Is critical care service relevant to Iran’s hospital care?

The numbers of acutely ill patients (AIP) are admitted in general hospital wards increased. The failing to identify, manage and deliver timely and optimal care to AIPs may lead to catastrophic outcomes. A qualitative study aimed to define the current state of AIPs in Iranian hospitals showed the flaws and shortcomings in the current services for identifying and managing AIPs. An evaluation study was designed to explore the potential impact of Critical Care Service (CCS) in an Iranian University Hospital. The study design was a Stepped-Wedge Cluster Randomized Controlled Trial. The study included, for each ward, an unexposed to the intervention, training, and an exposed to the intervention phase. The data was analyzed using three methods: all patients, matched randomized and before-after. The null-hypothesis was tested using the mixed effect logistic regression, linear mixed and the mixed effects models. The results showed that there are no significant differences in mortality, CPR, ICU admission and length of stay. A second qualitative to find the views of staffs toward the CCS indicated that the CCS had several favorable effects, however; overcoming contextual problems in the hospital, prior to implementation of CCS, may facilitate its implementation

Early warning systems and rapid response to the deteriorating patient in hospital: a realist evaluation.

AIM: To identify those contexts and mechanisms that enable or constrain the implementation of Rapid Response Systems on acute general hospital wards to recognise and respond to patient deterioration. BACKGROUND: Rapid Response Systems allow deteriorating patients to be recognised using Early Warning Systems, referred early via escalation protocols and managed at the bedside by competent staff. DESIGN: Realist Evaluation. METHODS: The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland which followed the principles of Realist Evaluation. We used various mixed methods including individual and focus group interviews, observation of nursing practice between June - November 2010 and document analysis of Early Warning Systems audit data between May - October 2010 and hospital acute care training records over 4.5 years from 2003-2008. Data were analysed using NiVivo8 and SPPS. RESULTS: A cross case analysis highlighted similar patterns of factors which enabled or constrained successful recognition, referral and response to deteriorating patients in practice. Key enabling factors were the use of clinical judgement by experienced nurses and the empowerment of nurses as a result of organisational change associated with implementation of Early Warning System protocols. Key constraining factors were low staffing and inappropriate skill mix levels, rigid implementation of protocols and culturally-embedded suboptimal communication processes. CONCLUSION: Successful implementation of Rapid Response Systems was dependent on adopting organisational and cultural changes that facilitated staff empowerment, flexible implementation of protocols and ongoing experiential learning. This article is protected by copyright. All rights reserved

Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review.

AIM: To determine the Rapid Response System programme theory and investigate how the mechanisms of implementation and the characteristics of context combine to enable or constrain the implementation of Rapid Response Systems and the achievement of desired outcomes. BACKGROUND: Rapid Response Systems have been implemented internationally to improve the recognition and management of patient deterioration, reduce the need for cardiopulmonary resuscitation and improve patient outcomes. DESIGN: Realist review. DATA SOURCES: We searched DARE, CENTRAL, NHSEED, MEDLINE, Medline In Process, EMBASE, CINAHL, PubMed, Scopus, The Web of Science and PychInfo databases from 1997 - 2017 in addition to purposively searching the grey literature looking for articles supporting, refuting or explaining Rapid Response System programme theories. REVIEW METHODS: Included studies were critically appraised and graded using the Critical Appraisal Skills Programme tool. Data extraction and synthesis investigated the Rapid Response System theoretical propositions against the empirical evidence to refine Rapid Response System programme theories. RESULTS: The review found that the Rapid Response System programme theory achieved desired outcomes when there were sufficient skills mix of experienced staff, EWS protocols were used flexibly alongside clinical judgement and staff had access to ongoing, multiprofessional, competency-based education. However, ward cultures, hierarchical referral systems, workload and staffing resources had a negative impact on the implementation of the Rapid Response System. CONCLUSION: To improve the recognition and management of patient deterioration, policymakers need to address those cultural, educational and organizational factors that have an impact on the successful implementation of Rapid Response Systems in practice

Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety

Errors prevention and patient safety in transfusion medicine are a serious concern. Errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. Root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. To specify system vulnerabilities and illustrate the potential of such an approach, we describe the root cause analysis of a case of transfusion error in emergency ward that could have been fatal. After reporting of the mentioned event, through reviewing records and interviews with the responsible personnel, the details of the incident were elaborated. Then, an expert panel meeting was held to define event timeline and the care and service delivery problems and discuss their underlying causes, safeguards and preventive measures. Root cause analysis of the mentioned event demonstrated that certain defects of the system and the ensuing errors were main causes of the event. It also points out systematic corrective actions. It can be concluded that health care organizations should endeavor to provide opportunities to discuss errors and adverse events and introduce preventive measures to find areas where resources need to be allocated to improve patient safety

Effectiveness of regionalization of trauma care services: a systematic review

Objectives Improving trauma systems in various forms has always been an important aspect of health policy. While several papers have reported the implementation of a structured trauma system of care, research evidence on the effectiveness of such regionalization for improvement in trauma outcome is limited. Study design Systematic review. Method Medline, EMbase, EconLit and Health Management Information Consortium were searched, using sensitive search terms, for interventional studies that reported a trauma regionalization system as their intervention, and compared important outcomes such as mortality and preventable deaths. At least two authors assessed eligibility for inclusion and risk of bias, and extracted data from the included studies. As meta-analysis was not possible for all studies, two controlled before–after studies were included in the meta-analysis, and a narrative analysis was conducted for the other studies. Results After title and abstract sifting, 66 papers were retrieved. After reading the full texts, a total of 24 studies from the USA, UK, Canada, Australia, and the Netherlands were included in this review. In spite of variation in study specifications, most were before–after studies with a high risk of bias. Although a reduction in mortality was shown in most studies, only two studies were eligible for meta-analysis, and the results showed a significant reduction in mortality after implementation of an organized trauma system (odds ratio 0.840, 95% confidence interval 0.756–0.924; P = 0.00). Conclusion Correlation was found between a regionalized network of trauma care and a reduction in trauma-related mortality, based on studies that did not exclude the effects of other concurrent changes on observed reductions. It is recommended that more studies with robust research designs should be conducted in a more diverse range of countries to assess the effectiveness of regionalization. Despite this limitation, the present findings support the regionalization of trauma care services

Views of patients undergo hematopoietic stem cell transplantation on their basic needs

Background: Today, hematopoietic stem cells transplantation (HSCT) has been accepted as a therapeutic approach and is widely applied in many patients with disorders of hematopoietic systems or patients with malignancies. Concomitant use of this therapeutic approach with long term chemotherapeutic procedures and hospitalization requires special care. This study was conducted to examine basic needs of patients after HSCT. Methods: In this study, 171 hospitalized patients were selected after transplantation, using convenience sampling method. They completed a questionnaire formulated on the basis of Yura and Walsh Theory of Basic Needs. Results: Most of the needs reported in the areas of vital functions, functional health status, and reaction to functional health status were chills (76.8), insomnia (68.5), and dissatisfaction with changes of lifestyle/habits (53.6), respectively. Furthermore, 94.1 of the patients were aware of their disease. Conclusion: This study identified a broad spectrum of the needs in HSCT patients. Given the importance of determining needs to reach a thorough nursing care, paying attention to the provided list can facilitate the achievement of the goals of the care program for these patients