Patients discharged in the emergency department often have poor understanding of their discharge instructions. Teach-back is a communication method that involves asking patients to explain in their ...own words what a health care provider just told them. The purpose of this project was to determine whether nurse-led teach-back at discharge could improve patient satisfaction with discharge information.
A teach-back method was used to educate patients on what to do if they do not feel better after leaving, using a single site quality improvement design. Patient satisfaction was measured using a standardized benchmark question on whether providers explained what to do if they did not feel better after leaving. The department goal for this question was established as achieving a response of “Yes, definitely” for 64.4% or more of the satisfaction surveys. Patient satisfaction data were collected before and after intervention through a survey given to patients within 24 hours after their visit. A statistical process chart was used to analyze whether the observed improvements coincided with implementation of the teach-back intervention.
Although there was an overall increase in post-intervention scores (61%) from baseline scores (59%), there were no special cause variations signaling that the intervention had a significant impact.
Teach-back may improve patient satisfaction with discharge information. Future implementation with measures of intervention adoption, fidelity, accountability, and sustainability are needed.
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ObjectivesGeriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the ...process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers.DesignWe used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group.SettingInterviews took place in a tertiary, 886-bed hospital located in Los Angeles, California.ParticipantsInterview participants included physicians, pharmacists, pharmacist technicians, and nurses.ResultsWe interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge.ConclusionsWhile we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.
Zenker's diverticulum peroral endoscopic myotomy (zPOEM) is a minimally invasive treatment strategy for Zenker's diverticulum, with excellent results for management of small-to-moderate Zenker's ...diverticulum. We evaluated its use in the management of large Zenker's diverticulum.
This was a retrospective multicenter cohort study across 11 international centers including adult patients with large Zenker's diverticulum ≥ 40 mm treated by zPOEM between March 2017 and March 2022. The primary outcome was clinical success (dysphagia score ≤ 1 without need for further intervention). Secondary outcomes included technical success (complete myotomy as intended), adverse events (AEs), and rate of recurrence.
83 patients (male 62.7 %, mean age 72.6 SD 11.5 years) underwent zPOEM for treatment of large Zenker's diverticulum (median size 50 mm, interquartile range IQR 41-55 mm, range 40-80 mm). The zPOEM procedure was technically successful in 82 patients (98.8 %), with a mean procedure time of 48.7 (SD 23.2) minutes. Clinical success was achieved in 71 patients (85.5 %). Median (IQR) symptom scores improved significantly from baseline for dysphagia (2 2 3 vs. 0 0-2;
< 0.001), regurgitation (3 2 3 4 vs. 0 0-0;
< 0.001), and respiratory symptoms (2 0-3 vs. 0 0-0;
< 0.001). Among patients achieving clinical success, only one recurrence (1.4 %) was recorded during a median follow-up of 12.2 months (IQR 3-28). Post-procedure AEs, all mild to moderate, occurred in four patients (4.8 %).
This study demonstrated safe and effective use of zPOEM in the management of large Zenker's diverticulum.
Background
The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task ...sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout.
Objective
To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout.
Design
Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods.
Participants
327 providers from 23 VA primary care practices within one VHA regional network.
Main Measures
The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables.
Key Results
In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle:
b
= 4.11, 95% CI = 0.39, 7.83,
p
= 0.03; educating patients:
b
= 3.83, 95% CI = 0.33, 7.32,
p
= 0.03).
Conclusions
Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.
Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early ...experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD.
We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a < 5 mm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips.
82 patients with a median defect size of 30 (interquartile range 25-40) mm were included. Technical success was achieved in 92.7 % (n = 76): TTS suturing only in 44 patients (53.7 %) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0 %). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3 % (n = 6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture.
The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible.
Although numerous scholars have emphasized the need for effective communication between members of interprofessional teams, few studies provide a clear understanding of what constitutes effective ...team communication in primary care settings, specifically where patient-centered medical home (PCMH) teams have been implemented. This paper describes the elements of effective communication as perceived by members of interprofessional PCMH primary care teams, and identifies elements of effective communication that have persisted over time. Using transcribed text from 75 semi-structured interviews, we applied the grounded theory method of constant comparison to categorize emergent themes relating to elements of team communication. Interprofessional PCMH team members described the elements of effective communication as: 1) shared knowledge, 2) situation/goal awareness, 3) problem-solving, 4) mutual respect; and communication that is 5) transparent, 6) timely, 7) frequent, 8) consistent, and 9) parsimonious. Parsimony is an emergent theme that may be especially relevant for interprofessional PCMH teams challenged with structured clinic schedules. Future work could focus on understanding how to teach and sustain effective parsimonious communication. Comprehensive quality improvement efforts incorporating a variety of strategies, including team communication training, information and communication technologies, and standardized communication tools may facilitate communication of pertinent patient information in a brief and concise manner.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using ...through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS.
A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding.
A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 66%) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 66%) or with TTSS and TTSCs (n = 32 34%), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate).
TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.
•Healthy work environment is associated with lower primary care nurse burnout.•True collaboration is associated with lower primary care registered nurse burnout.•Meaningful recognition is associated ...with lower primary care licensed vocational nurse burnout.•Quadruple aim may be achieved by fostering a healthy work environment in primary care settings.
Little is known about the relationship between primary care nurses’ work environment and burnout, particularly in settings where patient-centered medical homes (PCMH) have been implemented.
To investigate the relationship between PCMH nurses’ work environment and burnout.
Multivariable analyses were performed using two waves of survey data from PCMH registered nurses (RNs; n = 170) and PCMH licensed vocational nurses (LVNs; n = 181) in 23 primary care clinics.
True collaboration was inversely associated with PCMH RN burnout (b = −2.6, 95% confidence interval CI = −4.29, −0.08, p < .01). Meaningful recognition was inversely associated with PCMH LVN burnout (b = −5.1, 95% CI = −8.36, −1.82, p < .01). In models with all nurses, RN (vs. LVN) position was associated with higher levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01).
This study highlights the important role of the work environment in reducing PCMH nurse burnout. Strategies to foster team collaboration and meaningful recognition should be investigated to reduce PCMH nurse burnout.
High-resolution esophageal manometry (HREM) is a fundamental diagnostic tool in esophagology. Educational tools for this procedure have remained scarce. This quality improvement project aimed to ...develop an enhanced digital recording about HREM and assess the effect on patient knowledge, anxiety, satisfaction, and procedure abortion rates. The Institute for Healthcare Improvement Model for Improvement and the self-regulation theory guided this project. An interprofessional team was formed. A video recording of the pre-, peri-, and post-HREM care was created. Participants were recruited in the following four cycles: Baseline, Workstation, Manometry, and Home. Questionnaires were collected pre- and postvideo education. The results demonstrated a significant increase in knowledge from 60% to 96% ( p < .001), 58% to 96% ( p < .001), 79% to 96% ( p < .001), and 92% to 97% ( p = .02) and reductions in anxiety from 7.1 to 5.5 ( p = .003), 7.6 to 6.1 ( p = .003), 7.1 to 6.5 ( p < .001), and 6.4 to 6.1 ( p = .03) in all four groups. Almost all (99.5%) participants liked the recorded education and only 2.6% of cases were aborted during the 1-year project implementation period from June 2020 to May 2021. Findings from this project support the positive impact of recorded patient education. An educational recording is standardized and has the potential to be implemented in variable settings.
Korean immigrants are among the fastest-growing ethnic minority groups and make up the fifth-largest Asian group in the United States. A better understanding of the work environment factors and its ...impact on Korean American nurse and primary care provider (PCP) burnout may guide the development of targeted strategies to help mitigate burnout and workplace stressors, which is critical for the retention of Korean American nurses and PCPs to promote better alignment of national demographic trends and meet patients' preference for cultural congruence with their health care providers (HCPs). Although there is a growing number of studies on HCP burnout, a limited number of studies specifically focus on the experience of ethnic minority HCPs, particularly during the COVID-19 pandemic.
In light of these gaps in literature, the aim of this study was to assess burnout among Korean American HCPs and to identify work conditions during a pandemic that may be associated with Korean American nurse and PCP burnout.
A total of 184 Korean American HCPs (registered nurses RNs: n=97; PCPs: n=87) practicing in Southern California responded to a web-based survey between February and April 2021. The Maslach Burnout Inventory, Areas of Worklife Survey, and Pandemic Experience & Perceptions Survey were used to measure burnout and work environment factors during the pandemic. A multivariate linear regression analysis was used to assess work environment factors associated with the 3 subcategories of burnout.
No significant differences were found in the level of burnout experienced by Korean American nurses and PCPs. For RNs, greater workload (P<.001), lower resource availability (P=.04), and higher risk perception (P=.02) were associated with higher emotional exhaustion. Greater workload was also associated with higher depersonalization (P=.003), whereas a greater (professional) community (P=.03) and higher risk perception (P=.006) were associated with higher personal accomplishment. For PCPs, greater workload and poor work-life balance were associated with higher emotional exhaustion (workload: P<.001; worklife: P=.005) and depersonalization (workload: P=.01; worklife: P<.001), whereas only reward was associated with personal accomplishment (P=.006).
Findings from this study underscore the importance of strategies to promote a healthy work environment across multiple levels that recognize demographic variation among Korean American RNs and PCPs, potentially influencing their burnout mitigation needs. A growing recognition of identity-informed burnout experiences across frontline Korean American RNs and PCPs argues for future explorations that capture nuance both across and within this and other ethnic minority nurse and PCP groups. By recognizing and capturing these variations, we may better support the creation of targeted, burnout-mitigating strategies for all.
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