Community physiotherapy for people with dementia following hip fracture: fact or fiction

This is the author accepted manuscript. The final version is available from SAGE Publications via the DOI in this record.Background Physiotherapy is a core component of rehabilitation following a hip fracture. Approximately 40% of people sustaining a hip fracture will have dementia, but there is little evidence to guide physiotherapy interventions in this population. Objective This study forms part of a process evaluation seeking to explore reasons why people with dementia were not referred for physiotherapy following a hip fracture and challenges that are faced treating these people in the community. Methods We undertook a series of structured focus groups and interviews with physiotherapists based in community-rehabilitation services in the South West of England. Qualitative data sought to explain reasons why people with dementia were not being referred for onward physiotherapy following discharge from the acute setting after hip fracture. Framework analysis was used to make sense of the data. Results Four focus groups and interviews were undertaken with physiotherapists and assistants working in community settings. Three main themes were determined – beliefs, the importance of pathways of care and the effect of resources on decision making. Discussion Out data suggest that people with dementia were often labelled as having ‘no rehabilitation potential’ in the acute setting and this excluded them from receiving ongoing therapy in the community setting. It was also suggested that physiotherapists were judging this potential using biomedical measures of outcome which fails to recognise the importance of person centred care for this population. Conclusion There was suggestion of therapeutic nihilism when considering rehabilitation for this population, whereby it is assumed that people with dementia cannot be rehabilitated, so they are not given the opportunity. It is unsurprising that outcomes for this population are poor considering the reluctance to provide physiotherapy to people with dementia following hip fracture.National Institute for Health Research (NIHR)AGIL

Admission Decision-Making in Hospital Emergency Departments: the Role of the Accompanying Person

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 healthcare professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals’ standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients’ care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relations with patients. Taking a relationship-centered approach could improve attention to accompanying persons as co-producers of healthcare and participants in decision-making

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background: Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown. Aims: To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners. Methods: The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Findings: Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity. Conclusions: This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

International nursing advanced competency-based training for intensive care: a europe-wide survey.

This article is freely available via Open Access. Click on the 'Additional Link' above to access the full-text via the publisher's site.Published (Open Access

Construction and psychometric testing of the EMPATHIC questionnaire measuring parent satisfaction in the pediatric intensive care unit

Abstract PURPOSE: To construct and test the reliability and validity of the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire measuring parent satisfaction in the pediatric intensive care unit (PICU). METHODS: Structured development and psychometric testing of a parent satisfaction-with-care instrument with the results of two cohorts of parents (n = 2,046) from eight PICUs in the Netherlands. RESULTS: In the first cohort, 667/1,055 (63%) parents participated followed by 551/991 (56%) parents in the second cohort. The empirical structure of the instrument was established by confirmatory factor analysis with the first sample of parents confirming 65 statements within five theoretically conceptualized domains: information, care and cure, organization, parental participation, and professional attitude. The standardized factor loadings were greater than 0.40 in 63 statements. Cronbach's α, a measure of reliability, per domain ranged from 0.73 to 0.93 in both cohorts with no significant difference documenting the reliability over time. Beside rigorous content and face validity, the congruent validity of the instrument showed adequate correlation with four gold standard questions measuring overall satisfaction. The non-differential validity was confirmed with no significant differences between the population characteristics and the domains, except that parents with a child for a surgical admission were more satisfied on information issues. CONCLUSIONS: The final EMPATHIC questionnaire incorporates 65 statements. The empirical structure of the satisfaction statements and domains was satisfactory. The reliability and validity proved to be adequate. The EMPATHIC questionnaire is a valid quality performance indicator to measure quality of care as perceived by parents

Encountering the Victims of Romanian Communism: Young People and Empathy in a Memorial Museum

Many states in post-communist East-Central Europe have established memorial museums which aim to tell the story of suffering under the communist regime. They also seek to encourage visitors to develop empathy for the victims of communist repression.This paper explores the responses of a group of young people to a memorial museum in Romania (Sighet Memorial Museum), focusing on how these visitors experienced empathy for the victims of communist-era violence. Data were collected using focus groups. Most participants showed a degree of empa- thy for the victims of suffering but this was usually shallow in nature. However some visitors displayed more“active” empathy (characterized by deeper imaginative and cogni- tive engagement). The paper explores how both the design and environment of the museum and the back- ground experiences of visitors influenced the develop- ment of empathy. It argues that empathy is not an automatic response to suffering and instead can be con- sidered as an interaction between the design of the museum and the background knowledge of visitors. The paper argues that empathy is an important means for young people to participate in remembering the commu- nist period, and is a means to make“prosthetic”memories of an authoritarian past which they have not experienced first-hand

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

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Physiotherapy for people with dementia who fracture their hip

Outcomes for people with hip fracture are poor with approximately only 33% of people returning to their prior level of function and only 24% of people independently mobile by six months after hip fracture. The presence of dementia further worsens outcomes with a significantly increased risk of nursing home admission or death. Physiotherapy is a core treatment for people following surgery for hip fracture, yet there is little evidence to guide physiotherapists how to treat this population. The overall aim of this thesis was to determine the evidence surrounding the physiotherapy treatment for people with dementia following hip fracture and explore the experiences of those involved, thus leading to the development of an intervention which could be tested for feasibility. A series of four related studies were undertaken. The first of which was a scoping review which highlighted a paucity of evidence guiding the physiotherapy interventions for this population. Thirteen different databases were searched, with 26 articles being included in the review. Where there was evidence, there was a failure to describe the physiotherapy intervention. Consequently, two qualitative studies were undertaken. The first qualitative study explored the experiences of physiotherapists treating this population and involved semi-structured interviews with twelve physiotherapists. Physiotherapists cited resource pressures, historical reliance of biomedical practices and lack of knowledge as being the main barriers to adopting a person centred care approach that was described as a gold standard of care. The second study explored the experiences of six people with dementia (and five carers) receiving physiotherapy. Both studies concurred that the approach undertaken by the physiotherapist was often biomedical in nature and this failed to meet the needs of the person with dementia and did not reflect a person centred care approach that is suggested for this population. Patients and their carers reported the desire for treatment to be more person centred, but appreciated that physiotherapists were not able to deliver this. Data from the qualitative studies, in conjunction with existing biomedical evidence, informed the development of a logic model depicting a community based physiotherapy intervention for people with dementia following hip fracture. This formed the basis for the final stage of the thesis whereby a mixed-methods feasibility study was undertaken. The logic model incorporated the qualitative data and pre-existing physiological evidence in conjunction with components of behaviour change. The feasibility of recruiting to this study was poor, qualitative inquiry suggested that people with dementia were not being referred for on-going physiotherapy following discharge to the community setting. Failure to recruit to the study meant that testing of the intervention in a clinical setting was not possible. Further qualitative analysis proposed that people with dementia were being reported to have “no rehabilitation potential” in the acute setting as their assessment relied on biomedical measures of assessment. This label then prevented them from being offered further rehabilitation in community settings. Collectively, these series of studies suggested that the failure to approach people with dementia following hip fracture with a biopsychosocial approach, not only reduced their ability to improve, but actually prevented them from being given an opportunity to receive rehabilitation.National Institute for Health Research (NIHR

Admission decision-making in hospital emergency departments: the role of the accompanying person

In resource-stretched emergency departments, people accompanying patients play key roles in patients’ care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals’ standardization of the patient–carer relationship contrasted with accompanying persons’ varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients’ care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making