Functional Capacity but Not Early Uptake of Cardiac Rehabilitation Predicts Readmission in Patients With Metabolic Syndrome.

BACKGROUND: Phase II cardiac rehabilitation reduces hospital readmissions and cardiovascular disease risk factors and improves functional capacity. Cardiovascular disease risk factors double with patients with metabolic syndrome, a population less likely to adhere to cardiac rehabilitation. PURPOSE: The aim of this study was to determine relationships between cardiac rehabilitation uptake timing, demographic variables and functional capacity, and readmission in patients with metabolic syndrome. METHODS: This retrospective, medical records study involved 353 patients with metabolic syndrome who subsequently received cardiac rehabilitation. Logistic regression was used to examine relationships between time from discharge to cardiac rehabilitation uptake and readmission. Unordered categorical factors were compared between readmission groups using Pearson χ tests. Multivariable logistic regression was used to identify predictors of readmission. RESULTS: Patients readmitted within 30 and 90 days of hospitalization were more often women (P ≤ .018) and nonwhite (P ≤ .002) and had lower functional capacity (P < .001). In multivariable analysis, white race (odds ratio [OR], 0.50 [95% confidence interval (CI), 0.25-0.99]; P = .045) and higher functional capacity (OR, 0.80 [95% CI, 0.68-0.93]; P = .005) were protective against hospital readmission within the first 90 days. Race, sex, and functional capacity remained significant predictors of readmission at 1 year. In multivariable analysis, only race (OR, 0.41 [95% CI, 0.22-0.79]; P = .007) and functional capacity (OR, 0.83 [95% CI, 0.73-0.95]; P = .007) were significant. Early cardiac rehabilitation was not associated with readmission at any time point (P > .05). CONCLUSIONS: Sex, race, and functional capacity were important predictors of readmission for metabolic syndrome, even when cardiac rehabilitation intake was delayed. Results raise questions about the unique traits of patients with metabolic syndrome and need for novel approaches to improve cardiac rehabilitation utilization and functional capacity in metabolic syndrome.

Psychometric Evaluation of the Hospital Culture of Transitions Survey.

BACKGROUND: Ineffective or inefficient transitions threaten patient safety, hinder communication, and worsen patient outcomes. The Hospital Culture of Transitions (H-CulT) survey was designed to assess a hospital's organizational culture related to within-hospital transitions in care involving patient movement. In this article, psychometric properties of the H-CulT survey were examined to assess and refine the hospital culture of transitions. METHODS: A cross-sectional, multicenter, multidisciplinary correlational design and survey methods were used to examine the psychometric properties of the H-CulT survey. Exploratory factor analysis was used to quantify the accuracy of the previously identified structure. Specifically, the analysis involved the principal axis factor method with an oblique rotation, based on a polychoric correlation matrix. RESULTS: A sample of 492 respondents from 13 diverse hospitals participated. Cronbach's alpha for the instrument was 0.88, indicating strong internal consistency. Seven subscales emerged and were labeled: Hospital Leadership, Unit Leadership, My Unit's Culture, Other Units' Culture, Busy Workload, Priority of Patient Care, and Use of Data. Correlations between subscales ranged from 0.07 to 0.52, providing evidence that the subscales did not measure the same construct. Subscale correlations with the total score were near or above 0.50 (p <0.001). Use of a factor-loading cutoff of 0.40 resulted in the elimination of 12 items because of weak associations with the topic. CONCLUSION: The H-CulT is a psychometrically sound and practical survey for assessing hospital culture related to patient flow during transitions in care. Survey results may prompt quality improvement interventions that enhance in-hospital transitions and improve staff satisfaction and patient satisfaction with care.

Elaborating on theory with middle managers' experience implementing healthcare innovations in practice.

BACKGROUND: The theory of middle managers' role in implementing healthcare innovations hypothesized that middle managers influence implementation effectiveness by fulfilling the following four roles: diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. The theory also suggested several activities in which middle managers might engage to fulfill the four roles. The extent to which the theory aligns with middle managers' experience in practice is unclear. We surveyed middle managers (n = 63) who attended a nursing innovation summit to (1) assess alignment between the theory and middle managers' experience in practice and (2) elaborate on the theory with examples from middle managers' experience overseeing innovation implementation in practice. FINDINGS: Middle managers rated all of the theory's hypothesized four roles as "extremely important" but ranked diffusing and synthesizing information as the most important and selling innovation implementation as the least important. They reported engaging in several activities that were consistent with the theory's hypothesized roles and activities such as diffusing information via meetings and training. They also reported engaging in activities not described in the theory such as appraising employee performance. CONCLUSIONS: Middle managers' experience aligned well with the theory and expanded definitions of the roles and activities that it hypothesized. Future studies should assess the relationship between hypothesized roles and the effectiveness with which innovations are implemented in practice. If evidence supports the theory, the theory should be leveraged to promote the fulfillment of hypothesized roles among middle managers, doing so may promote innovation implementation.

Increasing Throughput: Results from a 42-Hospital Collaborative to Improve Emergency Department Flow.

BACKGROUND: An 18-month collaborative in 42 hospitals across 16 communities in the United States to improve emergency department (ED) flow was conducted from October 2010 through March 2012. METHODS: Hospitals were invited to participate through the Aligning Forces for Quality (AF4Q) program. Each participating hospital identified one or more interventions to improve ED flow and submitted data on four measures of ED flow: discharged length of stay (LOS), admitted LOS, boarding time, and left without being seen (LWBS) rates. Participating hospitals also provided quarterly progress reports on challenges encountered and lessons learned. Univariate linear regression was used to assess the effectiveness of interventions at the hospital level, where an improvement was defined as a negative slope in one or more of the throughput indicators. Challenges and lessons learned were tabulated and described. RESULTS: A total of 172 interventions were implemented across the 42 hospitals. Two thirds (n = 28) demonstrated improvement on at least one measure of ED flow. Among hospitals demonstrating improvement, the average reduction in discharged LOS was 26 minutes (95% confidence interval [CI] 11 to 41); admitted LOS, 36.5 minutes (95% CI 20 to 53), boarding time, 20.9 minutes (95% CI 12 to 30), and LWBS seen rates decreased by 1.4 absolute percentage points (95% CI 0.2 to 2.7). Teams were frequently challenged by issues related to leadership, staff buy-in, and resource constraints. CONCLUSION: The majority of hospitals in this collaborative improved on one or more ED flow measures. Many challenges were shared across hospitals, demonstrating that successful approaches to ED flow improvement require certain fundamental elements, including engaged leadership and staff, and sufficient resources.

Hospital Culture of Transitions in Care: Survey Development.

Understanding hospital culture is important to effectively manage patient flow. The purpose of this study was to develop a survey instrument that can assess a hospital's culture related to in-hospital transitions in care. Key transition themes were identified using a multidisciplinary team of experts from 3 health care systems. Candidate items were rigorously evaluated using a modified Delphi technique. Findings indicate 8 themes associated with hospital culture-mediating transitions. Forty-four items reflect the themes.

Enhancing care of older adults in the emergency department: old problems and new solutions.

The dramatic increase in the number of older adults in our society is creating greater demand for age-appropriate health care services. Because older adults use proportionally more emergency services than any other age group, it is important to address problems and find solutions to emergency care for this vulnerable population. Older adults often need specialized care to meet complex physical and psychological needs in an emergency department (ED). A new focus on establishing geriatric EDs holds promise for reducing barriers to ED access and decreasing suboptimal outcomes. Recently published geriatric ED guidelines provide health care professionals with recommendations to systematically improve emergency care for older adults.

The Affordable Care Act and emergency care.

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.

Solutions to emergency department 'boarding' and crowding are underused and may need to be legislated.

The practice of keeping admitted patients on stretchers in hospital emergency department hallways for hours or days, called "boarding," causes emergency department crowding and can be harmful to patients. Boarding increases patients' morbidity, lengths of hospital stay, and mortality. Strategies that optimize bed management reduce boarding by improving the efficiency of hospital patient flow, but these strategies are grossly underused. Convincing hospital leaders of the value of such solutions, and educating patients to advocate for such changes, may promote improvements. If these strategies do not work, legislation may be required to effect meaningful change.

More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States.

OBJECTIVES: Patient acuity triage systems can play an important role in supporting patient safety and emergency department (ED) operations. In 2003, the boards of the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) approved a joint statement calling for hospitals to adopt a reliable, valid, five-level triage scale such as the Emergency Severity Index (ESI). Still, there appears to be considerable variation in use of triage acuity systems in the United States, with many hospitals using three- and four-level systems that have not been validated. The purpose of this effort was to measure the use of various triage acuity systems in U.S. hospitals. METHODS: The authors conducted a cross-sectional analysis of secondary data. Data were obtained from the 2009 American Hospital Association (AHA) Annual Survey--an intensive questionnaire mailed to all U.S. general medical and surgical hospitals. In 2009, a question was added to the survey about hospitals' use of triage systems in EDs. Descriptive statistics were used to explore various triage acuity systems used by different types of hospitals. RESULTS: Of the 4,897 hospitals surveyed, 82% responded, and 62% (3,024 hospitals) provided information on their ED triage system. The 2009 data revealed that the most commonly used triage system types were the five-level ESI (56.9% of responding hospitals) and three-level triage systems (25.2%). More than 70% of large hospitals and teaching hospitals use the ESI, and the unvalidated three-level systems were more common in small hospitals, public hospitals, nonteaching hospitals, and hospitals in the Midwest. The majority (72.1%) of all ED patient visits to hospitals in our sample were assessed using ESI; only 13.1% of visits were assessed using a three-level system. CONCLUSIONS: Among our sample of more than 3,000 hospitals, the ESI was the most commonly used triage system, and more patients were triaged using the ESI than any other triage acuity system. Still, there is an opportunity to further promote the adoption of validated, reliable triage systems.

A field test of time-based emergency department quality measures.

STUDY OBJECTIVE: We examine practical aspects of collecting time-based emergency department (ED) performance measures. METHODS: Seven measures were implemented in 6 hospitals during 1 year. Structured interviews were used to assess the benefits and burdens of reporting. In 2 hospitals, Centers for Medicare & Medicaid Services (CMS) sample size requirements for 3 measures were compared to a reasonable sample size estimate (in which 95% of samples fell within 15 minutes of the population median). RESULTS: ED performance data on 29,587 admitted patients and 127,467 discharged patients were reported. Median throughput time for admitted patients ranged from 327 to 663 minutes and for discharged patients ranged from 143 to 311 minutes. Other performance measures varied similarly (2- to 3-fold between hospitals). In general, ED throughput was longer at academic sites and those with higher volume. Several benefits of reporting were identified, including promoting ED quality improvement, accountability, and practice standardization. The burdens included having to access multiple information technology systems and difficulties setting up the data collection. Most respondents found great value in the throughput measures and time to pain medication but less value in time to chest radiograph. The human capital required to implement measures varied by hospital and staff demonstrated a learning curve. Our empirically derived minimum reliable sample sizes were different from CMS recommendations. CONCLUSION: There is great variation in performance between EDs in time-based ED measures. There are multiple reporting benefits. Reporting burdens seemed to lessen after data systems were established. The CMS sample size requirements for throughput measures may not be optimal compared with actual ED throughput data.

The past, present, and future of urgent matters: lessons learned from a decade of emergency department flow improvement.

Over the past decade, emergency departments (ED) have encountered major challenges due to increased crowding and a greater public focus on quality measurement and quality improvement. Responding to these challenges, many EDs have worked to improve their processes and develop new and innovative models of care delivery. Urgent Matters has contributed to ED quality and patient flow improvement by working with hospitals throughout the United States. Recognizing that EDs across the country are struggling with many of the same issues, Urgent Matters-a program funded by the Robert Wood Johnson Foundation (RWJF)-has sought to identify, develop, and disseminate innovative approaches, interventions, and models to improve ED flow and quality. Using a variety of techniques, such as learning networks (collaboratives), national conferences, e-newsletters, webinars, best practices toolkits, and social media, Urgent Matters has served as a thought leader and innovator in ED quality improvement initiatives. The Urgent Matters Seven Success Factors were drawn from the early work done by program participants and propose practical guidelines for implementing and sustaining ED improvement activities. This article chronicles the history, activities, lessons learned, and future of the Urgent Matters program.