Patient and nurse preferences for implementation of bedside handover: Do they agree? Findings from a discrete choice experiment

Objective: To describe and compare patients' and nurses' preferences for the implementation of bedside handover. Design: Discrete choice experiment describing handover choices using six characteristics: whether the patient is invited to participate; whether a family member/carer/friend is invited; the number of nurses present; the level of patient involvement; the information content; and privacy. Setting: Two Australian hospitals. Participants: Adult patients (n=401) and nurses (n=200) recruited from medical wards. Main outcome measures: Mean importance scores for handover characteristics estimated using mixed multinomial logit regression of the choice data. Results: Both patient and nurse participants preferred handover at the bedside rather than elsewhere (P<.05). Being invited to participate, supporting strong two-way communication, having a family member/carer/friend present and having two nurses rather than the nursing team present were most important for patients. Patients being invited to participate and supporting strong two-way communication were most important for nurses. However, contrary to patient preferences, having a family member/carer/friend present was not considered important by nurses. Further, while patients expressed a weak preference to have sensitive information handed over quietly at the bedside, nurses expressed a relatively strong preference for handover of sensitive information verbally away from the bedside. Conclusions: All participants strongly support handover at the bedside and want patients to participate although patient and nurse preferences for various aspects of bedside handover differ. An understanding of these preferences is expected to support recommendations for improving the patient hospital experience and the consistent implementation of bedside handover as a safety initiative

Parent escalation of care for the deteriorating child in hospital: A health-care improvement study

Objective: To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition. Design: Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework. Methods: Implementation of the ‘Calling for Help’ (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups. Setting: Australian specialist paediatric hospital. Participants: Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses. Main outcome measures: Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation. Results: Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review. Conclusions: There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers

Patient and nurse preferences for nurse handover - using preferences to inform policy: a discrete choice experiment protocol

Introduction Nursing bedside handover in hospital has been identified as an opportunity to involve patients and promote patient-centred care. It is important to consider the preferences of both patients and nurses when implementing bedside handover to maximise the successful uptake of this policy. We outline a study which aims to (1) identify, compare and contrast the preferences for various aspects of handover common to nurses and patients while accounting for other factors, such as the time constraints of nurses that may influence these preferences.; (2) identify opportunities for nurses to better involve patients in bedside handover and (3) identify patient and nurse preferences that may challenge the full implementation of bedside handover in the acute medical setting. Methods and analysis We outline the protocol for a discrete choice experiment (DCE) which uses a survey design common to both patients and nurses. We describe the qualitative and pilot work undertaken to design the DCE. We use a D-efficient design which is informed by prior coefficients collected during the pilot phase. We also discuss the face-to-face administration of this survey in a population of acutely unwell, hospitalised patients and describe how data collection challenges have been informed by our pilot phase. Mixed multinomial logit regression analysis will be used to estimate the final results. Ethics and dissemination This study has been approved by a university ethics committee as well as two participating hospital ethics committees. Results will be used within a knowledge translation framework to inform any strategies that can be used by nursing staff to improve the uptake of bedside handover. Results will also be disseminated via peer-reviewed journal articles and will be presented at national and international conferences

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion: The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.N Hannaford, C Mandel, C Crock, K Buckley, F Magrabi, M Ong, S Allen, and T Schult

Improving the Estimation of Risk-Adjusted Grouped Hospital Standardized Mortality Ratios Using Cross-Jurisdictional Linked Administrative Data: A Retrospective Cohort Study.

Background: Hospitals and death registries in Australia are operated under individual state government jurisdictions. Some state borders are located in heavily populated areas or are located near to major capital cities. Mortality indicators for hospital located near state borders may not be estimated accurately if patients are lost as they cross state borders. The aim of this study was to evaluate how cross-jurisdictional linkage of state hospital and death records across state borders may improve estimation of the hospital standardized mortality ratio (HSMR), a tool used in Australia as a hospital performance indicator. Method: Retrospective cohort study of 7.7 million hospital patients from July 2004 to June 2009. Inhospital deaths and deaths within 30 days of hospital discharge from four state jurisdictions were used to estimate the standardized mortality ratio of hospital groups defined by geography and type of hospital (grouped HSMR) under three record linkage scenarios, as follows: (1) cross-jurisdictional person-level linkage, (2) within-jurisdictional (state-based) person-level linkage, and (3) unlinked records. All public and private hospitals in New South Wales, Queensland, Western Australia, and public hospitals in South Australia were included in this study. Death registrations from all four states were obtained from state-based registries of births, deaths, and marriages. Results: Cross-jurisdictional linkage identified 11,116 cross-border hospital transfers of which 170 resulted in a cross-border inhospital death. An additional 496 cross-border deaths occurred within 30 days of hospital discharge. The inclusion of cross-jurisdictional person-level links to unlinked hospital records reduced the coefficient of variation among the grouped HSMRs from 0.19 to 0.15; the inclusion of 30-day deaths reduced the coefficient of variation further to 0.11. There were minor changes in grouped HSMRs between cross-jurisdictional and within-jurisdictional linkages, although the impact of cross-jurisdictional linkage increased when restricted to regions with high cross-border hospital use. Conclusion: Cross-jurisdictional linkage modified estimates of grouped HSMRs in hospital groups likely to receive a high proportion of cross-border users. Hospital identifiers will be required to confirm whether individual hospital performance indicators change

Exploring enablers and barriers to accessing health services after a fall among people with intellectual disability

Background: Adults with intellectual disability experience high rates of falls making falls prevention an important health need. The purpose of the study was to seek perspectives of older adults with intellectual disability and their caregivers to (a) explore the experiences of older adults with intellectual disability when seeking healthcare services after a fall and (b) identify enablers and barriers when taking up evidence-based falls recommendations. Method: A qualitative exploratory study was undertaken as part of a prospective observational cohort study. Semi-structured interviews were conducted with a purposeful sample. Data were analysed thematically using Colaizzi\u27s method. Results: Seventeen interviews were conducted (n = 21). Emergent themes demonstrated that participants had limited knowledge about falls prevention. Enablers included individualizing falls prevention strategies. Barriers included not being offered access to established falls prevention pathways. Conclusion: There is an urgent need to develop high-quality falls prevention services for older adults with intellectual disability

A pilot randomised controlled trial using prophylactic dressings to minimise sacral pressure injuries in high risk hospitalised patients

This pilot randomised controlled trial examined the effect of prophylactic dressings to minimise sacral pressure injuries in high-risk hospitalised patients and assessed feasibility criteria to inform a larger study. Eighty patients were recruited at admission points (the Emergency Department and Surgical Care Unit) or directly from participating wards in the general medical surgical setting following assessment of high risk for sacral pressure injury. Participants were randomised into either the routine care or routine care and silicone foam border dressing group. Outcome assessment comprised digital photographs of each participant’s sacrum every 72 hours for evaluation by a blind-to-intervention assessor. Sixty-seven participants had at least one sacral photograph taken and assessed by a blind-to-intervention assessor. Three participants were assessed as having a Stage I pressure injury. While the use of photography was effective, feasibility criteria identified challenges related to bias, blinding, weight assessment, preparation of nursing staff and sample size estimation

"The Right Way at the Right Time": Insights on the Uptake of Falls Prevention Strategies from People with Dementia and Their Caregivers.

Strong evidence exists for effective falls prevention strategies for community-dwelling older people. Understanding the translation of these strategies into practice for people with dementia has had limited research focus. People with dementia desire to have their voice heard, to engage meaningfully in the health-care decision-making process, making it a priority for researchers and practitioners to better understand how to engage them in this process. This paper reports on the qualitative aspects of a series of studies, which aimed to identify the views of people with dementia and their caregivers regarding perceptions of falls prevention and the successes and challenges of adopting falls prevention strategies. Twenty five people with dementia and their caregivers were interviewed in their homes at baseline, and 24 caregivers and 16 people with dementia were interviewed at completion of a 6-month individualized falls prevention intervention. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed. Five themes were identified at baseline: perceptions of falls; caregivers navigating the new and the unpredictable; recognition of decline; health services - the need for an appropriate message; and negotiating respectful relationships. At 6?months, caregivers and people with dementia decided on "what we need to know" with firm views that the information regarding falls risk reduction needed to be in "the right way?…?at the right time." Rather than caregivers and people with dementia being only recipients of knowledge, they felt they were "more than just empty vessels to be filled" drawing on a "variety of resources" within their circle of influence to be able to positively "adapt to change." The voices of people with dementia and their caregivers add an important dimension to understanding the translation of falls prevention knowledge for this population. Insights from this study will enable community care health professionals to understand that people with dementia and their caregivers can, and wish to, contribute to implementing falls prevention strategies through their resourcefulness and inclusion in the therapeutic partnership

An effectiveness analysis of healthcare systems using a systems theoretic approach

<p>Abstract</p> <p>Background</p> <p>The use of accreditation and quality measurement and reporting to improve healthcare quality and patient safety has been widespread across many countries. A review of the literature reveals no association between the accreditation system and the quality measurement and reporting systems, even when hospital compliance with these systems is satisfactory. Improvement of health care outcomes needs to be based on an appreciation of the whole system that contributes to those outcomes. The research literature currently lacks an appropriate analysis and is fragmented among activities. This paper aims to propose an integrated research model of these two systems and to demonstrate the usefulness of the resulting model for strategic research planning.</p> <p>Methods/design</p> <p>To achieve these aims, a systematic integration of the healthcare accreditation and quality measurement/reporting systems is structured hierarchically. A holistic systems relationship model of the administration segment is developed to act as an investigation framework. A literature-based empirical study is used to validate the proposed relationships derived from the model. Australian experiences are used as evidence for the system effectiveness analysis and design base for an adaptive-control study proposal to show the usefulness of the system model for guiding strategic research.</p> <p>Results</p> <p>Three basic relationships were revealed and validated from the research literature. The systemic weaknesses of the accreditation system and quality measurement/reporting system from a system flow perspective were examined. The approach provides a system thinking structure to assist the design of quality improvement strategies. The proposed model discovers a fourth implicit relationship, a feedback between quality performance reporting components and choice of accreditation components that is likely to play an important role in health care outcomes. An example involving accreditation surveyors is developed that provides a systematic search for improving the impact of accreditation on quality of care and hence on the accreditation/performance correlation.</p> <p>Conclusion</p> <p>There is clear value in developing a theoretical systems approach to achieving quality in health care. The introduction of the systematic surveyor-based search for improvements creates an adaptive-control system to optimize health care quality. It is hoped that these outcomes will stimulate further research in the development of strategic planning using systems theoretic approach for the improvement of quality in health care.</p