Acceptability and Perceived Utility of Telemedical Consultation during Cardiac Arrest Resuscitation. A Multicenter Survey.

Rationale: Many clinicians who participate in or lead in-hospital cardiac arrest (IHCA) resuscitations lack confidence for this task or worry about errors. Well-led IHCA resuscitation teams deliver better care, but expert resuscitation leaders are often unavailable.Objectives: To determine the acceptability and perceived utility of using telemedicine technology to enable remote IHCA resuscitation participation by a critical care physician.Methods: We conducted an electronic, anonymous survey of nurses and attending physicians likely to participate in IHCA resuscitation at 21 hospitals in Utah and Idaho.Results: Complete survey responses were received from 855 (59%) of 1,442 clinicians contacted, of whom 764 met all eligibility criteria. Respondents were more likely to prefer that telemedicine physicians take an active role during IHCA events on the ward (83%; 95% confidence interval [CI], 77-88%) or intensive care unit (ICU; 66% [95% CI, 48-81%]) than the emergency department (53% [95% CI, 44-62%]), with most favorable responses recommending the telemedicine physician act as assistant/advisor ("copilot") for the on-site team. The majority of respondents expected a telemedical copilot for IHCA teams to exert a positive or neutral effect on patient care (51% [95% CI, 44-59%] and 33% [95% CI, 30-37%], respectively). Overall, 41% (95% CI, 31-51%) of respondents favored adding a telemedical critical care physician as IHCA team "copilot," 35% (95% CI, 30-40%) were neutral, and 24% (95% CI, 18-32%) were opposed. Clinicians based at smaller hospitals or on the ward or ICU were most likely to foresee beneficial effects from a telemedicine physician "copilot."Conclusions: ICU- and, especially, ward-based IHCA resuscitation teams at community and rural hospitals were amenable to adding a telemedical critical care physician consultant as IHCA team "copilot." Respondents expected the greatest benefits for IHCA events occurring on the wards.

Contextual Factors Influencing Implementation of Evidence-Based Care for Children Hospitalized With Asthma.

BACKGROUND AND OBJECTIVES: The translation of research findings into routine care remains slow and challenging. We previously reported successful implementation of an asthma evidence-based care process model (EB-CPM) at 8 (1 tertiary care and 7 community) hospitals, leading to a high health care provider (HCP) adherence with the EB-CPM and improved outcomes. In this study, we explore contextual factors perceived by HCPs to facilitate successful EB-CPM implementation. METHODS: Structured and open-ended questions were used to survey HCPs (n = 260) including physicians, nurses, and respiratory therapists, about contextual factors perceived to facilitate EB-CPM implementation. Quantitative analysis was used to identify significant factors (correlation coefficient ≥0.5; P ≤ .05) and qualitative analysis to assess additional facilitators. RESULTS: Factors perceived by HCPs to facilitate EB-CPM implementation were related to (1) inner setting (leadership support, adequate resources, communication and/or collaboration, culture, and previous experience with guideline implementation), (2) intervention characteristics (relevant and applicable to the HCP's practice), (3) individuals (HCPs) targeted (agreement with the EB-CPM and knowledge of supporting evidence), and (4) implementation process (participation of HCPs in implementation activities, teamwork, implementation team with a mix of expertise and professional's input, and data feedback). Additional facilitators included (1) having appropriate preparation and (2) providing education and training. CONCLUSIONS: Multiple factors were associated with successful EB-CPM implementation and may be used by others as a guide to facilitate implementation and dissemination of evidence-based interventions for pediatric asthma and other chronic diseases in the hospital setting.

Information needs for designing a home monitoring system for children with medical complexity.

Background Children with medical complexity (CMC) are a growing population of medically fragile children with unique healthcare needs, who have recurrent emergency department (ED) and hospital admissions due to frequent acute escalations of their chronic conditions. Mobile health (mHealth) tools have been suggested to support CMC home monitoring and prevent admissions. No mHealth tool has ever been developed for CMC and challenges exist. Objective To: 1) assess information needs for operationalizing CMC home monitoring, and 2) determine technology design functionalities needed for building a mHealth application for CMC. Methods Qualitative descriptive study conducted at a tertiary care children's hospital with a purposive sample of English-speaking caregivers of CMC. We conducted 3 focus group sessions, using semi-structured, open-ended questions. We assessed caregiver's perceptions of early symptoms that commonly precede acute escalations of their child conditions, and explored caregiver's preferences on the design functionalities of a novel mHealth tool to support home monitoring of CMC. We used content analysis to assess caregivers' experience concerning CMC symptoms, their responses, effects on caregivers, and functionalities of a home monitoring tool. Results Overall, 13 caregivers of CMC (ages 18 months to 19 years, mean = 9 years) participated. Caregivers identified key symptoms in their children that commonly presented 1-3 days prior to an ED visit or hospitalization, including low oxygen saturations, fevers, rapid heart rates, seizures, agitation, feeding intolerance, pain, and a general feeling of uneasiness about their child's condition. They believed a home monitoring system for tracking these symptoms would be beneficial, providing a way to identify early changes in their child's health that could prompt a timely and appropriate intervention. Caregivers also reported their own symptoms and stress related to caregiving activities, but opposed monitoring them. They suggested an mHealth tool for CMC to include the following functionalities: 1) symptom tracking, targeting commonly reported drivers (symptoms) of ED/hospital admissions; 2) user friendly (ease of data entry), using voice, radio buttons, and drop down menus; 3) a free-text field for reporting child's other symptoms and interventions attempted at home; 4) ability to directly access a health care provider (HCP) via text/email messaging, and to allow real-time sharing of child data to facilitate care, and 5) option to upload and post a photo or video of the child to allow a visual recall by the HCP. Conclusions Caregivers deemed a mHealth tool beneficial and offered a set of key functionalities to meet information needs for monitoring CMC's symptoms. Our future efforts will consist of creating a prototype of the mHealth tool and testing it for usability among CMC caregivers.

Clinician Perspectives Regarding In-Hospital Cardiac Arrest Resuscitation: A Multicenter Survey.

OBJECTIVES: Evaluate clinicians' sentiments about participating in cardiac arrest resuscitations and identify factors associated with confidence in resuscitation of cardiac arrest. DESIGN: Electronic survey. SETTING: Twenty-one hospitals in Utah and Idaho. SUBJECTS: All attending physicians, residents, and nurses in a multilevel healthcare system likely to participate in an in-hospital cardiac arrest resuscitation at least once every 2 years. INTERVENTIONS: None. MEASUREMENTS AND METHODS: A survey instrument evaluating clinician perceptions of in-hospital cardiac arrest resuscitation participation was developed after literature review and iteratively revised based on expert input and cognitive pretesting. Survey responses were collected anonymously. Sixty percent of 1,642 contacted clinicians (n = 977) submitted complete responses, of whom 874 met study inclusion criteria (190 attending physicians, 576 nurses, and 110 residents). Most respondents (74%) participated in less than or equal to six in-hospital cardiac arrest events per year, and 41% of respondents were most likely to participate in in-hospital cardiac arrest resuscitation at a community, rural, or critical access hospital. Confidence in in-hospital cardiac arrest participation was high overall (92%), but lower among residents (86%) than nurses (91%) or attending physicians (96%; p = 0.008). Fewer residents (52%) than nurses (73%) or attending physicians (95%; p < 0.001) reported feeling confident leading in-hospital cardiac arrest teams. Residents (63%) and attending physicians (36%) were more likely to worry about making errors during an in-hospital cardiac arrest event than nurses (18%; p < 0.001). Only 15% of residents and 50% of respondents overall reported they were both confident participating in in-hospital cardiac arrest resuscitation and did not worry about making errors. In-hospital cardiac arrest participation frequency was the dominant predictor of respondents' confidence leading or participating in an in-hospital cardiac arrest resuscitation. CONCLUSIONS: Many clinicians, especially residents, who participate in or lead in-hospital cardiac arrest resuscitation events lack confidence or worry about management errors. Hospitals-particularly smaller hospitals-should consider methods to provide in-hospital cardiac arrest teams additional "effective experience," potentially using simulation or telemedicine consultation.

Development of a novel tool for engaging children and parents in asthma self-management.

This paper describes the development and evaluation of an innovative application designed to engage children and their parents in weekly asthma self-monitoring and self-management to prompt an early response to deteriorations in chronic asthma control, and to provide their physicians with longitudinal data to assess the effectiveness of asthma therapy and prompt adjustments. The evaluation included 2 iterative usability testing cycles with 6 children with asthma and 2 parents of children with asthma to assess user performance and satisfaction with the application. Several usability problems were identified and changes were made to ensure acceptability of the application and relevance of the content. This novel application is unique compared to existing asthma tools and may shift asthma care from the current reactive, acute care model to a preventive, proactive patient-centered approach where treatment decisions are tailored to patients' individual patterns of chronic asthma control to prevent acute exacerbations.

Physician perspectives of nurse care management located in primary care clinics.

Care management has been suggested as a method to improve management of chronic disease, but its success can depend on the involvement of primary care physicians, especially with referral to care management. Our objective was to identify and characterize physicians' perspectives of care management in order to gain insight into the rationale for referral to care management. The study took place in primary care clinics within an integrated delivery system. Nineteen primary care physicians with varying levels of involvement with care management participated in the study. We performed a qualitative and quantitative analysis ofsemistructured interviews. Four referral patterns emerged that were related to physicians' recognition of care managers' abilities and how care managers were connected to their practice. Results from this study can be used to more effectively implement similar models of chronic disease management, where physician participation is a critical component for successful implementation.

Religiousness and depression: evidence for a main effect and the moderating influence of stressful life events.

The association between religiousness and depressive symptoms was examined with meta-analytic methods across 147 independent investigations (N = 98,975). Across all studies, the correlation between religiousness and depressive symptoms was -.096, indicating that greater religiousness is mildly associated with fewer symptoms. The results were not moderated by gender, age, or ethnicity, but the religiousness-depression association was stronger in studies involving people who were undergoing stress due to recent life events. The results were also moderated by the type of measure of religiousness used in the study, with extrinsic religious orientation and negative religious coping (e.g., avoiding difficulties through religious activities, blaming God for difficulties) associated with higher levels of depressive symptoms, the opposite direction of the overall findings.