Making the link : multi-professional care for acutely ill deteriorating patients : a constructivist grounded theory approach

The potential for decline in acutely ill and injured patients is ever-present. Rapid response systems exist to facilitate timely actions, but there are continued concerns over failure to rescue. Currently there is little understanding of what happens in ward areas when deterioration occurs and how it is recognised and managed. This study aimed to explore what happens when patients deteriorate, how professionals work together, define and communicate deterioration and make sense of what they say and do. Using constructivist grounded theory; data was gathered over 12 months from 33 multi-professional participants on three wards in one hospital. Data analysis, concurrent with collection, utilised theoretical sampling to identify further sources of data. Constant comparison was used to develop codes and concepts from the transcripts, and NVivo© software facilitated data organisation and an audit-trail. During 26 interviews and 48 hours of observation, 85 cases of patient deterioration were identified. Four concepts emerged from the analysis, 1) being vigilant through surveillance, 2) identifying deterioration and recognising urgency, 3) taking action by escalating and responding, 4) taking action by treating, all connected by a core concept, making the link. The need for support, use of subjective and objective indicators, competing priorities and hierarchical issues influenced the process but application of knowledge was crucial for making the link. Collectively knowing the patient and sharing this multi-professional knowledge was key to making the link and the nurse was ideally placed to facilitate a shared mental model of deterioration across the team. New elements were identified: lay person vigilance, where significant others contributed to the rescue process; and fear of harming patients by a rescue intervention was revealed as a barrier to treating deterioration. Recommendations included protecting and prioritising resources for surveillance, valuing subjectivity and the input of all levels of staff

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation A Report From the GARFIELD-AF Registry

IMPORTANCE Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes