Breah Paciotti

Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety

BACKGROUND Early warning scores (EWSs) assign points to clinical observations and generate scores to help clinicians identify deteriorating patients. Despite marginal predictive accuracy in retrospective datasets and a paucity of studies prospectively evaluating their clinical effectiveness, pediatric EWSs are commonly used. OBJECTIVE To identify mechanisms beyond their statistical ability to predict deterioration by which physicians and nurses use EWSs to support their decision making. DESIGN Qualitative study. SETTING A childrens hospital with a rapid response system. PARTICIPANTS Physicians and nurses who recently cared for patients with false-positive and false-negative EWSs (score failures). INTERVENTION Semistructured interviews. MEASUREMENTS Themes identified through grounded theory analysis. RESULTS Four themes emerged among the 57 subjects interviewed: (1) The EWS facilitates safety by alerting physicians and nurses to concerning changes and prompting them to think critically about deterioration. (2) The EWS provides less-experienced nurses with vital sign reference ranges. (3) The EWS serves as evidence that empowers nurses to overcome barriers to escalating care. (4) In stable patients, those with baseline abnormal physiology, and those experiencing neurologic deterioration, the EWS may not be helpful. CONCLUSIONS Although pediatric EWSs have marginal performance when applied to datasets, clinicians who recently experienced score failures still considered them valuable to identify deterioration and transcend hierarchical barriers. Combining an EWS with a clinicians judgment may result in a system better equipped to respond to deterioration than retrospective data analyses alone would suggest. Future research should seek to evaluate the clinical effectiveness of EWSs in real-world settings.

Barriers to Calling for Urgent Assistance Despite a Comprehensive Pediatric Rapid Response System

BACKGROUND Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a childrens hospital. METHODS Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.

A Hybrid Effectiveness-Implementation Trial of an Evidence-Based Exercise Intervention for Breast Cancer Survivors

BACKGROUND The primary aims of this hybrid Type 1 effectiveness-implementation trial were to quantitatively assess whether an evidence-based exercise intervention for breast cancer survivors, Strength After Breast Cancer, was safe and effective in a new setting and to qualitatively assess barriers to implementation. METHODS A cohort of 84 survivors completed measurements related to limb volume, muscle strength, and body image at baseline, 67 survivors completed measurements 12 months later. Qualitative methods were used to understand barriers to implementation experienced by referring oncology clinicians and physical therapists who delivered the program. RESULTS Similar to the efficacy trial, the revised intervention demonstrated safety with regard to lymphedema, and led to improvements in lymphedema symptoms, muscular strength, and body image. Comparison of effects in the effectiveness trial to effects in the efficacy trial revealed larger strength increases in the efficacy trial than in the effectiveness trial (P < .04), but few other differences were found. Qualitative implementation data suggested significant barriers around intervention characteristics, payment, eligibility criteria, the referral process, the need for champions (ie, advocates), and the need to adapt during implementation of the intervention, which should be considered in future dissemination and implementation efforts. CONCLUSIONS This trial successfully demonstrated that a physical therapy led strength training program for breast cancer survivors can be implemented in a community setting while retaining the effectiveness and safety of the clinical trial. However, during the translation process, strategies to reduce barriers to implementation are required. This new program can inform larger scale dissemination and implementation efforts.

What do patients say about emergency departments in online reviews? A qualitative study

Background Patients have adopted web-based tools to report on the quality of their healthcare experiences. We seek to examine online reviews for US emergency departments (EDs) posted on Yelp, a popular consumer ratings website. Methods We conducted a qualitative analysis of unstructured, publicly accessible reviews for hospitals available on http://www.yelp.com. We collected all reviews describing experiences of ED care for a stratified random sample of 100 US hospitals. We analysed the content of the reviews using themes derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) inpatient care survey. We also used modified grounded theory to iteratively code the text of the reviews, identifying additional themes specific to emergency care. The data were double-coded, and discrepancies were evaluated to ensure consensus. Results Of the 1736 total reviews, 573 (33%) described patient experiences involving the ED. The reviews contained several themes assessed by the HCAHPS survey, including communication with nurses, communication with doctors, and pain control. The reviews also contained key themes specific to emergency care: waiting and efficiency; decisions to seek care in the ED; and events following discharge, including administrative difficulties. Conclusions These exploratory findings suggest that online reviews for EDs contain similar themes to survey-based assessments of inpatient hospital care as well as themes specific to emergency care. Consumer rating websites allow patients to provide rapid and public feedback on their experience of medical care. Web-based platforms may offer a novel strategy for assessing patient-centred quality in emergency care.

An Exploratory Study of Employers’ Attitudes Towards a Clinical Doctorate in Genetic Counseling

Creation of an advanced degree in genetic counseling has been considered since the early 1980s. The Genetic Counseling Advanced Degree Task Force (GCADTF) was convened in 2012 to formally explore the potential suitability of a clinical doctorate (ClinD), though employer perspectives of advanced training were not part of the discussion. The conclusion of this group was that the field was not ready to move to an entry-level clinical doctorate at this time but that further education and research among other stakeholders was necessary (Nagy et al. 2014). In this study, we describe employers’ perspectives on developing a clinical doctorate in genetic counseling based upon thirty audio-recorded semi-structured phone interviews that were transcribed verbatim and qualitatively analyzed. Overall, employers expressed concerns regarding the economic viability of ClinD training but envisioned expanded roles for genetic counselors (especially in areas of education and research) and enhanced credibility. While some employers reported that they would provide flexibility and tuition assistance for acquisition of a ClinD, for many employers, support was contingent on perceived value of the degree. Some employers were not clear about the difference between a ClinD and a PhD, suggesting that there is a need for educating employers about advanced degree options for the genetic counseling field. Future research could include investigating employer attitudes about market needs, envisioned roles, and compensation formulas for counselors with a ClinD or other forms of advanced training.