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Background and purpose Patients with acute ischaemic stroke and a large vessel occlusion who present to a non‐endovascular‐capable centre often require inter‐hospital transfer for thrombectomy. Whether the inter‐hospital transfer time is associated with 3‐month functional outcome is poorly known. Methods Acute stroke patients enrolled between January 2015 and December 2022 in the prospective French multicentre Endovascular Treatment of Ischaemic Stroke registry were retrospectively analysed. Patients with an anterior circulation large vessel occlusion transferred from a non‐endovascular to a comprehensive stroke centre for thrombectomy were eligible. Inter‐hospital transfer time was defined as the time between imaging in the referring hospital and groin puncture for thrombectomy. The relationship between transfer time and favourable 3‐month functional outcome (modified Rankin Scale 0–2) was assessed through a mixed logistic regression model adjusting for centre and symptom‐onset‐to‐referring‐hospital imaging time, age, sex, diabetes, referring hospital National Institutes of Health Stroke Scale score, Alberta Stroke Programme Early Computed Tomography Score, occlusion site and intravenous thrombolysis use. Results Overall, 3769 patients were included (median inter‐hospital transfer time 161 min, interquartile range 128–195; 46% with favourable outcome). A longer transfer time was independently associated with lower rates of favourable outcome (p < 0.001). Compared to patients with transfer time below 120 min, there was a 15% reduction in the odds of achieving favourable outcome for transfer times between 120 and 180 min (adjusted odds ratio 0.85; 95% confidence interval 0.67–1.07), and a 36% reduction for transfer times beyond 180 min (adjusted odds ratio 0.64; 95% confidence interval 0.50–0.81). Conclusions A shorter inter‐hospital transfer time is strongly associated with favourable 3‐month functional outcome. A speedier inter‐hospital transfer is of critical importance to improve outcome.

Multimorbidity frequently co-occurs with behavioral health concerns and leads to increased healthcare costs and reduced quality and quantity of life. Unplanned readmissions are a primary driver of high healthcare costs. We tested the effectiveness of a culturally appropriate care transitions program for Latino adults with multiple cardiometabolic conditions and behavioral health concerns in reducing hospital utilization and improving patient-reported outcomes. Randomized, controlled, single-blind parallel-groups. Hispanic/Latino adults (N=536; 75% of those screened and eligible; M=62.3 years (SD=13.9); 48% women; 73% born in Mexico) with multiple chronic cardiometabolic conditions and at least one behavioral health concern (e.g., depression symptoms, alcohol misuse) hospitalized at a hospital that serves a large, mostly Hispanic/Latino, low-income population. Usual care (UC) involved best-practice discharge processes (e.g., discharge instructions, assistance with appointments). Mi Puente (\"My Bridge\"; MP) was a culturally appropriate program of UC plus inpatient and telephone encounters with a behavioral health nurse and community mentor team who addressed participants' social, medical, and behavioral health needs. The primary outcome was 30- and 180-day readmissions (inpatient, emergency, and observation visits). Patient-reported outcomes (quality of life, patient activation) and healthcare use were also examined. In intention-to-treat models, the MP group evidenced a higher rate of recurrent hospitalization (15.9%) versus UC (9.4%) (OR=1.91 (95% CI 1.09, 3.33)), and a greater number of recurrent hospitalizations (M=0.20 (SD=0.49) MP versus 0.12 (SD=0.45) UC; P=0.02) at 30 days. Similar trends were observed at 180 days. Both groups showed improved patient-reported outcomes, with no advantage in the Mi Puente group. Results were similar in per protocol analyses. In this at-risk population, the MP group experienced increased hospital utilization and did not demonstrate an advantage in improved patient-reported outcomes, relative to UC. Possible reasons for these unexpected findings are discussed. ClinicalTrials.gov Identifier: NCT02723019. Registered on 30 March 2016.

This study examined differences in learning outcomes among newborn intensive care unit (NICU) workers who underwent virtual reality simulation (VRS) emergency evacuation training versus those who received web-based clinical updates (CU). Learning outcomes included a) knowledge gained, b) confidence with evacuation, and c) performance in a live evacuation exercise. A longitudinal, mixed-method, quasi-experimental design was implemented utilizing a sample of NICU workers randomly assigned to VRS training or CUs. Four VRS scenarios were created that augmented neonate evacuation training materials. Learning was measured using cognitive assessments, self-efficacy questionnaire (baseline, 0, 4, 8, 12 months), and performance in a live drill (baseline, 12 months). Data were collected following training and analyzed using mixed model analysis. Focus groups captured VRS participant experiences. The VRS and CU groups did not statistically differ based upon the scores on the Cognitive Assessment or perceived self-efficacy. The virtual reality group performance in the live exercise was statistically (P<.0001) and clinically (effect size of 1.71) better than that of the CU group. Training using VRS is effective in promoting positive performance outcomes and should be included as a method for disaster training. VRS can allow an organization to train, test, and identify gaps in current emergency operation plans. In the unique case of disasters, which are low-volume and high-risk events, the participant can have access to an environment without endangering themselves or clients. (Disaster Med Public Health Preparedness. 2019;13:301-308).

IntroductionIneffective coordination during care transitions from hospitals to skilled nursing facilities (SNFs) costs Medicare US$2.8–US$3.4 billion annually and results in avoidable adverse events. Approximately 70% of patients experience medication errors during these transitions, resulting in downstream consequences such as medication-related problems and unplanned readmissions. Patients and caregivers report significant emotional distress and concerns, particularly regarding medication management. Current protocols often fail to ensure effective medication management and communication between hospital and SNF teams. Developed with input from multiple interest holders, the Pharmacy Integrated Transitions (PIT) programme enhances these transitions by improving medication safety and communication. The programme includes a pharmacist who reconciles patients’ medications during transitions from hospitals to SNFs, and a structured handoff between hospital and SNF clinical teams. A rigorous, pragmatic trial is needed to assess the programme’s effectiveness in enhancing care transitions compared with standard practices.The PIT trial aims to evaluate the effectiveness of the PIT programme in improving patients’ care transitions from hospitals to SNFs compared with usual care, and to characterise multiple interest holders’ perspectives on its implementation fidelity, effectiveness and needed support for sustainment.Methods and analysisThe PIT trial is a parallel cluster-randomised controlled crossover trial design, with randomisation occurring at the SNF cluster level. The trial is conducted across 4 hospitals and 14 independent SNFs in Washington State. SNFs are stratified by patient volume before being randomly assigned to either the PIT programme or usual care. The trial aims to include a diverse patient population transitioning from hospitals to SNFs. The primary outcome is medication-related problems within 30 days posthospital discharge. Clinical adverse events, readmission rates and emergency department visits will be compared. Additionally, we will conduct a mixed-methods summative evaluation to assess multiple interest holders’ perspectives on the PIT programme’s implementation fidelity, effectiveness and the support required for its sustainment.Ethics and disseminationThis trial was approved by the University of Washington’s Human Subjects Division on 9 September 2020 (STUDY00011018_PIT). The trial was reviewed by the University of Washington Institutional Review Board (IRB) and was issued a waiver of consent. The University of Washington serves as the IRB for all 14 of the Post Acute Care Skilled Nursing Facility study sites. Results from this trial will be published in peer-reviewed journals. Results may also be presented at international conferences.Trial registration numberNCT05241951.

Background Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate). Methods This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant. Results Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€. Conclusions Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents. Trial registration clinicaltrials.gov, NCT02677272.

Objectives This randomized controlled trial (RCT) evaluated the effect of a participatory organizational intervention for improved use of assistive devices (AD) in patient transfer. Methods We randomly allocated 27 departments from five hospitals in Denmark to a participatory intervention (14 clusters, 316 healthcare workers) or a control group (13 clusters, 309 healthcare workers). The intervention consisted of 2×2 hour workshops with managers, the hospital's health and safety staff, and 2-5 healthcare workers from each department. Based on an assessment of barriers and solutions conducted prior to randomization, participants developed an action plan for implementing department-specific solutions for improving the use of AD. Use of necessary AD (using digital counters as primary outcome), and general use of AD (using accelerometers as secondary outcome), pain intensity in the low-back, work-related back injuries during patient transfer, and communication and guidance in the use of AD were measured at baseline, 6 and 12 months. Results Use of necessary AD (primary outcome), low-back pain, and back injuries did not change in the intervention compared with control group at 12-month follow-up. However, general use of AD measured with accelerometers as well as communication and guidance improved significantly in the intervention versus control group. Conclusion The intervention did not result in more frequent use of the necessary AD but led to more general use of AD, as well as increased communication and guidance.

Care transitions from the hospital to home remain a vulnerable time for many patients, especially for those with heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Despite regular use in chronic disease management, it remains unclear how technology can best support patients during their transition from the hospital. We sought to evaluate the impact of a technology-supported care transition support program on hospitalizations, days out of the community and mortality. Using a pragmatic randomized trial, we enrolled patients (511 enrolled, 478 analyzed) hospitalized with CHF/COPD to “E-Coach,” an intervention with condition-specific customization and in-hospital and post-discharge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up versus usual post-discharge care (UC). The primary outcome was 30-day rehospitalization. Secondary outcomes included (1) rehospitalization and death and (2) days in the hospital and out of the community. E-Coach and UC groups were similar at baseline except for gender imbalance (p = 0.02). After adjustment for gender, our primary outcome, 30-day rehospitalization rates did not differ between the E-Coach and UC groups (15.0 vs. 16.3 %, adjusted hazard ratio [95 % confidence interval]: 0.94 [0.60, 1.49]). However, in the COPD subgroup, E-Coach was associated with significantly fewer days in the hospital (0.5 vs. 1.6, p = 0.03). E-Coach, an IVR-augmented care transition intervention did not reduce rehospitalization. The positive impact on our secondary outcome (days in hospital) among COPD patients, but not in CHF, may suggest that E-Coach may be more beneficial among patients with COPD.NIH trial registry number: NCT01135381Trial Protocol: http://dx.doi.org/10.1016/j.cct.2012.08.007

Background Multimorbidity affects four of ten US adults and eight of ten adults ages 65 years and older, and frequently includes both cardiometabolic conditions and behavioral health concerns. Hispanics/Latinos (hereafter, Latinos) and other ethnic minorities are more vulnerable to these conditions, and face structural, social, and cultural barriers to obtaining quality physical and behavioral healthcare. We report the protocol for a randomized controlled trial that will compare Mi Puente (My Bridge), a cost-efficient care transitions intervention conducted by a specially trained Behavioral Health Nurse and Volunteer Community Mentor team, to usual care or best-practice discharge approaches, in reducing hospital utilization and improving patient reported outcomes in Latino adults with multiple cardiometabolic conditions and behavioral health concerns. The study will examine the degree to which Mi Puente produces superior reductions in hospital utilization at 30 and 180 days (primary aim) and better patient-reported outcomes (quality of life/physical health; barriers to healthcare; engagement with outpatient care; patient activation; resources for chronic disease management), and will examine the cost effectiveness of the Mi Puente intervention relative to usual care. Methods Participants are enrolled as inpatients at a South San Diego safety net hospital, using information from electronic medical records and in-person screenings. After providing written informed consent and completing self-report assessments, participants randomized to usual care receive best-practice discharge processes, which include educational materials, assistance with outpatient appointments, referrals to community-based providers, and other assistance (e.g., with billing, insurance) as required. Those randomized to Mi Puente receive usual-care materials and processes, along with inpatient visits and up to 4 weeks of follow-up phone calls from the intervention team to address their integrated physical-behavioral health needs and support the transition to outpatient care. Discussion The Mi Puente Behavioral Health Nurse and Volunteer Community Mentor team intervention is proposed as a cost-effective and culturally appropriate care transitions intervention for Latinos with multimorbidity and behavioral health concerns. If shown to be effective, close linkages with outpatient healthcare and community organizations will help maximize uptake, dissemination, and scaling of the Mi Puente intervention. Trial registration ClinicalTrials.gov: NCT02723019 . Registered on 30 March 2016.

Background Patients on dialysis are physically inactive, with most reporting activity levels below the fifth percentile of healthy age-matched groups. Several small studies have reported efficacy of diverse exercise interventions among persons with CKD and those on dialysis. However, no single intervention has been widely adopted in real-world practice, despite a clear need in this vulnerable population with high rates of mortality, frailty, and skilled nursing hospitalizations. Methods/design We describe a pragmatic clinical trial for an exercise intervention among patients transitioning to dialysis. We will use an existing framework – Exercise is Medicine (EIM) – developed by the American College of Sports Medicine. After undertaking formative qualitative research to tailor the EIM framework to the advanced CKD population (eGFR < 30 ml/min/1.73m 2 ), we will randomize 96 patients from two regions—Atlanta and Bay Area—in two intervention arms with incremental levels of clinical-community integration: physical activity assessment during Nephrology clinical visit, brief counseling at pre-dialysis education, and physical activity wearable (group 1) versus group 1 intervention components plus a referral to a free, EIM practitioner-led group exercise program over 16 weeks (group 2; 8 week core intervention; 8-week follow up). We will assess efficacy by comparing between group differences in minutes/week of objectively measured moderate intensity physical activity. To evaluate implementation, we will use questionnaires for assessing barriers to referral, participation and retention along the path of the intervention. Further we will have a plan for dissemination of the intervention by partnering with relevant stakeholders. Discussion The overall goal is to inform the development of a practical, cost-conscious intervention “package” that addresses barriers and challenges to physical activity commonly faced by patients with advanced CKD and can be disseminated amongst interested practices. Trial registration ClinicalTrials.gov identifier (Dated:10/17/2017): NCT03311763 .

To assess the effect of a systematic, fast-track transition from oncological treatment to specialised palliative care at home on symptom burden, to explore intervention mechanisms through patient and intervention provider characteristics and to assess long-term survival and place of death. The effect of a systematic, fast-track transition from oncological treatment to specialised palliative care at home on patient symptom burden was studied in the Domus randomised clinical trial. Participants had incurable cancer and limited treatment options. The intervention was provided by specialised palliative home teams (SPT) based in hospice or hospital and was enriched with a psychological intervention for patient and caregiver dyad. Symptom burden was measured with Edmonton Symptom Assessment System (ESAS-r) at baseline, 8 weeks and 6 months follow-up and analysed with mixed models. Survival and place of death was analysed with Kaplan-Meier and Fisher's exact tests. The study included 322 patients. Tiredness was significantly improved for the Domus intervention group at 6 months while the other nine symptom outcomes were not significantly different from the control group. Exploring the efficacy of intervention provider demonstrated significant differences in favour of the hospice SPT on four symptoms and total symptom score. Patients with children responded more favourably to the intervention. The long-term follow-up demonstrated no differences between the intervention and the control groups regarding survival or home deaths. The Domus intervention may reduce tiredness. Moreover, the intervention provider and having children might play a role concerning intervention efficacy. The intervention did not affect survival or home deaths. NCT01885637.