The Impact on Professionals When Children Develop Central-Line Infections

Background/ObjectivesCentral-line associated bloodstream infections (CLABSIs) are a form of healthcare associated infection (HCAI) with devastating consequences for patients. Although the clinical outcomes of CLABSI are well-described, the impact on professionals who are involved in these events, and thus their ability to convey the severity of the condition has not been investigated.Design/MethodsSemi-structured interviews were conducted with fifteen multi-disciplinary professionals who had experience of caring for children who had developed CLABSI. Interviews were digitally recorded and transcribed verbatim. Data were analysed using the constant comparative method. ResultsAlthough CLABSI were familiar occurrences for healthcare professionals (HCPs) in this study, they were still traumatic events. They reported their experience of children with significant CLABSI becoming more unwell, more dramatically than other children. Further, memories of other children who had died as a result of CLABSI made the HCPs fearful that each subsequent child in their care would also die despite optimal treatment. They described significant emotional turmoil associated with making clinical decisions about the child’s care. Additionally, they felt that colleagues without personal experience of CLABSI were unable to appreciate the severity of the child’s condition, compared to other cases of sepsis. As a result, they often struggled to explain to their peers how unwell the child was. They believed this contributed to delays in accessing external support such as admissions to PICU or surgical removal of central lines.ConclusionsCLABSI are emotionally traumatic events for HCPs, leaving significant residual emotional impact of each case. The HCPs experience of CLABSI compared to its understanding to those who had not cared for children with CLABSI, made it difficult to adequately communicate with colleagues. This risks delays to the child’s care. A wider education on the severity and impact of CLABSI amongst allied specialties could improve awareness and may improve speed of access to potentially life-saving interventions.</p

The Impact of Central-Line Infections on Children and Families

Background/ObjectivesCentral-venous access devices (CVADs) are used in children with complex medical conditions to deliver life-saving treatments, such as chemotherapy and nutritional support. Infections of CVADs (central-line associated bloodstream infections; CLABSI), although rare, can result in prolonged hospital admissions, intensive care admissions and even death. As more children are facilitated to live at home, the impact of CLABSI on the emotional and mental health of the children at home and their families requires exploration.Design/MethodsSemi-structured interviews were conducted with parents of eleven children, and with twenty professionals. Interviews were digitally recorded and transcribed verbatim. Data were analysed using the constant comparative method. Data were collected as part of a larger study exploring care of invasive devices in the community.ResultsFour families had personal experience of CLABSI, and all families were aware of other children who had experienced or even died of CLABSI. CLABSIs were unpredictable and children could deteriorate rapidly. Parents who had experiences CLABSI recounted the frightening and traumatic event and described vivid memories of their child’s illness. All parents, irrespective of first-hand familiarity or not, experienced unrelenting fear that their child would develop an infection and die. Families described a state of constant vigilance where they continually monitored the child for signs of infection to ensure that they could receive treatment, further adding to their emotional workload. Hospital admissions further disrupted family life, affecting parents’ work, school, hobbies and family celebrations.ConclusionsCLABSIs are associated with significant disruption to children and families. The threat of CLABSI results in significant emotional distress for families in addition to their existing burdens. Professionals should be aware of this emotional burden when counselling families about the risk of CLABSI. Children and families with experience of CLABSI may benefit from additional psychological support.</p

Undertaking risk and relational work to manage vulnerability: Acute medical patients’ involvement in patient safety in the NHS

Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient's health status and vulnerability on their ability to participate in their safety. Drawing on qualitative interviews with 28 acute medical patients, this article aims to show how patients’ contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of how vulnerability shapes patients’ involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. Patients are made responsible for speaking up about their care but simultaneously, by virtue of the expectations of the sick role and their relational vulnerability, encouraged to remain passive, compliant or silent. We show how risk frames the extent to which patients can activate their role in creating patient safety at the point of care. Foregrounding the theory of vulnerability, the concept of the sick role and the relationship of both to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context

Education quality for future doctors: a case study of the introduction of an Education Quality Dashboard (EQD) in a UK teaching hospital

BACKGROUND: The quality of postgraduate training environments vary, but measures of the quality of training environments are lacking. This case study describes the use of management principles combined with educational expertise to facilitate the development and evaluation of an Education Quality Dashboard (EQD) for monitoring the quality of training in a large UK NHS teaching hospital. METHODS: Evaluation was conducted through the inspection of data-reporting trends and interviews with key stakeholders. Fourteen key stakeholders took part in semi-structured interviews about their experiences of implementing the EQD. Data were analysed thematically using nvivo 10. RESULTS: The introduction of the EQD drove improvements in completeness of data about education standards, and improvements in performance on key metrics. Interviewees suggested that the EQD was feasible to compile but required infrastructure for data collection to be established and maintained. The use of a dashboard format was seen as helping to raise the profile of education quality standards in the trust, particularly at the board level, although some limitations of the dashboard were noted. The EQD enabled proactive monitoring and managing of problems with the educational environment, and interviewees identified concrete improvements that had resulted from the use of the dashboard. Making the EQD work well required commitment and leadership from senior staff. Feeding back and acting on findings was seen as critical for continuing engagement. DISCUSSION: The dashboard is now embedded as part of routine practice across the hospital, and has the potential to be implemented nationally to help drive improvements in the quality of education provision

Quality and safety of in-hospital care for acute medical patients at weekends: a qualitative study.

BACKGROUND: The increased mortality risk associated with weekend admission to hospital (the 'weekend effect') has been reported across many health systems. More recently research has focused on causal mechanisms. Variations in the organisation and delivery of in-hospital care between weekends and weekdays have been identified, but this is not always to the detriment of weekend admissions, and the impact on mortality is uncertain. The insights of frontline staff and patients have been neglected. This article reports a qualitative study of patients and clinicians, to explore their views on quality and safety of care at weekends. METHODS: We conducted focus groups and interviews with clinicians and patients with experience of acute medical care, recruited from three UK hospital Trusts. We analysed the data using a thematic analysis approach, aided by the use of NVivo, to explore quality and safety of care at weekends. RESULTS: We held four focus groups and completed six in-depth interviews, with 19 clinicians and 12 patients. Four threats to quality and safety were identified as being more prominent at weekends, relating to i) the rescue and stabilisation of sick patients; ii) monitoring and responding to deterioration; iii) timely accurate management of the therapeutic pathway; iv) errors of omission and commission. CONCLUSIONS: At weekends patients and staff are well aware of suboptimal staffing numbers, skill mix and access to resources at weekends, and identify that emergency admissions are prioritised over those already hospitalised. The consequences in terms of quality and safety and patient experience of care are undesirable. Our findings suggest the value of focusing on care processes and systems resilience over the weekends, and how these can be better supported, even in the limited resource environment that exists in many hospitals at weekends

Sepsis and Antimicrobial Stewardship – Two Sides of the Same Coin

Sepsis and antimicrobial stewardship (AMS) programmes co-exist in healthcare settings; however, there can be tension between the goals of reducing sepsis mortality, and preventing antimicrobial resistance (AMR). How these goals are perceived and prioritised by health professionals and the public is likely shaped by media framing and compounded by nonalignment of sepsis and AMS programmes in healthcare organisations. Media sepsis reports use personal stories with solutions within the power of individuals whereas AMR is framed as a vague future threat involving multiple actors, with solutions requiring global efforts and policy change. Principles from behavioural economics could help to achieve a ‘recognition of necessity’ to change prescribing approaches. Importantly sepsis and AMS cannot be discussed in isolation, but should be portrayed as two sides of the same coin: in the framing of messages in the media and public health campaigns, and the alignment of organisational sepsis and AMS programmes

Reply to Peiffer-Smadja, et al.

We have read with interest the letter by Peiffer-Smadja and colleagues titled ‘Cultural differences between surgical and medical teams: is it time for comanagament’. The authors discuss the findings from an ethnographic study we conducted which described the differences in culture and team dynamics across medical and surgical specialties in relation to antibiotic decision-making and suggest a way forward to be co-management of the surgical patient. The European Journal of Internal Medicine have also just issued a strategy for co-management to improve outcomes of perioperative care. There are existing longstanding examples of effective multidisciplinary co-management from other disciplines, for example in HIV and TB that include nurse and pharmacist and are not limited to doctors

Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals.

BACKGROUND: Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. AIM: To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. METHODS: A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship. FINDINGS: The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services. CONCLUSIONS: When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice

Optimising antibiotic prescribing: Collective approaches to managing a common-pool resource.

BACKGROUND: Antimicrobial resistance (AMR) is one of the greatest threats in 21st century medicine. AMR has been characterised as a social dilemma. A familiar version describes the situation in which a collective resource (in this case, antibiotic efficacy) is exhausted due to over-exploitation. The dilemma arises because individuals are motivated to maximise individual payoffs, although the collective outcome is worse if all act in this way. OBJECTIVES: We aim to outline the implications for antimicrobial stewardship of characterising antibiotic overuse as a social dilemma. SOURCES: We conducted a narrative review of the literature on interventions to promote the conservation of resources in social dilemmas. CONTENT: The social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and the outcome of AMR, and the agency relationships inherent in the prescriber role. We identify seven strategies for shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of antibiotic efficacy: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution mechanisms. IMPLICATIONS: We conclude that this theoretic analysis of antibiotic stewardship could make the problem of optimising antibiotic prescribing more tractable, providing a theory base for intervention development

Symptom burden in patients with chronic kidney disease not requiring renal replacement therapy

Background: Although evidence shows that patients with end stage renal disease (ESRD) experience a high symptom burden which impacts on quality of life (QoL), less is known about patients with earlier stages of chronic kidney disease (CKD). This study aimed to explore symptom burden and potential contributing factors in patients with CKD Stage 1-5 not requiring renal replacement therapy (RRT). Methods: Patients with CKD Stage 1-5 and not on RRT were asked to report their symptoms using the Leicester Uraemic Symptom Score (LUSS), a questionnaire which assesses the frequency and intrusiveness of 11 symptoms commonly reported by kidney patients. Results: Symptoms were assessed in 283 CKD Stage 1-5 patients: 54% male, mean age 60.5 standard error± 1.0, mean eGFR 38ml/min/1.73m2. Some 96% (95% confidence interval 93.2-98.0) of participants reported experiencing at least one symptom, the median reported being six. Excessive tiredness (81%;76.0-85.6), sleep disturbance (70%;64.3-75.3) and pain in bones/joints (69%;63.4-74.6) were reported most commonly. Overall, few significant associations were found between biochemical markers of disease severity and symptom burden. Men tended to report fewer symptoms than women and South Asian patients often described experiencing symptoms with a greater severity. Older patients found musculoskeletal symptoms more intrusive whereas younger patients found reduced concentration more intrusive. Conclusions: Our findings suggest that patients with CKD stages 1-5 experience a multitude of symptoms that could potentially impact QoL. Using multidimensional tools like the LUSS, more exploration and focus could provide a greater opportunity for patient focussed symptom control from the earliest stages of CKD