Rapid Cycle Quality Improvement of Telemedicine Protocols in a Skilled Nursing Facility During the COVID-19 Pandemic.

Prior to the COVID-19 pandemic, telemedicine was not well adopted in US nursing facilities. Many nursing facilities have since acknowledged its value due to the need for stricter infection control and reduction of exposure risk from face-to-face visits. A quality improvement project was conducted to improve telemedicine protocols in a high-volume post-acute care nursing facility, enhance provider and facility capability for visits, improve attitudes and skills toward telemedicine, and expand patient access to medical care during the pandemic. Process improvement was facilitated through identifying core areas of need and implementing interventions to address them. Project impact was measured by a retrospective pre-post survey of 7 questions to evaluate process improvement, attitudes, skills, and perceptions using a 5-point Likert scale (5=strongly agree, 1=strongly disagree) completed by 22 respondents (8 medical providers and 14 staff). Scores from before and after implementation were compared using paired t-tests. Respondents expressed improvement in perceived value (3.2 vs 4.8), personal skill/efficiency (2.3 vs 4.2), comfort level (2.3 vs 4.5), and scheduling process (2.3 vs 3.9) for telemedicine visits (all P≤.001). Respondents expressed increased awareness of barriers/benefits of telemedicine (2.8 vs 4.7, P<.001) and improved leadership commitment (2.6 vs 4.4, P<.001). The weekly average number of telemedicine visits per respondent increased significantly after protocol implementation (6.5 vs 25.6, P=.002). With support of facility leadership, interdisciplinary team members and engagement of key stakeholders, a telemedicine protocol was implemented in a single, high-volume, post-acute care skilled nursing facility during the COVID-19 pandemic, allowing patients to receive needed care.

Assessing trainee's performance using reported observations: Perceptions of nurse meta-assessors.

BACKGROUND: Educational and health care organizations who prepare meta-assessors to fulfill their role in the assessment of trainees' performance based on reported observations have little literature to rely on. While the assessment of trainees' performance based on reported observations has been operationalized, we have yet to understand the elements that can affect its quality fully. Closing this gap in the literature will provide valuable insight that could inform the implementation and quality monitoring of the assessment of trainees' performance based on reported observations. OBJECTIVES: The purpose of this study was to explore the elements to consider in the assessment of trainees' performance based on reported observations from the perspectives of meta-assessors. METHODS: Design, Settings, Participants, data collection and analysis. The authors adopted Sandelowski's qualitative descriptive approach to interview nurse meta-assessors from two nursing programs. A semi-structured interview guide was used to document the elements to consider in the assessment of nursing trainees' performance based on reported observations, and a survey was used to collect sociodemographic data. The authors conducted a thematic analysis of the interview transcripts. RESULTS: Thirteen meta-assessors participated in the study. Three core themes were identified: (1) meta-assessors' appropriation of their perceived assessment roles and activities, (2) team climate of information sharing, and (3) challenges associated with the assessment of trainees' performance based on reported observations. Each theme is comprised of several sub themes. CONCLUSIONS: To optimize the quality of the assessment of the trainee's performance based on reported observations and ratings, HPE programs might consider how to clarify better the meta-assessor's roles and activities, as well as how interventions could be created to promote a climate of information sharing and to address the challenges identified. This work will guide educational and health care organizations for better preparation and support for meta-assessors and preceptors.

Chronic conditions patient's perception of post-COVID-19 pandemic teleconsulting continuation in primary care clinics: a qualitative descriptive study.

OBJECTIVES: The COVID-19 pandemic has led to the prioritisation of teleconsultation instead of face-to-face encounters. However, teleconsultation revealed some shortcomings and undesirable effects that may counterbalance benefits. This study aims to explore the perspective of patients with chronic diseases on teleconsultation in primary care. This article also proposes recommendations to provide patient-oriented and appropriate teleconsultations. DESIGN: We conducted a qualitative descriptive study that explored the patients' perception regarding teleconsultation services and the following themes: access, perceived benefits and disadvantages, interprofessional collaboration, patient-centred approach, specific competencies of professionals, and patient's global needs and preferences. SETTING: Six primary care clinics in three regions of Quebec. PARTICIPANTS: 39 patients were interviewed by telephone through semistructured qualitative interviews. RESULTS: Patients want to maintain teleconsultation for the postpandemic period as long as their recommendations are followed: be able to choose to come to the clinic if they wish to, feel that their individual and environmental characteristics are considered, feel involved in the choice of the modality of each consultation, feel that interprofessional collaboration and patient-centred approach are promoted, and to maintain the professionalism, which must not be lessened despite the remote context. CONCLUSION: Patients mainly expressed high satisfaction with teleconsultation. However, several issues must be addressed. Patients do and should contribute to the implementation of teleconsultation in primary care. They wish to be frequently consulted about their preferred consultation modality, which may change over time. The patient perspective must, therefore, be part of the balanced implementation of optimal teleconsultation that is currently taking place.

Interventions to Improve Trainers' Learning and Behaviors for Educating Health Care Professionals Using Train-the-Trainer Method: A Systematic Review and Meta-analysis.

INTRODUCTION: Train-the-trainer (TTT) programs are frequently used to facilitate knowledge dissemination. However, little is known about the effectiveness of these programs. Therefore, we sought to assess the impact of TTT programs on learning and behavior of trainers for educating health and social professionals (trainees). METHODS: Guided by the Cochrane Effective Practice and Organisation of Care, we conducted a systematic review. We searched 12 databases until April 2018 and extracted data according to the Population, Intervention, Comparison, Outcome model. Population was defined as trainers delivering training program to health care professionals, and the intervention consists in any organized activity provided by a trainer. There were no restrictive comparators, and outcomes were knowledge, attitude, skill, confidence, commitment, and behavior of trainers. We estimated the pooled effect size and its 95% confidence interval using a random-effect model. We performed a narrative synthesis when meta-analysis was not possible. RESULTS: Of 11,202 potentially eligible references, we identified 16 unique studies. Studies were mostly controlled before-and-after studies and covered a unique training intervention. Targeted trainers were mostly nurses (n = 10) and physicians (n = 5). The most frequent measured outcome was knowledge (n = 12). TTT programs demonstrated significant effect on knowledge (Standardized mean deviation = 0.58; 95% CI = 0.11-1.06; I2 = 90%; P < .01; 10 studies). No studies measured trainers' ability to deliver the training program. DISCUSSION: TTT programs may improve the knowledge of trainers. However, the heterogeneity and small number of studies hamper our ability to draw conclusions that are more robust.

[Teachers' assessment practices in context of nursing clinical education : a qualitative descriptive study.] / Les pratiques évaluatives d'enseignants en soins infirmiers lors des stages : une étude descriptive qualitative.

Since no study has yet been able to assess the Quebec portrait of teachers' evaluation practices in the context of clinical education in nursing. Considering the importance of clinical teaching and evaluation in the education of nursing students, this study is justified. This article presents the results of a study that aimed to describe and understand the experience of teachers in the ongoing assessment of nursing students' learning during clinical education. It aimed to describe the evaluation practices of teachers during the learning of students in clinical education and achievement context, and to identify factors influencing these practices. In the context of descriptive qualitative research, the data collection was mainly based on the description of practices reported and collected during interviews realized with 10 nursing teachers of a college of the region of Saguenay-Lac-Saint-Jean (SLSJ, Quebec, Canada). The results allowed, for instance, to identify and to describe the evaluation practices led in this specific context of the study : the direct and indirect observation ; the questions asked to the sudent and to the group of sutdents and individual and group feed-back. They also allowed to enumerate and to categorize factors which can influence these practices, that is facilitates factors, barriers and faiths.

Hysterectomy and urinary incontinence in postmenopausal women.

INTRODUCTION AND HYPOTHESIS: To evaluate an association between hysterectomy and urinary incontinence (UI) in postmenopausal women. METHODS: Women (aged 50-79) with uteri (N = 53,569) and without uteri (N = 38,524) who enrolled in the Women's Health Initiative (WHI) Observational Study between 1993 and 1996 were included in this secondary analysis. Baseline (BL) and 3-year demographic, health/physical forms and personal habit questionnaires were used. Statistical analyses included univariate and logistic regression methods. RESULTS: The baseline UI rate was 66.5 %, with 27.3 % of participants having stress urinary incontinence (SUI), 23 % having urge UI (UUI), and 12.4 % having mixed UI (MUI). 41.8 % of women had undergone hysterectomy, with 88.1 % having had the procedure before age 54. Controlling for health/physical variables, hysterectomy was associated with UI at BL (OR 1.25, 95 % CI 1.19, 1.32) and over the 3-year study period (OR 1.23, 95 % CI 1.11, 1.36). Excluding women with UI at BL, a higher incidence of UUI and SUI episodes was found in hysterectomy at year 3. Among women who had undergone hysterectomy, those with bilateral oophorectomy (BSO) did not have increased odds of developing UI at BL or over the 3-year study period. Hormone use was not associated with a change in UI incidence (estrogen + progesterone, p = 0.17; unopposed estrogen, p = 0.41). CONCLUSIONS: Risk of UI is increased in postmenopausal women who had undergone hysterectomy compared with women with uteri.

Combining quality improvement and geriatrics training: the nursing home polypharmacy outcomes project.

To examine sustained effects of an educational intervention, the authors repeated a successful quality improvement (QI) project on medication safety and cost effectiveness. In October 2007 and August 2008, the facility leadership and geriatrics faculty identified all patients receiving nine or more medications (polypharmacy cohort) in a 170-bed teaching nursing home. They then taught Geriatric Medicine fellows (n = 12 in 2007, 11 in 2008) to (a) systematically collect medication data; (b) generate medication recommendations (stop, taper, or continue) based on expert criteria (Beers criteria) or drug-drug interaction programs; (c) discuss recommendations with patients' attending physicians; and (d) implement approved recommendations. Over the two projects, the polypharmacy cohorts demonstrated decreased potentially inappropriate medications (odds ratio [OR] = .78, 95% confidence interval [95% CI] [0.69, 0.88], p < .001), contraindicated medications (OR = .63, 95% CI [0.47, 0.85], p = .002) and medication costs (OR = .97, 95% CI [0.96, 0.99], p < .001). Findings suggest that programs planning educational QI projects for trainees may benefit from a multiyear approach to maximize clinical and educational benefits.

Reducing cost by reducing polypharmacy: the polypharmacy outcomes project.

OBJECTIVE: To examine the effect of intervention by geriatric medicine fellows and a geriatrician on medication cost among long term care residents with polypharmacy. DESIGN: Interventional study. SETTING: A single hospital-affiliated long term care facility. PARTICIPANTS: Long term care residents with polypharmacy, defined as being on 9 or more medications. INTERVENTION: Medication lists of all nursing home residents were reviewed in October 2007 by geriatric medicine fellows and a faculty geriatrician using the 2003 Beers Criteria and the Epocrates online drug-drug interaction program. Recommendations for each resident were prepared and discussed directly with their primary physicians, who made the final decisions regarding medication discontinuation or taper. MEASUREMENTS: Mean monthly costs (derived from current retail prices) for overall as well as scheduled and pro re nata (PRN) medications were compared before and after the intervention. Estimated reduction in nursing administration time and cost were calculated based on published literature on medication administration time and nursing labor costs. RESULTS: Seventy-four (46.3%) of 160 residents were on 9 or more medications. Four residents died or were discharged before the intervention, leaving a final sample of 70 residents for the intervention. After the intervention, mean monthly medication costs per resident significantly decreased; overall medications, from $874.27 to $843.56 (P < .0001); scheduled medications, from $814.05 to $801.14 (P= .007); PRN medications, from $60.22 to $42.43 (P < .0001). Gastrointestinal medications demonstrated the highest cost savings of all medication categories (eg, promethazine and proton pump inhibitors), followed by central nervous system-active medications (including benzodiazepines and fluoxetine), then analgesics and diabetes medications. CONCLUSION: This polypharmacy reduction intervention by physicians used readily available tools, demonstrated a significant decrease in medication-related costs, and provided training in the core competencies of practice-based learning and improvement and systems-based practice to geriatric medicine fellows in long term care.

Effect of walking distance on 8-year incident depressive symptoms in elderly men with and without chronic disease: the Honolulu-Asia Aging Study.

OBJECTIVES: To determine the effect of walking on incident depressive symptoms in elderly Japanese-American men with and without chronic disease. DESIGN: Prospective cohort study. SETTING: The Honolulu-Asia Aging Study. PARTICIPANTS: Japanese-American men aged 71 to 93 at baseline. MEASUREMENTS: Physical activity was assessed according to self-reported distance walked per day. Depressive symptoms were measured using an 11-question version of the Centers for Epidemiologic Studies Depression Scale (CES-D 11) at the fourth examination (n=3,196) and at the seventh examination 8 years later (1999/00, n=1,417). Presence of incident depressive symptoms was defined as a CES-D 11 score of 9 or greater or taking antidepressants at Examination 7. Subjects with prevalent depressive symptoms at baseline were excluded. RESULTS: Age-adjusted 8-year incident depressive symptoms were 13.6%, 7.6%, and 8.5% for low (<0.25 miles/day), intermediate (0.25-1.5 miles/day), and high (>1.5 miles/day) walking groups at baseline (P=0.008). Multiple logistic regression analyses, adjusted for age, education, marital status, cardiovascular risk factors, prevalent diseases, and functional impairment, showed that those in the intermediate and highest walking groups had significantly lower odds of developing 8-year incident depressive symptoms (odds ratio (OR)=0.52, 95% confidence interval (CI)=0.32-0.83, P=.006 and OR=0.61, 95% CI= 0.39-0.97, P=.04, respectively). Analysis found that this association was significant only in participants without chronic diseases (coronary heart disease, cerebrovascular accident, cancer, Parkinson's disease, dementia, or cognitive impairment) at baseline. CONCLUSION: Daily physical activity (≥0.25 mile/day) is significantly associated with lower risk of 8-year incident depressive symptoms in elderly Japanese-American men without chronic disease at baseline.

Strength and influence of geriatrics departments in academic health centers.

The United States is establishing new medical schools and increasing class size by 30% in response to the predicted increased needs of the baby boom generation, which will retire soon and live longer than prior generations. Society in general and the medical profession in particular are ill equipped to care for the special needs of the elderly. Since the early 1980s, departments of geriatric medicine have been developed in the United States. However, the prevailing U.S. system for the training of physicians in geriatrics is through sections, divisions, or institutes. This article reviews the advantages and disadvantages of departments of geriatrics, using case examples from three (University of Oklahoma College of Medicine, Florida State University College of Medicine, and University of Hawaii at Mãnoa John A. Burns School of Medicine) of the extant 11 medical schools in the United States with departments of geriatrics. Commonalities among the three departments include a seat at the planning table in academic life, equal treatment and collaboration with other departments in academic and research program development, and direct access to key decision makers and opportunities for negotiation for funds. Each department has outreach to all undergraduate medical students through its training program. All three departments were launched through the investment of significant resources obtained both internally and externally. The challenge for the future will be to definitively demonstrate the efficacy of the department model versus the more prevalent section, division, and institute approach to training physicians to care for the elderly.

Arthritis as a risk factor for incident coronary heart disease in elderly Japanese-American males - the Honolulu Heart Program.

BACKGROUND: Arthritis is the most common chronic disease in the elderly. Studies show that rheumatoid arthritis is a risk factor for cardiovascular morbidity and mortality, and osteoarthritis is associated with an unfavorable cardiovascular risk factor profile. METHODS: At the Honolulu Heart Program's fourth examination in 1991 to 1993, arthritis status was assessed among a cohort of 3741 Japanese-American males, ages 71 to 93 years. Arthritis was determined by self-report of physician diagnosis, and subjects were divided into two groups: current arthritis and no current arthritis. Eight years of follow-up data are available for incident coronary heart disease (CHD) in 2777 subjects free of CHD at baseline. Age-adjusted rates of incident CHD and means of cardiovascular risk factors were compared in each group. Cox proportional hazards models were used to calculate relative risks, adjusting for common cardiovascular risk factors, alcohol, and use of aspirin or NSAIDs, or both. RESULTS: There were 279 cases of incident CHD in the cohort over 8 years; in those with arthritis, 11.7% developed incident CHD, compared to 9.8% in those without arthritis (p = 0.24). Age-adjusted rates of incident CHD in those with and without arthritis were 20.5 and 18.0 per 1000 person-years, respectively (p = 0.25). Arthritis was not significantly associated with CHD risk factors. Arthritis was not a significant independent predictor of incident CHD (relative risk, 1.06; 95% CI, 0.74 to 1.51). CONCLUSIONS: Arthritis, and most probably osteoarthritis, may not be associated with most CHD risk factors or 8-year incident CHD in elderly Japanese-American males.

Assessment of pain in older Asian Americans with cancer.

This cross-sectional study focused on pain assessment in a group of older Asian Americans with cancer. Thirty-six participants and their primary nurses were interviewed, and pain intensity was measured using 3 different scales: the Numeric pain intensity 0-10 scale, the Faces expression scale, and Visual analog scale (VAS). Overall, 56% of participants reported pain. Younger age (65-75 years old) was significantly associated with higher pain intensity (p < 0.05). High correlation was found between the participants' and their nurses' pain intensity ratings (r = 0.69, p < 0.0001). High correlation was also found among different pain intensity scales, with a Spearman correlation coefficient ranging from 0.89 to 0.96 (p < 0.0001), suggesting that they are reliable measures in this population.

Cardiovascular risk in women with non-specific chest pain (from the Women's Health Initiative Hormone Trials).

Women discharged with diagnoses of nonspecific chest pain (NSCP) may be at increased risk for subsequent coronary artery disease (CAD) events. The influence of hormone therapy on NSCP is unknown. The Women's Health Initiative (WHI) enrolled postmenopausal women aged 50 to 79 years. The duration of follow-up was 7.1 years in the WHI Estrogen-Alone trial (E-Alone) and 5.6 years in the WHI Estrogen Plus Progestin trial (E+P). After excluding women with previous cardiovascular disease, 9,427 women in E-Alone and 15,105 women in E+P were included in this analysis. NSCP, defined as having a primary hospital discharge diagnosis of NSCP by International Classification of Diseases, Ninth Revision, code, was reported in 322 women in E-Alone and 249 in E+P. Risks for subsequent CAD events were estimated using intent-to-treat Cox proportional-hazards models stratified by clinic and adjusted for age and other risk factors. In the fully adjusted models of the combined trials, women with NSCP had a twofold greater risk for subsequent nonfatal CAD events, including nonfatal myocardial infarction (2.3% vs 1.7%, hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.11 to 3.98), revascularization (3.5% vs 2.6%, HR 1.99, 95% CI 1.20 to 3.30), and hospitalized angina (3.7% vs 2.3%, HR 2.39, 95% CI 1.46 to 3.92). Hormone therapy did not appear to have a significant effect on either the incidence of NSCP hospitalizations (E-Alone: HR 1.04, 95% CI 0.81 to 1.32; E+P: HR 0.78, 95% CI 0.59 to 1.02) or the risk for a subsequent CAD event. In conclusion, a hospitalization for NSCP doubles the risk for a subsequent CAD event in postmenopausal women over the next 5 to 7 years and identifies them as candidates for aggressive risk factor treatment.

Factors associated with physician decision-making in starting tube feeding.

BACKGROUND: Because tube-feeding decisions are sometimes difficult, we examined physician, institutional, and patient factors associated with these decisions. METHODS: Primary care physicians (n = 388) likely to manage nursing home patients in Hawaii were surveyed. Respondents indicated the factors of great importance in tube feeding decisions based on a vignette of a poststroke patient failing to thrive and family disagreement with advance directives. chi(2) and multiple logistic regression analyses were used to examine associations between physician demographics and factors of importance to physicians and their decisions based on the vignette. RESULTS: Starting tube feeding (chosen by 31% of respondents) was associated with internal medicine specialty (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.6), and placing great importance on family preference (OR 5.4, 95% CI 3.0-9.8) and liability (OR 2.5, 95% CI 1.3-4.8). After 3 months without improvement, 58% chose to withdraw tube feeding. Continuing tube feeding was associated with placing great importance on family wishes (OR 3.0, 95% CI 1.8-5.1) and liability (OR 1.7, 95% CI 1.0-2.9). Placing great importance on the living will was associated with decreased likelihoods of starting (OR 0.1, 95% CI 0.04-0.3) and continuing (OR 0.1, 95% CI 0.04-0.3) tube feeding. CONCLUSIONS: The decision to start or withhold tube feeding is associated with the individual physician's perception of the importance of patient wishes versus family wishes and liability concerns. Physician awareness of the influence of these factors on medical decisions may improve the decision-making process.

Describing Hawai'i's nursing home physicians: the results of a survey.

INTRODUCTION: Despite a growing need for physicians providing care to nursing home patients, the characteristics of physicians providing such care are not well described. METHODS: A survey was sent to adult primary care physicians in Hawai'i; respondents' demographic data were obtained. Associations between physician characteristics, level of nursing home experience, and island of practice were analyzed using chi square and multivariate logistic regression models. RESULTS: Of 806 physicians, 388 (48%) returned surveys. Controlling for years of experience and other demographic factors, having nursing home experience was associated with physician age (40 years and over compared with under 40 years; OR 3.5, 95% Confidence Interval (CI) 1.4-8.5), Family Medicine specialty (compared with Internal Medicine, General Practice or Other; OR 4.0, 95% CI 1.4-11.4), private practice type (compared with employed, other, and trainee physicians; OR 2.3, 95% CI 1. 1-4.6), and practice location (neighbor islands compared with Oahu, OR 4.5, 95% CI 1.1-17.8). Physicians practicing on the neighbor islands were more likely to be aged 40 years and older (OR 3.9, 95% CI 1.4-10.3), and white (ethnicity compared with all other ethnicities, OR 4.1, 95% CI 2.1-7.7). CONCLUSION: The association of higher physician age with both nursing home experience and neighbor island practice has important implications for the training of physicians to provide nursing home care in Hawai'i.