822 research outputs found

    Exploring and improving the escalation of care process for deteriorating patients on surgical wards in UK hospitals

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    Despite impressive progress in technical skills, the rate of adverse events in surgery remains unfavourably high. The variation seen in surgical outcomes may be dependent on the quality of ward-based surgical care provided to post-operative patients with complications, specifically, the recognition, communication and response to patient deterioration. This process can be termed escalation of care and is an under-explored area of surgical research. This thesis demonstrates the impact of delays in the escalation of care process on patient outcome. The facilitators of, and barriers to, escalation of care are then identified and described in the context of the UK surgical department. In order to prioritise areas within the escalation of care process amenable to intervention, a systematic risk assessment was conducted revealing suboptimal communication technology and a lack of human factors education as key failures. To ensure that communication technology intervention was conducted based on evidence, several exploratory studies describe the current methods of communication in surgery and explore areas of innovation and intervention. Following this, a human factors intervention bundle was implemented within a busy surgical department, which successfully improved supervision, escalation of care and safety culture. This thesis describes, for the first time, escalation of care in surgery and outlines important strategies for intervention in this safety-critical process. To date, ward-based care has been one of the most under-researched areas in surgery, despite its clear importance. The tools to improve escalation of care in surgery have been described and initial attempts at implementation have demonstrated great promise. Future use of these strategies should benefit surgeons and other clinical staff of all grades and ultimately, the surgical patient.Open Acces

    Evaluating A Rapid Response Team Performance To Implement Best Practice in Rapid Response Team Protocol

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    Background Rapid Response Teams (RRT) provide clinical resources to improve patient safety outcomes at healthcare institutions. This team promptly responds to deteriorating patient conditions to prevent further deterioration and reduce mortality rates. Rapid response teams do not always perform optimally. Reasons for this performance failure include breakdowns in communication, team dynamics, or other variables that can often be adjusted when the team members understand the role these variables play in undermining the performance of the RRT. An understanding of the perceptions of the RRT members regarding their roles and potential areas of improvement did provide valuable data that was utilized to improve the efficiency and effectiveness of the RRT. Purpose The purpose of this project was to create an evidence-based protocol for best practices in RRT responses by evaluating the perceptions of the rapid response team members regarding RRT performance at a medical center in Michigan. Current RRT practices were compared to the evidence-based standards of care that influenced recommendations for improvement based on the gaps identified. -- Method. This project utilized a qualitative approach with the use of semi-structured guided interviews held via Zoom to gather data related to the experiences of RRT members, to gain an in-depth understanding on the issues concerning the performances of the RRT. Seventeen participants who met the research criteria were selected. Participants who consented to be interviewed were scheduled in chronological order in which they gave consent. Participants were recruited via hospital unit huddles and one on one encounters, based on the project inclusion criteria, and were then scheduled for individual interviews that were audio-recorded, transcribed, and analyzed for thematic contents. This project was guided by Kurt Lewin\u27s Change Theory, which is a change model geared at preparing team members to become change agents. Applying this model will ensure that team members will be equipped to implement the quality improvement changes in the rapid response system. Associates will be provided with the necessary strategies to unlearn the ineffective old ways of clinical practices and embrace the new evidenced based practice guidelines. Results Data analysis revealed major themes that have been affecting the performances of the RRT. They were ineffective team dynamics, activation barriers, inadequate competency training/skills validation, staffing challenges, and failure to debrief after RRT encounters. Other issues emerged during this study that were important issues affecting the performances of the RRT. They were delayed response time of RT, attitudes of providers, and unavailability of attending physicians. Conclusion Ineffective team dynamics, poorly defined roles, crowd control issues, and inadequate education and training were the most critical factors interfering with the efficiency of the RRT. A change in policy that has the potential to optimize the performance of the RRT was developed in accordance with the best practice guidelines. The rapid response team is an important player in early recognition of declining patient conditions outside of intensive care areas. There is documented evidence of what excellent rapid response teams need to maintain their efficient performance. Teams may not always function at the optimum levels they desire. The qualitative interview results derived from experienced rapid response team members was compared with evidence based standards of practice. Improvements and recommendations were developed and shared with the management team at the project site

    The development of a half-day workshop to assist novice nurses in the identification and management of clinical deterioration

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    Background: Patient safety is an essential part of quality nursing care. Promoting a culture of patient safety has been shown to improve patient outcomes. To provide quality patient care, it is important for registered nurses to have the assessment skills to detect when a patient’s condition is deteriorating. The surgical inpatient unit at Carbonear General Hospital (CGH) has seen a high turnover of staff in recent years. An increased number of novice nurses employed on the unit has contributed to patient safety issues. An educational workshop, provided as part of the orientation program, would benefit novice nurses working on this unit as a strategy to promote patient safety by increasing their knowledge and expertise in the early identification and management of the deteriorating patient. Purpose: The purpose of this practicum project was to develop an educational workshop to help novice nurses identify and manage the deteriorating patient. Methods: Three methods were used in the development of this workshop. A literature review and consultations with key stakeholders (e.g., nurses, nurse educators, and nurse managers) was conducted to determine the factors influencing novice nurses’ ability to identify and manage the deteriorating patient. Stakeholders were also asked to provide feedback on the content and delivery of the workshop. An environmental scan was completed with clinical educators within Eastern Health to determine what resources are available to assist novice nurses in the identification and management of clinical deterioration. Results: Key findings were assimilated to guide the development of the one-day workshop. The lack of knowledge, experience, and confidence of novice nurses combined with organizational problems such as unit practices, communication issues, poor staffing levels, and inconsistent patient assignments contribute to their inability to determine a change in patient status. Within Eastern Health, there are limited resources available related to the identification and management of clinical deterioration. Conclusion: Using Morrison, Ross, Kalman and Kemp’s (2013) instructional design model, Knowles’ Principles of Adult Learning (1984) and Benner’s Novice to Expert Theory (1982), an interactive, half-day educational workshop was developed to assist novice nurses in the early identification and management of clinical deterioration

    What is the Relationship among Team Psychological Safety, Nursing Agency, and Rapid Response System Activation?

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    When patients show signs of clinical deterioration, nurses should activate the rapid response system (RRS) to summon specialized help to the bedside. Failure or delay to activate the RRS is associated with increased length of stay and increased mortality. Currently, nurses only activate the RRS 21-57% of the time. Nurses’ fear of criticism for making the wrong call has been identified as a reason or avoiding or delaying activation. Currently, only limited individual level factors affecting nurse RRS activation has been identified, but team-level barriers or facilitators or nurse RRS activation has not been systematically studied. A cross-sectional study was conducted to investigate the relationships among team psychological safety, nursing agency, and nurse RRS activation. Findings suggest that nurses’ personal sense of power, which may be a foundational disposition of nursing agency, is a predictor of nurse RRS activation. Strategies to develop nurses’ personal sense of power may be key to ensure nurses can exercise their full agency to overcome barriers and act on behalf of their patients

    Use of Secure Messaging By United States Veterans and Significant Others

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    ABSTRACT USE OF SECURE MESSAGING BY UNITED STATES VETERANS AND SIGNIFICANT OTHERS By Claudia S. Derman The University of Wisconsin-Milwaukee, 2014 Under the Supervision of Professor Karen H. Morin, PhD, RN, ANEF, FAAN The purpose of this study was to describe the topics discussed using secure messaging (SM), the pattern of use of SM, and whether the themes discussed and/or the pattern of use varied based on gender and age of the SM user. Secure messaging is an example of a technology that focuses on patient-centered communication. Secure messaging allows patients to communicate with their clinicians using the Internet and at their convenience, while maintaining the privacy of the information exchanged. Secure messages, if approved by the patient, may also be written by family members or significant others for the patient. By its nature, the use of SM is indicative of an individual\u27s involvement in their healthcare, utilizing self-management skills. Few studies were found that reported on the content of messages written by patients or their families. No studies were found that reviewed the topics patients write about in these secure messages nor were studies found that tracked the number of messages written by patients and relating to the days and time that were most utilized. A review of 1200 secure messages written by veterans and their caregivers was undertaken to determine what information was contained within the secure messages. The 1200 messages contained 1720 themes that were grouped using content analysis to yield a total of ten topics. The day of week and the time of day of messages were additionally reviewed by gender and age of the individual. Messages written by friends of family members were reviewed and compared to those written by patients. The topic most addressed as that of medications, with more than one-third of the 1720 themes within messages relating to medications. Veterans aged 55 to 64 years were the greatest users of the SM system followed closely by those between the ages of 65 to 74. Men wrote most frequently about medications while women wrote more themes related to the topics of complaints and concerns and consultations with specialists. Pattern of use of relative to time of day and day of the week was also reviewed in subset of the sample (n= 600). The most common time frame during which messages were sent was between 9:00 a.m. and 6 p.m., accounting for more than 70% of all messages. Tuesdays and Thursdays were the most often utilized days of week for SM. The implications of this study include revisiting how MyHealtheVet is configured to enhance the veteran\u27s ability to communicate effectively and appropriately with healthcare providers. It is possible that participants employed SM rather than other identified means to contact providers as they were assured of a response within a defined period of time. Findings have implications for users, clinicians, hospital administrators, and technical staff. The purposes of SM can be revisited with users, clinicians may wish to consider alternative strategies, and administrators may wish to revisit the current structure in terms of identifying a method to sort the information contained in SM

    Emergencies and Public Health Crisis Management- Current Perspectives on Risks and Multiagency Collaboration

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    The successful management of emergencies and public health crises depends on adequate measures being implemented at all levels of the emergency chain of action, from policy makers to the general population. It starts with appropriate risk assessment, prevention, and mitigation and continues to prehospital and hospital care, recovery, and evaluation. All levels of action require well-thought out emergency management plans and routines based on established command and control, identified safety issues, functional communication, well-documented triage and treatment policies, and available logistics. All these characteristics are capabilities that should be developed and trained, particularly when diverse agencies are involved. In addition to institutional responses, a robust, community-based disaster response system can effectively mitigate and respond to all emergencies. A well-balanced response is largely dependent on local resources and regional responding agencies that all too often train and operate within “silos”, with an absence of interagency cooperation. The importance of this book issue is its commitment to all parts of emergency and public health crisis management from a multiagency perspective. It aims to discuss lessons learned and emerging risks, introduce new ideas about flexible surge capacity, and show the way it can practice multiagency collaboration

    Improving interdisciplinary care on the general medical ward

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    General medical wards deliver the majority of inpatient care. Despite technological and therapeutic advances, these wards expose 10% of patients to preventable adverse events, and disproportionately contribute to preventable hospital deaths. Improving ward team performance is often proposed as a mechanism to improve patient outcomes. The overarching goal of this thesis is to identify effective strategies to improve interdisciplinary team care on the medical ward. Chapter 1 introduces key concepts in healthcare quality, and specific issues in the delivery and measurement of interdisciplinary ward care. The existing literature for ward improvement strategies is then described. A narrative review identifies common targets for ward interventions [chapter 2], and a systematic review evaluates interdisciplinary team care interventions, finding little evidence of significant impact on objective patient outcomes [chapter 3]. The development and evaluation of prospective clinical team surveillance (PCTS) is then reported. PCTS is a novel interdisciplinary team care intervention, engaging staff to identify barriers to care delivery, with facilitation and feedback. A programme theory and mixed methods evaluation are presented, using a stepped wedge, cluster controlled trial [chapter 4]. Mixed-effects models show a significant reduction in excess length of stay with high fidelity PCTS [chapter 5]. Surveys, focus groups and auto-ethnography identify PCTS’ mechanisms of action, and its impact on incident reporting, safety and teamwork climates [chapter 6]. Implementation outcomes, facilitators and barriers are described in chapter 7. Other perspectives on improvement are also explored. A model of organisational alignment is developed [chapter 8], and an interview study with patients and carers elicits their priorities [chapter 9]. Finally, chapter 10 summarises the findings, highlighting opportunities to develop medical ward outcome sets and construct a model of interdisciplinary team effectiveness. These can be used to support improvements in interdisciplinary care, through changes in policy and practice.Open Acces

    Early Detection and Treatment of Acute Clinical Decline in Hospitalized Patients: An Observational Study of ICU Transfers and an Assessment of the Effectiveness of a Rapid Response Program: A Dissertation

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    The Institute for Healthcare Improvement (IHI) has promoted implementing a RRS to provide safer care for hospitalized patients. Additionally, the Joint Commission made implementing a RRS a 2008 National Patient Safety Goal. Although mandated, the evidence to support the effectiveness of a RRS to reduce cardiac arrests on hospital medical or surgical floors and un-anticipated ICU transfers remains inconclusive, partly because of weak study designs and partly due to a failure of published studies to report all critical aspects of their intervention. This study attempted to evaluate the effectiveness and the implementation of a RRS on the two campuses of the UMass Memorial Medical Center (UMMMC). The first study presented was an attempt to identify the preventability and timeliness of floor to ICU transfers. This was done using 3 chief residents who reviewed 100 randomly selected medical records. Using Cohen’s kappa to assess the inter-rater reliability it was determined that 13% of the cases could have possibly been preventable with earlier intervention. The second study was an evaluation of the effectiveness of the Rapid Response System. Outcomes were cardiac arrests, code calls and floor to ICU admissions. There were two study periods 24 months before the intervention and 24 months after. A Spline regression model was used to compare the two time periods. Though there was a consistent downward trend over all 4 years there were no statistically significant changes in the cardiac arrests and ICU transfers when comparing the before and after periods. There was a significant reduction in code calls to the floors on the University campus. The third study was a modified process evaluation of the Rapid Response intervention that will assess fidelity of RRS implementation, the proportion of the intended patient population that is reached by the RRS, the overall number of RRS calls implemented (dose delivered) and the perceptions of the hospital staff affected by the RRS with respect to acceptability and satisfaction with the RRS and barriers to utilization. The process evaluation showed that that the Rapid Response System was for the most part being used as it was designed, though the nurses were not using the specific triggers as a deciding factor in making the call. Staff satisfaction with the intervention was very high. Overall these studies demonstrated the difficulty in clearly defining outcomes and data collection in a large hospital system. Additionally the importance of different study designs and analysis methods are discussed

    Making the link : multi-professional care for acutely ill deteriorating patients : a constructivist grounded theory approach

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    The potential for decline in acutely ill and injured patients is ever-present. Rapid response systems exist to facilitate timely actions, but there are continued concerns over failure to rescue. Currently there is little understanding of what happens in ward areas when deterioration occurs and how it is recognised and managed. This study aimed to explore what happens when patients deteriorate, how professionals work together, define and communicate deterioration and make sense of what they say and do. Using constructivist grounded theory; data was gathered over 12 months from 33 multi-professional participants on three wards in one hospital. Data analysis, concurrent with collection, utilised theoretical sampling to identify further sources of data. Constant comparison was used to develop codes and concepts from the transcripts, and NVivo© software facilitated data organisation and an audit-trail. During 26 interviews and 48 hours of observation, 85 cases of patient deterioration were identified. Four concepts emerged from the analysis, 1) being vigilant through surveillance, 2) identifying deterioration and recognising urgency, 3) taking action by escalating and responding, 4) taking action by treating, all connected by a core concept, making the link. The need for support, use of subjective and objective indicators, competing priorities and hierarchical issues influenced the process but application of knowledge was crucial for making the link. Collectively knowing the patient and sharing this multi-professional knowledge was key to making the link and the nurse was ideally placed to facilitate a shared mental model of deterioration across the team. New elements were identified: lay person vigilance, where significant others contributed to the rescue process; and fear of harming patients by a rescue intervention was revealed as a barrier to treating deterioration. Recommendations included protecting and prioritising resources for surveillance, valuing subjectivity and the input of all levels of staff

    Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study

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    BackgroundUnchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.ObjectiveTo determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.DesignA mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).SettingEnglish hospitals participating in the NCAA audit.ParticipantsNHS staff (approximately 300) and patients (13 million).InterventionsEducation, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.Main outcome measuresIHCA rates, survival and hospital-wide mortality.Data sourcesNCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.MethodsA literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).ResultsAcross NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.LimitationsThe organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.ConclusionsStandardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.Future workTo assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.FundingThe National Institute for Health Research Health Services and Delivery Research programme.</jats:sec
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