Using the Translating Research into Practice framework to develop a diabetes prevention intervention in primary care: a mixed-methods study.

BACKGROUND: Pre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a gap remains in effectively translating and increasing uptake of these interventions into routine care. METHODS: We applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake. RESULTS: In phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components. CONCLUSIONS: The TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.

Investigating the Trajectory and Associated Risk Factors of Clinical Outcomes for Early Childhood Disruptive Behavior Disorders Using Real World Data.

Disruptive behavior disorders (DBDs) are common mental health problems among early childhood American youth that, if poorly managed, pose costly psychological and societal burdens. There is limited real world evidence on how parent management training (PMT) - the evidence-based treatment model of choice - implemented in common practice settings within the United States influences the behavioral progress of early childhood DBDs, and the risk factors associated with poor outcomes. This study used data from a measurement feedback system implemented within a U.S.-based private practice to study how behavioral outcomes change as a function of PMT treatment engagement and associated risk factors for 4-7 year-old children diagnosed with DBDs. Over 50% of patients reached optimal outcomes after 10 appointments. Attending 24-29 appointments provided maximum treatment effect - namely, 75% of patients reaching optimal outcomes by end of treatment. Outcomes attenuate after reaching the maximum effect. Patients also had higher odds of reaching optimal outcomes if they had consistent attendance throughout the treatment course. Notable risk factors associated with lower odds of reaching optimal outcomes included Medicaid insurance-type, greater clinical complexity, and having siblings concurrently in treatment. Increased implementation of systems that monitor and provide feedback on treatment outcomes in U.S.-based practice settings and similar investigations using its data can further enhance 'real world' management of early childhood DBDs among American youth.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19.

BACKGROUND: Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge. METHODS: Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization. RESULTS: Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization. CONCLUSIONS: HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Tobacco smoking and nicotine vaping in persons with first episode psychosis.

Tobacco smoking is highly prevalent in persons with psychosis and is the leading cause of preventable mortality in this population. Less is known about tobacco smoking in persons with first episode psychosis (FEP) and there have been no estimates about the prevalence of nicotine vaping in FEP. This study reports rates of tobacco smoking and nicotine vaping in young people with FEP enrolled in Coordinated Specialty Care programs in Pennsylvania and Maryland. Using data collected from 2021 to 2023, we examined lifetime and recent smoking and vaping and compared smokers and vapers to nonusers on symptoms, functioning, and substance use. The sample included 445 participants aged 13-35 with recent psychosis onset. Assessments were collected by program staff. Overall, 28 % of participants engaged in either smoking or vaping within 30 days of the admission assessment. Smokers and vapers were disproportionately male, cannabis users, and had lower negative symptom severity than non-smokers. Vapers had higher role and social functioning. Both smoking and vaping were related to a longer time from psychosis onset to program enrollment. We compare these findings to previous studies and suggest steps for addressing smoking and vaping in this vulnerable population.

Healthcare organization characteristics in cancer care delivery: an integrated conceptual framework with content validation.

Context can influence cancer-related outcomes. For example, healthcare organization characteristics including ownership, leadership, and culture can impact care access, communication, and patient outcomes. Healthcare organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming healthcare organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-, organization-, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in healthcare delivery-and their dynamics-is an important, yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. However, the field lacks conceptual grounding to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Centering Health Equity in the Implementation of the Hospital Incident Command System: A Qualitative Case Comparison Study.

OBJECTIVE: Disasters exacerbate inequities in health care. Health systems use the Hospital Incident Command System (HICS) to plan and coordinate their disaster response. This study examines how 2 health systems prioritized equity in implementing the Hospital Incident Command System (HICS) during the coronavirus disease 2019 (COVID-19) pandemic and identifies factors that influenced implementation. METHODS: This is a qualitative case comparison study, involving semi-structured interviews with 29 individuals from 2 US academic health systems. Strategies for promoting health equity were categorized by social determinants of health. The Consolidated Framework for Implementation Research (CFIR) guided analysis using a hybrid inductive-deductive approach. RESULTS: The health systems used various strategies to incorporate health equity throughout implementation, addressing all 5 social determinants of health domains. Facilitators included HICS principles, external partnerships, community relationships, senior leadership, health equity experts and networks, champions, equity-stratified data, teaming, and a culture of health equity. Barriers encompassed clarity of the equity representative role, role ambiguity for equity representatives, tokenism, competing priorities, insufficient resource allocation, and lack of preparedness. CONCLUSIONS: These findings elucidate how health systems centered equity during HICS implementation. Health systems and regulatory bodies can use these findings as a foundation to revise the HICS and move toward a more equitable disaster response.

Embedding Equity into the Hospital Incident Command System: A Narrative Review.

BACKGROUND: Disasters exacerbate health inequities, with historically marginalized populations experiencing unjust differences in health care access and outcomes. Health systems plan and respond to disasters using the Hospital Incident Command System (HICS), an organizational structure that centralizes communication and decision-making. The HICS does not have an equity role or considerations built into its standard structure. The authors conducted a narrative review to identify and summarize approaches to embedding equity into the HICS. METHODS: The peer-reviewed (PubMed, SCOPUS) and gray literature was searched for articles from high-income countries that referenced the HICS or Incident Command System (ICS) and equity, disparities, or populations that experience inequities in disasters. The primary focus of the search strategy was health care, but the research also included governmental and public health system articles. Two authors used inductive thematic analysis to assess commonalities and refined the themes based on feedback from all authors. RESULTS: The database search identified 479 unique abstracts; 76 articles underwent full-text review, and 11 were included in the final analysis. The authors found 5 articles through cited reference searching and 13 from the gray literature search, which included websites, organizations, and non-indexed journal articles. Three themes from the articles were identified: including equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community. CONCLUSION: Several efforts to embed equity into the HICS and disaster preparedness and response were discovered. This review provides practical strategies health system leaders can include in their HICS and emergency preparedness plans to promote equity in their disaster response.

A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative.

OBJECTIVES: To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. DESIGN: Cross-sectional survey conducted May 2021-January 2022. SETTING: Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. SUBJECTS: Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). CONCLUSIONS: Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.

Efficacy and Adherence Rates of a Novel Community-Informed Virtual World-Based Cardiac Rehabilitation Program: Protocol for the Destination Cardiac Rehab Randomized Controlled Trial.

BACKGROUND: Innovative restructuring of cardiac rehabilitation (CR) delivery remains critical to reduce barriers and improve access to diverse populations. Destination Cardiac Rehab is a novel virtual world technology-based CR program delivered through the virtual world platform, Second Life, which previously demonstrated high acceptability as an extension of traditional center-based CR. This study aims to evaluate efficacy and adherence of the virtual world-based CR program compared with center-based CR within a community-informed, implementation science framework. METHODS: Using a noninferiority, hybrid type 1 effectiveness-implementation, randomized controlled trial, 150 patients with an eligible cardiovascular event will be recruited from 6 geographically diverse CR centers across the United States. Participants will be randomized 1:1 to either the 12-week Destination Cardiac Rehab or the center-based CR control groups. The primary efficacy outcome is a composite cardiovascular health score based on the American Heart Association Life's Essential 8 at 3 and 6 months. Adherence outcomes include CR session attendance and participation in exercise sessions. A diverse patient/caregiver/stakeholder advisory board was assembled to guide recruitment, implementation, and dissemination plans and to contextualize study findings. The institutional review board-approved randomized controlled trial will enroll and randomize patients to the intervention (or control group) in 3 consecutive waves/year over 3 years. The results will be published at data collection and analyses completion. CONCLUSIONS: The Destination Cardiac Rehab randomized controlled trial tests an innovative and potentially scalable model to enhance CR participation and advance health equity. Our findings will inform the use of effective virtual CR programs to expand equitable access to diverse patient populations. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05897710.

Improving Diabetes Screening in the Primary Care Clinic.

BACKGROUND: In our suburban primary care clinic, the average rate of screening for diabetes among eligible patients was only 51%, similar to national screening data. We conducted a quality improvement project to increase this rate. METHODS: During the 6-month preintervention phase, we collected baseline data on the percentage of eligible patients screened per week (percentage of patients with hemoglobin A1c checked in the prior 3 years out of patients eligible for screening who completed a visit during the week). We then implemented a two-phase intervention. In phase 1 (approximately 8 months), we generated an electronic health record (EHR) report to identify eligible patients and pended laboratory orders for physicians to sign. In phase 2 (approximately 3 months), we replaced the phase 1 intervention with an EHR clinical decision support tool that automatically identifies eligible patients. We compared screening rates in the preintervention vs. intervention period. For phase 1, we also assessed laboratory completion rates and the laboratory results. We surveyed physicians regarding intervention acceptability and satisfaction at 3, 6, 9, and 12 months during the intervention period. RESULTS: The weekly percentage of patients screened increased from an average of 51% in the preintervention phase to 65% in the intervention phase (p < 0.001). During phase 1, most patients underwent laboratory blood testing as recommended (83% within 3 months), and results were consistent with prediabetes in 23% and with diabetes in 4%. Overall, most physicians believed that the intervention appropriately identified patients due for screening and was helpful (100% of respondents agreed at 9 months vs. 71% at 3 months). CONCLUSION: We successfully implemented a systematic screening intervention involving a manual workflow and EHR tool and improved diabetes screening rates in our clinic.

Outpatient visits before and after Lyme disease diagnosis in a Maryland employer-based health plan.

BACKGROUND: Insurance claims data have been used to inform an understanding of Lyme disease epidemiology and cost of care, however few such studies have incorporated post-treatment symptoms following diagnosis. Using longitudinal data from a private, employer-based health plan in an endemic US state, we compared outpatient care utilization pre- and post-Lyme disease diagnosis. We hypothesized that utilization would be higher in the post-diagnosis period, and that temporal trends would differ by age and gender. METHODS: Members with Lyme disease were required to have both a corresponding ICD-9 code and a fill of an antibiotic indicated for treatment of the infection within 30 days of diagnosis. A 2-year 'pre- diagnosis' period and a 2-year 'post-diagnosis period' were centered around the diagnosis month. Lyme disease-relevant outpatient care visits were defined as specific primary care, specialty care, or urgent care visits. Descriptive statistics examined visits during these pre- and post-diagnosis periods, and the association between these periods and the number of visits was explored using generalized linear mixed effects models adjusting for age, season of the year, and gender. RESULTS: The rate of outpatient visits increased 26% from the pre to the post-Lyme disease diagnosis periods among our 317-member sample (rate ratio = 1.26 [1.18, 1.36], p < 0.001). Descriptively, care utilization increases appeared to persist across months in the post-diagnosis period. Women's care utilization increased by 36% (1.36 [1.24, 1.50], p < 0.001), a significantly higher increase than the 14% increase found among men (1.14 [1.02, 1.27], p = 0.017). This gender difference was mainly driven by adult members. We found a borderline significant 17% increase in visits for children < 18 years, (1.17 [0.99, 1.38], p = 0.068), and a 31% increase for adults ≥ 18 years (1.31 [1.21, 1.42], p < 0.001). CONCLUSIONS: Although modest at the population level, the statistically significant increases in post-Lyme diagnosis outpatient care we observed were persistent and unevenly distributed across demographic and place of service categories. As Lyme disease cases continue to grow, so will the cumulative prevalence of persistent symptoms after treatment. Therefore, it will be important to confirm these findings and understand their significance for care utilization and cost, particularly against the backdrop of other post-acute infectious syndromes.

Service Utilization for Parent Management of Early Childhood Behavior Problems in a Private Outpatient Behavioral Clinic: The Impact of Out-of-Pocket Cost, Travel Distance, and Initial Treatment Progress.

Poorly-managed early childhood disruptive behavior disorders (DBDs) have costly psychological and societal burdens. While parent management training (PMT) is recommended to effectively manage DBDs, appointment adherence is poor. Past studies on influential factors of PMT appointment adherence focused on parental factors. Less well studied are social drivers relative to early treatment gains. This study investigated how financial and time cost relative to early gains influence PMT appointment adherence for early childhood DBDs in a clinic of a large behavioral health pediatric hospital from 2016 to 2018. Using information obtained from the clinic's data repository, claims records, public census and geospatial data, we assessed how owed unpaid charges, travel distance from home to clinic, and initial behavioral progress influences total and consistent attendance of appointments for commercially- and publicly-insured (Medicaid and Tricare) patients, controlling for demographic, service, and clinical differences. We further assessed how social deprivation interacted with unpaid charges to influence appointment adherence for commercially-insured patients. Commercially-insured patients had poorer appointment adherence with longer travel distances, or having unpaid charges and greater social deprivation; they also attended fewer total appointments with faster behavioral progress. Comparatively, publicly-insured patients were not affected by travel distance and had higher consistent attendance with faster behavioral progress. Longer travel distance and difficulty paying service costs while living in greater social deprivation are barriers to care for commercially-insured patients. Targeted intervention may be needed for this specific subgroup to attend and stay engaged in treatment.

Development and Validation of the Hospital-to-Home-Health Transition Quality (H3TQ) Index: A Novel Measure to Engage Patients and Home Health Providers in Evaluating Hospital-to-Home Care Transition Quality.

BACKGROUND: Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions. OBJECTIVE: To describe the development, initial psychometric validation, and feasibility of the Hospital-to-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks. METHODS: Development: A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing: Prospective H3TQ implementation on older adults' hospital-to-HH transitions. Populations Studied: Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists). RESULTS: The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients' lack of general understanding of care plans (27%). CONCLUSIONS: The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition.

Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission.

ABSTRACT: This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.

'All my co-workers are good people, but ': collaboration dynamics between frontline workers in rural Uttar Pradesh, India.

Multisectoral collaboration has been identified as a critical component in a wide variety of health and development initiatives. For India's Integrated Child Development Services (ICDS) scheme, which serves >100 million people annually across more than one million villages, a key point of multisectoral collaboration-or 'convergence', as it is often called in India-is between the three frontline worker cadres jointly responsible for delivering essential maternal and child health and nutritional services throughout the country: the Accredited Social Health Activist (ASHA), Anganwadi worker (AWW) and auxiliary nurse midwife (ANM) or 'AAA' workers. Despite the long-recognized importance of collaboration within this triad, there has been relatively little documentation of what this looks like in practice and what is needed in order to improve it. Informed by a conceptual framework of collaborative governance, this study applies inductive thematic analysis of in-depth interviews with 18 AAA workers and 6 medical officers from 6 villages across three administrative blocks in Hardoi district of Uttar Pradesh state to identify the key elements of collaboration. These are grouped into three broad categories: 'organizational' (including interdependence, role clarity, guidance/support and resource availability); 'relational' (interpersonal and conflict resolution) and 'personal' (flexibility, diligence and locus of control). These findings underscore the importance of 'personal' and 'relational' collaboration features, which are underemphasized in India's ICDS, the largest of its kind globally, and in the multisectoral collaboration literature more broadly-both of which place greater emphasis on 'organizational' aspects of collaboration. These findings are largely consistent with prior studies but are notably different in that they highlight the importance of flexibility, locus of control and conflict resolution in collaborative relationships, all of which relate to one's ability to adapt to unexpected obstacles and find mutually workable solutions with colleagues. From a policy perspective, supporting these key elements of collaboration may involve giving frontline workers more autonomy in how they get the work done, which may in some cases be impeded by additional training to reinforce worker role delineation, closer monitoring or other top-down efforts to push greater convergence. Given the essential role that frontline workers play in multisectoral initiatives in India and around the world, there is a clear need for policymakers and managers to understand the elements affecting collaboration between these workers when designing and implementing programmes.

Controlling the chaos: Information management in home-infusion central-line-associated bloodstream infection (CLABSI) surveillance.

Objectives: Access to patient information may affect how home-infusion surveillance staff identify central-line-associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards. Design: Qualitative study using semistructured interviews. Setting and participants: The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion. Results: Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers. Conclusions: Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition.

OBJECTIVE: Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation. DESIGN: Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches. SETTING: This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia. PARTICIPANTS: Staff performing home-infusion CLABSI surveillance. METHODS: From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation. RESULTS: Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive. CONCLUSIONS: The home-infusion CLABSI surveillance definition was valid and feasible to implement.

The use of telemedicine for perioperative pain management during the COVID-19 pandemic.

INTRODUCTION: Using a human factors engineering approach, the Johns Hopkins Personalized Pain Program adopted telemedicine for perioperative pain management in response to the COVID-19 pandemic. This study examines the impact of telemedicine adoption on the quality and outcomes of perioperative pain management. METHODS: A mixed-methods study with a convergent parallel design was conducted. From June 2017 to December 2021, 902 patients participated in the Personalized Pain Program. Quantitative data on daily opioid consumption, pain severity and interference, physical and mental health status, and patient satisfaction and engagement were continuously collected with all patients using chart review and patient surveys. Beginning 23 March 2020, the Personalized Pain Program transitioned to telemedicine. A pre-post quasi-experimental design was used to examine the impact of telemedicine. In addition, qualitative interviews were conducted with 3 clinicians and 17 patients to explore their experience with telemedicine visits. RESULTS: The monthly number of new patients seen in the Personalized Pain Program did not significantly change before and after telemedicine adoption. Compared to patients having in-person visits before the pandemic, patients having telemedicine visits during the pandemic achieved comparable improvements in daily opioid consumption, pain severity and interference, and physical health status. While telemedicine helped overcome many challenges faced by the patients, the limitations of telemedicine were also discussed. CONCLUSION: The COVID-19 pandemic stimulated the use of telemedicine. To facilitate telemedicine adoption beyond the pandemic, future research is needed to examine best practices for telemedicine adoption and provide additional evidence on the effectiveness of telemedicine.