Implementing and Sustaining Team-Based Telecare for Bipolar Disorder: Lessons Learned from a Model-Guided, Mixed Methods Analysis.

BACKGROUND: Telemental health interventions have empirical support from clinical trials and structured demonstration projects. However, their implementation and sustainability under less structured clinical conditions are not well demonstrated. INTRODUCTION: We conducted a follow-up analysis of the implementation and sustainability of a clinical video teleconference-based collaborative care model for individuals with bipolar disorder treated in the Department of Veterans Affairs to (a) characterize the extent of implementation and sustainability of the program after its establishment and (b) identify barriers and facilitators to implementation and sustainability. MATERIALS AND METHODS: We conducted a mixed methods program evaluation, assessing quantitative aspects of implementation according to the Reach, Efficacy, Adoption, Implementation, and Maintenance implementation framework. We conducted qualitative analysis of semistructured interviews with 16 of the providers who submitted consults, utilizing the Integrated Promoting Action on Research Implementation in the Health Services implementation framework. RESULTS: The program demonstrated linear growth in sites (n = 35) and consults (n = 915) from late 2011 through mid-2016. Site-based analysis indicated statistically significant sustainability beyond the first year of operation. Qualitative analysis identified key facilitators, including consult content, ease of use via electronic health record, and national infrastructure. Barriers included availability of telehealth space, equipment, and staff at the sites, as well as the labor-intensive nature of scheduling. DISCUSSION: The program achieved continuous growth over almost 5 years due to (1) successfully filling a need perceived by providers, (2) developing in a supportive context, and (3) receiving effective facilitation by national and local infrastructure. CONCLUSION: Clinical video teleconference-based interventions, even multicomponent collaborative care interventions for individuals with complex mental health conditions, can grow vigorously under appropriate conditions.

Feasibility of routinely using hydrogen peroxide vapor to decontaminate rooms in a busy United States hospital.

During a 22-month period at a 500-bed teaching hospital, 1,565 rooms that had housed patients infected with multidrug-resistant pathogens were decontaminated using hydrogen peroxide vapor. Hydrogen peroxide vapor decontamination required a mean time of 2 hours and 20 minutes, compared with 32 minutes for conventional cleaning. Despite the greater time required for decontamination, hydrogen peroxide vapor decontamination of selected patient rooms is feasible in a busy hospital with a mean occupancy rate of 94%.

Delay in the diagnosis of acute myocardial infarction: effect on quality of care and its assessment.

BACKGROUND: Delay in diagnosis of acute myocardial infarction (AMI) may affect quality of care and its assessment. OBJECTIVES: To examine over time the frequency of delay in AMI diagnosis and the effect of this delay on the quality of patient care and its assessment. METHODS: The authors examined the trend in coded admission diagnosis, age, comorbidities, procedures during hospitalization, and discharge status for 42,406 Connecticut Medicare cases with the principal discharge diagnosis of AMI for the time period 1992 through 2001. For 2,583 cases discharged in 1992 and 1993 and for 1,398 cases discharged in 1998 through 2001, the rates of administration of aspirin (ASA) and beta blocker (BB) on admission and discharge, by admission diagnosis, were ascertained. RESULTS: For patients discharged with the principal diagnosis of AMI over the decade examined, the proportion with this diagnosis on admission fell (59% to 40%, p < 0.001), the proportion with a non-acute coronary syndrome (ACS) admission diagnosis rose (18% to 26%, p < 0.001), and the population aged (proportion older than 85 years of age increased from 16% to 28%, p < 0.001). Patients with ACS as the admission diagnosis more frequently received cardiac catheterization (during 2000-2001, 39% versus 17%, p < 0.001), percutaneous coronary intervention (19% versus 4%, p < 0.001), and evidence-based therapy; during 1998-2001, opportunities to give ASA or BB on admission were fulfilled for 88% versus 73% (p < 0.001), and on discharge, for 87% versus 74% (p < 0.005). CONCLUSIONS: The diagnosis of AMI is delayed after admission for a significant proportion of cases who receive care that is measured to be of lower quality. There is a need to more effectively diagnose and treat these cases with delayed diagnosis and to develop new quality measures to address changes in the characteristics of patients who are hospitalized with AMI.

The emergency department community-acquired pneumonia trial: Methodology of a quality improvement intervention.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.