Background Our objective was to identify and validate clinical and continuity of care variables associated with Oral anticoagulant (OAC)-related adverse events within 30 days of hospital discharge amongst seniors. Methods and Analysis This was a population-based retrospective cohort study of all adults aged 66 years or older who were discharged from hospital on an OAC from September 2010 to March 2015 in Ontario, Canada. The primary outcome was a composite of the time to first hospitalization or Emergency Department visit for a hemorrhage or thromboembolic event or mortality within 30 days of hospital discharge. A Cox proportional hazards model was used to determine the association between the composite outcome and a set of prespecified covariates. A split sample method was applied to validate the final model. Results We included 120 721 Ontario seniors of which 5423 suffered one of the primary adverse events. Patients discharged on a direct-acting oral anticoagulant (DOAC); dispensed the same OAC in the past 12 months; who had a history of a thromboembolic event; had a recent joint replacement or major surgery; had a cardiologist, hematologist or orthopedic surgeon as compared to a family medicine physician as the physician prescribing the OAC at discharge had a lower risk for the composite outcome. Though continuity of care was a variable in the final multivariate Cox model, it was not significant. The Cox model was stable with acceptable discrimination but poor goodness-of-fit. Conclusion In this study, we found that continuity of care as measured by outpatient follow-up in the 7 days post-discharge was not significantly associated with the composite outcome. Further exploration to improve the current model’s calibration and interpretation are required. / Thesis / Master of Science (MSc) / Background Oral anticoagulants (OACs) are associated with serious adverse events, with high rates immediately post-hospitalization. We aimed to identify and validate clinical and continuity of care variables in seniors discharged from hospital on an OAC, which are associated with OAC-related harm in the short-term high-risk period following hospitalization. Methods Data from administrative health databases in Ontario were used to identify and validate risk factors associated with time to first OAC-related serious events including hospitalization or emergency department visit for a bleeding or thromboembolic event, and mortality. Cox proportional hazards model and split-sample methods were utilized. Results We included 120,721 seniors of which 5423 suffered one of the primary events. Patient-, physician- and index hospitalization-characteristics were all associated with time to the composite outcome. Though continuity of care risk factor was part of the final model, it was not a significant predictor for the outcome. Conclusion Exploration of this model through sensitivity analysis is required.

Yes / Multiple changes are made to older patients' medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post-discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life. To explore the experiences of older patients and their family carers as they enacted post-discharge medicines management. Semi-structured interviews took place in participants' homes, approximately two weeks after hospital discharge. Data analysis used the Framework method. Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty-seven participants aged 75 plus who lived with long-term conditions and polypharmacy, and nine family carers, were interviewed. Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health-care professionals about medicines changes often lacked detail, which disrupted some participants' knowledge and medicines management capabilities. Participants used multiple strategies to support post-discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied. Participants experienced gaps in their post-discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines-related care during the hospital-to-home transition. / This work was supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). This independent research is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0317-20010).

Patient Safety: Improving Medication Reconciliation Accuracy for Long-Term Care Residents by Annisa L. Stover MSN, Southern University, 2008 BSN, Our Lady of the Lake College, 2005 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2016 During transition of care, inaccurate medication reconciliation is associated with increased risk of adverse events for patients. Older adults are the population most often affected by medication errors, and long-term care facilities struggle to accurately document medication reconciliation. Errors are more common at hospital discharge, but the critical moment for detecting and resolving them is during hospital or long-term care admission. Guided by Rosswurm and Larrabee's model for change, Rogers' diffusion of innovation, and the Multi-Center Medication Reconciliation Quality Improvement toolkit, a 6-member interdisciplinary team composed of nurses, pharmacists, and institutional stakeholders was mobilized to develop policy and practice guidelines as well as secondary documentation necessary to implement and evaluate a quality improvement initiative to address medication reconciliation. Current evidence was explored and used to develop policy and practice guidelines for medication reconciliation, then submitted to 4 scholars, including 2 practice experts, a nurse administrator, and a specialist in pharmacy, to validate content. Scholarly validation supported the premise that the developed products would be beneficial in the accurate documentation of medication reconciliation. Scholarly feedback was evaluated by comparing to current best practices for medication reconciliation. Implementation, education, and evaluation plans were developed to guide operationalization of policy and practice guidelines. This project may positively affect social change by fostering a new practice policy, practice guidelines, and supporting documents to manage medication reconciliation of long-term care residents transitioning to acute care settings, thereby improving medication safety at transitions of care for vulnerable populations.

The need for transition of care for adult survivors of chronic conditions of childhood onset is an area that has received increasing attention in the healthcare literature; however, gaps in understanding and implementation persist. The complexity of transitioning from pediatric to adult care environments present numerous challenges for patients, their families, and health care providers. Ineffectual transitions can result in increased morbidity, a decline in quality of life, and unnecessary health care spending. The fundamental challenges in transitions of care for this population originates from a lack of institutional support to develop structured transition protocols. Healthcare institutions lack impetus to develop transition programs as their utility has not been sufficiently demonstrated because of inadequate research upon which to base clinical decisions. Therefore, patients transitioning from pediatric to adult care often confront difficulties ranging from fragmented care coordination to extended lapses continuous care, which can exacerbate the progression of their chronic conditions. The primary aim of this study is to examine the current literature regarding the ability of pediatric to adult transition programs for survivors of chronic disease to determine whether they are effective in delaying disease progression. The secondary aim is to examine whether evidence exists to demonstrate cost effectiveness of such interventions. Subsequently we explore potential barriers to adoption for healthcare institutions to adopt pediatric to adult transition care programs on a broad scale. This systematic review employs methodology to extract, analyze and synthesize data from relevant peer-reviewed articles, observational studies, and clinical trials. Preliminary findings indicate that improving transition protocols can indeed enhance patient outcomes, potentially reduce hospital readmissions, and may thereby be cost-effective for health care organizations. We posit that providing optimized transitions of care during this vulnerable life stage could enhance patient outcomes for managing various chronic conditions of childhood onset supporting the argument that better transitions of care are not only desirable but also achievable and worthwhile goals for health care systems to adopt. By examining the intricacies of transitioning care for adult survivors of chronic conditions of childhood onset, we aim to open a critical dialog and make recommendations for future research and clinical practice that may significantly impact health care practices, models, and policies thereby potentially and significantly impacting health for adult survivors. / Urban Bioethics

Interhospitala överföringar har ökat de senaste åren och tidigare forskning har fokuserat på transportfasen utifrån olika perspektiv. Det saknas däremot forskning kring intensivvårdssjuksköterskans upplevelse av att ta emot och vårda patienter efter interhospital överföring, därför valde vi att fokusera på detta ämne. Syftet med studien är att beskriva intensivvårdssjuksköterskans upplevelser av vårdandet av patienter efter en interhospital överföring. En kvalitativ intervjustudie genomfördes. Nio specialistsjuksköterskor inom intensivvård med erfarenhet av att vårda patienter efter interhospitala överföringar intervjuades. Dataanalysen är baserad på kvalitativ innehållsanalys och resulterade i åtta subteman och tre teman: Upplevelse av kontroll, Upplevelse av ambivalens kring överföringar, Upplevelse av samhörighet med andra. Det upplevs positivt att ta emot och vårda patienter efter interhospital transport när det finns möjlighet till förberedelse, både praktiskt och mentalt. Samma känsla infinner sig när mötet med patienten och anhöriga blir bra och när samarbetet på avdelningen och mellan enheterna är tillfredställande. Dock upplevs viss stress om det finns brister i dokumentation och informationsöverföring eller om mottagandet av patienten och dess närstående känns otillräckligt. Resultatet illustrerar komplexiteten av mottagandet efter överföring och betonar vikten av en bra överlämning. Utvecklingsområden finns såsom enhetliga journalsystem mellan regioner och att undvika interhospitala överföringar på grund av resursbrist. / Interhospital transfers have increased in number over the last years and at this point there is a good amount of research focussed on the transport phase of transfers that even includes different perspectives. There is, however, a lack of research concerned with the aftermath of a patient transfer such as taking over and caring for the patient. We therefore decided to make this the focus of our study. The aim of this study was to investigate the experience of critical nurses of caring for patients after interhospital transfer. We conducted a qualitative interview study where we interviewed nine critical care nurses from two mid-level general intensive care units. Data analysis was performed using qualitative content analysis. This resulted in 8 sub-themes and 3 main themes: Experience of control, Ambivalence regarding transfers and Experiencing fellowship. The result demonstrates that critical care nurses have a positive experience of receiving and caring for patients after interhospital transfer given that they had to opportunity to be mentally and practically prepared. Meeting the patient and their family members also generates a positive experience when the cooperation and information transfer between units has been satisfactory. Critical care nurses experience stress when they perceive threats to patient safety such as incomplete transfer of information or documentation or when the encounter with the patient and their family members was marked by problems. The result shows the complexity of taking over patients after transfer and the importance of a high-quality patient handover. Areas of improvement for transfers are seen by introducing a unified national medical record system and avoiding interhospital transfers due to lack of resources.

Aims: The aim of this study was to understand the eating and drinking experiences of people living with dementia and dysphagia in care homes from their perspective and those of their family members, formal care staff and Speech and Language Therapists (SLT). Design and methods: In this multi-method qualitative study, semi-structured interviews were carried out with 14 care home residents, seven family members of people living with dementia and dysphagia, and 13 care home staff with a variety of roles. Structured observations, using Dementia Care Mapping, were carried out with eight people living with dementia and dysphagia. Additionally, focus groups were carried out with a total of 31 SLTs. Data were analysed using thematic analysis. Findings: The findings of this study highlighted the changes experienced by people living in care homes, and those living with dementia and dysphagia, in relation to eating and drinking. In particular an impact on identity was found. This study highlighted the challenges of multiple people being involved in dysphagia care, with unclear roles and responsibilities and ineffective channels of communication. Despite the challenges identified, there were also examples of positive eating and drinking experiences through connections with others and the celebration of meaningful events. Conclusion: This was the first study that sought to explore and understand the eating and drinking experiences of people living with dementia and dysphagia from multiple perspectives. The findings highlight the challenges involved and possible solutions to promote a more person-centred approach to eating and drinking for people living with dementia and dysphagia. / Alzheimer’s Society; Compass Group

There are numerous threats to medication safety at care transitions, which are heightened for older people, because they live with multiple long-term conditions as well as polypharmacy, and have frequent hospital admissions. Whilst evidence of the severity and scale of these medicines-related problems exists, there is insufficient detail about the lived experience of post-discharge medicines management, in particular what helps or what hinders, and how better support could be enabled. This thesis, underpinned by the Medicines Research Council framework for complex intervention design, aimed to find acceptable intervention components, which would enhance patient experience. This research followed a sequential, mixed method design to: establish the evidence base through critical literature review, develop theory using an interview study grounded in behaviour change theory, and finally to model potential intervention components by expert consensus. Interviews revealed that there were gaps in current service provision, which impacted on participants’ knowledge of and capabilities with their medicines. Despite these challenges, some participants took actions to safeguard from problems after discharge. The literature review found that effective components of trialled interventions were self-management advice, post-discharge telephone follow up and medicines reconciliation. Further behaviour change techniques from the literature, alongside expert consensus and theory-driven analysis of interview findings resulted in final selection of eight potential components. Real-world implementation of these must be coupled with key changes to current healthcare practices and policy, including better engagement with patients and carers, as well as pro-active post-discharge follow-up. Future work must carefully explore how these components can be tested pragmatically.

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