Applying Noninvasive Ventilation in Treatment of Acute Exacerbation of COPD Using Evidence-Based Interprofessional Clinical Practice.

When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Identifying patients appropriate for NIV, and subsequently providing close monitoring to determine an improvement in clinical condition involves a team consisting of physician, nurse, and respiratory therapist in institutions that successfully implement NIV. We describe to our knowledge the first known evidence-based algorithm speaking to initiation, titration, monitoring, and weaning of NIV in treatment of acute exacerbation of COPD that incorporates the necessary interprofessional collaboration among physicians, nurses, and respiratory therapists caring for these patients.

Front-Line Health Care Workers' COVID-19 Infection Contamination Risks: A Human Factors and Risk Analysis Study of Personal Protective Equipment.

Infectious risks escalate with complex donning and doffing personal protective equipment (PPE) protocols. Recent studies suggest that PPE donning and doffing behaviors that deviate from protocol during PPE reuse compounded the risks of health care worker (HCW) self-contamination. This study quantified the occurrence of behaviors associated with known risks in PPE use and reuse. We conducted a prospective study of emergency department HCWs and video-recorded PPE donning and doffing 5 times in simulated patient encounters. Trained coders recorded HCW behaviors according to an evidence-based guide. All 28 participants deviated from the Centers for Disease Control and Prevention (CDC) sanctioned donning and doffing protocol order, and most were documented to have (92.85%) self-contaminated at least once during each simulated clinical encounter. Behaviors that compounded self-contamination due to PPE reuse were also observed. Wide variation in PPE donning and doffing behaviors was found among front-line, experienced HCWs. Future work is needed to determine which deviations put HCWs at increased risk for accidental self-contamination and what changes are needed to the CDC protocol for protecting HCW from infections.

What can we learn from COVID-19?: examining the resilience of primary care teams.

Introduction: The COVID-19 pandemic continues to place an unprecedented strain on the US healthcare system, and primary care is no exception. Primary care services have shifted toward a team-based approach for delivering care in the last decade. COVID-19 placed extraordinary stress on primary care teams at the forefront of the pandemic response efforts. The current work applies the science of effective teams to examine the impact of COVID-19-a crisis or adverse event-on primary care team resilience. Methods: Little empirical research has been done testing the theory of team resilience during an extremely adverse crisis event in an applied team setting. Therefore, we conducted an archival study by using large-scale national data from the Veterans Health Administration to understand the characteristics and performance of 7,023 Patient Aligned Care Teams (PACTs) during COVID-19. Results: Our study found that primary care teams maintained performance in the presence of adversity, indicating possible team resilience. Further, team coordination positively predicted team performance (B = 0.53) regardless of the level of adversity a team was experiencing. Discussion: These findings in turn attest to the need to preserve team coordination in the presence of adversity. Results carry implications for creating opportunities for teams to learn and adjust to an adverse event to maintain performance and optimize team-member well-being. Teamwork can act as a protective factor against high levels of workload, burnout, and turnover, and should be studied further for its role in promoting team resilience.

Mi-CARE: Comparing Three Evidence-Based Interventions to Promote Colorectal Cancer Screening among Ethnic Minorities within Three Different Clinical Contexts.

Multiple evidence-based interventions (EBIs) have been developed to improve the completion of colorectal cancer (CRC) screening within Federally Qualified Health Centers (FQHCs) and other safety net settings in marginalized communities. Little effort has been made, however, to evaluate their relative effectiveness across different clinical contexts and populations. To this end, we tested the relative effectiveness of three EBIs (mailed birthday cards, lay navigation, and provider-delivered education) among a convenience sample of 1252 patients (aged 50-75 years old, who were due for CRC screening and scheduled for a visit at one of three clinics within a network of Federally Qualified Health Centers (FQHCs) in the United States. To be eligible for the study, patients had to identify as African American (AA) or Latino American (LA). We compared the effects of the three EBIs on CRC screening completion using logistic regression. Overall, 20% of the study population, an increase from a baseline of 13%, completed CRC screening. Clinical demographics appeared to influence the effectiveness of the EBIs. Mailed birthday reminders appeared to be the most effective within the multi-ethnic clinic (p = 0.03), provider-delivered education within the predominantly LA clinic (p = 0.02), and lay navigation within the predominantly AA clinic (p = 0.03). These findings highlight the importance of understanding clinical context when selecting which evidence-based interventions to deploy.

Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units.

CONTEXT: Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D). OBJECTIVE: The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies. METHOD: SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders). RESULTS: AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation. CONCLUSION: Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Blood pressure measurement and blood pressure control in Veterans Affairs medical centers.

The Veterans Affairs (VA) medical centers provide care for millions of Veterans at high risk of cardiovascular disease and accurate BP measurement in this population is vital for optimal BP control. Few studies have examined terminal digit preference (TDP), a marker of BP measurement bias, clinician perceptions of BP measurement, and BP control in VA medical centers. This mixed methods study examined BP measurements from Veterans aged 18 to 85 years with hypertension and a primary care visit within 8 VA medical centers. TDP for all clinic BP measurements was examined using a goodness of fit test assuming 10% frequency for each digit. Interviews were also conducted with clinicians from 3 VA medical centers to assess perceptions of BP measurement. The mean age of the 98,433 Veterans (93% male) was 68.5 years (SD 12.7). BP was controlled (<140/90 mmHg) in 76.5% and control rates ranged from 72.2% to 81.0% across the 8 VA medical centers. Frequency of terminal digits 0 through 9 differed significantly from 10% for both SBP and DBP within each center (P < .001) but level of TDP differed by center. The highest BP control rates were noted in centers with highest TDP for digits 0 and 8 for both SBP and DBP. Clinicians reported use of semi-automated oscillometric devices for clinic BP measurement, but elevated BP readings were often confirmed by auscultatory methods. Significant TDP exists for BP measurement in VA medical centers, which reflects continued use of auscultatory methods.

Analysis of shared cognitive tasks in the application of non-invasive ventilation to patients with COPD exacerbation.

Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview (n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training.

The feasibility of academic detailing for acute oral pain management in outpatient dentistry: A pilot study.

BACKGROUND: Opioids are overprescribed in the outpatient dental setting. Therefore, opportunities exist for opioid stewardship. OBJECTIVES: The purpose of this pilot study was to test the feasibility of an academic detailing (AD) intervention to promote appropriate prescribing of opioids in outpatient dentistry. METHODS: We implemented an AD intervention targeting management of acute oral pain in a Midwestern Veterans Affairs outpatient dental facility. The intervention targeted dentists who actively prescribed opioids at the time of the study. The pilot study tested feasibility, adoption, and acceptance of the AD campaign. Visit-based prescribing rates were obtained from the Veterans Health Administration's Corporate Data Warehouse for baseline and postintervention using difference-in-differences analyses to detect potential changes in health service outcomes. RESULTS: Results indicate moderate levels of feasibility through participation rates (n = 5, 55.5%) and high levels of organizational readiness for change (average of 88.6% agree to strongly agree). Furthermore, fidelity of the AD intervention was high. Adoption measures show moderate indication of motivation to change, and trends suggest that participating dentists decreased their visit-based opioid prescribing rates (P > 0.05). CONCLUSION: The intervention demonstrated feasibility with some indications of adoption of intervention techniques and decrease in opioid prescribing. We further recommend working closely with frontline providers to gather feedback and buy-in before scaling and implementing the AD campaign.

A qualitative exploration of dentists' opioid prescribing decisions within U.S. veterans affairs facilities.

ABSTRACT: The U.S. Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States and provides dental care to approximately one-half million veterans annually. In response to the opioid crisis, the VA released several opioid risk mitigation strategies. Although opioid prescribing by VA dentists has decreased on the whole, the implementation experiences at the level of dentists remains unclear. Our objective was to explore the barriers and facilitators that affect opioid decision making for management of acute dental pain among VA dentists. Dentists practicing in the VA facilities with the highest and lowest volume of opioid prescriptions were recruited. Standardized qualitative interviews by telephone followed a semistructured guide designed around the Capability (C), Opportunity (O), Motivation (M), and Behaviour (B) model. Audio recordings were transcribed and independently double-coded using NVivo to identify potential targets for future guideline-based opioid interventions. Of 395 eligible general and specialty dentists, 90 (24.8%) completed an interview representing 33 VA facilities. Opportunities for prescribing opioids included 1) completion of dental procedures associated with acute dental pain, 2) caring for patients who presented with existing dental pain, and 3) responding to patient opioid requests. Capabilities included using resources (eg, electronic medical records), clinical judgement (eg, evaluation of medical history including medication use), communication skills, and ability to screen for opioid misuse. Motivation themes focused on alleviating patients' acute dental pain. Barriers and facilitators of opioid prescribing varied across facilities. The results can offer intervention targets for continued opioid risk mitigation efforts.

A qualitative approach to examining antimicrobial prescribing in the outpatient dental setting.

Objective: To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting. Design: Semistructured interviews. Setting: Outpatient dental setting. Participants: Dentists from 40 Veterans' Health Administration (VA) facilities across the United States. Methods: Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing. Results: In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist's decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities. Conclusions: Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists' ongoing professional development and improve evidence-based prescribing.

The Content of COVID-19 Information Searches and Vaccination Intention: An Implication for Risk Communication.

OBJECTIVE: The main objective of this study was to examine the association between COVID-19 information search activities and vaccination intention. METHODS: Cross-sectional data were collected using online surveys. Independent variables included COVID-19 information search on the (1) science of viral effects of COVID-19 on the body, (2) origin of COVID-19, (3) symptoms and outcomes, (4) transmission and prevention, (5) future outbreak, and (6) policies/procedures to follow. The outcome variable was vaccination intention. A multivariable regression analysis was conducted. RESULTS: Participants (N = 501) had a mean age of 32.44 ± 11.94 years, were 55.3% female, and 67.9% were white. Most COVID-19 information searches were on symptoms and outcomes (77.7%) and policies/procedures to follow (69.9%). Intention to vaccinate against COVID-19 was higher among participants who searched for information on the science of viral effects of COVID-19 on the body (ß = 0.23, 95% CI: 0.03-0.43; P = 0.03) and policies/procedures to follow (ß = 0.24, 95% CI: 0.03-0.41; P = 0.02). CONCLUSIONS: People who searched for information about (1) the science of viral effects of COVID-19 and (2) policies/procedures recommendations also reported higher vaccination intention. Risk communication seeking to increase vaccination should meet the consumers' information demand by prioritizing the scientific rationale for COVID-19 vaccination and by clarifying what policies/procedures are recommended.

How Can Personal Protective Equipment Be Best Used and Reused: A Closer Look at Donning and Doffing Procedures.

OBJECTIVE: The aim of this study was to examine safety-related contamination threats and risks to health-care workers (HCWs) due to the reuse of personal protective equipment (PPE) among emergency department (ED) personnel. METHODS: We used a Participatory Design (PD) approach to conduct task analysis (TA) of PPE use and reuse. TA identified the steps, risks, and protective behaviors involved in PPE reuse. We used the Centers for Disease Control and Prevention (CDC) guidance for PPE donning and doffing specifying the recommended task order. Then, we convened subject matter experts (SMEs) with relevant backgrounds in Patient Safety, Human Factors and Emergency Medicine to iteratively identify and map the tasks, risks, and protective behaviors involved in the PPE use and reuse. RESULTS: Two emerging threats were associated with behaviors in donning, doffing, and re-using PPE: (i) direct exposure to contaminant, and (ii) transmission/spread of contaminant. Protective behaviors included: hand hygiene, not touching the patient-facing surface of PPE, and ensuring a proper fit and closure of all PPE ties and materials. CONCLUSIONS: TA was helpful revealed that the procedure for donning and doffing of re-used PPE does not protect ED personnel from contaminant spread and risk of exposure, even with protective behaviors present (e.g., hand hygiene, respirator use, etc.). Future work should make more apparent the underlying risks associated with PPE use and reuse.

Identifying themes to inform nursing decisions when caring for patients with acute exacerbation of chronic obstructive pulmonary disease on noninvasive ventilation: A qualitative descriptive study.

Prior studies analyzing patient experience with noninvasive ventilation (NIV) found the most impactful interaction that patients remembered was with nurses, however a survey of nurses regarding the management of patients treated with NIV has shown that most nurses felt unprepared to care for these sick patients. Our qualitative descriptive study explored the current nursing experience using NIV as a treatment for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Nine (n = 9) subject matter expert nurses practicing in a variety of clinical settings participated in semi-structured interviews. The COnsolidated criteria for REporting Qualitative research checklist was followed for interview development. Interview transcripts were subsequently analyzed using deductive thematic analysis. Themes identified from the interviews pertained to patient assessment, novice nurses' need for clinical support, team communication, and nursing education. Improving interprofessional team communication and collaboration skills, and implementing guidelines for NIV utilization were specified as essential components of NIV education for nurses. Even though the nursing role in the care of AECOPD NIV patient could be institution dependent, the themes presented in our study are useful in identifying opportunities for NIV nursing education and areas for further research. Patient or Public Contribution: Nurses served as interviewees for this study.

An evidence-based, structured, expert approach to selecting essential indicators of primary care quality.

BACKGROUND: The purpose of this article is to illustrate the application of an evidence-based, structured performance measurement methodology to identify, prioritize, and (when appropriate) generate new measures of health care quality, using primary care as a case example. Primary health care is central to the health care system and health of the American public; thus, ensuring high quality is essential. Due to its complexity, ensuring high-quality primary care requires measurement frameworks that can assess the quality of the infrastructure, workforce configurations, and processes available. This paper describes the use of the Productivity Measurement and Enhancement System (ProMES) to compile a targeted set of such measures, prioritized according to their contribution and value to primary care. METHODS: We adapted ProMES to select and rank existing primary care measures according to value to the primary care clinic. Nine subject matter experts (SMEs) consisting of clinicians, hospital leaders and national policymakers participated in facilitated expert elicitation sessions to identify objectives of performance, corresponding measures, and priority rankings. RESULTS: The SMEs identified three fundamental objectives: access, patient-health care team partnerships, and technical quality. The SMEs also selected sixteen performance indicators from the 44 pre-vetted, currently existing measures from three different data sources for primary care. One indicator, Team 2-Day Post Discharge Contact Ratio, was selected as an indicator of both team partnerships and technical quality. Indicators were prioritized according to value using the contingency functions developed by the SMEs. CONCLUSION: Our article provides an actionable guide to applying ProMES, which can be adapted to the needs of various industries, including measure selection and modification from existing data sources, and proposing new measures. Future work should address both logistical considerations (e.g., data capture, common data/programming language) and lingering measurement challenges, such as operationalizating measures to be meaningful and interpretable across health care settings.

Exploring the Patient Experience with Noninvasive Ventilation: A Human-Centered Design Analysis to Inform Planning for Better Tolerance.

BACKGROUND: This study brings a human-centered design (HCD) perspective to understanding the patient experience when using noninvasive ventilation (NIV) with the goal of creating better strategies to improve NIV comfort and tolerance. METHODS: Using an HCD motivational approach, we created a semi-structured interview to uncover the patients' journey while being treated with NIV. We interviewed 16 patients with chronic obstructive pulmonary disease (COPD) treated with NIV while hospitalized. Patients' experiences were captured in a stepwise narrative creating a journey map as a framework describing the overall experience and highlighting the key processes, tensions, and flows. We broke the journey into phases, steps, emotions, and themes to get a clear picture of the overall experience levers for patients. RESULTS: The following themes promoted NIV tolerance: trust in the providers, the favorable impression of the facility and staff, understanding why the mask was needed, how NIV works and how long it will be needed, immediate relief of the threatening suffocating sensation, familiarity with similar treatments, use of meditation and mindfulness, and the realization that treatment was useful. The following themes deterred NIV tolerance: physical and psychological discomfort with the mask, impaired control, feeling of loss of control, and being misinformed. CONCLUSIONS: Understanding the reality of patients with COPD treated with NIV will help refine strategies that can improve their experience and tolerance with NIV. Future research should test ideas with the best potential and generate prototypes and design iterations to be tested with patients.

Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration.

OBJECTIVE: The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. BACKGROUND: Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. METHOD: We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. RESULTS: We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. CONCLUSIONS: Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. APPLICATION: Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.

Associations between safety outcomes and communication practices among pediatric nurses in the United States.

PURPOSE: To gain a deeper understanding of RNs communication related to patient safety. RESEARCH AIMS: To determine: (1) the associations between the communication of registered nurses (RNs) within their health care teams and the frequency that they reported safety events; (2) the associations between RNs' communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs' communication had improved from 2016 to 2018. THEORETICAL FRAMEWORK AND METHODS: We used the United Kingdom's Safety Culture model as the theoretical framework for this study. Our secondary data analysis from the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture included 2016 (n = 5298) and 2018 (n = 3476) using multiple regression models to determine associations between responses for Communication Openness and Feedback & Communication About Error, and outcome responses for Frequency of Events Reported and Overall Perceptions of Safety. RESULTS: Our findings were: 1). In both 2016 and 2018 datasets, Feedback About Error had a greater impact on Reporting Frequency than Open Communication; 2). Feedback About Error had a greater impact on Safety Perceptions than Open Communication; 3). Open Communication and Feedback About Error and their associations with Reporting Frequency and Safety Perceptions showed little change; and, 4). The proportion of variance was low, indicating factors other than Open Communication and Feedback About Error were involved with Reporting Frequency and Safety Perceptions. CONCLUSION: Pediatric RNs' communication, reporting, and perceptions of patient safety have not improved. (245 words).

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety.

ABSTRACT: Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.

Update to the study protocol for an implementation-effectiveness trial comparing two education strategies for improving the uptake of noninvasive ventilation in patients with severe COPD exacerbation.

BACKGROUND: There is strong evidence that noninvasive ventilation (NIV) improves the outcomes of patients hospitalized with severe COPD exacerbation, and NIV is recommended as the first-line therapy for these patients. Yet, several studies have demonstrated substantial variation in NIV use across hospitals, leading to preventable morbidity and mortality. In addition, prior studies suggested that efforts to increase NIV use in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, our initial project aimed to compare two educational strategies: online education (OLE) and interprofessional education (IPE), which targets complex team-based care in NIV delivery. Due to the impact of the COVID-19 pandemic on recruitment and planned intervention, we had made several changes in the study design, statistical analysis, and implementation strategies delivery as outlined in the methods. METHODS: We originally proposed a two-arm, pragmatic, cluster, randomized hybrid implementation-effectiveness trial comparing two education strategies to improve NIV uptake in patients with severe COPD exacerbation in 20 hospitals with a low baseline rate of NIV use. Due to logistical constrains and slow recruitment, we changed the study design to an opened cohort stepped-wedge design with three steps which will allow the institutions to enroll when they are ready to participate. Only the IPE strategy will be implemented, and the education will be provided in an online virtual format. Our primary outcome will be the hospital-level risk-standardized NIV proportion for the period post-IPE training, along with the change in rate from the period prior to training. Aim 1 will compare the change over time of NIV use among patients with COPD in the step-wedged design. Aim 2 will explore the mediators' role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and effectiveness. Finally, in Aim 3, through interviews with providers, we will assess the acceptability and feasibility of the educational training. CONCLUSION: The changes in study design will result in several limitation. Most importantly, the hospitals in the three cohorts are not randomized as they enroll based on their readiness. Second, the delivery of the IPE is virtual, and it is not known if remote education is conducive to team building. However, this study will be among the first to test the impact of IPE in the inpatient setting carefully and may generalize to other interventions directed to seriously ill patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04206735 . Registered on December 20, 2019.

Improving team coordination in primary-care settings via multifaceted team-based feedback: a non-randomised controlled trial study.

BACKGROUND: Coordination is critical to successful team-based health care. Most clinicians, however, are not trained in effective coordination or teamwork. Audit and feedback (A&F) could improve team coordination, if designed with teams in mind. AIM: The effectiveness of a multifaceted, A&F-plus-debrief intervention was tested to establish whether it improved coordination in primary care teams compared with controls. DESIGN & SETTING: Case-control trial within US Veterans Health Administration medical centres. METHOD: Thirty-four primary care teams selected from four geographically distinct hospitals were compared with 34 administratively matched control teams. Intervention-arm teams received monthly A&F reports about key coordination behaviours and structured debriefings over 7 months. Control teams were followed exclusively via their clinical records. Outcome measures included a coordination composite and its component indicators (appointments starting on time, timely recall scheduling, emergency department utilisation, and electronic patient portal enrolment). Predictors included intervention arm, extent of exposure to intervention, and degree of multiple team membership (MTM). RESULTS: Intervention teams did not significantly improve over control teams, even after adjusting for MTM. Follow-up analyses indicated cross-team variability in intervention fidelity; although all intervention teams received feedback reports, not all teams attended all debriefings. Compared with their respective baselines, teams with high debriefing exposure improved significantly. Teams with high debriefing exposure improved significantly more than teams with low exposure. Low exposure teams significantly increased patient portal enrolment. CONCLUSION: Team-based A&F, including adequate reflection time, can improve coordination; however, the effect is dose dependent. Consistency of debriefing appears more critical than proportion of team members attending a debriefing for ensuring implementation fidelity and effectiveness.