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

Measuring non-technical skills in medical emergency care: a review of assessment measures.

Aim: To review the literature on non-technical skills and assessment methods relevant to emergency care. Background: Non-technical skills (NTS) include leadership, teamwork, decision making and situation awareness, all of which have an impact on healthcare outcomes. Significant concerns have been raised about the rates of adverse medical events, many of which are attributed to NTS failures. Methods: Ovid, Medline, ProQUEST, PsycINFO and specialty websites were searched for NTS measures using applicable access strategies, inclusion and exclusion criteria. Publications identified were assessed for relevance. Results: A range of non-technical skill measures relevant to emergency care was identified: leadership (n = 5), teamwork (n = 7), personality/behavior (n = 3) and situation awareness tools (n = 1). Of these, 9 have been used with emergency care populations/clinicians. All had varying degrees of reliability and validity. In the last decade there has been some development of teamwork measures specific to emergency care with a predominantly global and collective rating of broad skills. Conclusion: A variety of non-technical skill measures are available; only a few have been used in the emergency care arena. There is a need for an increase in the focused assessment of teamwork skills for a greater understanding of team performance to enhance patient safety in medical emergency care

Nurses’ knowledge, experience and self-reported adherence to evidence-based guidelines for prevention of ventilator-associated events: A national online survey

Objective: To explore Australian intensive care nurses' knowledge of ventilator-associated pneumonia and self-reported adherence to evidence-based guidelines for the prevention of ventilator-associated events. Design: A quantitative cross-sectional online survey was used. Setting: The study was conducted in two Australia intensive care units, in large health services in Victoria and an Australia-wide nurses' professional association (Australian College of Critical Care Nurses). Main outcome measures: Participants' knowledge and self-reported adherence to evidence-based guidelines. Results: The median knowledge score was 6/10 (IQR: 5-7). There was a significant positive association between completion of post graduate qualification and their overall knowledge score p = 0.014). However, there was no association (p = 0.674) between participants' years of experience in intensive care nursing and their overall score. The median self-reported adherence was 8/10 (IQR: 6-8). The most adhered to procedures were performing oral care on mechanically ventilated patients (n = 259, 90.9%) and semi-fowlers positioning of the patient (n = 241, 84.6%). There was no relationship between participants' knowledge and adherence to evidence-based guidelines (p = 0.144). Conclusion: Participants lack knowledge of evidence-based guidelines for the prevention of ventilator-associated pneumonia. Specific education on ventilator-associated events may improve awareness and guideline adherence.This article is available to RD&E staff via NHS OpenAthens. Click on the Publisher URL to access it via the publisher's site.published version, accepted version (12 month embargo

Women's experiences of managing digitation: do we ask enough in primary care?

The aim of this paper was to consider the available evidence for the current management of pelvic organ prolapse, which is a common presentation in primary care. However, not all women will present, only presenting when symptoms become bothersome. Particular attention was paid to understanding the problem of rectocele and its influence on obstructive defaecation symptoms. The burden of rectocele and its consequences are not truly known. Furthermore, healthcare professionals may not always enquire about bowel symptoms and patients may not disclose them. Complex emotions around coping and managing stress add to the challenges with seeking healthcare. Therefore, the impact on the lived experience of women who have difficulty with rectal emptying can be significant. The review identified a dearth of knowledge about women living with the problem of obstructive defaecation resulting in the use of digitation. Improving the management of digitation, an under-reported problem, is necessary to improve the quality of life for women. Primary care needs to increase access to conservative measures for women struggling with bothersome symptoms, such as constipation, the need to digitate or anxiety

Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done

AbstractBackgroundAppropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process.MethodsThirty Applied Cognitive Task Analysis interviews were conducted with clinical experts (> 4 years' experience) including Ward Nurses (n = 7), Outreach or Sepsis Nurses (n = 8), Nurse Manager or Consultant (n = 6), Physiotherapists (n = 4), Advanced Practitioners (n = 4), and Doctor (n = 1) from two National Health Service hospitals and analysed using Framework Analysis. Task-related elements of care escalation were identified and represented in a Functional Resonance Analysis Model.FindingsThe NEWS2's clinical escalation response constitutes eight unique tasks and illustrates work-as-prescribed, but our interview data uncovered an additional 24 tasks (n = 32) pertaining to clinical judgement, decisions or processes reflecting work-as-done. Over a quarter of these tasks (9/32, 28 %) were identified by experts as cognitively challenging with a high likelihood of performance variability. Three out of the nine variable tasks were closely coupled and interdependent within the Functional Resonance Analysis Model (‘synthesising data points’, ‘making critical decision to escalate’ and ‘identifying interim actions’) so representing points of potential escalation failure. Data assimilation from different clinical information systems with poor usability was identified as a key cognitive challenge.ConclusionOur data support the emphasis on the need to retain clinical judgement and suggest that future escalation protocols and audit guidance require in-built flexibility, supporting staff to incorporate their expertise of the patient condition and the clinical environment. Improved information systems to synthesise the required data surrounding an unwell patient to reduce staff cognitive load, facilitate decision-making, support the referral process and identify actions are required. Fundamentally, reducing the cognitive load when assimilating core escalation data allows staff to provide better and more creative care.Study registration (ISRCTN 38850) and ethical approval (REC Ref 20/HRA/3828; CAG-20CAG0106)

Early Sepsis in Children Assessment by Parents: an Evaluation

Sepsis is one of the leading causes of death in children worldwide. The death rate among children caused by sepsis is around 10-20% globally. No figures are available in the UK about the number of deaths in children who suffered from sepsis. However, fever often indicates the onset of an infection or sepsis in children. Current figures indicate that parent-reported symptoms of fever in their child range between 20-40% and fever is the second most common cause of a child’s hospital admission. Although most children with fever suffer from a viral infection, it could be possible that a child is suffering from a serious bacterial infection (sepsis). Thus, early recognition of signs and symptoms of sepsis is crucial and influences the survival of children. Two interventions have been developed to improve early sepsis recognition in children: the Sepsis Assessment & Management (SAM) leaflet for parents and the Desktop SAM application for General Practitioners (GPs). Both tools have been designed to connect the observations of the parents to the observations of the GPs and to support a common language understanding each other observations. The SAM leaflet uses amber and red fields to look for signs and symptoms: (1) Colour, (2) Activity, (3) Breathing, (4) Circulation, (5) Temperature & Body, and (6) Vomiting, Diarrhoea and Hydration. The leaflet also provided details regarding who to contact in case symptoms appear in the amber or red areas. Similar features are incorporated in the Desktop SAM. Both interventions were based on the NICE guideline ‘Feverish illness in children’ and developed with a large group of stakeholders, including parents. This project aimed to evaluate the feasibility and pilot the implementation of the SAM leaflet and the Desktop SAM. Specifically, the objectives were to evaluate the use of the SAM leaflet by parents and GPs, and to evaluate the application and effectiveness of the Desktop SAM at GP practices. The methods used in the project were online surveys for parents and GPs and interviews with GPs. The survey for parents included questions about the experiences of using the SAM leaflet, their experiences with a GP visit, and also a standard questionnaire about the empowerment of families related to the health services of their children. The survey of the GPs asked questions about the use of the Desktop SAM application, the content, and how it helped them in making decisions about diagnosis and management of the sick child. In total, 77 parents completed the online survey. Of these, 12 parents completed the questions related to the SAM leaflet, 66 parents completed the GP questions and 49 parents completed the questions about family empowerment. The parents were positive about the SAM leaflet and found the leaflet useful, as one parent wrote: ‘Very useful for deciding whether to get further advice or not’. The majority of the parents were satisfied with their GP visit and they were treated with respect and giving enough time. The parents who responded to the family empowerment questions felt fairly confident about their child health services. However, 24% of the parents stated ‘sometimes’ when asked if they know what services their child needs. This was in line with the question if parents have a good understanding of the health service system for their child; only 18% of the parents stated ‘very often’ on this topic. Therefore, the SAM leaflet might provide guidance to parents to contact the right health service at the right time, in order for their child to receive the right care. The GP survey revealed a positive attitude toward the Desktop SAM. Nearly 70% of the GPs found that the Desktop SAM contributed to their clinical assessment. More than 60% of the GP were positive about the Desktop SAM and thought this application assists them in clinical decision-making. Some suggestions were made to improve the Desktop Sam, which were mostly related to adding space for notes of the overall history taking and management plan. The interviews with the GPs revealed that there was an overall positive experience about the usability of the Desktop SAM. The application was found to be easy for data entry and was seen as a good ‘prompt’ tool. Also, the GPs found that the Desktop SAM provided a good reference for supporting parents, particular the option to print the SAM leaflet directly from the application and discuss the leaflet with the parent. Although this project has some limitations, such as the number of parents and GPs responding to the surveys, it is believed that the SAM leaflet and Desktop SAM can play a key-role in recognising early sepsis and timely treatment of sick children. Therefore, the recommendations are related to further implementation of the SAM leaflet and the Desktop SAM on a regional and national level. Recommendations for SAM leaflet: 1. Develop a strategy to implement the SAM leaflet with a clear pathway to increase the awareness of the leaflet in the wider public, with a special focus on parents. 2. Develop an educational strategy for parents and healthcare professionals to increase the knowledge and understanding of the SAM leaflet. 3. Evaluate the SAM leaflet by assessing the effectiveness, understanding the change when using the SAM leaflet, and assess the cost-effectiveness. Recommendations for Desktop SAM: 1. Develop a strategy to implement the Desktop SAM in healthcare settings. 2. Develop an educational strategy for healthcare professionals to increase the knowledge and understanding of the Desktop SAM. 3. Evaluate the Desktop SAM by assessing the effectiveness, understanding the decision-making processes, and assess the cost-effectiveness. The development of the SAM leaflet and Desktop SAM was prompted by the tragic death from sepsis of a 3 year old child called Sam. The wider implementation and dissemination of the SAM leaflet and Desktop SAM needs to be undertaken by a collaborative network of parents, healthcare professionals, and other stakeholders. After all, parents, healthcare professionals, the NHS, the public, and politicians do not want to experience a so-called ‘never event’ again with the result of an unnecessary death of a child

The Experiences of Specialist Nurses Working Within the Uro-oncology Multidisciplinary Team in the United Kingdom.

PURPOSE: United Kingdom prostate cancer nursing care is provided by a variety of urology and uro-oncology nurses. The experience of working in multidisciplinary teams (MDT) was investigated in a national study. DESIGN: The study consisted of a national survey with descriptive statistics and thematic analysis. METHODS: A secondary analysis of a data subset from a UK whole population survey was undertaken (n = 285) of the specialist nursing workforce and the services they provide. Data were collected on the experience of working in the MDT. RESULTS: Forty-five percent of the respondents felt that they worked in a functional MDT, 12% felt that they worked in a dysfunctional MDT, and 3.5% found the MDT meeting intimidating. Furthermore, 34% of the nurses felt that they could constructively challenge all members of the MDT in meetings. Themes emerging from open-ended questions were lack of interest in nonmedical concerns by other team members, ability to constructively challenge decisions or views within the meeting, and little opportunity for patients' wishes to be expressed. CONCLUSIONS: Despite expertise and experience, nurses had a variable, often negative, experience of the MDT. It is necessary to ensure that all participants can contribute and are heard and valued. More emphasis should be given to patients' nonmedical needs

Outcomes sensitive to critical care nurse staffing levels: A systematic review protocol

The data set consists of the Systematic Review protocol. when the Review is complete a link to the full publication and associated data files will be added.Variation in nurse staffing levels have been linked to outcomes such as patient mortality and nurse burnout. However, previous reviews on staffing have either excluded critical care settings or focused on other settings such as acute care. Other reviews have narrowed their scope to include only specific outcomes, such as renal anaemia but it is possible that further patient outcomes may be more appropriate for the ICU setting. This review will therefore identify outcomes sensitive to nurse staffing levels in critical care. The objective of this review is to identify outcomes sensitive to variations in nurse staffing levels in critical care