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Patients discharged following hospitalization for COVID-19 require clear discharge protocols, information resources and communications to adequately prepare them to safely and successfully transition from hospital to home. Our study focuses on the patients' transition to recovering at home including their hospital discharge preparation and hospital experiences.A qualitative descriptive study design involved interviewing patients who had been hospitalized for COVID-19 in one urban Alberta, Canada centre. Purposive sampling was used to select patients from a centralized COVID-19 hospital patient database stratified by month between March 2020 and February 2021. Other inclusion criteria (e.g., sex and age) were also considered. Semi-structured interviews with patients were recorded, transcribed and analysed using thematic analysis. Data sufficiency and saturation were determined.Twelve patients shared their lived experiences and recovery journey from COVID-19. Themes were reported under three main areas as framed by the study aim-the current status of patients recovering at home, including the supports they used to manage; their discharge process and preparation to go home; and their various hospital-related experiences. Suggestions for improving aspects of the patient journey were also captured.Findings provided details of the needs, information gaps and what matters most to patients when they are recovering from COVID-19 at home, including their preparation to safely and successfully transition from hospital to home (i.e., feeling well prepared to go home, including being adequately assessed and having clear discharge protocols and communication). Key learnings were applied to improve or develop patient discharge and transition resources.A patient/family advisor and patient experience partners were involved throughout the study, codeveloping all aspects, from the study design to the reporting and application of the findings. Leading into the study, patient experiences and feedback regarding the home from hospital recovery journey informed multiple aspects, including the codevelopment of the interview guide.

Multiple clinical practice guidelines recommend minimizing radiation in trauma patients but there is a knowledge gap on the importance of this problem for trauma transfers. We aimed to estimate the incidence of pretransfer and repeat posttransfer computed tomography (CT) overall and in patients with an indication for immediate transfer, to assess interhospital practice variation, to identify predictors, and to quantify the influence of pretransfer CT on time to transfer. Methods We conducted a retrospective multicenter cohort study on patients transferred to major trauma centers from 2013 to 2019. Multilevel generalized linear regression was used to generate intraclass correlation coefficients (ICCs) to assess interhospital variation, multilevel logistic regression to generate odds ratios for each predictor, and geometric mean ratios to quantify the influence of CT on time to transfer. Results Of 18,244 patients included, 8501 (47%) had a pretransfer CT and one-quarter (26%) had a repeat posttransfer CT. Interhospital variation was moderate for pretransfer CT (5%-66%, ICC 12.5%) and for repeat posttransfer CT (7%-44%, ICC 14.7%). Pretransfer imaging was more frequent in elders and in males and repeat posttransfer imaging decreased over the study period but was more frequent in patients transferred in from Level III/IV centers than nondesignated hospitals. Time to transfer was doubled in patients who had a pretransfer CT.Results suggest that pretransfer CT and repeat posttransfer CT are frequent and are subject to significant practice variation. In addition, pretransfer CT is associated with increased times to transfer though additional studies are needed to demonstrate causation. These results highlight potential opportunities to reduce low-value imaging for trauma transfers.

Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients.A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of16. Articles were critically appraised and data were extracted into a pre-specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead.Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non-emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances.There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well-designed prospective cohort studies are required to bridge this knowledge gap.

Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay.Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P 0.05.After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P 0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P 0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P 0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P 0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P = 0.0035).In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.

An increasing number of children have complex care needs (CCN) that impact their health and cause limitations in their lives. More of these youth are transitioning from paediatric to adult healthcare due to complex conditions being increasingly associated with survival into adulthood. Typically, the transition process is plagued by barriers, which can lead to adverse health consequences. There is an increased need for transitional care interventions when moving from paediatric to adult healthcare. To date, literature associated with this process for youth with CCN and their families has not been systematically examined.The objective of this scoping review is to map the range of programmes in the literature that support youth with CCN and their families as they transition from paediatric to adult healthcare.The review was conducted in accordance with the Joanna Briggs Institute's methodology for scoping reviews. A search, last run in April 2021, located published articles in PubMed, CINAHL, ERIC, PsycINFO and Social Work Abstracts databases.The search yielded 1523 citations, of which 47 articles met the eligibility criteria. A summary of the article characteristics, programme characteristics and programme barriers and enablers is provided. Overall, articles reported on a variety of programmes that focused on supporting youth with various conditions, beginning in the early or late teenage years. Financial support and lack of training for care providers were the most common transition program barriers, whereas a dedicated transition coordinator, collaborative care, transition tools and interpersonal support were the most common enablers. The most common patient-level outcome reported was satisfaction.This review consolidates available information about interventions designed to support youth with CCN transitioning from paediatric to adult healthcare. The results will help to inform further research, as well as transition policy and practice advancement.

BACKGROUND: Despite the rapid growth of assisted living (AL) and frequent hospitalizations among AL residents, little is known about their patterns of post-acute care transitions and outcomes. This study examined the post-acute care transitions among AL residents and their association with outcomes in the first 30 and 60 days after hospital discharge. METHODS: This study used data form 2018 national Medicare enrollment and claims datasets, the Minimum Data Set (MDS), and Medicare Provider Analysis and Review (MedPAR) of 104,497 unique Medicare beneficiaries residing in ALs in the U.S. Post-acute care referrals, based on hospital discharge status, to skilled nursing facilities (SNF), home with home health care (HHC), home without HHC, and other settings. Outcomes included 30-day and 60-day hospital readmissions, emergency department (ED) visits, long-stay care nursing home placement, and mortality. Multinomial logistic regression analysis and logistic regression analysis were conducted. RESULTS: The most common post-acute care referral was to SNF (40%), followed by home without HHC (28%), home with HHC (17%), and others (15%). Compared to discharge home without HHC, discharge to SNF was associated with lower likelihood of ED visits (Odds Ratio=0.597, p

To review and synthesise the current literature on social support and hospital readmission rates.Hospital readmission rates have not declined significantly since 2010 despite efforts to identify and implement strategies to reduce readmissions. After discharge, patients often report the need for help at home with personal care, medical care and/or transportation. Social factors can positively or negatively affect the transition from hospital to home and the extended recovery period experienced by patients.Published primary studies in peer-reviewed journals, written in English, assessing the adult medical/surgical population and discussing social support and hospital readmission rates were included. A Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was completed for this scoping review.The search resulted in 2919 articles. After removing duplicates and reviewing content for the inclusion and exclusion criteria, 23 articles were selected for review. Social support is provided by those within one's social circle. There are several types of social support and depending on the needs to the patient, the type of social required and provided is different.The most common form of social support needed at home for people recovering after a hospitalisation was instrumental support, tangible care in the form of assistance with daily personal and medical care, and transportation. Patients who lacked adequate social support after discharge were at an increased risk of hospital readmission.Identifying factors, such as social support, that may impact hospital readmission rates is important for quality hospital to home care transitions. Assessing patients' needs and available social support to meet those needs may be an essential part of the discharge planning process to decrease the risk of hospital readmission.

BACKGROUND Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge. METHODS We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. RESULTS Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). CONCLUSIONS The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Purpose To determine whether Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Care Transitions (CTM-3) Scores were associated with timely (14-day) primary care provider (PCP) follow-up visits, and to look for disparities across various types of urban and rural hospitals. Methods Data were obtained for 3,299 hospitals: 2,000 urban, 544 micropolitan prospective payment system (PPS), 109 micropolitan critical access hospital (CAH), 252 noncore rural PPS, and 394 noncore rural CAH. HCAPPS data were drawn from CMS Hospital Compare (2015). The dependent variable, 14-day PCP follow-up rate for each hospital, was drawn from the 2015 Dartmouth Atlas. Findings In analysis adjusting only for hospital characteristics, higher CTM-3 scores were positively associated with PCP follow-up; however, the relationship was no longer significant after controlling for area-level (contextual) measures, such as percent minority population, percent unemployed, and percent uninsured. In the fully adjusted model, rates of PCP follow-up were significantly higher for micropolitan PPS, noncore PPS, and noncore CAH hospitals than for urban hospitals. Conclusions In fully adjusted analysis, the lack of significance between CTM-3 scores and PCP follow-up suggests that community characteristics facilitate or impede timely PCP follow-up to an extent that may overshadow in-hospital efforts. Disparities between CAHs and rural PPS hospitals may be due to differing enrollments in quality incentive plans; future research is needed to address this issue. Compounding this issue, the strong negative relationship between percent Medicaid reimbursement (payor mix) and PCP follow-up suggests possible disparities for safety net hospitals.

Background Transitioning from pediatric to adult healthcare can be challenging and lead to severe consequences if done suboptimally. The Transition Readiness Assessment Questionnaire (TRAQ) was developed to assess adolescent and young adult (AYA) patients' transition readiness. In this study, we aimed to (1) document the psychometric properties of the French-language version of the TRAQ (TRAQ-FR), (2) assess agreements and discrepancies between AYA patients' and their primary caregivers' TRAQ-FR scores, and (3) identify transition readiness contributors. Methods French-speaking AYA patients (n = 175) and primary caregivers (n = 168) were recruited from five clinics in a tertiary Canadian hospital and asked to complete the TRAQ-FR, the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0), and a sociodemographic questionnaire. The validity of the TRAQ-FR was assessed using confirmatory factor analyses (CFA). Agreements and discrepancies were evaluated using intraclass correlation coefficients and paired-sample t tests. Contributors of transition readiness were identified using regression analyses. Results The five-factor model of the TRAQ was supported, with the TRAQ-FR global scale showing good internal consistency for both AYA patients' and primary caregivers' scores (α = .85-.87). AYA patients and primary caregivers showed good absolute agreement on the TRAQ-FR global scale with AYA patients scoring higher than primary caregivers (ICC = .80; d = .25). AYA patients' age and sex were found to be contributors of transition readiness. Conclusions The TRAQ-FR was found to have good psychometric properties when completed by both AYA patients and primary caregivers. Additional research is needed to explore the predictive validity and clinical use of the TRAQ-FR.

Introduction The transition process from the intensive care unit (ICU) to hospital ward may impact the illness trajectory and compromise the continuity of safe care for ICU survivors. ICU and ward nurses are involved with the transition and are responsible for the quality of the transitional care. Aim The aim was to explore ICU and ward nurses' views on assignments in relation to patients' transition between ICU and hospital ward. Methods We conducted a qualitative study with 20 semi-structured interviews with ICU nurses and ward nurses and analysed data by content analysis. Setting A university hospital with 690 beds and an 11-bed mixed medical/surgical ICU. Findings The overarching themes were (1) 'Ritual of hand over' with the categories: (a) 'Ready, able and willing', (b) 'Transfer of responsibility' and (c) 'Nice to know versus need to know' and (2) 'From lifesaving care to rehabilitative care' with the categories: (a) 'Complex care needs persist', (b) 'Fight or flight mode' and (c) '"Weaning" the family'. Nurses were highly focused on the ritual of the actual handover of the patient and discussed readiness as an indicator of quality and the feeling of passing on the responsibility. Nurses had different opinions on what useful knowledge was and thus necessary to communicate during handover. Although patients' complex care needs may not have been resolved when exiting the ICU, ward nurses had to receive patients in a setting where nurses were mostly comfortable within their own specialty - this was worrying for both type of nurses. Patients could enter the ward very exhausted and weak or in 'fight mode' and demand rehabilitation at a pace the ward was not capable of delivering. ICU nurses encouraged families to be demanding after the ICU stay, and ward nurses asked them to trust them and steep back.

Surgical patients with glycemic controller devices and insulin pumps Key words: glycemic controller, insulin, insulin pump, glucose monitoring, blood glucose level. Using leftover IV fluids to clean the surgical incision site after closure Key words: IV fluid, sterile field, infection, contamination. A certified surgical first assistant's scope of practice after obtaining RN licensure Key words: scope of practice, certified surgical first assistant, RN first assistant (RNFA), license. Using instruments outside the scope of the manufacturer's instructions for use Key words: instructions for use (IFU), instrument, manufacturer, risk. Transferring patients from a prone position on the OR bed to a supine position on the stretcher Key words: patient transfer, positioning device, repositioning, alignment, prone.

Aim The aim was to critically analyse the body of evidence regarding the effectiveness of PFCC transition interventions on the quality of care and the experience of patients. Design We conducted a systematic review using the Cochrane Handbook's guidelines and adhered to a standardized reporting format: Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA). Methods Four databases and grey literature were searched. Following a two‐step screening process, data from the eligible studies were extracted. Risk of bias and quality of the studies were also assessed. Narrative synthesis and vote counting were used for the data analysis. Results A total of 28 articles met our inclusion criteria. Interventions varied in regards to the extent of the PFCC focus and the comprehensiveness of the transition of care. Educating patients to promote self‐management was the most commonly included component and it was described in all 28 interventions.

AIMS To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors. DESIGN A cross-sectional nationwide study. METHODS The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods. RESULTS In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p

Aim To explore the experiences of being discharged from hospital of older patients with chronic diseases at time of discharge. Design Multi-centre descriptive qualitative study. Methods Semi-structured interviews were conducted with older patients with chronic diseases discharged from two Italian university hospitals, between March 2017 and October 2019. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis. Several strategies were used to ensure the credibility, dependability, confirmability, authenticity and transferability of the findings. The study was reported in accordance with Standards for Reporting Qualitative Research and Consolidated criteria for reporting qualitative research. Results Sixty-five patients participated in the study. Six main categories emerged: feelings, need for information, time of fragility, need for support, need for trusting relationships, and home as a caring place. Conclusion Older patients with chronic diseases are patients who require quality discharge planning with a patient-centred care vision. Healthcare professionals should intervene more extensively and deeply in the discharge process, balancing the patients' perception of their needs against organizational priorities and the wish to return home with that of not being abandoned. Impact Discharge from hospital remains an area of concern as older people have varying degrees of met and unmet needs during and following hospital discharge. Discharge is characterized by conflicting feelings of patients, who need information and support of healthcare professionals through trusting and continuous relationships. Understanding the experience of discharge is essential to support older patients with chronic diseases, considering that discharge from hospital is not an end point of care but a stage of the process involving care transition. The reframing of discharge as another transition point is crucial for healthcare professionals, who will be responsible for making their patients fit for discharge by preparing them to manage their chronic condition at home.

BACKGROUND: The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored. AIMS AND OBJECTIVES: To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers. DESIGN: A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2). METHODS: The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed. RESULTS: The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment." CONCLUSIONS: Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented. RELEVANCE TO CLINICAL PRACTICE: Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork.

First-episode services (FES) improve outcomes in recent onset psychosis, but there is growing concern about how patients fare after discharge from these time-limited services.A quality improvement approach (QI) was used to improve patient engagement in the discharge planning process (disposition), and successful engagement in care 3 months after discharge from the FES (transfer). Data from 144 consecutive discharges over 62 months are presented. A planning phase was followed by recurrent Plan-Do-Study-Act cycles (PDSA) that included the introduction of proactive efforts targeting disposition planning (with patients and families) and follow-up to facilitate transfer after discharge. Fisher's exact test was used to compare disposition and transfer outcomes across the QI phases.This QI approach was sustained through a three-fold escalation in discharge volume. Transfer status at 3 months was significantly different between the pre- and post PDSA phases (p = .02). A greater proportion were confirmed transfers post-PDSA (54.3 vs. 37%), but of those with known status at 3 months, similar proportions were successfully transferred (76, 73%). Patients discharged post-PDSA were less likely to have unknown treatment status (26 vs. 51%). Disposition outcomes were also significantly improved post-PDSA (p = .03). Patients were more likely to engage with discharge planning (69.7 vs. 48.6%) and less likely to be lost to follow-up (13.8 vs. 25.7%), or to refuse assistance (11.0 vs. 20.0%).This QI approach offers a feasible way to improve disposition and transfer after FES and can be built upon in efforts to sustain functional gains in onward pathways.

BACKGROUND: Discharge from the hospital to a post–acute care setting can be complex and potentially dangerous, with opportunities for errors and lapses in communication between providers. Data collected through the Extension for Community Health Outcomes–Care Transitions (ECHO-CT) model were used to identify and classify transition-of-care events (TCEs). METHODS: The ECHO-CT model employs multidisciplinary videoconferences between a hospital-based team and providers in post–acute care settings; during these conferences, concerns regarding the patient’s care transition were identified and recorded. The videoconferences took place from January 2016 to October 2018 and included patients discharged from inpatient medical and surgical services to a total of eight participating post–acute care facilities (skilled nursing facilities or long-term acute care hospitals). RESULTS: During the interdisciplinary videoconferences in this period, 675 patients were discussed. A total of 139 TCEs were identified; 58 (41.7%) involved discharge communication or coordination errors and 52 (37.4%) were classified as medication issues. CONCLUSION: The TCEs identified in this study highlight areas in which providers can work to reduce issues arising during the course of discharge to post–acute care facilities. Standardized processes to identify, record, and report TCEs are necessary to provide high-quality, safe care for patients as they move across care settings.

BackgroundHistorically, safety mental health research has tended to focus on risks of homicide, suicide and deaths. Although wider safety issues are now recognized in regards to mental health services, the safety of mental health transitions, a key research and policy priority according to World Health Organisation, has not been explored.ObjectiveThe purpose of this study was to investigate perceptions of safety in mental health transitions (hospital to community) amongst five stakeholder groups.Design and settingAn online, international cross‐sectional, open‐ended questionnaire.ParticipantsThere were five stakeholder participant groups: service users; families/carers; mental health‐care professionals; researchers; and end users of research.ResultsNinety‐three participants from 12 different countries responded. Three overarching themes emerged: ‘individual/clinical’, ‘systems/services’ and ‘human, behavioural and social’ elements of safe mental health transitions. Whilst there was a great focus on clinical elements from researchers and healthcare professionals, service users and carers considered safety in terms of human, behavioural and social elements of transitional safety (ie loneliness, emotional readiness for discharge) and systems/services (ie inter‐professional communication).DiscussionSafety in mental health‐care transitions is perceived differently by service users and families compared to healthcare professionals and researchers. Traditional safety indicators for care transitions such as suicide, self‐harm and risk of adverse drug events are raised as important. However, service users and families in particular have a much wider perception of transitions safety.ConclusionFuture quality and safety research and policy should consider including a service user voice and consider integration of psychosocial elements in discharge interventions.

Extracorporeal life support (ECLS) is an essential component of a modern congenital cardiac surgery program. The circuit components and bedside management team may, however, vary among institutions. Here, we evaluate our initial experience with a modified ventricular assist device-based ECLS circuit primarily managed by the bedside nurse. We hypothesize that our outcomes are comparable to Extracorporeal Life Support Organization (ELSO) registry data. All patients who received ECLS from January 1, 2016 to December 31, 2019 at a single institution were included. Primary outcomes were survival to ECLS decannulation and discharge or transfer. Secondary outcomes included complications from ECLS. Data were compared to available ELSO registry data. Thirty-seven patients underwent 44 ECLS runs during the study period. Forty percent of patients had single ventricle physiology. Nearly 46% of patients received ECLS as part of extracorporeal cardiopulmonary resuscitation (eCPR). Survival to ECLS decannulation (68.2%) and survival to discharge or transfer (61.4%) did not differ from overall ELSO outcomes (69.7%, P = .870 and 50.7%, P = .136), as well as survival to discharge or transfer in a comparable cohort of ELSO centers (53.1%, P = .081). Patients with complications had a lower rate of survival to discharge or transfer but this did not reach statistical significance (47.7% vs. 75.0%, P = .455). Neurologic (50.0%), hemorrhagic (45.5%), and renal complications (31.8%) were most common in this cohort. A modified ventricular assist device-based ECLS circuit with primary management by the bedside nurse can provide comparable support in a neonatal and pediatric cardiac surgery population. Cost analyses and further delineation of the complication profile are necessary for a complete characterization of this system.

Nurses have important roles as members of the healthcare transition (HCT) planning interdisciplinary team. Nursing's scope of practice and framework of care brings a distinctive and complementary approach to this expanding field in pediatric care. It is therefore relevant to better understand the extent to which pediatric nurses are involved with the provision of HCT services and model development.This was a qualitative analysis of a national survey of pediatric nurses. A thematic iterative process was used to code data. Three coders separately analyzed responses and then met to compare and discuss until a final list of codes was achieved. The codes were further analyzed until themes and subthemes emerged. Throughout the process, disagreements were discussed and resolved until consensus was achieved.A sample of 1814 pediatric nurses and nurse practitioners from two US professional organizations participated in this national survey to gather data on their involvement in HCT planning. This survey contained 17 items, one of which was an open-ended question stating: Is there anything else you would like to share about your role with the population of transitioning youth and young adults with chronic illness and/or disability? The analysis of responses provided by 154 nurses is presented. Initial coding resulted in 11 categories of data. Four major themes, including four subthemes, emerged from the analysis of responses: Support for the need for transition (subtheme: Nursing involvement); Guidance needed for professional practice (subtheme: Types of guidelines and training); Lack of service linkages to adult providers; and Difficulty letting go (two subthemes: Pediatric providers; Parents).These findings indicated strong support for the need of HCT services and the importance of nursing involvement. However, challenges to HCT implementation were identified that include systemic, psychosocial, and educational barriers. As this field of practice and research continues to grow, it is important that pediatric nurses recognize the opportunities to have a clinical voice to develop nurse-led HCT services and programs.

It is now expected that most individuals with congenital heart disease will survive to adulthood, including those with complex heart conditions. Maintaining lifelong medical care requires those with congenital heart disease to eventually transfer from pediatric to adult-oriented health care systems. Developing health care transition skills and gaining independence in managing one's own health care is imperative to this process and to ongoing medical and psychosocial success. This scientific statement reviews the recent evidence regarding transition and provides resources, components, and suggestions for development of congenital heart disease transition programs with the goals of improving patient knowledge, self-management, and self-efficacy skills to the level they are capable to eventually integrate smoothly into adult-oriented health care. Specifically, the scientific statement updates 3 sections relevant to transition programming. First, there is a review of specific factors to consider, including social determinants of health, psychosocial well-being, and neurocognitive status. The second section reviews costs of inadequate transition including the public health burden and the impairment in individual quality of life. Finally, the last section discusses considerations and suggestions for transition program design including communication platforms, a family-centered approach, and individual models. Although this scientific statement reviews recent literature surrounding transitions of care for individuals with congenital heart disease there remain significant knowledge gaps. As a field, we have yet to determine ideal timing and methods of transition, and barriers to transition and transfer remain, particularly for the underserved populations. The consequences of poor health care transition are great and garnering outcomes and information through organized, multifaceted, collaborative approaches to transition is critical to improving the lifelong care of individuals with congenital heart disease. ispartof: JOURNAL OF THE AMERICAN HEART ASSOCIATION vol:11 issue:7 ispartof: location:England status: published

Objectives To characterize pretransfer on-site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long-stay residents transferred for behavioral concerns. Design This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns. Setting NHs in central Indiana were utilized (N = 19). Participants This study included long-stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers). Measurements The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on-site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses. Results Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia-related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses. Conclusion Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns.

Background/objectives To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. Design PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. Setting A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. Participants A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. Intervention Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. Measurements Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. Results There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. Conclusion An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.

BACKGROUND Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills. AIMS AND OBJECTIVES This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care? DESIGN Systematic review of quantitative studies and meta-analysis. METHODS Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool. RESULTS Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge. CONCLUSION This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge. RELEVANCE TO CLINICAL PRACTICE While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.

Aims: This audit aimed to assess the prevalence and completeness of documented medication handover regarding opioid substitution therapy (OST) during transitions of care in to and out of a major tertiary teaching hospital, focusing on surgical admissions. The secondary aim was to evaluate the proportion of handover episodes that involved a clinical pharmacist, and to determine the impact of pharmacist involvement on the completeness of documented OST handover. Method and Results: A 5‐year retrospective audit was conducted for surgical patients undergoing OST prior to admission to a major tertiary teaching hospital. Data were collected pertaining to: handover on admission of 13 OST‐related metrics deemed important for appropriate ongoing clinical care, whether medication handover to the community OST team was documented on discharge, and the involvement and impact of pharmacists in these processes. Sixty‐one admissions were included in the audit. On average, just over half (7.4/13) of the predefined OST‐related metrics audited, were documented on admission. Only 57% of patients had OST handover to the community team documented on discharge. Pharmacist involvement on discharge significantly increased completeness of OST handover documentation on admission and increased the proportion of patients with documented OST handover on discharge. Conclusion: Medication handover relating to OST on admission and discharge was frequently incomplete, posing a potential risk to safe and appropriate ongoing care, highlighting the need for education and procedures to guide this process. Pharmacist contribution in handover of OST medication‐related information increased completeness of documentation, demonstrating their role in facilitating medication‐related communication during transitions of care. Refereed/Peer-reviewed

OBJECTIVE Older adults discharged from the emergency department (ED) are at high risk for adverse outcomes. Adherence to ED discharge instructions is necessary to reduce those risks. The objective of this study is to determine the individual-level factors associated with adherence with ED discharge instructions among older adult ED outpatients. METHODS We performed a secondary analysis of data from the control group of a randomized controlled trial testing a care transitions intervention among older adults (age ≥ 60 years) discharged home from the ED in two states. Taking data from patient surveys and chart reviews, we used multivariable logistic regression to identify patient characteristics associated with adherence to printed discharge instructions. Outcomes were patient-reported medication adherence, provider follow-up visit adherence, and knowledge of "red flags" (signs of worsening health requiring further medical attention). RESULTS A total 824 patients were potentially eligible, and 699 had data in at least one pillar. A total of 35% adhered to medication instructions, 76% adhered to follow-up instructions, and 35% recalled at least one red flag. In the multivariate analysis, no factors were significantly associated with failure to adhere to medications. Participants with poor health status (adjusted odds ratio [AOR] = 0.55, 95% confidence interval [CI] = 0.31 to 0.98) were less likely to adhere to follow-up instructions. Participants who were older (AORs trended downward as age category increased) or depressed (AOR = 0.39, 95% CI = 0.17 to 0.85) or had one or more functional limitations (AOR = 0.62, 95% CI = 0.41 to 0.94) were less likely to recall red flags. CONCLUSION Older adults discharged home from the ED have mixed rates of adherence to discharge instructions. Although it is thought that some subgroups may be higher risk than others, given the opportunity to improve ED-to-home transitions, EDs and health systems should consider providing additional care transition support to all older adults discharged home from the ED.

OBJECTIVE Identifying adverse outcomes and examining trends and causes of nonelective admissions among persons with epilepsy would be beneficial to optimize patient care and reduce health services utilization. We examined the association of epilepsy with discharge status, in-hospital mortality, length-of-stay, and charges. We also examined 10-year trends and causes of hospital admissions among those with and without epilepsy. METHODS Nonelective hospital admission in persons with epilepsy was identified in the 2005-2014 National Inpatient Sample (NIS) using a validated International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) case definition. The NIS is the largest US all-payer database including patient and hospital-level variables, and represents hospitalizations in the general population. Descriptive statistics on trends and causes of admissions and multivariable regression analysis summarizing the association of epilepsy with the outcomes of interest are presented. RESULTS Of 4 718 178 nonelective admissions in 2014, 3.80% (n = 179 461) were in persons with epilepsy. Admissions in persons with epilepsy increased from 14 636 to 179 461 (P

PURPOSE Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs. METHODS This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay. RESULTS Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF. CONCLUSION Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.