Assessing cardiovascular status: a guide for acute nurses

Many patients admitted to acute care areas of a hospital experience cardiovascular compromise due to conditions such as acute myocardial infarction (AMI), acute coronary syndrome or exacerbations of chronic heart failure. Additionally, patients can experience cardiovascular collapse due to bleeding or cardiac arrhythmias postoperatively. As a consequence, nurses in acute care settings need to be competent in assessing the cardiovascular status of adult patients. The authors provide a framework for assessing the cardiovascular status of patients in acute care settings using the determinants of cardiac output. They provide a brief review of the determinants of cardiac output before discussing both the aims of cardiovascular assessment and how to perform, such an assessment. (non- author abstract)<br /

Characteristics and outcomes of patients requiring rapid response system activation within 24 hours of emergency admission

Objectives:&nbsp;To establish the prevalence of emergency responses for clinical deterioration (cardiac arrest team or medical emergency team [MET] activation) within 24 hours of emergency admission, and determine if there were differences in characteristics and outcomes of ward patients whose emergency response was within, or beyond, 24 hours of emergency admission. Design, setting and participants: A retrospective, descriptive, exploratory study using MET, cardiac arrest, emergency department and inpatient databases, set in a 365-bed urban district hospital in Melbourne, Australia. Participants were adult hospital inpatients admitted to a medical or surgical ward via the emergency department (ED) who needed an emergency response for clinical deterioration during 2012. Main outcome measures: Inhospital mortality, unplanned intensive care unit admission and hospital length of stay (LOS). Results: A total of 819 patients needed an emergency response for clinical deterioration: 587 patients were admitted via the ED and 28.4% of emergency responses occurred within 24 hours of emergency admission. Patients whose first emergency response was within 24 hours of emergency admission (compared with beyond 24 hours) were more likely to be triaged to Australasian triage scale category 1 (5.4% v 1.2%, P=0.005), less likely to require ICU admission after the emergency response (7.6% v 13.9%, P=0.039), less likely to have recurrent emergency responses during their hospital stay (9.7% v 34%, P &lt; 0.001) and had a shorter median hospital LOS (7 days v 11 days, P &lt; 0.001). Conclusions: One-quarter of emergency responses after admission via the ED occurred within 24 hours. Further research is needed to understand the predictors of deterioration in patients needing emergency admission.</div

Critical care nurses\u27 haemodynamic decision making

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses\u27 decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses\u27 haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses\u27 experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses\u27 haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses\u27 decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses\u27 decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses\u27 emotions and actions and decision making practices. Findings revealed nurses\u27 experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses\u27 experience, and the environment in which decisions were made influenced the quality of nurses\u27 decision making and created an environment of team decision making, which, in turn, influenced nurses\u27 emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision

Physiological status during emergency department care : relationship with inhospital death after clinical deterioration

OBJECTIVE: To examine the relationship between patient physiological status in the emergency department (ED) and inhospital mortality after rapid response team (RRT) or cardiac arrest team (CAT) activations within 72 hours of emergency admission to medical or surgical wards. DESIGN, SETTING AND PARTICIPANTS: A multisite, retrospective, cohort study of 660 randomly selected (220 patients per site) adult medical or surgical patients who were admitted from the ED during 2012 and who had had an RRT or CAT activation within 72 hours of admission, at three hospitals in Melbourne, Australia. MAIN OUTCOME MEASURE: Inhospital mortality. RESULTS: There were 825 RRT activations (for 634 patients) and 42 CAT activations (for 35 patients). The median time to the first RRT or CAT activation was 18.8 hours and was significantly shorter in patients who died in hospital (14.6 v 20.6 hours, P=0.036). Compared with survivors, patients who died were more likely to have at least one observation meeting RRT criteria during their ED stay (45.9% v 34.8%; P=0.029): tachypnoea (21.1% v 13.4%, P=0.039), hypotension (20.2% v 11.8%, P=0.018), hypoxaemia (8.3% v 3.1%, P=0.001) and altered conscious state (6.2% v 1.3%, P=0.001) were more common in patients who died. The risk-adjusted odds ratio (OR) for inhospital death was highest for patients with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365-15.728; P=0.014). CONCLUSIONS: In patients who needed an RRT or CAT activation within the first 72 hours of emergency admission to medical or surgical wards, there was a strong association between physiological derangement during ED care and inhospital death

Using On-line Guided-Self Determination to Provide High Quality Diabetes Self-Management: An analysis with Activity Theory

This paper presents and evaluation of the use of a developed on line guided Self-Determination (GSD) solution for young adults with Type 1 diabetes. Activity theory is proffered as a suitable analysis lens to highlight and unpack key social interactions. An exploratory descriptive design with four stages that involved: (1) developing the GSD program online; (2) training diabetes educators to use the GSD program in an online format; (3) implementing and pilot testing the GSD program; and (d) evaluating the online version formed the adopted methodology

Transitional experiences of Australian health science researchers: where is academic teaching preparedness?

Academic career development relies on a combination of teaching and research skills. In Australia, it is common for recent Doctor of Philosophy graduates to have a short-term post-doctoral research experience to build publication track-record and increase grant competitiveness, before securing a combined research and teaching or ‘academic’ role at a university. Other scientists work as full-time researchers for several years before transitioning to academic roles with expectations they can teach. The aim of this study was to explore the experiences of health and biomedical science researchers transitioning into academic roles using a mixed methods design. Sixty-six participants working in health and biomedical sciences at over 20 Australian Universities who had been in an academic role for 5 years or less completed an online survey. Of 66 participants, 18 (27%) had never been in a research-only role before, while 48 (63%) had held a research-only role for up to 11 years before starting their current academic role. Findings showed most academics were not trained nor equipped to successfully undertake scholarly teaching. They reported a lack of awareness of teaching expectations, practical resources, and direct support provision at the start of their appointment. For former researchers specifically, these experiences led to low confidence and poor enjoyment in their academic role, with the potential to decrease overall teaching quality, student learning and student satisfaction. We postulate that these issues may be mitigated by the implementation of teaching-specific training programs catering for the research-only background of staff entering health and biomedical academic roles in the higher education workforce

Students perceive Team-Based Learning facilitates development of graduate learning outcomes and professional skills

In tertiary education, generic professional skills should be developed along with discipline-specific knowledge and skills. Team-Based Learning (TBL), an active learning strategy, creates deep learning and enhanced student engagement; however, its effects on the development of generic learning outcomes are unknown. The aim of this study was to evaluate postgraduate specialty nursing students’ perspectives of how TBL impacts the acquisition of skills defined by the university’s eight Graduate Learning Outcomes (GLOs). A descriptive exploratory design was used in this study. Postgraduate nursing students in 2016-2017 at one university were invited to participate. Data were collected via demographic survey, a ranking tool, and written reflections. Data were analysed using descriptive statistics and content analysis. The response rate was 97.2 per cent (172/177). Participants were mostly females (n=152, 88.4%) aged 25–34 years (n=115, 66.9%). Student (n=156) rankings showed TBL contributed to the acquisition of critical thinking (n=90, 57.7%) and problem solving skills (n=56, 35.9%) the most. Students (n=144) made 2719 comments regarding how TBL led to the acquisition of GLOs in written reflections. Almost 98 per cent (n=2657) of all reflective comments were positive. All students mentioned at least one GLO positively due to TBL. Most positive reflections related to self-management (n=520, 19.6%) and communication (n=434, 16.3%).Postgraduate specialty nursing students perceived TBL classes contributed to the acquisition of their university’s GLOs, particularly critical thinking, problem solving, and self-management skills. The active learning strategy of TBL facilitates learning and engagement, and the attainment of essential professional attributes which are highly valued by employers

Physiological antecedents and ward clinician responses before medical emergency team activation

OBJECTIVES: To investigate the frequency, characteristics and timing of objectively measured clinical instability in adult ward patients in the 24 hours preceding activation of the medical emergency team (MET). We also examined ward clinician responses to documented clinical instability. DESIGN, SETTING AND PARTICIPANTS: A descriptive, exploratory design with a retrospective medical record audit. We descriptively analysed data from 200 ward patients reviewed by the MET at a tertiary teaching hospital in Melbourne, Australia, during 2014. MAIN OUTCOME MEASURES: Frequency and characteristics of urgent clinical review (UCR) criteria breaches in the 24 hours preceding MET activation, and in-hospital mortality. RESULTS: Overall, 78.5% of patients breached UCR criteria at least once in the 24 hours preceding MET activation, with 80.9% having multiple breaches. The most common causes of UCR criteria breaches were hypoxaemia without supplemental oxygen (27.4%, n = 43) and hypoxaemia with supplemental oxygen (21.7%, n = 34) for first UCR criteria breaches, and tachycardia (33.1%, n = 42) for last UCR criteria breaches during the 24 hours we examined. The median time before MET activation for first and last breaches was 17.1 hours and 1.2 hours, respectively. Examination of the clinician documentation suggested a high incidence of pre-MET activation afferent limb failure. In-hospital mortality was 12%. CONCLUSIONS: Patients commonly and repeatedly breached objectively measured UCR criteria in the 24 hours preceding MET activation, providing numerous opportunities for clinicians to recognise and respond to early clinical deterioration. The high incidence of pre- MET afferent limb failure requires further exploration