Synthetic cannabinoid use in a case series of patients with psychosis presenting to acute psychiatric settings : Clinical presentation and management issues

Background: Novel Psychoactive Substances (NPS) are a heterogeneous class of synthetic molecules including synthetic cannabinoid receptor agonists (SCRAs). Psychosis is associated with SCRAs use. There is limited knowledge regarding the structured assessment and psychometric evaluation of clinical presentations, analytical toxicology and clinical management plans of patients presenting with psychosis and SCRAs misuse. Methods: We gathered information regarding the clinical presentations, toxicology and care plans of patients with psychosis and SCRAs misuse admitted to inpatients services. Clinical presentations were assessed using the PANSS scale. Vital signs data were collected using the National Early Warning Signs tool. Analytic chemistry data were collected using urine drug screening tests for traditional psychoactive substances and NPS. Results: We described the clinical presentation and management plan of four patients with psychosis and misuse of SCRAs. Conclusion: The formulation of an informed clinical management plan requires a structured assessment, identification of the index NPS, pharmacological interventions, increases in nursing observations, changes to leave status and monitoring of the vital signs. The objective from using these interventions is to maintain stable physical health whilst rapidly improving the altered mental state.Peer reviewedFinal Published versio

Revising acute care systems and processes to improve breastfeeding and maternal postnatal health: a pre and post intervention study in one English maternity unit

Background Most women in the UK give birth in a hospital labour ward, following which they are transferred to a postnatal ward and discharged home within 24 to 48 hours of the birth. Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women’s views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated. Methods Using a Continuous Quality Improvement approach, routine antenatal, intrapartum and postnatal care systems and processes were revised to support implementation of evidence based postnatal practice. To identify if implementation of a multi-faceted QI intervention impacted on outcomes, data on breastfeeding initiation and duration, maternal health and women’s views of care, were collected in a pre and post intervention longitudinal survey. Primary outcomes included initiation, overall duration and duration of exclusive breastfeeding. Secondary outcomes included maternal morbidity, experiences and satisfaction with care. As most outcomes of interest were measured on a nominal scale, these were compared pre and post intervention using logistic regression. Results Data were obtained on 741/1160 (64%) women at 10 days post-birth and 616 (54%) at 3 months post-birth pre-intervention, and 725/1153 (63%) and 575 (50%) respectively postintervention. Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care. Conclusions It is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement

A fundamental conflict of care: nurses' accounts of balancing sleep with taking vital signs observations at night.

AIMS AND OBJECTIVES: To explore why adherence to vital signs observations scheduled by an Early Warning Score protocol reduces at night. BACKGROUND: Regular vital signs observations can reduce avoidable deterioration in hospital. Early Warning Score protocols set the frequency of these observations by the severity of a patient's condition. Vital signs observations are taken less frequently at night, even with an Early Warning Score in place, but no literature has explored why. DESIGN: A qualitative interpretative design informed this study. METHODS: Seventeen semi-structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital signs observations. A thematic analysis approach was used. RESULTS: At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital signs observations. The night-time frequency of these observations was determined by clinical judgement, ward-level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under-monitored while patients nearing the end of life could be over-monitored. CONCLUSION: In this study we found an Early Warning Score algorithm focused on deterioration prevention did not account for long-term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital signs observations at night. However the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the Early Warning Score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions. RELEVANCE TO CLINICAL PRACTICE: Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital signs observations are missed at night, identify which groups are under-monitored and provide guidance on prioritising competing expectations. Early Warning Score protocols should take account of different care trajectories. This article is protected by copyright. All rights reserved

First do no harm: Teaching and assessing the recognition and rescue of deteriorating patients to nursing students

Failure to recognise and appropriately rescue the deteriorating patient is a global issue which has the potential to cause serious harm to patients. Such recognition and rescue of a deteriorating patient requires both technical and non-technical skills and there are multiple points for potential failure. The taking and recording of vital observations is one of the cornerstones of recognising deterioration. However, such observations are often delegated to students and the least experienced staff. This paper explores the teaching and assessment of under-graduate nursing students to recognise and arrange the rescue of a deteriorating patient within the first 16 weeks of their course. The paper describes the development of an integrated Objective Structured Clinical Examination (OSCE) and the subsequent evaluation of this using survey data, student performance results and unobtrusive methods. The results suggest that it is possible to use an integrated OSCE to assess students even at such an early stage in their course. Although data from other Higher Education Institutions in the UK suggests that integrated OSCEs at such an early stage are rare. The appropriate teaching of vital observations, structured hand off and reporting enable students to contribute to safer care and to adhere to the maxim “First Do No Harm”

Digital early warning scores in cardiac care settings: Mixed-methods research

The broad adoption of the National Early Warning Score (NEWS2) was formally endorsed for prediction of early deterioration across all settings. With current digitalisation of the Early Warning Score (EWS) through electronic health records (EHR) and automated patient monitoring, there is an excellent opportunity for facilitating and evaluating NEWS2 implementation. However, no evidence yet shows the success of such standardisation or digitalisation of EWS in cardiac care settings. Individuals with cardiovascular disease (CVD) have a significant risk of developing critical events, and CVD-related morbidity is a critical burden for health and social care. However, there is a gap in research evaluating the performance and implementation of EWS in cardiac settings and the role of digital solutions in the implementation and performance of EWS and clinicians' practice. This PhD aims to provide high-quality evidence on the effectiveness of NEWS2 in predicting worsening events in patients with CVD, the implementation of the digital NEWS2 in two healthcare settings, the experience of escalation of care during the COVID-19 pandemic, and the evaluation of EHR-integrated dashboard for auditing NEWS2 and clinicians' performance