Disposition decision-making in the emergency department (ED) is critical to patient safety and quality of care. Disposition decision-making has particularly important implications for older adults who comprise a significant portion of ED visits annually and are vulnerable to suboptimal outcomes throughout ED care transitions. We conducted a secondary inductive content analysis of interviews with ED physicians (N= 11) to explore their perceptions of who they involve in disposition decision-making and what information they use to make disposition decisions for older adults. ED physicians cited 7 roles (5 types of clinicians, patients and families) and 11 information types, both clinical (e.g. test/lab results) and non-clinical (e.g. family's preference). Our preliminary findings represent a key first step toward the development of interventions that promote patient safety and quality of care for older adults in the ED by supporting the cognitive and communicative aspects of disposition decision-making.
IN BRIEF Goal-setting has consistently been promoted as a strategy to support behavior change and diabetes self-care. Although goal-setting conversations occur most often in outpatient settings, clinicians across care settings need to better understand and communicate about the priorities, goals, and concerns of those with diabetes to develop collaborative, person-centered partnerships and to improve clinical outcomes. The electronic health record is a mechanism for improved communication and collaboration across the continuum of care. This article describes a quality improvement project that was intended to improve the person-centeredness of care for adults with diabetes by offering goal-setting and self-management support during and after hospitalization.
The Department of Veterans Affairs ( VA ) Coordinated‐Transitional Care (C‐TraC) program is a low‐cost transitional care program that uses hospital‐based nurse case managers, inpatient team integration, and in‐depth posthospital telephone contacts to support high‐risk patients and their caregivers as they transition from hospital to community. The low‐cost, primarily telephone‐based C‐TraC program reduced 30‐day rehospitalizations by one‐third, leading to significant cost savings at one VA hospital. Non‐ VA hospitals have expressed interest in launching C‐TraC, but non‐ VA hospitals differ in important ways from VA hospitals, particularly in terms of context, culture, and resources. The objective of this project was to adapt C‐TraC to the specific context of one non‐ VA setting using a modified Replicating Effective Programs ( REP ) implementation theory model and to test the feasibility of this protocolized implementation approach. The modified REP model uses a mentored phased‐based implementation with intensive preimplementation activities and harnesses key local stakeholders to adapt processes and goals to local context. Using this protocolized implementation approach, an adapted C‐TraC protocol was created and launched at the non‐ VA hospital in July 2013. In its first 16 months, C‐TraC successfully enrolled 1,247 individuals with 3.2 full‐time nurse case managers, achieving good fidelity for core protocol steps. C‐TraC participants experienced a 30‐day rehospitalization rate of 10.8%, compared with 16.6% for a contemporary comparison group of similar individuals for whom C‐TraC was not available (n = 1,307) ( P < .001). The new C‐TraC program continues in operation. Use of a modified REP model to guide protocolized adaptation to local context resulted in a C‐TraC program that was feasible and sustained in a real‐world non‐ VA setting. A modified REP implementation framework may be an appropriate foundational step for other clinical programs seeking to harness protocolized adaptation in mentored dissemination activities.
The purpose of the study was to demonstrate how clinical nurse specialists (CNSs) can use information pulled from the electronic health record (EHR) in innovative ways to improve nursing care of vulnerable older adults.As the number of older adults increases, the need will grow for easier access to evidence-based practice nursing interventions for the older population. Clinical nurse specialists are the experts in evaluating research and will also need to find innovative ways to bring the evidence-based practice pertinent to the care of older adults to the bedside nurse.Clinical information from various parts of the EHR is pulled into computer-generated reports that focus on identifying older adult patients with specific high-risk indicators. The specific clinical information pulled into the reports and examples of how the reports are used will be presented. Four reports are described including new hospital admissions of patients older than 65 years, current hospitalized patients with dementia/delirium, current hospitalized patients on cholinesterase inhibitors, and a comprehensive report of all current hospitalized patients older than 65 years focusing on specific geriatric indicators identified in the literature.Computerized reports can be used to facilitate the use of nursing practice guidelines and evidence-based clinical tools such as the confusion assessment method and to increase use of nursing plans of care. The reports can also provide real-time key indicators that can be used to facilitate identification of older adult patients in need of CNS and/or geriatric team consultation. More research still needs to be done regarding the impact of the EHR on nursing indicators such as number of falls, delirium, and use of restraints.
