13 research outputs found

    Identifying Transfer of Care Gaps: Electronic Health Record Capture of Perioperative Handoff Communications

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    Transitions in patient care are held together by interdisciplinary handoff communications intended to coordinate the patient\u27s ongoing care requirements. Patients with complexity in care encumber the transfer of care process requiring a higher level of care coordination between the interdisciplinary team (Coleman, 2003; Naylor et al., 2004). While the literature is abundant on the characteristics and quality of handoff communications, it is limited on the requirements of what data is necessary for ongoing care following transfer communications (Galatzan & Carrington, 2018). This dissertation explores the verbal information transferred during Operating Room (OR) to Post Anesthesia Care Unit (PACU) nursing handoff communications and whether the data is captured in the electronic health record (EHR) to represent the information critical to ongoing patient care and care planning. the study builds on the Kennedy Integrated Theoretical Framework (KITF) (Kennedy, 2012) integrating cognition theory, patterns of knowledge theory, and clinical communication space theory to support the human-technology characteristics within perioperative handoffs. Evidence of wisdom was present in the KITF in addition to elements of non-verbal communication patterns emerging from shared common ground contributed to the framework\u27s expansion. to understand the contributions of the perioperative nursing interface terminology, the Perioperative Nursing Data Set (PNDS), makes to postsurgical care transitions, the study examines nursing diagnoses, interventions, interim outcomes and goals relationships to the handoff data communicated between OR and PACU Registered Nurses. Study findings revealed a complex fragmented process of verbal communications and electronic documentation for the handoff process. While the EHR is prominent in data procurement for the handoff process, the design of handoff artifacts (e.g., paper, electronic) significantly impact the value of information received. Incomplete handoff tools or missing EHR data adds to a cycle of information decay while contributing to increase cognitive load and potentiating opportunities for information and knowledge loss. the absence of nursing diagnoses in the automation of the PNDS challenges the integrity of the language within the documentation platform and raises considerations for hierarchical representation within interface terminologies. This study reinforces literature to reconsider user requirements in the design and functionality of healthcare information technology (HIT) to enable data and information flow and preserve knowledge development. the inclusion of mobile technology, cognitive support aids including clinical decision support tools, and other HIT will further enable the effectiveness of transfer communication, knowledge development, and the safety of ongoing patient care

    An Optimisation-based Framework for Complex Business Process: Healthcare Application

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    The Irish healthcare system is currently facing major pressures due to rising demand, caused by population growth, ageing and high expectations of service quality. This pressure on the Irish healthcare system creates a need for support from research institutions in dealing with decision areas such as resource allocation and performance measurement. While approaches such as modelling, simulation, multi-criteria decision analysis, performance management, and optimisation can – when applied skilfully – improve healthcare performance, they represent just one part of the solution. Accordingly, to achieve significant and sustainable performance, this research aims to develop a practical, yet effective, optimisation-based framework for managing complex processes in the healthcare domain. Through an extensive review of the literature on the aforementioned solution techniques, limitations of using each technique on its own are identified in order to define a practical integrated approach toward developing the proposed framework. During the framework validation phase, real-time strategies have to be optimised to solve Emergency Department performance issues in a major hospital. Results show a potential of significant reduction in patients average length of stay (i.e. 48% of average patient throughput time) whilst reducing the over-reliance on overstretched nursing resources, that resulted in an increase of staff utilisation between 7% and 10%. Given the high uncertainty in healthcare service demand, using the integrated framework allows decision makers to find optimal staff schedules that improve emergency department performance. The proposed optimum staff schedule reduces the average waiting time of patients by 57% and also contributes to reduce number of patients left without treatment to 8% instead of 17%. The developed framework has been implemented by the hospital partner with a high level of success

    Patient Safety and Quality: An Evidence-Based Handbook for Nurses

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    Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

    Handover communication and continuity of care for chronic disease patients in India: a mixed-methods investigation

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    This thesis research investigated handover communication and continuity of care for patients with chronic, non-communicable diseases (NCDs) in Himachal Pradesh and Kerala states, India. A systematic review explored the literature on quality of handover communication and interventions for handover communication in low and middle-income countries (LMICs). Mixed-methods were employed to investigate the following in Himachal Pradesh and Kerala states, India: handover and healthcare communication within and between levels of care for chronic NCD patients, the association between quality of discharge handover communication and chronic NCD patient outcomes, healthcare provider (HCP) training and protocols for handover communication and possible strategies to improve the storage and exchange of healthcare information for chronic NCD patients. The systematic review found a relative dearth of LMIC literature and that sub-optimal recording and/or transfer of patient information was a commonly reported issue in all areas of handover communication (i.e. shift-change, discharge, referrals and transfers). A number of system, organisational cultural and individual healthcare provider issues were described as affecting the quality of each area of handover. The majority of interventional studies were non-randomised, of medium to low quality and reported improvements in handover communication. Regarding handover and healthcare communication in Himachal Pradesh and Kerala states, India, the mixed-methods outpatient and quantitative inpatient studies evidenced that most patients who visited public healthcare outpatient clinics (OPC) and who were discharged from public hospitals received unstructured patient-held medical documents that contained deficient information for facilitating effective continuity of care. In the mixed-methods outpatient and the qualitative and prospective inpatient studies, patient reports indicated notable inconsistencies regarding HCP healthcare management communication. In the mixed-methods outpatient, qualitative inpatient and cross-sectional HCP studies, HCP reports revealed a lack of standardised procedures for handover communication between levels of care across public and private healthcare facilities. Factors affecting the quality of handover communication were also identified; HCPs in the mixed-methods outpatient study reported that public healthcare OPCs did not maintain in-house patient records. In both the mixed-methods outpatient and qualitative inpatient studies the following factors were identified by HCPs/patients: time constraints, inconsistent referral practices, unstructured medical documents, inconsistent patient transportation of medical documents and deficient HCP handover training. In the cross-sectional HCP study, the following factors were most frequently reported as “highly applicable” to referral and discharge communication: excessive workload and poor health systems and integration. Regarding discharge handover communication and patient outcomes, the prospective inpatient study evidenced significant associations between low-quality documented discharge communication and death (AOR=3.00; 95% CI 1.27,7.06) and low-quality verbal discharge communication and self-reported deterioration of chronic NCD/s (AOR=0.46; 95% CI 0.25,0.83) within 18 weeks of follow-up. Regarding HCP training and protocols, the majority of HCPs in the cross-sectional HCP study reported that they had not received structured training for shift-change, discharge or referral. HCPs in both the mixed-methods outpatient and qualitative inpatient studies also reported an absence of handover training and structured referral protocols. One private tertiary hospital in Kerala was found to have policies and structured documents for clinical handover. Other than standards/guides for voluntary quality accreditation schemes, no further handover-specific protocols, policies, guidelines or training documents were identified across Himachal Pradesh and Kerala. Regarding strategies for improving handover communication, HCPs in the qualitative inpatient study reported the following: increased public healthcare resources, formal referral systems and computerised “e-health” systems. In both the mixed-methods outpatient and qualitative inpatient studies, patients and HCPs supported the idea of structured patient-held booklets for storing and transporting medical documents. In conclusion, the findings suggest that continuity and safety of chronic NCD patient care are likely being compromised by suboptimal recording and transfer of patient information, as well as a lack of standardised handover communication protocols and HCP training. They have also highlighted a context-relevant and acceptable intervention for improving patient information exchange and the need for further highquality handover communication research in India and other LMICs

    Experiences of Children Undergoing Dental Treatment Under General Anesthesia: A Qualitative Study in Canada

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    The abstract of this item is unavailable due to an embargo

    The Nature of evidence to inform critical care nursing practice.

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    This thesis presents a body of publications, in the area of critical care nursing, for consideration for the award of Doctor of Philosophy by Publication. The thesis is presented in three chapters: Introduction; Body of Work; and Research, Knowledge, Evidence and Practice. In the first chapter the emergence of evidence-based practice is described, in general. Initially, an overview of the origins and trends of nursing research methodology is provided; the purpose of which is to set in context the body of work. Utilising a narrative approach (Boje, 2001; McCance et aL, 2001; Sandelowski, 199 1; Vezeau, 1994) as a 'personal journal of discovery' I then reflexively describe my own development as a nurse researcher practitioner, drawing on my own publications to illustrate my progress, the development of my thinking, my research practice and the development of my understanding of pragmatice pistemology. The second chapter is comprised of my publications relevant to critical care nursing. Spanning a period of eleven years, they represent my contribution to critical care nursing knowledge. In the concluding chapter I have summarised initially my own contribution to critical care nursing knowledge, before moving on to a more detailed critique of evidence-based practice. Finally I have made recommendations for the way forward. In addition to presenting my body of work, the aim of this PhD is to challenget he current concept of evidence-based practice, arguing that its definition is too narrow to encompass the rage of different types of knowledge that nurses use when caring for critically ill patients. I have utilised my own publications, to demonstrate how a variety of approaches are necessary to provide the best evidence for developing practice. I have positioned my argument within a theoretical understanding of pragmatic epistemology. In this way, I am working towards the development of a science of practice. Simultaneously I am also, to some extent, challenging conventional concepts of what constitutes doctoral level knowledge and how a PhD looks. My conclusion is that critical care nursing knowledge is drawn from many sources, and should be applied in an integrated way that enables practitioners to make a positive difference to the life of patients.Knowledge that is not or cannot be applied to practice is therefore of no value. The valuing of practice knowledge brings with it the requirement that all forms of knowledge (and their relevant methodologies) are considered as equal,in terms of their potential to impact on practice and that nothing should be rejected on paradigmatic grounds. In contemporary healthcare evidence is hierarchically valued and this raises many questions of equity. Where the value of knowledge becomes unequal is when its application to practice is limited. The corollary of a pragmatice pistemology is that it requires a pragmatic process to make it work. For me, at this point in time, the best available is practice development. In summary,this thesis represents a construction of work that makes an original contribution to knowledge. The product of my thesis is a theory of pragmatic epistemology as the basis for a science of practice

    The Efficacy of Analgesic Subdissociative Dose Ketamine in Trauma Casualties Treated by U.S. Military Special Operations Medical Professionals in a Prehospital Environment

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    Research Focus. This study’s main objective was to determine the efficacy of sub-dissociative ketamine to reduce the pain of trauma casualties treated by U.S. military medical professionals in a prehospital environment evidenced by the 0–10 numeric rating scale (NRS) for pain. Research Methods. This quantitative study was accomplished using a pragmatic approach integrating social cognitive theory complemented by mixing methods using qualitative phenomenological influence through narrative inquiry. This exploratory retrospective, cross-sectional study, utilizing a quasi-experimental pretest-posttest design, used deidentified sample data (N = 47) for secondary analysis from U.S. Special Operations medical providers and were included in a casualty data collection tool. Quantitative study inclusion criteria were adult casualties treated by U.S. military medical professionals with ketamine in a prehospital environment, had documented injury data, and had both pre- and post-ketamine pain scores. Descriptive statistics, followed by inferential statistical analyses using Shapiro-Wilkes, Wilcoxon Signed Rank, Spearman rho, and Kruskal Wallis tests were used. Additionally, phenomenology guided the analysis of two (n = 2) case studies. In vivo coding was used to develop themes and subthemes. Case studies collected from U.S. military medical professionals provided qualitative insight that reinforced the quantitative data and provided clinical validity to the study. Research Results/Findings. The study showed safe, efficacious use of analgesic sub-disociative ketamine use in prehospital trauma casualties relative to the 0–10 NRS for pain. The median reported pre-ketamine pain scale for casualties was 9.0 (IQR 2). The median post-ketamine pain scale was 0.0 (IQR 3). The mean total dosage of ketamine administered was 98.19 mg (SE = 9.545). There were 6 (12.8%) casualties who experienced side effects from ketamine that were neither permanent nor life-threatening. The case studies provided the human aspect of the study, reinforced the quantitative data, and provided clinical validity. Post-ketamine pain scores were better than pre-ketamine pain scores. Higher dosages of ketamine provided greater pain relief. No life threatening nor adverse drug reactions were found in this study. Conclusions From Research. This study demonstrated a safe, efficacious analgesic ketamine use in prehospital trauma casualties used by U.S. military special operations medical professionals relative to the 0–10 NRS for pain. The results of this study may inform medical practitioners and policymakers regarding the efficacy of analgesic ketamine in a prehospital environment, aid in making informed treatment decisions regarding trauma casualties, and provide facts for updating and improving clinical practice guidelines and policies focused on the U.S. military. Advancing the understanding to promote better prehospital pain management guidelines, procedures, and practices is essential. Education efforts will make medical professionals aware of the importance of analgesic ketamine for trauma casualties in a prehospital environment. @font-face {font-family: Cambria Math ; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:-536870145 1107305727 0 0 415 0;}@font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-536859905 -1073732485 9 0 511 0;}@font-face {font-family: Calibri HeadingsHeadings ; panose-1:2 11 6 4 2 2 2 2 2 4; mso-font-alt:Calibri; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:auto; mso-font-signature:0 0 0 0 0 0;}p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent: ; margin:0in; mso-pagination:widow-orphan; font-size:11.0pt; font-family: Calibri ,sans-serif; mso-fareast-font-family:Arial; mso-bidi-font-family: Calibri HeadingsHeadings ; color:black; mso-themecolor:text1;}.MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-size:11.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; font-family: Calibri ,sans-serif; mso-ascii-font-family:Calibri; mso-fareast-font-family:Arial; mso-hansi-font-family:Calibri; mso-bidi-font-family: Calibri HeadingsHeadings ; color:black; mso-themecolor:text1; mso-font-kerning:0pt; mso-ligatures:none;}div.WordSection1 {page:WordSection1;

    Development of clinical guidelines for the management of post-operative pain within the medico-socio-cultural context of Ghana

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    Philosophiae Doctor - PhDLiterature on post-operative pain indicates that post-operative pain is inadequately managed in many countries including Ghana. Little was also known about post-operative pain (POP) response and management in Ghana. This study sought to describe post-operative pain response and management among Ghanaian surgical nurses and post-operative patients within the medico-socio-cultural context. It also explored factors that influenced POP response and management and subsequently aimed to develop clinical guidelines within which post-operative pain could be managed in the medico-socio-cultural context. Research questions answered included: „what are the factors influencing post-operative pain responses among surgical patients and nurses; what clinical guidelines would be appropriate to guide post-operative pain management within the medico-socio-cultural context of Ghana?‟The study was designed as a multi-step focused ethnography which allowed the exploration of a specific sub-culture such as the surgical environment. The philosophical underpinnings of ethnography permit the investigator to use different data collection methods to fully understand the phenomenon investigated. Data collection during the ethnographic exploration phase involved individual interviews, clinical observations, and review of patients‟ clinical charts. At the stage of guideline development, data was collected through participant/expert review, systematic literature review, and consensus forum. Participants were sampled purposively and included 53 interview participants, 27 expert reviewers, and 29 consensus panel members. Also, there were 16 sections of clinical observation and review of 44 charts. The participants included nurses, patients and their relatives, the multidisciplinary team, key informants, experts, and stakeholders. The study was conducted at the Korle-Bu Teaching Hospital (KBTH) and Ridge Hospital, in Accra, Ghana. Appropriate ethical clearance was sought and individual informed consent was obtained.Concurrent analysis of data was done applying the principles of thematic content analysis and data was managed with NVivo 9. Themes that emerged from the patients‟ data were subjectivism which described pain dimensions and expressions and factors that influenced patients‟ pain experience were psycho-socio-cultural factors such as personal inclinations and socio-cultural background; and health system factors such as personnel attitude and health financing.The study also found that nurses perceived POP as an individual phenomenon and responded to pain by administering analgesics and by employing non-pharmacologic measures such as positioning and reassurance. Factors that influenced the nurses‟ pain response were individual factors such as commitment, discretion, and fear of addiction; and organizational factors such as organizational laxity and challenges of teamwork. Patients‟ relatives were also influenced by empathy, faith, and commitment to care for their post-operative patients. The multidisciplinary team and key informants were influenced by knowledge and experience in their respective specialty areas. Subsequently, the clinical guideline developed had four dimensions which highlighted patient and family education,effective teamwork, effective leadership and monitoring, and use of contemporary evidence for POP management.The study recommended that health professionals should be conscious of the subjectivenature of pain and they should educate and involve the patient on pain management decisions. Also, hospital leadership and the multidisciplinary team should be actively involved in pain management

    Factors influencing the outcome of nurse delivered procedural sedation and analgesia during atrial fibrillation ablation: a mixed methods study

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    Despite continual rising demand for atrial fibrillation ablation, numbers of cases performed have plateaued. One reason for this is a shortage of appropriately skilled sedationists. Administration of sedation by nurses using a protocol is a potential solution, but virtually no research exists on the impact of this on the quality of patient care. This project aimed to evaluate the use of such a protocol in a single NHS Trust in terms of safety and patient experience. By doing so, it was intended that it should ascertain the feasibility of protocol-based sedation by nurses, and identify areas in the practice studied requiring alteration in order to optimise patient outcomes. A two-stage mixed methods project was undertaken. An initial survey phase provided statistical data that allowed comparison between the safety of protocolised nurse-led sedation and other sedation practices. Fuzzy set Qualitative Comparative Analysis (QCA) of the survey data allowed for exploration of patterns of complexity between components determining patient experience, a possibility identified within existing theories of pain such as the 'Gate Control Theory'. Subsequently pathways leading to positive experiences were modelled. These pathways were then tested using a series of case studies to ascertain the existence of causal links between the identified factors and positive outcomes as well as the extent to which protocol-adherence facilitated positive outcomes. This thesis presents findings from both stages. These include the conclusion that nurse-delivered sedation is at least as safe as other methods. It establishes more than one pathway to positive patient experiences may exist, but finds strongest evidence that effective management of patient anxiety leads to a positive outcome. However, it also concludes that creating this outcome depends on the clinical judgement of the individual nurse, and identifies alterations in the status of the protocol and its content to facilitate optimal outcomes

    The Efficacy and Maturity of Quality Improvement Approaches in the New Zealand Healthcare System

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    Purpose The purpose of this research is to critically evaluate the quality improvement (QI) phenomenon in healthcare providing organisations (clinics, hospitals, etc.) and propose an agenda for system-wide continuous improvement for their care delivery processes, using New Zealand’s healthcare sector as a case study. Design/methodology/approach A systematic literature review (SLR) highlighted multiple gaps regarding quality improvement methodologies and the scope of their implementation in healthcare providing organisations across the world. Based on the SLR, a quality improvement maturity model was developed and used to analyse the use of QI methodologies and their scope of implementation within the District Health Boards (DHBs) operating in the New Zealand. In-depth interviews with quality improvement managers from 15 DHBs were conducted. In addition to the interviews, internal documents and operational data detailing the quality improvement activities and initiatives undertaken by DHBs were analysed using qualitative methods. This provided basis for a sector-wide analysis of QI implementation in New Zealand DHBs. Findings While healthcare providing organisations strongly portray inclination towards different quality improvement methodologies, their overall understanding and use of quality tools is very similar to each other. This inclination towards different QI methodologies is primarily based on the personal preferences of quality improvement managers, who are assigned with leading, supporting and managing quality improvement activities. Similarly, the majority of the proposed benefits and criticisms of different methodologies are based on their origin from outside of the healthcare sector. Second, the quality improvement managers and their teams are rarely given the appropriate authority and resources to fully offer change, i.e., manpower, power, influence and commitment from staff and senior leadership towards quality improvement. Finally, the scope of quality improvement in healthcare tends to be narrow and siloed—within singular value-streams or wards—and the concept and benefit of linking internal and external supply chains with quality improvement activities is missing in the care delivery processes. Research limitations This research is located within the New Zealand healthcare system. While, the healthcare delivery processes are largely similar to Australia and the UK, there can still be many inbuilt cultural and policy-related features that may limit the research findings to the New Zealand’s healthcare context. Research implications This research findings highlight a need to move forward from obtuse discussions about seeking the best quality improvement methods in healthcare sector. Selection of a specific QI methodology does not guarantee success or failure of QI initiatives. Instead, healthcare providing organisations need to realise the true meaning of QI, its principles, and implement them in their wider supply networks, to remove operational waste and increase value for the end-users – the patients, each and every one of us. Originality/value QI phenomenon in the healthcare sector is less mature compared to the manufacturing industries. Partly because, the institutional logics of healthcare environment are not aligned with the institutional logics associated with quality improvement. This mismatch arises from multiple factors, ranging from simple misunderstandings regarding quality improvement methods to the use of inappropriate jargon and complications in conducting QI work, which has created resistance in the healthcare workforce. However, pressure from government and public, healthcare organisations and their employees perform quality improvement initiatives that are narrow in scope and the implementation of quality tools and techniques. This narrow focus was observed not only in singular interviews, but also in the maturity analysis of participating District Health Boards
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