Mixed-initiative decision support for care planning based on clinical practice guidelines

Care Plan On-Line (CPOL) is an intranet based system that supports a “Coordinated Care” model for chronic/complex disease management. CPOL combines provision of solicited and unsolicited advice features based on integration of the electronic medical record (EMR) with its decision support logic. The objective is to support General Practitioners (GPs) in formulating a 12-month care plan of services such that: (a) the plan is proactive and patient-centered; (b) the GP is kept in awareness of project- and diseasespecific clinical practice guidelines; and (c) the support integrates with GP workflow in a natural fashion. A key feature of our approach is to blur the distinction of EMR and decision support by presenting guidelines in layers with the top-most being a problem-oriented presentation of patient status, progressing on through to patient-independent supporting evidence. In conjunction with a degree of automated inclusion of care planning services, the system demonstrates mixed user and software initiative. We describe the CPOL deployment setting, the challenges of guideline-based clinical decision support, our approach to guideline delivery, and the CPOL architecture.

Ethics and advance care planning in a culturally diverse society

Emerging international research suggests that in multicultural countries, such as Australia and the United States, there are significant disparities in end-of-life care planning and decision making by people of minority ethnic backgrounds compared with members of mainstream English-speaking background populations. Despite a growing interest in the profound influence of culture and ethnicity on patient choices in end-of-life care, and the limited uptake of advance care plans and advance directives by ethnic minority groups in mainstream health care contexts, there has been curiously little attention given to cross-cultural considerations in advance care planning and end-of-life care. Also overlooked are the possible implications of cross-cultural considerations for nurses, policy makers, and others at the forefront of planning and providing end-of-life care to people of diverse cultural and language backgrounds. An important aim of this article is to redress this oversight.

Uptake of a newly implemented advance care planning program in a dementia diagnostic service

BACKGROUND: advance care planning (ACP) provides a framework for discussion and documentation of future care preferences when a person loses cognitive capacity. It can assist people in the early stages of dementia to document their preferences for care at later stages of the illness. METHOD: a three-stage project introduced ACP to clients with mild cognitive impairment (MCI) or recently diagnosed dementia and their families through a specialist memory clinic. Over 8 months, all English-speaking clients (n = 97) and carers (n = 92) were mailed a survey assessing completed documentation for future care; understanding of the principles of ACP and willingness to get further information about ACP (Stage 1). Participants wanting more information were invited to a seminar introducing the ACP program and service (Stage 2). Participants wanting to complete ACP documentation could make an appointment with the ACP clinicians (Stage 3). RESULTS: forty-eight (52.2%) carers and 34 clients (35.1%) responded to the survey. Most clients (62.1%) and carers (79.1%) expressed interest in ACP, and 78.6% of clients and 63.6% of carers believed that clients should be involved in their future medical decisions. Nine clients (26.5%; diagnoses: MCI = 5; AD = 3; mixed dementia = 1) and 9 carers (18.8%) attended the seminars, and 2/48 (4%) carers and 3/34 (8.8%) clients (diagnoses: MCI = 2; AD = 1) completed ACP. CONCLUSION: despite initial interest, ACP completion was low. The reasons for this need to be determined. Approaches that may better meet the needs of people newly diagnosed with MCI and dementia are discussed.

A model driven approach to care planning systems for consumer engagement in chronic disease management

This work demonstrates a model-driven approach to the development of care plan systems, amenable to: (a) a flexible and extensible definition of care plan scope; and (b) deployment of care plan viewing and tracking functionality to a wide range of physical computing devices. The approach utilises a care plan domain model from which guideline implementers formulate care plan templates aligning to specific clinical guidelines. A clinical end user would subsequently constrain that template (e.g., selecting a subset of available activities and specific targets) to create a care plan instance for an individual patient. An XML care plan visualisation definition created using the Marama tool is transformed to OpenLaszlo script from which Shockwave Flash objects can be compiled, creating Flash applications that run on a variety of hardware for both clinical and patient users. The approach is illustrated with respect to an overweight and obesity guideline.

Automated attention flags in chronic disease care planning

Objectives: To assess the value of computerised decision support in the management of chronic respiratory disease by comparing agreement between three respiratory specialists, general practitioners (care coordinators), and decision support software.
Methods: Care guidelines for two chronic obstructive pulmonary disease projects of the SA HealthPlus Coordinated Care Trial were formulated. Decision support software, Care Plan On-Line (CPOL), was created to represent the intent of these guidelines via automated attention flags to appear in patients' electronic medical records. For a random sample of 20 patients with care plans, decisions about the use of nine additional services (eg,.smoking cessation, pneumococcal vaccination) were compared between the respiratory specialists, the patients' GPs and the CPOL attention flags.
Results: Agreement among the specialists was at the lower end of moderate (intraclass correlation coefficient [ICC], 0.48; 95% CI, 0.39-0.56), with a 20% rate of contradictory decisions. Agreement with recommendations of specialists was moderate to poor for GPs (le, 0.49; 95% CI, 0.33-0.66) and moderate to good for CPOL (K, 0.72; 95% CI, 0.55-0.90). CPOL agreement with GPs was moderate to poor (le, 0.41; 95% CI, 0.24-0.58). GPs were less likely than specialists or CPOL to decide in favour of an additional service (P< 0.001). CPOL was 87% accurate as an indicator of specialist decisions. It gave a 16% false-positive rate according to specialist decisions, and flagged 61% of decisions where GPs said No and specialists said Yes.
Conclusions: Automated decision support may provide GPs with improved access to the intent of guidelines; however, further investigation is required.

Communication at the bedside to enhance patient care : a survey of nurses’ experience and perspective of handover

Strategies to support continuity of care and improve patient safety during clinical handover have been developed. The aims of this study were to identify the strengths and limitations in current practice of nursing clinical handover and implement a new bedside handover process. A total of 259 nurses completed a cross-sectional survey at change of shift on 1 day, which was followed by an audit of the pilot implementation of bedside handover. The survey results showed great variation in the duration, location and method of handover with significant differences in the experience of nurses employed part-time compared with full-time. Following implementation of standardized bedside handover on two wards, the audit revealed significant improvement in the involvement of patients, use of Situation-Background-Assessment-Recommendation, active patient checks and checking of documentation. These findings suggest the use of standardized protocols and communication tools for bedside handover improve continuity of patient care

Improving renal patient care without compromising safety: interactive simulated e-learning

The nephrology educators network [NEN] recognised in 2007 that inequities existed in the access and delivery of evidence based renal education programs particularly to nurses in regional and remote areas. To address this, a web-based approach to learning, through the development of peer reviewed, interactive nephrology e-learning programs was adopted. These programs aligned with the tenets of e-learning instructional design and afforded more effective and consistent clinical support and induction for nurses in the renal specialty. The e-learning programs promote a standardised evidence-based approach to nephrology education and were developed by content experts from across Australia and New Zealand. The design methodology avoided the duplication of resources while also encouraging knowledge transfer between participating health organisations.

This paper will discuss the development and successful implementation of these e-learning programs across renal healthcare units in Australasia. Implemented packages include: Introduction to Buttonhole Cannulation – featuring an interactive ultrasound and cannulation application; Introduction to Haemodialysis; Introduction to Peritoneal Dialysis [PD], featuring simulated PD machines, allowing for the teaching of troubleshooting without compromising patient safety. E-learning programs are further supported through interactive case scenarios that present unfolding real world simulations and enable learners to meet different patients and manage their care while learning about key messages relating to renal health. Modules currently in development include; Acute Kidney Injury; Fluid Assessment, Water Quality and Vascular Access. The implementation of these programs assist the facilitation of positive change in teaching and learning practices in nephrology nursing aimed at improving patient outcomes.

The impact structured patient assessment frameworks have on patient care: an integrative review

Aims and objectives:
To evaluate structured patient assessment frameworks' impact on patient care.

Background:
Accurate patient assessment is imperative to determine the status and needs of the patient and the delivery of appropriate patient care. Nurses must be highly skilled in conducting timely and accurate patient assessments to overcome environmental obstacles and deliver quality and safe patient care. A structured approach to patient assessment is widely accepted in everyday clinical practice, yet little is known about the impact structured patient assessment frameworks have on patient care.

Design:
Integrative review.

Methods:
An electronic database search was conducted using Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System, PubMed and ProQuest Dissertations and Theses. The reference sections of textbooks and journal articles on patient assessment were manually searched for further studies. A comprehensive peer review screening process was undertaken. Research studies were selected that evaluated the impact structured patient assessment frameworks have on patient care. Studies were included if frameworks were designed for use by paramedics, nurses or medical practitioners working in prehospital or acute in-hospital settings.

Results:
Twelve studies met the inclusion criteria. There were no studies that evaluate the impact of a generic nursing assessment framework on patient care. The use of a structured patient assessment framework improved clinician performance of patient assessment. Limited evidence was found to support other aspects of patient care including documentation, communication, care implementation, patient and clinician satisfaction, and patient outcomes.

Conclusion:
Structured patient assessment frameworks enhance clinician performance of patient assessment and hold the potential to improve patient care and outcomes; however, further research is required to address these evidence gaps, particularly in nursing.

Relevance to clinical practice:
Acute care clinicians should consider using structured patient assessment frameworks in clinical practice to enhance their performance of patient assessment.

Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities

The purpose of this retrospective, cross-sectional study was to determine the prevalence of advance care planning (ACP) among older people presenting to an Emergency Department (ED) from the community or a residential aged care facility. The study sample comprised 300 older people (aged 65+ years) presenting to three Victorian EDs in 2011. A total of 150 patients transferred from residential aged care to ED were randomly selected and then matched to 150 people who lived in the community and attended the ED by age, gender, reason for ED attendance and triage category on arrival. Overall prevalence of ACP was 13.3% (n = 40/300); over one-quarter (26.6%, n = 40/150) of those presenting to the ED from residential aged care had a documented Advance Care Plan, compared to none (0%, n = 0/150) of the people from the community. There were no significant differences in the median ED length of stay, number of investigations and interventions undertaken in ED, time seen by a doctor or rate of hospital admission for those with an Advance Care Plan compared to those without. Those with a comorbidity of cerebrovascular disease or dementia and those assessed with impaired brain function were more likely to have a documented Advance Care Plan on arrival at ED. Length of hospital stay was shorter for those with an Advance Care Plan [median (IQR) = 3 days (2–6) vs. 6 days (2–10), P = 0.027] and readmission lower (0% vs. 13.7%). In conclusion, older people from the community transferred to ED were unlikely to have a documented Advance Care Plan. Those from residential aged care who were cognitively impaired more frequently had an Advance Care Plan. In the ED, decisions of care did not appear to be influenced by the presence or absence of Advance Care Plans, but length of hospital admission was shorter for those with an Advance Care Plan.