Strong leadership is required if the vision of transformed healthcare is to be realized. The nursing profession must produce leaders who can serve to guide change in collaboration with other healthcare professionals. Nursing leadership serves to design, implement, evaluate, as well as advocate for ongoing reforms in healthcare. One of the key areas that nursing leadership must emphasize is quality improvement through the use of evidence-based practice. Quality improvement can serve to address issues with cost, patient experience, and reimbursement that are key in the transformation of healthcare today. This discussion focuses on the identification of a quality issue that can benefit from practice change and the role of nursing leadership in change implementation.
A1. Problem or Issue
Healthcare can be unpredictable, complicated, and stressful because of the volume of patients handled and the constant communication that is required. The quality of communication and interaction between healthcare providers is an area that poses challenges to many hospitals today (Tiwary et al., 2019). The problem that I would like to identify for this task is poor communication between inpatient and outpatient departments in a mental health setting. The transfer of patients between these two departments requires good communication for continuity of care and to prevent errors that may arise. To ensure quality improvement and the promotion of patient safety, there is a need to implement a program that can change how communication is done between the two units. This would be achieved by using proper handoff reports that are supported by evidence to counter communication breakdown in healthcare.
A1a. Explanation of Problem or Issue
Communication is an interaction that involves the exchange of information through speaking or writing and is crucial during healthcare service delivery. The breakdown of communication channels can have significant health benefits to patients and poor relationships among healthcare providers. In healthcare, the quality of services provided is highly dependent on good communication (Wang et al., 2017). For example, nurses must communicate during shift changes to ensure continuity of care. Also, outpatient staff must communicate the findings from assessment and diagnosis during admission to inpatient settings. Without the existence of clear communication channels, it becomes difficult to receive adequate information that can guide the subsequent delivery of care to patients.
The problem of communication is observed to affect the exchange of information between the outpatient and inpatient departments in my healthcare organization. The lack of focus on the area of communication has contributed to the poor handoff of patient information by staff. For example, there have been no recent projects in the organization focusing on the area of communication. Data obtained from the nursing education office indicates that programs to address communication were reviewed five years ago. The continued focus on programs that directly influence cost and reimbursements has hindered the identification of the communication challenges observed.
The outpatient and inpatient mental health departments continuously collaborate to ensure patients are well-treated and referred appropriately. The existence of collaborative ties between these two units means that communication should be effective. Currently, the healthcare organization faces problems with delayed admission of patients and poor relationship between healthcare workers. The outpatient staff argues that the heavy workload impairs the full documentation of patient information. During the exchange of reports when admitting the patient, the two departments have experienced challenges in communicating all patient data. There is substantial evidence that several errors in medication administration have occurred because of communication barriers. I have also documented various instances when the nurses failed to agree on what areas should be filled in the outpatient department before inpatient admissions. These differences make it difficult to deliver quality care to patients and affect relationships among staff.
Accurate and efficient communication between healthcare teams is a prerequisite for improved patient outcomes. Communication improves patient safety because it provides nurses with information used to make key decisions (Vermier et al., 2015). During the process of investigation, I observed that there exist poor working relationships between inpatient and outpatient staff. For instance, there was a time when I accompanied the outpatient nurse to admit a patient and noticed reluctance in information exchange. The outpatient department did not inform the other unit about the admission of the patient and this delayed the preparation for receiving the patient. Through this observation, I learned that there existed a communication challenge between the two departments.
It is well-documented that poor communication hinders quality outcomes by increasing errors, mortality rates, and patient readmissions (Wang et al., 2017). The second step of investigating the communication challenge focused on the number of errors and adverse outcomes observed in the inpatient unit. There was a significant number of patients who received delayed treatment because of poor communication from the outpatient staff. In most cases, delayed treatment was a result of inadequate preparation for admission. There was no clear channel of communication that could alert the inpatient staff about incoming admission. In some other cases, the inpatient charge nurse documented that they had to re-take a complete patient history because of communication issues that existed.
A2a. Evidence of Problem or Issue
Communication is important in the field of medicine because of its influence on patient outcomes. Failure of good communication during the exchange of patient information can lead to errors and adverse outcomes. Both technical and relational communication should exist to ensure the passage of accurate care to other providers. Good communication promotes patient-centered care by allowing providers to interact well with patients, obtain information, and involve them in their care (Tiwary et al., 2019). Poor communication between providers can be evidenced by various measures. For example, poor patient satisfaction scores can demonstrate the existence of poor communication channels. Organizational assessment data shows gaps in the aspect of communication between the two departments.
During the investigation of the communication problem in the inpatient and outpatient mental health setting, several errors were observed. Organizational assessment data shows increased medication errors for the past year because of poor communication. For example, instances of double sedation of patients have been documented in the facility owing to poor information exchange between staff. Another important statistical measure is the waiting time between patient transfer to inpatient units and admission. Most patients complained about the lack of clear channels for admission making their experience pathetic in some instances. Information from the inpatient and outpatient unit charge nurses demonstrated gaps in good relationships between the two departments. To effectively address the patient’s concerns, there needs to be good communication between healthcare providers in these hospital departments.
The problem of communication is recognized internationally to be among the major causes of preventable adverse events in healthcare (Tiwary et al., 2019). Poor communication between healthcare providers affects the areas of patient satisfaction and compliance with medication and the overall health status of patients. Among patients receiving care, poor communication is associated with poor adherence to instructions and inefficient utilization of resources. Overall, communication breakdown results in negative patient outcomes which impair healthcare quality (Vermier et al., 2015). Healthcare providers must possess effective communication skills to ensure information is correctly portrayed to patients, families, and colleagues.
One of the widely studied areas related to communication involves shift handoff. Nurses use shift handoffs to communicate care and allow continuity of service delivery to patients by new healthcare team members. According to research, poor communication during shift handoffs results in medical errors and adverse patient outcomes (Wang et al., 2017). Communication breakdown can be in the form of inadequate data given to oncoming nurses, poor documentation of data, or lack of adequate time to communicate all required aspects of care. Continuous barriers to communication like lack of time cause poor passage of information and subsequently affects relationships between staff and patients (Wang et al., 2017). Additionally, poor communication results in poor identification of the patient’s needs and ineffective attendance to those that require close attention.
Effective communication is essential in any business, especially in healthcare. Hospitals can be very chaotic and with the many distractions available, communication may become challenging sometimes. Internal communication between healthcare providers is the most crucial aspect because of its benefits to patients and the organization. Communication in healthcare needs to be efficient and time-sensitive as possible to minimize errors and delays in treatment. Communication challenges have always existed in healthcare and various strategies are proposed to address this issue. Even with the increased utilization of communication technologies, the issue of ineffective communication remains a burden to many facilities.
The issue of communication in the facility prompts one to think about the benefits of communication. As described above, communication failure between the outpatient and inpatient mental health departments has resulted in poor patient outcomes. According to studies, communication challenges have always carried a cost in terms of lost productivity. Secondly, poor communication makes providers have insufficient time with patients and it promotes prolonged length of hospital stay (Brady et al., 2017). The issue of waste is another point that can explain why communication is important. Timely and effective communication can save providers time that is spent looking for unnecessary documentation or making follow-ups. Medicare reimbursement uses communication as one of the metrics to reward hospitals. Poor communication promotes low patient satisfaction scores which in turn lower Medicare reimbursements.
Communication failures usually occur during shift change when providers hand over care. The outpatient and inpatient departments usually communicate by handing over information about the patient to be admitted. As observed in the facility, the inpatient and outpatient nurses, or rather staff, lack an effective communication method. Sometimes the inpatient staff has to go through the documentation to observe what is to be done and if it is required, new history is taken from the patient. poor utilization of communication technologies impairs communication between the two departments. When incomplete or inaccurate information is passed to another staff there is an increased probability of mistakes happening. According to research, 30% of all malpractice claims are a result of poor communication (Tiwary et al., 2019). There is a significant amount of capital spent to address adverse outcomes of poor communication in many institutions. Addressing the issue of communication breakdown can serve to save institutions a lot of capital and improve the quality of care given to patients.
The increased use of technology in healthcare today has improved communication, but also caused difficulties in establishing meaningful connections. For example, almost all documentation is done electronically today and members of the healthcare team do not have to frequently communicate to obtain information. Although this method saves time and eliminates spelling errors that may occur, healthcare providers still need to establish meaningful connections with each other. Communicating directly can create an atmosphere to feel what the patient needs even without looking at the notes. In my healthcare organization, the increased use of technology has also affected how nurses communicate patient care. The decrease in informal communication that arises from the use of technology could be a factor that makes it hard for healthcare team members to communicate effectively.
A3a. Areas Contributing to Problem or Issue
The world of medicine has changed significantly due to technological advances, but the aspect of communication remains a challenge. The most frequent communication breakdowns include miscommunication of patient information, poor documentation, inadequate informed consent, and poor response to patients. One of the areas that contribute to the problem of communication in the institution is the lack of standardized handoff procedures. Standardized communication is a strategy that is available to ensure information communicated between healthcare teams is structured, concise, and accurate. While I was doing my analysis, I did not find a standardized method of communicating patient information during admission and discharge. Using standardized communication tools may be among the best options to ensure important information is passed to other healthcare teams.
Good communication skills are essential for high-quality and safe medical practice today. Healthcare professionals must be aware of their own communication practices and undergo periodic appraisals to improve them (Moore et al., 2018). During my analysis, I observed that there was a problem with communication skills among inpatient and outpatient staff. For example, professional communication was poorly practiced in most exchanges leading to inadequate communication of patient information. Professional communication is an important building block in healthcare which ensures good relationships are constructed. Recognizing that communication is a two-way process among healthcare teams can improve how they pass information. Helping the employees understand the importance of professional communication could be another strategy for addressing the observed challenge.
Poor documentation of patient information can impair the quality of communication during handoffs. Documented information should be clear and able to be understood by other healthcare team members. During my analysis, I noticed most nurses did not document properly before handing over information. Poor documentation contributed to delays in communicating patient information and poor relationships between staff. For example, one of the inpatient nurses noted that outpatient staff only scribbled information and left some sections open for inpatient nurses to fill. These differences in documentation were also observed to cause personal differences between staff which impaired the quality of communication. Good documentation of patient information makes it easier for other individuals to know what is required to be done even in the absence of the writer.
Good communication must be accompanied by skills for passing information in a manner that is acceptable to others. Communication is not just about giving information but giving information in a manner that promotes understanding. During my analysis, I observed that the lack of enough knowledge about the nature of healthcare communication and the essential communication skills promoted communication breakdown. A few staff I interviewed noted that they have not attended a seminar or educational program emphasizing professional communication. These staff lacked essential skills like self-awareness, reflection, and empathy which are crucial during patient care. Courses that improve communication skills have in the past helped to ensure nurses communicate properly and maintain professional boundaries when communicating patient data (Moore et al., 2018). Education and training can be a good solution to address poor communication among providers in the facility.
A4. Proposed Solution or Innovation
A recurrent theme observed in the handoff literature is the conveying of essential information using proper handoff reports. Patient handoffs are an important component of patient care which serve to transition care from one staff to another. Handoff communication must include up-to-date information regarding the patient’s condition, treatment, anticipated changes, and course of treatment (Ruhomauly et al., 2019). Proper handoffs allow for the verification of received information to minimize errors. The proposed solution to address the challenge of communication in the healthcare organization is the use of standardized hand-off communication tools. One of the tools that can be used to improve this practice is the situation-background-assessment-recommendation (SBAR) technique.
In the era of collaborative care, effective communication among healthcare providers is crucial to facilitate continuity of care. International organizations like the World Health Organization (WHO) and the Joint Commission require that the handoff process involve discussion between the giver and receiver of patient information. Overall, a good handoff should be characterized by interactive communications, limited interruptions, a verification process, and an opportunity to review data (Muller et al., 2018). Both the receiver and giver of information should interact to promote a deep understanding of the patient’s understanding and other features that are not documented in the patient’s charts. Structured forms of communication like SBAR should be considered to promote the use of written and verbal communication of patient data. This method utilizes the face-to-face information exchange form which is the most preferred way to interact with one another.
SBAR communication is recognized as the most effective tool for information exchange in healthcare settings. This tool provides a framework for providers to organize the patient’s information into portions that can be easily communicated and understood by other providers (Ruhomauly et al., 2019). The Institute of Healthcare Improvement (IHI) provides a standardized SBAR checklist that outlines what information should be communicated by physicians, nurses, and other healthcare team members. The main reason for adopting this communication strategy is to address patient safety concerns that arise due to errors. SBAR communication strategy is divided into four parts as explained below.
The first aspect of communication involves describing the current condition of the patient and the reason for seeking further treatment. The giver must identify himself and the unit where the patient comes from. The patient must be identified by name and other particulars that distinguish the patient from others. Lastly, concerns about the patient’s health are raised to give the receiver a clear picture of what to expect.
The second part briefly describes the patient’s condition and other pertinent data about the illness. The giver highlights the reasons for recommending admission of the patient and other information that should be monitored. For those with chronic conditions, the giver must communicate procedures, treatment approaches, allergies, and other important information that can guide future decision-making.
The assessment part deals with the giver’s analysis of the patient’s condition and elaborates further on why additional care is required. There should be a description of investigations done to support the current diagnosis and why other routine tests have been or have not been done. During the hand-off process, the giver should express concerns about the patient’s condition and inform the receiver what to expect upon admission of the patient. For mental health patients, things like mood changes, mania, and suicidal ideations should be noted to warn the receiver about the need to be watchful.
Recommending the right treatment approach for the patient and further investigation is the last part of the handoff communication. The giver should help the receiver to make the right choice or recommend consulting with the doctor for further instructions. The receiver is given an opportunity to ask questions and seek clarification on crucial points.
Effective healthcare teams are characterized by trust, respect, and collaboration which is promoted through communication. Barriers to effective communication exist in many healthcare settings and this promotes poor service delivery to patients. The proposed solution of using the SBAR communication strategy can help to bridge the gap between inpatient and outpatient transfer of patient information. I believe this strategy can help to formalize communication in the institution and prevent errors that arise from miscommunication of patient information.
A4a. Justification of Proposed Solution or Innovation
Ineffective communication among healthcare providers is a major factor that leads to adverse events today. Studies demonstrate that the use of standardized communication improves the passage of information among healthcare providers (Müller et al., 2018). SBAR communication is a technique that is recommended by professional organizations like IHI and WHO to improve communication. This tool is observed to have positive influence n patient outcomes by reducing errors and improving decision-making processes. Studies have associated the use of SBAR communication with positive patient outcomes like reduced patient falls, unexpected deaths, and 30-day readmissions (Muller et al., 2018). Healthcare providers can communicate effectively and make decisions based on the information received. This tool can be used to reduce adverse events occurring in patients admitted to the inpatient mental health unit.
SBAR implementation is a strategy that is seen to reduce errors and costs associated with hospitalization. This strategy provides a quick method of transferring patients from one department to another and this creates more time to attend to other patients. There is substantial evidence available to explain the role of standardized communication in minimizing errors (Müller et al., 20180. For example, SBAR communication is observed to reduce costs associated with medication errors and a significant reduction in unintended deaths. Through effective communication using this technique, hospitals can save costs related to patient falls and readmissions.
Standardized communication has helped nurses to have focused and easy communication during the transition of care. One of the key benefits of this communication technique is that it improves relationships among healthcare providers and promotes patient-centered care (Ruhomauly et al., 2019). For instance, during care transition, healthcare teams work to gather and exchange information that is used to influence healthcare decisions. The use of handoff communication tools like SBAR provides healthcare professionals and patients an opportunity to ask questions and seek clarification. Studies demonstrate that SBAR communication links patients, families, and providers and enables access to the right care (Muller et al., 2018). The tool brings together healthcare providers’ thoughts and ensures thinking outside the box to influence patient outcomes.
The quality of communication among healthcare providers is dependent on many factors, some of which hinder good communication. For instance, some providers might lack good communication skills that can promote positive interactions with colleagues. SBAR provides a standardized communication platform that can be adopted by any healthcare provider. Specifically, the electronic SBAR communication tools reduce communication difficulties associated with language barriers and poor communication skills (Ruhomauly et al., 2019). This tool can be used to address challenges observed among inexperienced nurses who must communicate the patient’s findings and recommend care at the end of each shift. Implementing this strategy can help increase the input of each healthcare professional toward patient care and improve overall outcomes.
A5. Implementation Resources
The implementation of the new strategy will require a few resources. The first part will focus on seeking approval from the management. I will explain the importance of SBAR in addressing the challenge of communication in the institution. I will support my claims using collected evidence and demonstrate how the organization can benefit from the new strategy. Upon approval, I will need support from my colleagues and other key stakeholders. For example, the outpatient and inpatient unit managers will be involved in designing the implementation plan based on staffing ratios and other key parameters. I will need the assistance of the IT department to be able to utilize electronic health records together with the new communication strategy. Another key human resource for this project will be the nurse educator. This individual will be charged with organizing educational sessions for staff regarding SBAR and its effective use.
The pilot project will require capital to plan for the education and training of staff. The top management will be approached to provide funds that can facilitate the implementation and monitoring phases of the project. A few things that will be needed include a seminar room, chairs, audio and visual media for education, and writing material. Hard copies of the SBAR communication strategy will be printed and mounted on the rooms to ensure staff learns to utilize the strategy.
A5a. Cost Benefit Analysis
The cost of implementing SBAR communication in the organization will be minimal. Financial expenditure for the project will concentrate on the aspects of education and training of staff. The organization will spend capital on purchasing education materials and paying the academic nurse educator for providing education to outpatient and inpatient staff. The most important resource that will be utilized and required is time. SBAR communication can be time-consuming because it requires a step-by-step presentation of data to the receiver of information. Given the busy nature of the outpatient department, it may require extra effort from staff to adhere to the new protocol. Because the hospital already has an EHR management system, no extra costs will be required to purchase new technology.
Implementing SBAR communication can be beneficial to the organization in many ways. Firstly, there will be improved communication between staff which will promote positive working relationships. Improved communication will ensure providers get to understand the needs of the patient and this will improve the quality of care provided. Research demonstrates that SBAR communication is effective in reducing medical errors and preventing safety events like patient falls (Muller et al., 2018). The organization will be able to save revenue associated with falls and readmissions. The implementation of the SBAR communication strategy will have a positive impact on patient satisfaction. Increased patient satisfaction will in turn improve Medicare reimbursement from the CMS.
The implementation of this project will take six weeks. The first week will involve meeting with the preceptor to discuss the healthcare issue and practice changes to address this issue. This week will also involve seeking approval from the healthcare organization to conduct the research. Week 2 will involve a literature review and identification of best practices. The literature will highlight the importance of implementing the project and the information gathered will be used to convince the top management to approve the implementation of the project. Week 3 will involve the communication of the project to the inpatient and outpatient staff to buy their acceptance of the new change to come.
Week 4 will involve the identification of key stakeholders to help in the implementation of the project. Key stakeholders will involve the hospital administration, inpatient and outpatient charge nurses, nurse educators, and IT personnel. Week 5 will focus on assembling resources for the education and training of staff. Both inpatient and outpatient staff will be educated about SBAR communication techniques and how to apply this strategy to improve communication. Week 6 of this project will involve pilot testing using simulation to ensure employees have understood the SBAR communication strategy. Full implementation of the project will begin from week 7 with subsequent monitoring to ensure the strategy works.
A7. Identification of Key Stakeholders and/or Partners
The key stakeholders that will be involved in the implementation of the project will include the hospital administration, nurse educators, inpatient, and outpatient mental health unit charge nurses, and the information technology team.
Hospital administration. Hospital management is always involved in making key decisions that affect organizational performance. This team will be involved in approving the new project and allocating funds to sustain it. Additionally, acceptance of the project by the administration will promote its acceptance by employees.
Nurse educator. The academic nurse educator will be responsible for organizing education and training sessions for employees. This individual will ensure all materials required for education are available and ensure the pilot study works. During the implementation phase, this individual will participate in monitoring the progress and make necessary changes.
Unit managers. The inpatient and outpatient unit managers will be tasked with monitoring the application of SBAR communication in the institution. They will monitor the nurses and assist them in any areas that will be challenging. Additionally, these managers will communicate the findings and recommend any changes.
Information technology team. Health information technology presents many opportunities to improve healthcare delivery today. The IT personnel will be tasked with designing the electronic SBAR communication forms and monitoring important data like patient satisfaction scores. The electronic version will ensure time is reduced in documenting patient information and tracking the project’s progress.
A7a. Engagement with Key Stakeholders and/or Partners
The primary method used to engage the stakeholders was through a meeting. I called a meeting to discuss the proposal and to seek the support of each member. With the help of the academic nurse educator, I was able to provide evidence of why change is required in the organization and its long-term effects. I asked the charge nurses to provide records of adverse events and errors occurring due to poor communication. The evidence from these units helped to convince other stakeholders why SBAR communication was needed. Apart from the group meetings, I individually met with the administration and explained how the project could improve patient satisfaction and reduce costs. I maintained communication with each key stakeholder using emails and phone calls. The feedback received from all stakeholders was positive and they all promised to support the implementation of the new change in the organization.
I intend to work with the key stakeholders throughout the project until success is achieved. I will maintain open communication and conduct weekly meetings to provide updates about the project. I will seek advice from experienced team members like the nurse educator regarding difficult aspects of the project. the success of the project will depend on the engagement of each key stakeholder. To ensure all stakeholders are motivated, I will ask the administration to provide an appreciation token according to the level of involvement and success. I intend to work with the administration by providing regular reports about the project. The charge nurses will be required to monitor every aspect of communication, especially that involving admission or discharge of patients. An SBAR communication checklist will be available and recorded each time crucial information about the patient is passed. The weekly meetings will review the checklist and make changes in the aspects that will be performing poorly.
A8a. Evaluation for Success of Implementation
This project could be implemented using a simple approach within a short time period. For instance, the key stakeholders will meet and identify the required implementation resources. The hospital administration will approve the project and provide financial support. The nurse educator will then educate employees about SBAR communication and conduct a pilot study to ensure all staff understands what is required. During the actual implementation, the inpatient and outpatient unit managers will monitor the quality of communication and record findings. Weekly meetings will be held to discuss the progress of the project and make necessary changes. At the end of the implementation period, data about the quality of communication will be collected including employee satisfaction with the new change.
The success of the project will be evaluated using two parameters. The first aspect will involve a reduced number of errors due to communication breakdown. The second aspect will involve a review of patient satisfaction scores.
B1. Role of Scientist
Nurses bring an important perspective to research and healthcare knowledge that often goes unrecognized by many. Nurse scientists identify research questions, collect data, analyze it, and report findings. As a scientist, the graduate nurse is supposed to apply scientific evidence when planning and providing care to patients (Tsai, 2021). To fulfill this role, I began my project by investigating the challenge of communication in the organization. I collected data about the effects of poor communication and searched for evidence from the literature on how to address this challenge. During the implementation of the project, my role was to collect data and analyze it to ensure the findings informed future decisions in the organization. Additionally, I participated in interviewing healthcare workers about the causes of the identified problems and the effectiveness of the implemented strategy. I believe the information gathered during this project will help the organization to make an informed decision about the method of improving communication among healthcare workers.
B2. Role of Detective
As a detective, the nurse practitioner is entitled to detect subtle changes and deviations from expected health patterns when managing patients (Tsai, 2021). The nurse ought to identify the consequences of the observed changes and analyze how they can be managed. During this project, I engaged in the process of detecting a healthcare challenge in the organization and the impact it had on patients. I detected changes in the behavior of the inpatient and outpatient nurses during shift handoffs that allowed me to note issues with communication. Secondly, I was able to observe that most nurses lacked adequate education about professional communication. The majority of staff in these two units had less nursing experience that perhaps contributed to the communication problem. During the assessment of the communication problem, I witnessed that poor documentation of information by the outpatient staff angered the inpatient staff and this contributed to poor work-related relationships. Noticing these things made it possible to make an appropriate recommendation that could entirely solve most of the issues leading to communication breakdown.
B3. Role of Manager of Healing Environment
Nurses have long been leaders in creating optimal healing environments through their actions. The nurse is responsible for predicting situations and responding to them with appropriate flexibility and creativity (Tsai, 2021). Better healthcare is the prime responsibility of nurses and other healthcare providers. During this project, I demonstrated better healthcare delivery by thinking about a process that can be changed to improve patient outcomes. I went to lengths to investigate the issue of communication and propose a long-term solution to the problem. Engaging various stakeholders like administrators, nurse educators, and IT personnel demonstrated the urge to influence care delivery through interprofessional collaboration. Overall, this project demonstrates how nurses can influence can create environments that promote patient safety.
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Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open, 8(8), e022202. https://doi.org/10.1136/bmjopen-2018-022202
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