Patient deterioration : the effect of humans and systems in one health care system

The failure to recognise and to respond to adult deteriorating patients in general hospital wards leads to unexpected and potentially preventable deaths. Aims. 1. To improve the understanding of the clinical processes and influences involved in managing patient deterioration. 2. To examine the effect of a deteriorating patient intervention on clinical processes and patient outcome. 3. To determine if the effects of a deteriorating patient intervention are sustainable. Methods. Quantitative Studies. i. Observational Study: Clinical processes in 34 patients undergoing 45 Medical Emergency Team reviews were examined retrospectively. ii. lnterventional Study: A prospective controlled trial, before and after a multifaceted intervention for managing patient deterioration was undertaken in two wards in two hospitals for two{u00AD} four month periods. Changes in deteriorating patient clinical processes and outcome were measured. iii. Sustainability Study: Adult patients admitted to two wards in one hospital during three four{u00AD} month periods, one before, one immediately after the patient deterioration intervention and one two years later. Changes in deteriorating patient clinical processes and outcome were measured. Qualitative Studies. i. Behavioural Study: Interviews of 12 healthcare workers involved in the patient deterioration intervention were undertaken to generate a model of why behaviour changed with the installation of the multifaceted intervention for managing patient deterioration. Grounded theory methodology described on page 80 was used. ii. Human Element Study: Focus groups of healthcare workers were held to generate discussion and used to generate a model of the influences on healthcare professionals in managing patient deterioration. Grounded theory methodology was used. Results. Clinical processes for managing patient deterioration were found to be deficient. Deficiencies included infrequent documentation of vital signs, particularly respiratory rate and limited involvement of senior decision makers leaving junior clinicians to manage patient deterioration, which delayed appropriate treatment. The multifaceted intervention significantly improved patient outcome and improved behaviour such as documentation of vital signs, supported by a hospital policy, and timeliness of medical review, triggered by more confident nursing staff underpinned by objective evidence (the modified early warning score) of patient deterioration. Improvement in timeliness of medical review and documentation of vital signs were sustained two years later but patient hospital outcome and the nurses calling for further medical help were not. Further investigation of behaviours that were not sustained revealed that junior medical and nursing staff lacked adequate clinical experience to facilitate timely decision making necessitating input from their consultants. Timely and appropriate communication was hindered through fear, lack of confidence or lack of knowledge and poor consultant approachability. Conclusion. Identified shortcomings in the teamwork managing patient deterioration improved with the installation of a multifaceted intervention and, improved patient hospital outcome. Significant behavioural issues, especially communication with consultants, were identified as likely to hamper further improvement. In an age of shift work and reduced clinical experience, enhanced decision making will need a more intelligent system that can accurately detect patients at risk of patient deterioration and improved access to consultants to gain maximal benefit from the healthcare team

SEXUAL ABUSE OF DOCTORS BY DOCTORS PROFESSIONALISM COMPLEXITY AND THE POTENTIAL FOR HEALING

Contemporary attitudes to sexual abuse are changing. The Royal Commission into Institutional Responses to Child Sexual Abuse, the response of the Australian Defence Force to allegations of sexual abuse in the military and the work of the Australian Human Rights Commission around sexual harassment in the workplace all indicate a shift in community values. They also represent a shift in our understanding of the nature and scope of professionalism. As each respected institution has its professional failures exposed, it becomes obvious that no group is immune. Existing codes of professional conduct have not protected colleagues or clients from toxic behaviour

Australian Capital Territory COVID-19 Intensive Care Triage Principles and Process: Consumer, Carer, and Community Consultation Report

Executive Summary The ACT Clinical Health Emergency Coordination Centre engaged the research team in May 2020 to conduct a review of the ethical decision-making processes for allocating critical care resources should demand exceed supply during the global COVID-19 pandemic. ES.1 Methodology The methodology for this review broadly included undertaking a scoping review of ethical decision-making frameworks in other jurisdictions; a systematic review of consumer, carer, and community engagement in ethical decision-making frameworks; and a series of consultative processes. The outcomes from each of these activities were then integrated into the ACT Ethical Decision-Making Framework which had been drafted by the Clinical Ethics Committee of Canberra Health Services earlier in the pandemic. Based on a ‘Scoping Review of Ethical Decision-Making Frameworks’ and a ‘Systematic Review of Consumer Engagement in Ethical Decision-Making Frameworks’, a consultation process was developed whereby relevant consumer, carer, and community groups from across the ACT region were given a range of opportunities to provide input into what principles should form the basis of ethical decision-making in the context of COVID-19 should demand for acute care resources exceed capacity. ES.2 Recommendations The recommendations developed through analysis of the consultations are: 1. There should be a primacy of Human Rights underpinning decision-making processes, 2. Non-discrimination should be embedded in triage, 3. Triage should be primarily based on immediate health concerns (that is, with no assumptions or value judgements about people’s health conditions), 4. Triage processes should minimise bias, and 5. Triage processes should be transparent

"I can't make all this work." : end of life care provision in natural disasters : a qualitative study

Background: Natural disasters are becoming more frequent and severe and profoundly impact the end-of-life care experience, including service provision. There is a paucity of research examining healthcare workers’ experiences in responding to care demands when disasters strike. This research aimed to fill this gap by exploring end-of-life care providers’ perceptions of the impact of natural disasters on end-of-life care. Methods: Between Feb 2021-June 2021 ten in-depth semi-structured interviews were conducted with healthcare professionals providing end-of-life care during recent natural disasters, COVID-19, and/or fires and floods. Interviews were audio-recorded, transcribed, and analysed using a hybrid inductive and deductive thematic approach. Results: The overarching theme from the healthcare workers’ accounts was of being unable to provide effective compassionate and quality care - “I can’t make all this work.” They spoke of the considerable burdens the system imposed on them, of being overextended and overwhelmed, having their roles overturned, and losing the human element of care for those at end-of-life. Conclusion: There is urgent need to pioneer effective solutions to minimise the distress of healthcare professionals in delivering end-of-life care in disaster contexts, and to improve the experience of those dying

Long-term follow-up for Psychological stRess in Intensive CarE (PRICE) survivors:Study protocol for a multicentre, prospective observational cohort study in Australian intensive care units

Introduction There are little published data on the long-term psychological outcomes in intensive care unit (ICU) survivors and their family members in Australian ICUs. In addition, there is scant literature evaluating the effects of psychological morbidity in intensive care survivors on their family members. The aims of this study are to describe and compare the long-term psychological outcomes of intubated and non-intubated ICU survivors and their family members in an Australian ICU setting. Methods and analysis This will be a prospective observational cohort study across four ICUs in Australia. The study aims to recruit 150 (75 intubated and 75 non-intubated) adult ICU survivors and 150 family members of the survivors from 2015 to 2018. Long-term psychological outcomes and effects on health-related quality of life (HRQoL) will be evaluated at 3 and 12 months follow-up using validated and published screening tools. The primary objective is to compare the prevalence of affective symptoms in intubated and non-intubated survivors of intensive care and their families and its effects on HRQoL. The secondary objective is to explore dyadic relations of psychological outcomes in patients and their family members. Ethics and dissemination The study has been approved by the relevant human research ethics committees (HREC) of Australian Capital Territory (ACT) Health (ETH.11.14.315), New South Wales (HREC/16/HNE/64), South Australia (HREC/15/RAH/346). The results of this study will be published in a peer-reviewed medical journal and presented to the local intensive care community and other stakeholders.This work was supported by the ACT Health Private Practice Fund and Maurice Sando Foundation Sponsorship Scheme 2015 by a local competitive grant process

What are the long-term holistic health consequences of COVID-19 among survivors? An umbrella systematic review.

Many people who have survived COVID-19 have experienced negative persistent impacts on health. Impacts on health have included persistent respiratory symptoms, decreased quality of life, fatigue, impaired functional capacity, memory deficits, psychological impacts, and difficulties in returning to paid employment. Evidence is yet to be pooled to inform future directions in research and practice, to determine the physical, psychological, social, and spiritual impacts of the illness which extend beyond the acute phase of COVID-19 survivors. This umbrella review (review of systematic reviews) critically synthesized physical (including abnormal laboratory parameters), psychological, social, and spiritual impacts which extended beyond the acute phase of COVID-19 survivors. The search strategy was based on the sample, phenomena of interest, design, evaluation, research model and all publications were double screened independently by four review authors for the eligibility criteria. Data extraction and quality assessment were conducted in parallel independently. Eighteen systematic reviews were included, which represented a total of 493 publications. Sample sizes ranged from n = 15 to n = 44 799 with a total of n = 295 455 participants. There was incomplete reporting of several significant data points including the description of the severe acute respiratory syndrome coronavirus 2 variant, COVID-19 treatments, and key clinical and demographic data. A number of physical, psychological, and social impacts were identified for individuals grappling with post-COVID condition. The long term sequalae of acute COVID-19 and size of the problem is only beginning to emerge. Further investigation is needed to ensure that those affected by post-COVID condition have their informational, spiritual, psychological, social, and physical needs met in the future

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns.

BACKGROUND: Healthcare organisations often fail to harvest and make use of the 'soft intelligence' about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns. METHODS: Qualitative study involving personnel from three academic hospitals in two countries. Interviews were conducted with 165 participants from a wide range of occupational and professional backgrounds, including senior leaders and those from the sharp end of care. Data analysis was based on the constant comparative method. RESULTS: Leaders reported that they valued employee voice; they identified formal organisational channels as a key route for the expression of concerns by employees. Formal channels and processes were designed to ensure fairness, account for all available evidence and achieve appropriate resolution. When processed through these formal systems, concerns were destined to become evidenced, formal and tractable to organisational intervention. But the way these systems operated meant that some concerns were never voiced. Participants were anxious about having to process their suspicions and concerns into hard evidentiary facts, and they feared being drawn into official procedures designed to allocate consequence. Anxiety about evidence and process was particularly relevant when the intelligence was especially 'soft'-feelings or intuitions that were difficult to resolve into a coherent, compelling reconstruction of an incident or concern. Efforts to make soft intelligence hard thus risked creating 'forbidden knowledge': dangerous to know or share. CONCLUSIONS: The legal and bureaucratic considerations that govern formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. Leaders responsible for quality and safety should consider complementing formal mechanisms with alternative, informal opportunities for listening to concerns