Registered Nurse Strain Detection Using Ambient Data: An Exploratory Study of Underutilized Operational Data Streams in the Hospital Workplace.

BACKGROUND: Registered nurses (RNs) regularly adapt their work to ever-changing situations but routine adaptation transforms into RN strain when service demand exceeds staff capacity and patients are at risk of missed or delayed care. Dynamic monitoring of RN strain could identify when intervention is needed, but comprehensive views of RN work demands are not readily available. Electronic care delivery tools such as nurse call systems produce ambient data that illuminate workplace activity, but little is known about the ability of these data to predict RN strain. OBJECTIVES: The purpose of this study was to assess the utility of ambient workplace data, defined as time-stamped transaction records and log file data produced by non-electronic health record care delivery tools (e.g., nurse call systems, communication devices), as an information channel for automated sensing of RN strain. METHODS: In this exploratory retrospective study, ambient data for a 1-year time period were exported from electronic nurse call, medication dispensing, time and attendance, and staff communication systems. Feature sets were derived from these data for supervised machine learning models that classified work shifts by unplanned overtime. Models for three timeframes -8, 10, and 12 hours-were created to assess each model's ability to predict unplanned overtime at various points across the work shift. RESULTS: Classification accuracy ranged from 57 to 64% across three analysis timeframes. Accuracy was lowest at 10 hours and highest at shift end. Features with the highest importance include minutes spent using a communication device and percent of medications delivered via a syringe. CONCLUSION: Ambient data streams can serve as information channels that contain signals related to unplanned overtime as a proxy indicator of RN strain as early as 8 hours into a work shift. This study represents an initial step toward enhanced detection of RN strain and proactive prevention of missed or delayed patient care.

Better access, quality, and cost for clinically complex veterans with home-based primary care.

In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.

Long-term outcomes of shamanic treatment for temporomandibular joint disorders.

BACKGROUND: Temporomandibular joint disorders (TMDs) are chronic, often refractory, pain conditions affecting the jaw and face. Patients least likely to respond to allopathic treatment have the most marked biologic responsiveness to external stressors and concomitant psychosocial and emotional difficulties. From a shamanic healing perspective, this describes individuals who are thought to be "dispirited" and may benefit from this ancient form of spiritual healing. OBJECTIVE: To report on the long-term quantitative and qualitative outcomes relative to end-of-treatment status of a phase I study that evaluated the feasibility and efficacy of shamanic healing for people with TMDs. METHODS/DESIGN: Participants were contacted by telephone at one, three, six, and nine months after treatment and asked to report pain and disability outcomes and qualitative feedback. SETTING: Portland, OR. PARTICIPANTS: Twenty-three women aged 25 to 55 years diagnosed with TMD. PRIMARY OUTCOME MEASURES: Participants rated their TMD-related pain and disability (on the TMD Research Diagnostic Criteria Axis II Pain Related Disability and Psychological Status Scale) at each follow-up call and were asked to describe their condition qualitatively. RESULTS: Improvements in usual pain, worst pain, and functional impairment reported at end of treatment did not change during the 9 months after treatment ended (p > 0.18). CONCLUSION: Shamanic healing had lasting effects on TMDs in this small cohort of women.

Feasibility and short-term outcomes of a shamanic treatment for temporomandibular joint disorders.

CONTEXT: Temporomandibular joint disorders (TMDs) are chronic, recurrent, non-progressive pain conditions affecting the jaw and face. Patients least likely to respond to allopathic treatment are those with the most marked biological responsiveness to external stressors and concomitant emotional and psychosocial difficulties. These characteristics describe individuals who are "dispirited" and may benefit from shamanic healing, an ancient form of spiritual healing. OBJECTIVE: This phase 1 study tested feasibility and safety of shamanic healing for TMDs. DESIGN: Participants were randomized to 1 of 4 shamanic practitioners and attended 5 shamanic healing sessions. Self-reported pain and disability were recorded at baseline and each treatment visit and at 1, 3, 6, and 9-month follow-ups. Participants also were clinically evaluated at baseline and end of treatment. In-depth interviews, part of our mixed methods design, were conducted at baseline and end of treatment to evaluate acceptability and nonclinical changes associated with treatment. SETTING: Portland, Oregon. PATIENTS OR OTHER PARTICIPANTS: Twenty-three women with diagnosed TMDs. INTERVENTION: Shamanic treatment carried out during 5 treatment visits. MAIN OUTCOME MEASURES: Change from baseline to posttreatment in diagnosis of TMDs by Research Diagnostic Criteria (RDC) exam and participant self-ratings on the "usual" pain, "worst" pain, and functional impact of TMDs subscales of the RDC Axis II Pain Related Disability and Psychological Status Scale. This paper reports on outcomes at end of treatment. RESULTS: This study demonstrated the feasibility and acceptability of clinical trials of shamanic healing. The mean of usual pain went from 4.96 to 2.70, P<.0001; worst pain from 7.48 to 3.60, P<.0001, and functional impact of TMDs from 3.74 to 1.15, P<.0052. Only 4 women were clinically diagnosed with TMDs at the end of treatment.

Adapting to psychiatric disability and needs for home- and community-based care.

The objective of the study was to describe adaptation strategies and use of formal and informal support by individuals with psychiatric disabilities, to delineate remaining needs, and to determine how home- and community-based services might address those needs. Using in-depth interviews and structured questionnaires, we examined functional status, adaptation, and needs for home- and community-based care among 33 severely mentally ill members of a large health maintenance organization. Despite success in community living, participants had significant functional deficits (physical and emotional), relied heavily on only one or two key informal caregivers, and often needed significant support from mental health professionals. Limited numbers of caregivers and social isolation placed participants at risk of negative outcomes if informal support resources were to be lost. Home- and community-based care interventions that attempt to increase informal support networks and provide instrumental help (cooking, cleaning, transport) on short notice during flare-ups could augment existing (but limited) informal caregiving, help severely mentally ill individuals remain independent, and reduce the likelihood that loss of an informal caregiver would result in unwanted outcomes.