No abstract

Objective: With the rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), and the subsequent alterations to the delivery of health care, telehealth has become an essential service worldwide. Neuropsychology is similarly attempting to adopt telecommunication to deliver neuropsychological services to clients. The purpose this article is to review the utility and value of teleneuropsychological assessment, discuss practical issues and possible barriers related to its implementation and use, and propose considerations and achievable goals to increase the use, acceptance, and clinical utility of teleneuropsychological evaluations. Method: We reviewed the published literature to extract information about the efficacy and limitations of the methods that are currently used to deliver teleneuropsychological services, as well as current guidelines and ethical principles most salient to teleneuropsychological practice. Conclusions: Current literature suggests that teleneuropsychological assessment is feasible and acceptable in many patient populations. Practitioners wishing to implement teleneuropsychological assessment should consider using secure testing platforms, participate in continuing education on the topic of remote/online evaluation, and become familiar with alternative technologies. We implore clinicians, researchers, and trainees who have successfully integrated teleneuropsychology into their current practice to keep detailed records of their methods and results in hopes of adding this data to a larger data repository or to publish these results to add to the small, but growing, teleneuropsychology literature. Future research should focus on generating new normative datasets for tests administered remotely, which will involve the pooling of data from multiple sources using teleneuropsychological assessment.

Innovation Concept: Emergency physicians (EP) rarely receive timely, iterative feedback on clinical performance that aids their reflective practice. The Calgary zone ED recently implemented a novel email-based alert system wherein an EP is notified when a patient whose ED care they were involved in is admitted to hospital within 72-hours of discharge from an index ED visit. Our study sought to evaluate the general acceptability of this form of audit and feedback and determine whether it encourages practice reflection. Methods: This mixed methods realist evaluation consisted of two sequential phases. An initial quantitative phase used data from our electronic health record and a survey to examine the general features and acceptability of 72-hour readmission alerts sent from May 2017-2018. A subsequent qualitative phase involved semi-structured interviews exploring the alert's role in greater depth. Quantitative data were summarized using descriptive statistics and qualitative data were analyzed using thematic and template analysis techniques. Results of both phases were used to guide construction of context-mechanism-outcome statements to refine our program theory. Curriculum, Tool, or Material: 4024 alerts were sent over a 1-year period, with each physician receiving approximately 17 alerts per year (Q1: 7, Q3: 25, IQR: 18). The top five CEDIS complaints on index presentations were abdominal pain, flank pain, shortness of breath, vomiting and/or nausea, and chest pain (cardiac features). The majority of re-admissions (78.6%) occurred within 48 hours after discharge. Immediate alert survey feedback provided by EP's noted that 52.65% (N = 471) of alerts were helpful. Thematic analysis of 17 semi-structured interviews suggests that the alert was generally acceptable to physicians, However, certain EPs were concerned that the alert impacted hire/fire decisions even when leadership didn't endorse this sentiment. Physicians who didn't believe alerts were involved in hire/fire decisions, described greater engagement in the reflective process. Conversely, physicians, who believed alerts were involved in hire/fire decisions, were more likely to defensively change their practice. Conclusion: Most EPs noted that timely notification of 72-hour readmissions made them more mindful of documenting discharge instructions. Our implementation of a 72- hour readmission alert was an acceptable format for audit and feedback and appeared to facilitate physician reflection under certain conditions.

Background physician refelection requires personalized, timely and growth-oriented feedback. Iterative learning from multiple low-pressure events can be personalized to target areas of weakness and show sequential growth. Since emergency physicians typically work individually to deliver episodic care, opportunities for them to obtain iterative feedback on their clinical performace is often limited. Our study sought to evaluate whether physician reflection is facilitated through the 72hr re-admission alert received by emergency physicians in the Calgary zone. Implementation The 72-hr readmission alert is already part of feedback received in the Calgary Zone. Our study was specifically looking at understanding the utility of these alerts to emergency physicians through qualitative interviews. Our team of two interviewers (DA and CP) collected and banked the data through anonymized one-on-one interviews. Themes from these interviews will be used to guide future adjustments made to the alert and dictate it’s future role in emergency physician feedback. Current changes based on preliminary data have included the ability to customize re-admission alert time-frames based on personal preference. We are currently in the process of analyzing the themes that will shape further improvements made to the alert. Evaluation Methods This mixed methods realist evaluation consisted of two sequential phases: an initial quantitative phase examining the general features of 72-hr readmission alerts sent over a 1-year period (4024 alerts from May 2017-2018) and a subsequent qualitative phase involving 17 semi-structured interviews to generate “context-mechanism-outcome” (CMO) statements to guide refinement of our program theory. Results CMO statements revealed emergency physician stakeholders were concerned that the alert impacted personnel decisions, changed patient return expectations and didn’t involve consulting services. Physicians, who didn’t believe alerts were involved in personnel decisions, were more likely to pursue balanced reflection/acquisition after each alert when receiving illness related returns. Conversely, physicians, who believed alerts were involved in performance assessment/hiring decisions, were more likely to defensively change their practice. Commonly cited areas of improvement were the ability to personally adjust time criteria for alerts and involving consulting services in feedback. Advice and Lessons Learned It is essential to partner with local departments who can use formal (newsletters) and informal (word of mouth) avenues to encourage participation in the study. Participant anonymity must be emphasized when recruiting for qualitative interviews in order to receive the full scope of perspectives. Clear and concise scripts highlighting the objective of each question can ensure the quality of responses received and help interviewers probe further into the topic when necessary. When performing quality improvement studies on formal feedback mechanisms, faculty leadership buy-in is essential in order to ensure a safe environment for all participants.