Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study

Transitional medication management, in which individual needs are balanced against organizational priorities, is crucial for safe discharge processes. The aim of this study was to explore hospital nurses’ transitional medication management in the discharge of older patients with multi-morbidity. Using an ethnographic approach the data were collected through participant observations at a mixed medical ward at a Danish university hospital for two weeks. The participants were five registered nurses, responsible for nursing care of 23 patients with multi-morbidity and planned for discharge. The data comprised field notes that were analysed using iterative processes of domain, taxonomic and component analysis. The reporting adhered to the COREQ checklist. Hospital nurses’ transitional medication management was characterized by unpredictability and inconsistency in patient situations, fragmentation and discontinuity in working processes and complexity in communication systems. Special attention to nurses’ needs assessment skills and clinical decision making in caring for patients with multi-morbidity in a single focused healthcare system is required

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic

Abstract Background This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development. Methods We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctorsâ workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention. Results The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind. Conclusions The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic

Abstract Background This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development. Methods We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctorsâ workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention. Results The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind. Conclusions The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role

Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study

Transitional medication management, in which individual needs are balanced against organizational priorities, is crucial for safe discharge processes. The aim of this study was to explore hospital nurses’ transitional medication management in the discharge of older patients with multi-morbidity. Using an ethnographic approach the data were collected through participant observations at a mixed medical ward at a Danish university hospital for two weeks. The participants were five registered nurses, responsible for nursing care of 23 patients with multi-morbidity and planned for discharge. The data comprised field notes that were analysed using iterative processes of domain, taxonomic and component analysis. The reporting adhered to the COREQ checklist. Hospital nurses’ transitional medication management was characterized by unpredictability and inconsistency in patient situations, fragmentation and discontinuity in working processes and complexity in communication systems. Special attention to nurses’ needs assessment skills and clinical decision making in caring for patients with multi-morbidity in a single focused healthcare system is required

Additional file 1: of The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic

Paediatric education in a Danish context [ 36, 37 ]. (DOCX 86 kb

Decreasing trends, and geographical variation in outpatient antibiotic use: a population-based study in Central Denmark

Abstract Background Antimicrobial overuse and misuse of broad-spectrum antibiotics increases the risk for antimicrobial resistance. Investigating unwarranted variation in antibiotic prescription has therefore gained global priority. Methods We examined recent time trends in the utilization of narrow- and broad-spectrum antibiotics as well as the variation in antibiotic use by sex, age, and municipality of residence. Complete individual-level data on all redeemed out-of hospital prescriptions for antibiotics in the entire adult population of Central Denmark (1.3 million inhabitants) was obtained for the period 2006–2015. Results Following an initial increase of 2% between 2006 and 2011, the overall rate of redeemed prescriptions for antibiotics per 1000 person years declined by 17% between 2011 and 2015. Among persons aged over 65 years, the decline in use began later (from 2013) and was less pronounced. Antibiotic use in 2015 remained substantially higher among females (289/1000 person-years) vs. males (182/1000 person-years) and among the very old (520/1000 person-years in >85y old) vs. middle-aged (204/1000 person-years in 45-65y old). A decreasing trend in antibiotic use over time was observed in all municipalities, mainly due to a decrease in narrow-spectrum antibiotics. However, a striking and unexplained 1.6-fold geographical variation in antibiotic use, including tetracyclines, macrolides and fluoroquinolones remained in 2015. Of concern, among females aged ≥65 years and males aged ≥85 years, a continuous increasing trend in broad-spectrum antibiotic use was observed. Conclusions Antibiotic use has decreased almost 20% in Central Denmark after 2011, possibly related to a nationwide antibiotic stewardship program in Denmark. However, substantial geographical variation in antibiotic prescription remains and the use of broad-spectrum antibiotics has increased in adults of older age. Continuous focus on avoiding unnecessary use of broad-spectrum antibiotics is requested

Repeated ambulance use is associated with chronic diseases - a population-based historic cohort study of patients’ symptoms and diagnoses

Abstract Background There is a growing demand for emergency medical services (EMS) and patients are repeatedly transported by ambulance services. For many patients, especially those with chronic disease, there may be better ways of delivering care. We examined the symptom at time of emergency call and the hospital diagnosis for those ambulance users who repeatedly received an ambulance. Methods Population-based historic cohort study of patients receiving an ambulance after an emergency call between 2011 and 2014: one-time users (i.e. one ambulance run in any 12 month period) were compared to two-time users (two runs in any 12 month period) and frequent users (>two runs). The presenting symptom according to the Danish Index for Emergency Care from the EMS calls and the hospital ICD-10 discharge diagnoses were obtained from patient records. Results We included 52 533 patients (65 932 emergency ambulance runs). Repeated users constituted 16% of the patients (two-time users 11% and frequent users 5%) and one third of all ambulance runs. The symptoms showing the largest increase in frequency with increasing ambulance use were breathing difficulty (N = 3 905–15% were frequent users); seizure (N = 2 437–10% were frequent users), chest pain (N = 7 616–17% were frequent users), and alcohol intoxication (N = 1 998–5% were frequent users). The hospital diagnoses with a corresponding increase were respiratory diseases (N = 4 381) - 13% were frequent users), mental disorders (predominately abuse of alcohol) (N = 3 087–10% were frequent users) and neurological diseases (predominately epilepsy) (N = 2 207–6% were frequent users). 5% of one-time users, 12% of two-time users and 16% of frequent users had a Charlson Comorbidity Index > = 3. Conclusion Repeated use of ambulance services was common and associated with chronic health problems such as chronic respiratory diseases, epilepsy, mental disorders with alcohol abuse and comorbidity. Alternative methods of caring for many of these patients should be considered. Trial registration None

Additional file 2 of Validation of retail food outlet data from a Danish government inspection database

Additional file 2. List of search terms and characteristics for identification, location and classification of food outlets in the Smiley Register; Search terms are mainly given for the moderate definitions. Further, search terms are given for coffee shops that are included in the broad definitions of restaurants and fast food

Repeated ambulance use is associated with chronic diseases - a population-based historic cohort study of patients’ symptoms and diagnoses

Abstract Background There is a growing demand for emergency medical services (EMS) and patients are repeatedly transported by ambulance services. For many patients, especially those with chronic disease, there may be better ways of delivering care. We examined the symptom at time of emergency call and the hospital diagnosis for those ambulance users who repeatedly received an ambulance. Methods Population-based historic cohort study of patients receiving an ambulance after an emergency call between 2011 and 2014: one-time users (i.e. one ambulance run in any 12 month period) were compared to two-time users (two runs in any 12 month period) and frequent users (>two runs). The presenting symptom according to the Danish Index for Emergency Care from the EMS calls and the hospital ICD-10 discharge diagnoses were obtained from patient records. Results We included 52 533 patients (65 932 emergency ambulance runs). Repeated users constituted 16% of the patients (two-time users 11% and frequent users 5%) and one third of all ambulance runs. The symptoms showing the largest increase in frequency with increasing ambulance use were breathing difficulty (N = 3 905–15% were frequent users); seizure (N = 2 437–10% were frequent users), chest pain (N = 7 616–17% were frequent users), and alcohol intoxication (N = 1 998–5% were frequent users). The hospital diagnoses with a corresponding increase were respiratory diseases (N = 4 381) - 13% were frequent users), mental disorders (predominately abuse of alcohol) (N = 3 087–10% were frequent users) and neurological diseases (predominately epilepsy) (N = 2 207–6% were frequent users). 5% of one-time users, 12% of two-time users and 16% of frequent users had a Charlson Comorbidity Index > = 3. Conclusion Repeated use of ambulance services was common and associated with chronic health problems such as chronic respiratory diseases, epilepsy, mental disorders with alcohol abuse and comorbidity. Alternative methods of caring for many of these patients should be considered. Trial registration None

Additional file 1: of Repeated ambulance use is associated with chronic diseases - a population-based historic cohort study of patients’ symptoms and diagnoses

Age distribution among symptom groups. Histograms showing the distribution of age as percentage among the included symptom groups. (TIF 1025 kb