Nursing conference, a policy dialogue "Creating Healthy Work Environments to Address the Quadruple Aim" was convened focusing on creating healthy work environments by addressing stressors such as violence and bullying. That discussion is encapsulated in this article, providing proven and practical strategies for reducing risk.

Background Significant resources have been allocated to decreasing the number of preventable deaths in hospitals, but identifying preventable factors and then leveraging them to effect system-wide change remains challenging. Objective To determine the ability of a novel in-person, multidisciplinary “rapid mortality review” process to identify deaths that are preventable and action items that lead to improvements in care. Methods Rapid mortality review sessions were conducted weekly for patients who died in the medical intensive care unit. Patient data and clinician opinions regarding preventable deaths were discussed and recorded. Bivariate analyses were done to detect associations between case variables and the formation of an action item. Results From 2013 to 2018, 542 patient deaths were reviewed; of those, 36 deaths (7%) were deemed potentially preventable. Facilitators identified issues in 294 cases (54%). A total of 253 action items were identified for 175 cases (32%); 60% of those action items were subsequently completed and led to tangible systemic change in 29 instances (11%). Action items were more likely to be identified for patients who had not been receiving comfort care (P < .001), for patients who had received cardiopulmonary resuscitation (P < .001), when the treatment team (P < .001) or the rapid mortality review facilitator (P < .001) had care-related concerns, and when the patient’s death had been preventable (P < .001). Conclusions Even in settings with low reported rates of preventable deaths, an in-person multidisciplinary mortality review can successfully identify areas where care can be improved, leading to systemic change.

Author(s): Bakr, Omar; Afsar-Manesh, Nasim; Raja, Naveen; Dermenchyan, Anna; Goldstein, Noah J; Shu, Suzanne B; May, Folasade P | Abstract: IntroductionColorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality in the United States. Although various interventions have improved screening rates, they often require abundant resources and can be difficult to implement. Social psychology and behavioral economics principles offer an opportunity for low-cost and easy-to-implement strategies but are less common in clinical settings.MethodsWe randomized 2,000 patients aged 50-75 years eligible for CRC screening to one of the 2 mailed interventions: a previously used text-based letter describing and offering fecal immunochemical testing (FIT) and colonoscopy (usual care arm); or a letter leveraging social psychology and behavioral economics principles (e.g., implied scarcity and choice architecture), minimal text, and multiple images to offer FIT and colonoscopy (intervention arm). We compared total screening uptake, FIT uptake, and colonoscopy uptake at 1-month intervals in each group.ResultsThere were 1,882 patients included in the final analysis. The mean age was 69.3 years, and baseline characteristics in the 2 groups were similar. Screening completion at 26 weeks was 19.5% in the usual care arm (16.3% FIT vs 3.2% colonoscopy, P l 0.01) and 24.1% in the intervention arm (22.1% FIT vs 2.0% colonoscopy, P l 0.01) (P = 0.02).DiscussionAmong primary care patients aged 50-75 years in an academic setting, mailed CRC outreach employing social psychology and behavioral economics principles led to a higher participation in CRC screening than usual care mailed outreach.Translational impactMailed interventions to increase CRC screening should incorporate social psychology and behavioral economics principles to improve participation.

Background: Hospitalization for heart failure (HF) and heart transplant is associated with a high likelihood of readmission within 30 days of discharge. Our study objective was to identify risk factors and causes for readmission at a high acuity tertiary academic medical center in order to develop targeted interventions aimed at HF readmission reduction. Methods: We retrospectively reviewed 49 sequential cases of patients readmitted within 30 days of hospitalization for HF (41) or heart transplant (8) between Q3-Q4 2014. Two unblinded reviewers determined the root causes of readmission, likelihood of readmission prevention, and interventions most likely to prevent similar readmissions from recurring. Results: HF exacerbation was the primary reason for readmission in 47% (23/49) of cases. Also in 47% (23/49) of the readmissions, the possibility for preventing the readmission had an appropriate intervention been implemented was determined to be at least 50%. The other 53% (26/49) of readmissions were considered unlikely to have been readily preventable. Medical complications were the primary cause of readmission in 14% (7/49) of cases, of which acute kidney injury (AKI) was the most common. Over one-fourth (13/49) of all readmissions were found to have at least a 15% increase in creatinine level from time of discharge to time of readmission. Dietary indiscretion (8% i.e. 4/49), psychosocial factors (8%), and progression of disease (8%) were other notable root causes for readmission. When assessing the most likely part of patient care to address to prevent readmission, more proactive follow-up/monitoring was considered to be the most high-yield intervention in 14% of cases i.e. 7/49. Also of note, reclassifying admissions as observation status based on length of stay would have prevented 33% (16/49) of cases from meeting readmission criteria. Conclusion: Our study supports a multifaceted, multidisciplinary approach to reducing HF readmissions, given the array of readmission causes and targeted areas for intervention identified. It also demonstrates that AKI may be an underappreciated cause for readmission, with 28% of all-cause readmissions presenting with creatinine elevations of at least 15%. Therefore, in addition to a multidisciplinary approach to discharge planning, we recommend institutions implement specific strategies to reduce AKI.

The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses’ involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.