Abraham A. Brody

Abstract

Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.

Abstract

Background/Objective: Increased attention has been directed at the intersection of emergency and palliative medicine, since decisions made in the emergency department (ED) often determine the trajectory of subsequent medical treatments. Specifically, we examined whether inpatient admissions after palliative care (PC) consultation initiated in the ED were associated with decreased length of stay (LOS), compared with those in which consultations were initiated after hospital admission. Methods: Education and training on PC and the consultation service were provided to ED physicians and nurses. The PC service evaluated patients in the ED during weekdays and provided telephone consultation nights and weekends with postadmission follow-up. We compared the outcomes of these patients with those whose PC needs were identified and addressed through consultation postadmission. PC consultation data between January 2006 and December 2010 were retrospectively collected from the administrative records system and analyzed using propensity scores within multivariate regression. Results: Included in the analysis were 1435 PC consultations, 50 of which were initiated in the ED across the 4-year study period. Propensity scores were calculated using patient-level characteristics, including All Patient Refined Diagnostic Related Group (APRDRG) risk of mortality (ROM) and severity of illness (SOI), age, gender, readmission status, facility, and insurance type. Regression results showed that consultation in the ED was associated with a significantly shorter LOS by 3.6 days (p<0.01). Conclusions: Early initiation of PC consultation in the ED was associated with a significantly shorter LOS for patients admitted to the hospital, indicating that the patient-and family-centered benefits of PC are complemented by reduced inpatient utilization.

Abstract

Despite a major shift in the care of older adults from acute care to home health, few home health care nurses are adequately prepared to manage the complex needs of geriatric patients. This study examined the feasibility of a web-based education program to help nurses improve their treatment of geriatric pain and depression. Nurses' knowledge, confidence, and attitudes were assessed before and 3 months after a web-based education program. Nurses randomized to the experimental group showed significant improvement in attitudes 3 months after the intervention, however little long-term retention of knowledge. This study showed it is feasible to perform web-based geriatric training to nurses in home health care, though it needs to be accompanied by structural and procedural changes in care for long-term success.

Abstract

The number of individuals with dementia is expected to increase dramatically over the next 20 years. Given the complicated clinical, sociobehavioral, and caregiving skills that are needed to comprehensively assess and manage individuals with dementia, the gold standard of care requires involvement of interprofessional teams. This systematic review examined 4,023 abstracts, finding 18 articles from 16 studies where an interprofessional dissemination program was performed. Most studies found some improvement in clinician knowledge or confidence, or patient outcomes, though methods and patient and clinician populations were disparate. Although a significant evidence base for assessing and managing individuals with dementia has been developed, few studies have examined how to disseminate this research, and even fewer in an interprofessional manner. These findings suggest that greater emphasis needs to be placed on disseminating existing evidence-based care and ensuring that programs are interprofessional in nature so that excellent, patient-centered care is provided.

Abstract

Objective: This study aimed to examine the effects of participation in staff nurse-led practice councils on nurse job satisfaction and professional development. Background: Although evidence-based practice (EBP) has become a key component of improving the quality of care, few studies have examined how implementation of staff nurse led councils model affect the involved nurses. Methods: A 3-stage evaluation involving ethnography, semi-structured phenomenological private interviews and a 10-item survey were conducted with nurses, managers and executives participating in or involved with EBP councils tasked with improving patient outcomes at 6 community hospitals in a single non-profit hospital system. Results: Five themes were identified as outcomes: empowerment, meaningfulness, leadership growth, exposure to quality improvement, and vision. Conclusions: Staff-led councils have the potential to improve quality of care, job satisfaction, vision and leadership provided that managers and executives are sufficiently prepared to work with and support the councils.

Abstract

Engaging bedside clinicians, especially nurses, is essential for the success of sustainable process improvement programs and thus for improving the quality of health care. Studies have shown that properly implemented professional councils can be effective in engaging and empowering bedside clinicians to create lasting and meaningful improvements. This case study describes a 5-year program to implement and operate staff-led councils to lead evidence-based practice (EBP) quality improvement initiatives at 6 community hospitals. The outcomes presented in this case study demonstrate that staff-led councils have the potential to improve patient safety and quality of care as evidenced by observed reductions in ventilator-associated pneumonias, central line-associated bloodstream infections, and mortality from acute myocardial infarction and severe sepsis.

Abstract

Overview: Inpatient palliative care teams' (PCT) contribution to improved quality of life and patient satisfaction as well as decreased utilization and costs has been well established. Yet few studies have examined the specific effect of an inpatient PCT on discharge disposition, despite evidence of an association between hospice enrollment, decreased rehospitalization, and improved resource utilization. Methods: Patients admitted to a large nonprofit multisite hospital between June 2004 and December 2007 and seen by the PCT were matched to usual care (UC) patients on age, mortality risk, prior year hospitalized days, and disease severity. Discharge disposition and demographic factors were abstracted from hospital administrative claims; mortality data was collected from the social security death index. Analyses were performed using Wilcoxon's test, χ2 analysis, and multinomial logit regression. Results: Three hundred sixty-one matched pairs were available for analysis. Compared to UC, patients who received a PCT consultation were 3.24 times more likely to be discharged to hospice (p< 0.0001), 1.52 times more likely to be discharged to a nursing facility, and 1.59 times more likely to be discharged home with services (p< 0.001), controlling for patient demographics and disease severity. PCT patients were also referred to hospice earlier in their disease trajectory, rather than in the last few weeks of life. Conclusion: Patients receiving an inpatient PCT consultation are more likely to receive follow-up services upon discharge from the hospital. These services likely contribute to better quality of care and financial benefits, and warrants further study, especially considering the current focus on health care efficiency and quality.