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  • 1.
    Flink, Maria
    et al.
    Karolinska Institutet; Karolinska Universitetsjukhuset.
    Lindblad, Marléne
    Karolinska institutet; Kungliga Tekniska högskolan (KTH).
    Frykholm, Oscar
    Karolinska Institutet.
    Kneck, Åsa
    Karolinska Institutet.
    Nilsen, Per
    Linköpings universitet.
    Årestedt, Kristofer
    Linnéuniversitetet; Länssjukhuset i Kalmar.
    Ekstedt, Mirjam
    Karolinska institutet; Kungliga Tekniska högskolan (KTH); Länssjukhuset i Kalmar.
    The supporting patient activation in transition to home (sPATH) intervention: a study protocol of a randomised controlled trial using motivational interviewing to decrease re-hospitalisation for patients with COPD or heart failure2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 7, p. 1-8, article id e014178Article in journal (Refereed)
    Abstract [en]

    Introduction Deficient hospital discharging and patients struggling to handle postdischarge self-management have been identified as potential causes of re-hospitalisation rates. Despite an increased interest in interventions aiming to reduce re-hospitalisation rates, there is yet no best evidence on how to support patients in being active participants in their self-management postdischarge. The aim of this paper is to describe the study protocol for an upcoming randomised controlled trial (RCT) of the Supporting Patient in Activation to Home (sPATH) intervention.

    Methods/analysis The described study is a randomised, controlled, analysis-blinded, two-site trial, with primary outcome re-hospitalisation within 90 days. In total, 290 participants aged 18 years or older with chronic obstructive pulmonary disease or congestive heart failure who are admitted to hospital and who are living in an own home will be eligible for inclusion into an intervention (n=145) or control group (n=145). Patients who need an interpreter to communicate in Swedish, or who have a diagnosis of dementia or cognitive impairment, will be excluded from inclusion. The sPATH intervention, developed with a theoretical base in the self-determination theory, consists of five postdischarge motivational interviewing sessions (face to face or by phone). The intervention covers the self-management areas medication management, follow-up/care plan, symptoms/signs of worsening condition and relations/contacts with healthcare providers. This RCT will add to the literature on evidence to support patient activation in postdischarge self-management.

    Ethics and dissemination The study is approved by the Regional Research Ethics Committee (No. 2014/1498-31/2) in Stockholm, Sweden. The results of the study will be published in peer-reviewed journals and presented at international and national scientific conferences. 

    Trial registration number NCT02823795; Pre-results.

  • 2.
    Flink, Maria
    et al.
    Karolinska institutet.
    Tessma, Mesfin
    Karolinska institutet.
    Cvancarova Småstuen, Milada
    Norge.
    Lindblad, Marléne
    Ersta Sköndal Bräcke University College, Department of Health Care Sciences. Karolinska institutet.
    Coleman, Eric A
    USA.
    Ekstedt, Mirjam
    Karolinska institutet, Linnéuniversitetet.
    Measuring care transitions in Sweden: validation of the care transitions measure.2018In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 30, no 4, p. 291-297Article in journal (Refereed)
    Abstract [en]

    Objective: To translate and assess the validity and reliability of the original American Care Transitions Measure, both the 15-item and the shortened 3-item versions, in a sample of people in transition from hospital to home within Sweden.

    Design: Translation of survey items, evaluation of psychometric properties.

    Setting: Ten surgical and medical wards at five hospitals in Sweden.

    Participants: Patients discharged from surgical and medical wards.

    Main outcome measure: Psychometric properties of the Swedish versions of the 15-item (CTM-15) and the 3-item (CTM-3) Care Transition Measure.

    Results: We compared the fit of nine models among a sample of 194 Swedish patients. Cronbach's alpha was 0.946 for CTM-15 and 0.74 for CTM-3. The model indices for CTM-15 and CTM-3 were strongly indicative of inferior goodness-of-fit between the hypothesized one-factor model and the sample data. A multidimensional three-factor model revealed a better fit compared with CTM-15 and CTM-3 one factor models. The one-factor solution, representing 4 items (CTM-4), showed an acceptable fit of the data, and was far superior to the one-factor CTM-15 and CTM-3 and the three-factor multidimensional models. The Cronbach's alpha for CTM-4 was 0.85.

    Conclusions: CTM-15 with multidimensional three-factor model was a better model than both CTM-15 and CTM-3 one-factor models. CTM-4 is a valid and reliable measure of care transfer among patients in medical and surgical wards in Sweden. It seems the Swedish CTM is best represented by the short Swedish version (CTM-4) unidimensional construct.

  • 3.
    Lindblad, Marléne
    et al.
    Ersta Sköndal Bräcke University College, Department of Health Care Sciences. Kungliga Tekniska högskolan.
    Flink, Maria
    Karolinska institutet.
    Ekstedt, Mirjam
    Karolinska institutet, Linnéuniversitetet.
    Exploring patient safety in Swedish specialised home healthcare: an interview study with multidisciplinary teams and clinical managers.2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 12, p. 1-7, article id e024068Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives.

    DESIGN: An explorative qualitative study.

    SETTING: Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden.

    METHODS: Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis.

    RESULTS: Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology.

    CONCLUSION: Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority.

  • 4.
    Lindblad, Marléne
    et al.
    Ersta Sköndal University College, Department of Health Care Sciences. KTH.
    Flink, Maria
    Karolinska institutet.
    Ekstedt, Mirjam
    Karolinska institutet, Linnéuniversitetet.
    Safe medication management in specialized home healthcare - an observational study.2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, article id 598Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Medication management is a complex, error-prone process. The aim of this study was to explore what constitutes the complexity of the medication management process (MMP) in specialized home healthcare and how healthcare professionals handle this complexity. The study is theoretically based in resilience engineering.

    METHOD: Data were collected during the MMP at three specialized home healthcare units in Sweden using two strategies: observation of workplaces and shadowing RNs in everyday work, including interviews. Transcribed material was analysed using grounded theory.

    RESULTS: The MMP in home healthcare was dynamic and complex with unclear boundaries of responsibilities, inadequate information systems and fluctuating work conditions. Healthcare professionals adapted their everyday clinical work by sharing responsibility and simultaneously being authoritative and preserving patients' active participation, autonomy and integrity. To promote a safe MMP, healthcare professionals constantly re-prioritized goals, handled gaps in communication and information transmission at a distance by creating new bridging solutions. Trade-offs and workarounds were necessary elements, but also posed a threat to patient safety, as these interim solutions were not systematically evaluated or devised learning strategies.

    CONCLUSIONS: To manage a safe medication process in home healthcare, healthcare professionals need to adapt to fluctuating conditions and create bridging strategies through multiple parallel activities distributed over time, space and actors. The healthcare professionals' strategies could be integrated in continuous learning, while preserving boundaries of safety, instead of being more or less interim solutions. Patients' and family caregivers' as active partners in the MMP may be an underestimated resource for a resilient home healthcare.

  • 5.
    Lindblad, Marléne
    et al.
    Ersta Sköndal Bräcke University College, Department of Health Care Sciences. KTH.
    Schildmeijer, Kristina
    Linnéuniversitetet.
    Nilsson, Lena
    Linköpings universitet.
    Ekstedt, Mirjam
    Karolinska institutet.
    Unbeck, Maria
    Danderyds sjukhus; Karolinska institutet.
    Development of a trigger tool to identify adverse events and noharm incidents that affect patients admitted to home healthcare2018In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 27, no 7, p. 502-511Article in journal (Refereed)
    Abstract [en]

    Background Adverse events (AEs) and no-harm incidents are common and of great concern in healthcare. A common method for identification of AEs is retrospective record review (RRR) using predefined triggers. This method has been used frequently in inpatient care, but AEs in home healthcare have not been explored to the same extent. The aim of this study was to develop a trigger tool (TT) for the identification of both AEs and no-harm incidents affecting adult patients admitted to home healthcare in Sweden, and to describe the methodology used for this development. Methods The TT was developed and validated in a stepwise manner, in collaboration with experts with different skills, using (1) literature review and interviews, (2) a five-round modified Delphi process, and (3) twostage RRRs. Ten trained teams from different sites in Sweden reviewed 600 randomly selected records. Results In all, triggers were found 4031 times in 518 (86.3%) records, with a mean of 6.7 (median 4, range 1-54) triggers per record with triggers. The positive predictive values (PPVs) for AEs and no-harm incidents were 25.4% and 16.3%, respectively, resulting in a PPV of 41.7% (range 0.0%-96.1% per trigger) for the total TT when using 38 triggers. The most common triggers were unplanned contact with physician and/or registered nurse, moderate/severe pain, moderate/severe worry, anxiety, suffering, existential pain and/or psychological pain. AEs were identified in 37.7% of the patients and no-harm incidents in 29.5%. Conclusion This study shows that adapted triggers with definitions and decision support, developed to identify AEs and no-harm incidents that affect patients admitted to home healthcare, may be a valid method for safety and quality improvement work in home healthcare.

  • 6.
    Schildmeijer, Kristina Görel Ingegerd
    et al.
    Linnéuniversitetet.
    Unbeck, Maria
    Danderyds sjukhus, Karolinska institutet.
    Ekstedt, Mirjam
    Linnéuniversitetet, Karolinska institutet.
    Lindblad, Marléne
    Ersta Sköndal Bräcke University College, Department of Health Care Sciences. Kungliga tekniska högskolan .
    Nilsson, Lena
    Linköpings universitet.
    Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology.2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 1, article id e019267Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare.

    DESIGN: A study using retrospective record review and trigger tool methodology.

    SETTING AND METHODS: Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed.

    PRIMARY AND SECONDARY OUTCOME MEASURES: The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs.

    RESULTS: The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers.

    CONCLUSIONS: AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.

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