Dataset Information

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

ABSTRACT:

Objective

To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care.

Design

Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting.

Setting

Cardiac surgical unit in New Zealand.

Participants

Culturally diverse patients in hospital undergoing heart surgery.

Main outcomes

A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort.

Results

Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment.

Conclusions

These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

SUBMITTER: Wensley C

PROVIDER: S-EPMC7239554 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

Wensley Cynthia C Botti Mari M McKillop Ann A Merry Alan F AF

BMJ open 20200518 5

<h4>Objective</h4>To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care.<h4>Design</h4>Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting.<h4>Setting</h4>Cardi ...[more]

PMID: 32430447

Similar Datasets

Project description:ObjectivesTo estimate the frequency, severity, and preventability of adverse events associated with perioperative care, and to describe the setting and professions concerned.DesignMulticenter retrospective cohort study.Setting11 US hospitals.Participants1009 patients from a randomly selected sample of 64 121 adults admitted for surgery during 2018.Main outcome measuresAdverse events during inpatient perioperative care were assessed using a trigger method, identifying information previously associated with similar events, and from a comprehensive review of electronic health records. Trained nurses reviewed all records and flagged admissions with possible adverse events, which were then adjudicated by physicians, who confirmed the occurrence and characteristics of the events. Adverse events were classified as major if they resulted in serious harm requiring substantial intervention or prolonged recovery, involved a life threatening event, or led to a fatal outcome. Potentially preventable events included those definitively, probably, or possibly preventable.ResultsAmong 1009 patients reviewed, adverse events were identified in 38.0% (95% confidence interval 32.6 to 43.4), with major adverse events occurring in 15.9% (12.7 to 19.0). Of 593 identified adverse events, 353 (59.5%) were potentially preventable and 123 (20.7%) were definitely or probably preventable. The most common adverse events were related to surgical procedures (n=292, 49.3%), followed by adverse drug events (n=158, 26.6%), healthcare associated infections (n=74, 12.4%), patient care events (n=66, 11.2%), and blood transfusion reactions (n=3, 0.5%). Adverse events were most frequent in general care units (n=289, 48.8%), followed by operating rooms (n=155, 26.1%), intensive care units (n=77, 13.0%), recovery rooms (n=20, 3.3%), emergency departments (n=11, 1.8%), and other in-hospital locations (n=42, 7.0%). Professions most involved were attending physicians (n=531, 89.5%), followed by nurses (n=349, 58.9%), residents (n=294, 49.5%), advanced level practitioners (n=169, 28.5%), and fellows (n=68, 11.5%).ConclusionsAdverse events were identified in more than one third of patients admitted to hospital for surgery, with nearly half of the events classified as major and most potentially preventable. These findings emphasize the critical need for ongoing improvement in patient safety, involving all health professionals, throughout perioperative care.

Project description:ImportanceThe Centers for Medicare & Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied.ObjectiveTo determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes.Design, settings, and participantsThis nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024.Main outcomes and measuresBilled ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death).ResultsThe total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P < .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant.Conclusions and relevanceThis nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

Project description:Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.Six Veterans Affairs Medical Centers (VAMCs).Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n?=?6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

Project description:BackgroundThere are limited data on the effectiveness of the vaccines against symptomatic coronavirus disease 2019 (Covid-19) currently authorized in the United States with respect to hospitalization, admission to an intensive care unit (ICU), or ambulatory care in an emergency department or urgent care clinic.MethodsWe conducted a study involving adults (≥50 years of age) with Covid-19-like illness who underwent molecular testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We assessed 41,552 admissions to 187 hospitals and 21,522 visits to 221 emergency departments or urgent care clinics during the period from January 1 through June 22, 2021, in multiple states. The patients' vaccination status was documented in electronic health records and immunization registries. We used a test-negative design to estimate vaccine effectiveness by comparing the odds of a positive test for SARS-CoV-2 infection among vaccinated patients with those among unvaccinated patients. Vaccine effectiveness was adjusted with weights based on propensity-for-vaccination scores and according to age, geographic region, calendar time (days from January 1, 2021, to the index date for each medical visit), and local virus circulation.ResultsThe effectiveness of full messenger RNA (mRNA) vaccination (≥14 days after the second dose) was 89% (95% confidence interval [CI], 87 to 91) against laboratory-confirmed SARS-CoV-2 infection leading to hospitalization, 90% (95% CI, 86 to 93) against infection leading to an ICU admission, and 91% (95% CI, 89 to 93) against infection leading to an emergency department or urgent care clinic visit. The effectiveness of full vaccination with respect to a Covid-19-associated hospitalization or emergency department or urgent care clinic visit was similar with the BNT162b2 and mRNA-1273 vaccines and ranged from 81% to 95% among adults 85 years of age or older, persons with chronic medical conditions, and Black or Hispanic adults. The effectiveness of the Ad26.COV2.S vaccine was 68% (95% CI, 50 to 79) against laboratory-confirmed SARS-CoV-2 infection leading to hospitalization and 73% (95% CI, 59 to 82) against infection leading to an emergency department or urgent care clinic visit.ConclusionsCovid-19 vaccines in the United States were highly effective against SARS-CoV-2 infection requiring hospitalization, ICU admission, or an emergency department or urgent care clinic visit. This vaccine effectiveness extended to populations that are disproportionately affected by SARS-CoV-2 infection. (Funded by the Centers for Disease Control and Prevention.).

Project description:BackgroundThere is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings.ObjectiveTo compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs).DesignCluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites.ParticipantsOne hundred thirty-two providers from PCCTs at 47 VAMCs.InterventionsBoth training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers.Main measurementsSeveral processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates.Key resultsEighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement.ConclusionFindings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used.Trial registrationClinicalTrials.gov identifier: NCT02383173.

Project description:Rigorous healthcare design research is critical to inform design decisions that improve human experience. Current limitations in the field include a lack of consistent and valid measures that provide feedback about the role of the built environment in producing desirable outcomes. Research findings about nurses' efficiency, quality of care, and satisfaction related to inpatient unit designs have been mixed, and there was previously no validated instrument available to quantitatively measure nurses' ability to work efficiently and effectively in their environment. The objective of this study was to develop, refine, and validate a survey instrument to measure affordance of the care environment to nurse practice, based on various aspects of their work in inpatient units. The HDR Clinical Activities Related to the Environment (CARE) Scale Inpatient Version was developed using item design, refinement, and reliability and validity testing. Psychometric methods from classical test theory and item response theory, along with statistical analyses involving correlations and factor analysis, and thematic summaries of qualitative data were conducted. The four-phase process included (1) an initial pilot study, (2) a content validation survey, (3) cognitive interviews, and (4) a final pilot study. Results from the first three phases of analysis were combined to inform survey scale revisions before the second pilot survey, such as a reduction in the number and rewording of response options, and refinement of scale items. The updated 9-item scale showed excellent internal consistency and improved response distribution and discrimination. The factor analysis revealed a unidimensional measure of nurse practice, as well as potential subscales related to integration, efficiency, and patient care. Within the healthcare design industry, this scale is much needed to generate quantitative and standardized data and will facilitate greater understanding about the aspects of an inpatient healthcare facility that best support nurses' ability to provide quality patient care.

Dataset Information

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

Objective

Design

Setting

Participants

Main outcomes

Results

Conclusions

Publications

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets