National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (2)
- Antimicrobial Stewardship (1)
- Care Coordination (2)
- Children/Adolescents (1)
- Chronic Conditions (2)
- Communication (3)
- Elderly (3)
- Emergency Department (1)
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- Health Information Technology (HIT) (2)
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- Medication: Safety (1)
- Mortality (1)
- Nursing Homes (2)
- Outcomes (1)
- Patient and Family Engagement (1)
- (-) Patient Safety (9)
- Provider (2)
- Provider: Clinician (1)
- Provider: Physician (1)
- Surgery (1)
- (-) Transitions of Care (9)
- Trauma (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 9 of 9 Research Studies DisplayedMueller S, Zheng J, Orav EJ
Inter-hospital transfer and patient outcomes: a retrospective cohort study.
Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied. The purpose of this retrospective cohort study was to evaluate the association between IHT and healthcare utilisation and clinical outcomes. The investigators concluded that IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category.
AHRQ-funded; HS023331.
Citation: Mueller S, Zheng J, Orav EJ .
Inter-hospital transfer and patient outcomes: a retrospective cohort study.
BMJ Qual Saf 2019 Nov;28(11):e1. doi: 10.1136/bmjqs-2018-008087..
Keywords: Transitions of Care, Hospitals, Patient Safety, Elderly, Outcomes, Chronic Conditions, Mortality, Medicare
Kapoor A, Field T, Handler S
Adverse events in long-term care residents transitioning from hospital back to nursing home.
This study looked at adverse event rates of long-term care residents transitioning back to their nursing home after hospitalization. A prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017 was conducted, and residents were followed up for 45 days. A random sample of 32 nursing homes located in 6 New England states was used, and 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Most of the cohort were female (65.5%) and non-Hispanic white (93.7%). The study used trained nurse abstractors to review nursing home records to determine if an adverse event occurred. Out of 762 discharges there were 379 adverse events. The most common adverse events were pressure ulcers, skin tears, and falls followed by health care-acquired infections. 145 adverse events were considered less serious, with 28 life-threatening, and 8 were fatal. Most of the adverse events were considered preventable or ameliorable.
AHRQ-funded; HS024596.
Citation: Kapoor A, Field T, Handler S .
Adverse events in long-term care residents transitioning from hospital back to nursing home.
JAMA Intern Med 2019 Sep;179(9):1254-61. doi: 10.1001/jamainternmed.2019.2005..
Keywords: Adverse Events, Long-Term Care, Nursing Homes, Transitions of Care, Elderly, Patient Safety, Hospital Discharge, Hospitalization
Campbell Britton M, Hodshon B, Chaudhry SI
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
This study focused on increasing better communication during transfers from hospitals and skilled nursing facilities (SNFs). Warm handoffs between hospital and SNF physicians was implemented. Participation in warm handoffs gradually increased – starting at 15.78% in stage 1 and increasing to 46.89% in stage 3. A total of 2417 patient discharges were included in this study.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Hodshon B, Chaudhry SI .
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
J Patient Saf 2019 Sep;15(3):198-204. doi: 10.1097/pts.0000000000000529..
Keywords: Communication, Patient Safety, Hospital Discharge, Transitions of Care, Care Coordination, Hospitals, Nursing Homes
Hoonakker PLT, Wooldridge AR, Hose BZ
Information flow during pediatric trauma care transitions: things falling through the cracks.
In order to investigate information flow during pediatric trauma care transitions, researchers interviewed 18 clinicians about communication and coordination between the emergency department, operating room, and pediatric intensive care unit, then surveyed the clinicians about patient safety during these transitions. They found that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To manage the transition of this fragile and complex population better, they recommend finding ways to manage the information flow during these transitions better by, for instance, providing technological support to ensure shared mental models.
AHRQ-funded; HS023837.
Citation: Hoonakker PLT, Wooldridge AR, Hose BZ .
Information flow during pediatric trauma care transitions: things falling through the cracks.
Intern Emerg Med 2019 Aug;14(5):797-805. doi: 10.1007/s11739-019-02110-7..
Keywords: Children/Adolescents, Communication, Emergency Department, Healthcare Delivery, Intensive Care Unit (ICU), Patient Safety, Provider, Provider: Clinician, Surgery, Transitions of Care, Trauma
Dyer AP, Dodds Ashley E, Anderson DJ
Total duration of antimicrobial therapy resulting from inpatient hospitalization.
The purpose of this study was to assess the feasibility of electronic data capture of post-discharge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays. Results showed that discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays and suggested that discharge prescription data can be feasibly captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.
AHRQ-funded; HS023866.
Citation: Dyer AP, Dodds Ashley E, Anderson DJ .
Total duration of antimicrobial therapy resulting from inpatient hospitalization.
Infect Control Hosp Epidemiol 2019 Aug;40(8):847-54. doi: 10.1017/ice.2019.118..
Keywords: Antimicrobial Stewardship, Health Information Technology (HIT), Hospitalization, Patient Safety, Transitions of Care
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Mueller SK, Schnipper JL
Physician perspectives on interhospital transfers.
This study examined physician perspectives of the common problems that occur during acute care hospital interhospital transfers. The process tends to be nonstandardized which creates a number of issues. These issues include: patients sometimes, frequently, or always arriving without required specialized care (56% of the time), arriving with unrealistic expectations of care (77.2% of responses), arrived more than 24 hours after accepted transfer in 80.1% of responses, and arrived without necessary transfer records 86.9% of the time. The last issue and also time of day of arrival many physicians felt posed a risk to the transferred patients.
AHRQ-funded; HS023331.
Citation: Mueller SK, Schnipper JL .
Physician perspectives on interhospital transfers.
J Patient Saf 2019 Jun;15(2):86-89. doi: 10.1097/pts.0000000000000312..
Keywords: Healthcare Delivery, Hospitals, Patient Safety, Provider, Provider: Physician, Transitions of Care
Xiao Y, Abebe E, Gurses AP
Engineering a foundation for partnership to improve medication safety during care transitions.
Current approaches to safe, self-medication management for patients and caregivers after hospital discharge tend to focus on adding isolated strategies. Positing the concept that medication safety during care transition and at patient homes is the property of a "work system," in which the patient and caregivers are in collaboration with health professionals, this article argues that system thinking can enable a fundamental transformation that redesigns professionals' interactions with patients and caregivers, with the explicit goal of developing patients and caregivers into true partners with targeted roles. The authors describe a set of recommendations based on human factors principles that creates an engineering partnership with patients and their caregivers at different stages during a care episode, to enable productive interactions.
AHRQ-funded; HS024436.
Citation: Xiao Y, Abebe E, Gurses AP .
Engineering a foundation for partnership to improve medication safety during care transitions.
J Patient Saf Risk Manag 2019 Feb 1;24(1):30-36. doi: 10.1177/2516043518821497..
Keywords: Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Transitions of Care
Arbaje AI, Hughes A, Werner N
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
The goal of this study was to identify information management (IM) process failures made during home health visits to middle-aged and older adults after hospital discharge. Communication risks included information overload, information underload, information scatter, information conflict, and erroneous information.
AHRQ-funded; HS022916.
Citation: Arbaje AI, Hughes A, Werner N .
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
BMJ Qual Saf 2019 Feb;28(2):111-20. doi: 10.1136/bmjqs-2018-008163..
Keywords: Elderly, Home Healthcare, Hospital Discharge, Patient Safety, Transitions of Care