The Permanente journal最新文献

Introduction: Adverse childhood experiences (ACEs) are strongly correlated with many of the most common causes of preventable illness, preventable death, and health disparities. In January 2020, California launched the first statewide initiative to integrate ACE screening throughout its Medicaid system. A key element of the initiative was the California ACEs Learning and Quality Improvement Collaborative, a 48-clinic, 16-month learning collaborative. This evaluation aimed to determine whether developing a trauma-informed environment of care was associated with uptake of ACE screening.

Methods: Participants included 40 of 48 clinics that participated in the statewide learning collaborative. Clinics completed an assessment of progress in 5 essential components of trauma-informed health care at baseline and 1-year follow-up. Clinics tracked data on ACE screens completed on an ongoing basis and submitted data quarterly. A hierarchical linear model was used to examine the association between change in readiness for trauma-informed health care and change in quarterly screens.

Results: Readiness for trauma-informed health care increased for all participating clinics over the course of the learning collaborative. The average number of quarterly screens also increased, with considerable variability among clinics. Clinics with larger increases in readiness for trauma-informed health care had larger increases in quarterly screens.

Discussion: The findings align with long-standing recommendations for trauma screening to occur in the context of trauma-informed environments of care.

Conclusion: A trauma-informed clinic is the foundation for successful adoption of ACE screening. ACE screening initiatives should include education and sufficient support for clinics to embrace a trauma-informed systems change process.

Atrial fibrillation (AF) is an arrhythmia characterized by disorganized atrial activity with an associated unevenly irregular ventricular response on an electrocardiogram. It is the most common sustained arrhythmia, with a lifetime risk of 25% in patients older than 40 years old. The incidence of AF increases with age and is associated with an increased risk for heart failure, stroke, adverse cardiac events, and dementia. The 2 main aims of AF treatment include anticoagulation for thromboembolism prophylaxis as well as rate vs rhythm control. The focus of this article will be on the treatment strategies in managing AF. Rate control refers to the use of atrioventricular nodal blocking medications, including beta blockers and calcium channel blockers, to maintain a goal heart rate. Rhythm control, on the other hand, refers to a treatment strategy focused on the use of antiarrhythmic drugs (AAD), cardioversion, and ablation to restore and to maintain a patient in sinus rhythm. Currently, the ideal treatment strategy remains greatly debated. Thus, we hope to compare the risks and benefits of rate to rhythm control to highlight how patients with AF are managed here at Kaiser Permanente Northern California.

Background: Trauma is common in the United States, increases risk of long-term adverse health effects, and individuals who experience it often find seeking medical care difficult. Trauma-informed care (TIC) builds trust and fosters healing relationships between clinicians and patients; however medical education has lacked consistent training in TIC. Using recently published competencies for undergraduate medical education (UME), this manuscript provides curricular examples across 8 domains to assist faculty in developing educational content.

Methods: The authors identified published curricula for each of the 8 competency domains using a published search strategy and publicly available database. Inclusion criteria were published works focused on UME in the United States; abstracts and curricula not focused on UME were excluded. The authors used a consensus-based process to review 15 eligible curricula for mapping with the competencies.

Results: Of 15 published UME curricula, 11 met criteria and exemplify each of the 8 UME competency domains. Most of the available curricula fall into the Knowledge for Practice and Patient Care domains. Most were offered in the first 2 years of medical school.

Conclusion: Competency-based medical education for TIC is new, and most current educational offerings are foundational in nature. Additional innovation is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development. This manuscript offers a set of curricular examples that can be used to aid efforts at implementing TIC competencies in UME; future work must focus on improving assessment methods and developmental sequencing as more students are exposed to TIC principles.

Clinical empathy is a multidimensional ability to feel the patient's suffering, branched into components such as cognitive, emotional, and action, which results in benefits for patients, parents, health professionals, medical students, and others. The authors performed a critical review of the literature about empathy in neonatal care, in 2 databases, and analyzed the co-occurrence of keywords in the last 10 years. Nine articles were included in the qualitative synthesis. They highlight the interconnection between empathy, communication, ethics, and palliative care. Empathy was analyzed in situations that included pain, death, and suffering in the neonate, especially related to critically ill neonates. Strategies such as self-reflection and digital storytelling may help increase the clinical empathy education of health professionals. There are gaps in research considering the measurement of clinical empathy in neonatal care, and this measurement should be encouraged. To change care practices, education on empathy for health professionals, especially physicians, should be improved.

Introduction: Advanced Care at Home is a clinical model that delivers hospital-level care in a patient's home. This model of care has been studied for decades, but there have been difficulties scaling the model to a higher census because of poor physician participation. Kaiser Permanente at Home, an Advanced Care at Home model created by Kaiser Permanente Northwest, was able to quickly increase its patient census by using several different change management interventions. The aim of this study was to describe the specific physician change management interventions used and to determine their relative impacts on physician participation with Kaiser Permanente at Home.

Methods: This study used a retrospective qualitative approach. Hospitalist and emergency department (ED) physicians completed an online survey in December 2021. This was followed by focused, one-on-one interviews that were held in February 2022. Content analysis was performed using a general inductive approach to identify core themes.

Results: Of 78 ED and 79 hospitalist physicians recruited, 35% submitted responses. Of these respondents, 16 (29%) were ED physicians, and 39 (61%) were hospitalist physicians. Of these respondents, 90% rated Kaiser Permanente at Home favorably over the course of a year. More than 90% of respondents rated a combination of multiple approaches as impactful, but respondents overwhelmingly noted that physician-to-physician engagement was the most important (51%).

Conclusion: In the development of the Kaiser Permanente at Home, physicians highlighted that a multifactorial change management approach centered on peer-to-peer engagement had the most substantial effect on their participation, a process that could extend up to a year.

Background: Screening for adverse childhood experiences (ACEs) in prenatal and pediatric populations is recommended by the California ACEs Aware initiative and is a promising practice to interrupt ACEs in children and mitigate ACEs-related health complications in children and families. Yet, integrating ACEs screening into clinical practice poses several challenges.

Objective: The objective of this report was to evaluate the Kaiser Permanente Northern California and Kaiser Permanente Southern California pilots and implementation of ACEs screening into routine prenatal (Kaiser Permanente Northern California) and pediatric (Kaiser Permanente Southern California) care.

Materials and methods: These pilots were evaluated and compared to identify common challenges to implementation and offer promising practices for negotiating these challenges. Evaluation methods included feedback from staff, clinicians, and patients, as well as comparisons of methods to overcome various barriers to screening implementation.

Results: Implementing ACEs screening, like implementation of any new component of clinical care, takes careful planning, education, creation of content and workflows, and continuous integration of feedback from both patients and staff.

Conclusion: This evaluation can serve as support for care teams who are considering implementing ACEs screening or who are already screening for ACEs. More research is needed regarding the relationship between ACEs and preventable and treatable health outcomes to improve health for patients and their families.