Creating spaces in intensive care for safe communication : a video-reflexive ethnographic study

The built environment in acute care settings is a new focus in patient safety research, with few studies focusing primarily on the design of ward environments and the location and choice of material objects such as light fittings and hand-washing basins.

Findings of the first ANZICS conference on the role of intensive care in Rapid Response Teams.

Rapid Response Teams (RRTs) are specialised teams introduced into hospitals to improve the outcomes of deteriorating ward patients. Although Rapid Response Systems (RRSs) were developed by the intensive care unit (ICU) community, there is variability in their delivery, and consultant involvement, supervision and leadership appears to be relatively infrequent. In July 2014, the Australian and New Zealand Intensive Care Society (ANZICS) convened the first conference on the role of intensive care medicine in RRTs in Australia and New Zealand. The conference explored RRSs in the broader role of patient safety, resourcing and staffing of RRTs, effect on ICU workload, different RRT models, the outcomes of RRT patients and original research projects in the area of RRSs. Issues around education and training of both ICU registrars and nurses were examined, and the role of team training explored. Measures to assess the effectiveness of the RRS and RRT at the level of health system and hospital, team performance and team effectiveness were discussed, and the need to develop a bi-national ANZICS RRT patient database was presented. Strategies to prevent patient deterioration in the 'pre-RRT' period were discussed, including education of ward nurses and doctors, as well as an overarching governance structure. The role of the ICU in deteriorating ward patients was debated and an integrated model of acute care presented. This article summarises the findings of the conference and presents recommendations on the role of intensive care medicine in RRTs in Australia and New Zealand.

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.

BACKGROUND: Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback METHODS/DESIGN: A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.

Investigating the efficacy of an intelligent operation planning and support tool for acute healthcare contexts

Nurses are the largest group of healthcare professionals in hospitals providing 24-hour care to patients. Hence, nurses are pivotal in coordinating and communicating patient care information in the complex network of healthcare professionals, services and other care processes. Yet, despite nurses' central role in health care delivery, intelligent systems have historically rarely been designed around nurses' operational needs. This could explain the poor integration of technologies into nursing work processes and consequent rejection by nursing professionals. The complex nature of acute care delivery in hospitals and the frequently interrupted patterns of nursing work suggest that nurses require flexible intelligent systems that can support and adapt to their variable workflow patterns. This study is designed to explore nurses' initial reactions to a new intelligent operational planning and support tool (IOPST) for acute healthcare. The following reports on the first stage of a longitudinal project to use an innovative approach involving nurses in the development of the IOPST; from conceptualization to implementation.

Preventive social health programs : are they Australia's answer to rising health care costs in rural communities?

Although we have good evidence to support the notion that early intervention, prevention and community education programs can mitigate the impact of preventable disease, expanded primary health care is also being promoted by Australian governments as a panacea for reducing growth in demand generally. While preventive programs do reduce acute demand, they may not do so the extent that resources, currently allocated to the acute sector, can be substituted to provide the additional primary care services necessary to reduce acute demand permanently. These developments have particular relevance for rural and isolated communities where access to acute services is already very limited. What appears to be occurring, in rural South Australia at least, is that traditional acute services are being reduced and replaced with lower level care and social intervention programs. This is well and good, but eventually the acute care being provided in rural health units now will still need to be provided by other units elsewhere and probably at much higher cost to the system and to consumers. Where rural communities have previously managed much of their own acute service demand, they may now be forced to send patients to more distant centres for care but at much greater social and economic cost to individuals and the system.

Patient participation in postoperative care activities in patients undergoing total knee replacement surgery: multimedia intervention for managing patient experience (MIME). Study protocol for a cluster randomised crossover trial

BACKGROUND: Patient participation is an important indicator of quality care. Currently, there is little evidence to support the belief that participation in care is possible for patients during the acute postoperative period. Previous work indicates that there is very little opportunity for patients to participate in care in the acute context. Patients require both capability, in terms of having the required knowledge and understanding of how they can be involved in their care, and the opportunity, facilitated by clinicians, to engage in their acute postoperative care. This cluster randomised crossover trial aims to test whether a multimedia intervention improves patient participation in the acute postoperative context, as determined by pain intensity and recovery outcomes.

METHODS/DESIGN: A total of 240 patients admitted for primary total knee replacement surgery will be invited to participate in a cluster randomised, crossover trial and concurrent process evaluation in at least two wards at a major non-profit private hospital in Melbourne, Australia. Patients admitted to the intervention ward will receive the multimedia intervention daily from Day 1 to Day 5 (or day of discharge, if prior). The intervention will be delivered by nurses via an iPad™, comprising information on the goals of care for each day following surgery. Patients admitted to the control ward will receive usual care as determined by care pathways currently in use across the organization. The primary endpoint is the "worst pain experienced in the past 24 h" on Day 3 following TKR surgery. Pain intensity will be measured using the numerical rating scale. Secondary outcomes are interference of pain on activities of daily living, length of stay in hospital, function and pain following TKR surgery, overall satisfaction with hospitalisation, postoperative complications and hospital readmission.

DISCUSSION: The results of this study will contribute to our understanding of the effectiveness of interventions that provide knowledge and opportunity for patient participation during postoperative in-hospital care in actually increasing participation, and the impact of participation on patient outcomes. The results of this study will also provide data about the barriers and enablers to participation in the acute care context.

Risk factors for incident delirium in an acute general medical setting: a retrospective case – control study

Aims and ObjectivesTo determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission.BackgroundIncident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients that are most susceptible to incident delirium.DesignRetrospective case-control study with two controls per case.MethodsAn audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data was collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1st January 2012 and 31st December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation.ResultsIdentified using logistic regression modelling, predisposing risk factors for incident delirium were: dementia, cognitive impairment, functional impairment, previous delirium, and fracture on admission. Precipitating risk factors for incident delirium were: use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission.ConclusionsMultiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation.Relevance to clinical practiceNurses and other health care professionals should be aware of patients that have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

Challenging the handover : recommendations for research and practice

Communicating nursing care during the patient's total hospital stay is a difficult task to achieve within the context of high patient turnover, a lack of overlap time between shifts, and time constraints. Clear and accurate communication is pivotal to delivering high quality care and should be the gold standard in any clinical setting. Handover is a commonly used communication medium that requires review and critique. This study was conducted in five acute care settings at a major teaching hospital. Using a grounded theory approach, it explored the use of three types of handover techniques (verbal in the office, tape-recorded, and bedside handovers). Data were obtained from semi-structured interviews with nurses and participant field observations. Textual data were managed using NUD-IST. Transcripts were critically reviewed and major themes identified from the three types of handovers that illustrated their strengths and weaknesses. The findings of this study revealed that handover is more than just a forum for communicating patient care. It is also used as a place where nurses can debrief, clarify information and update knowledge. Overall, each type of handover had particular strengths and limitations; however, no one type of handover was appraised as being more effective. Achieving the multiple goals of handover presents researchers and clinicians with a challenging task. It is necessary to explore more creative ways of conducting the handover of patient care, so that an important aspect of nursing practice does not get classified as just another ritual.

Work context, personal control, and burnout amongst nurses

While situational factors such as high workloads have been found to be predictive of burnout, not all people in the same work context develop burnout. This suggests that individual factors are implicated in susceptibility to burnout. We investigated the relationships between care type (acute/chronic), neuroticism, control (primary/secondary), and symptoms of burnout (exhaustion, cynicism, and reduced professional efficacy) amongst 21 chronic care nurses and 83 acute care nurses working in a public hospital in regional Australia. Similar levels of burnout symptomatology and neuroticism were found in each group of nurses, and neuroticism was found to be associated with exhaustion, cynicism, and reduced professional efficacy in the total sample of nurses. Our prediction that primary control would protect against burnout symptoms in acute care nurses was supported only for professional efficacy, and the prediction that secondary control would protect against burnout in chronic care nurses was not supported.

The impetus for the development of hospital in the home (HITH) programs: a literature review

Alternative health care delivery models such as Hospital in the Home (HITH) are proliferating in Australia and in most Western countries. Such models facilitate patients who would otherwise be hospitalised to be cared for in their own homes. This paper reports a review of the literature related to the development of HITH programs. It reveals that the driving force behind the implementation of acute care programs comes from political and managerial aims to reduce health care spending. Home is clearly an appropriate care option for certain acute patients however, there is no strong evidence to suggest that it suits everyone. Very little attention has been given to the patient's experience of home care and the ethical and social consequences are largely ignored.

The reliability of clinical indicators of oxygenation: a literature review

Despite oxygen being one of the most frequently administered substances in the hospital environment, there is little empirical data regarding its use. Review of the literature regarding the clinical assessment of hypoxia and hypoxaemia reveals inconsistency in the definition of terms and raises questions as to the reliability of the clinical indicators currently used to assess the need for supplemental oxygen. Assessment of the need for supplemental oxygen and continued re-evaluation of the patient's oxygen requirements is a nursing responsibility. Physical assessment, in combination with pulse oximetry, is the most common method used by nurses to assess oxygenation status. This paper critically appraises the literature to examine the reliability of clinical indicators of oxygenation used by nurses in acute care settings.

A trial of nurse practitioner scope of practice

Aims. The aim of this paper is to report a trial to investigate the feasibility of the nurse practitioner role in local health service delivery and to provide information about the educational and legislative requirements for nurse practitioner practice.

Background. Nurse practitioners have been shown to offer a beneficial service and fill a gap in health care provision. However, the lack of publications describing, critiquing, or defending the way that existing nurse practitioner roles have been developed may lead to a lack of clarity in comparing the nurse practitioner scope of practice internationally. In Australia, credible exploratory research is needed to realize the potential of nurse practitioners to bridge the divide of inequitable distribution of health services. A trial of nurse practitioner services in the Australian Capital Territory provided an excellent opportunity to investigate these scope and continuity issues.

Methods. This was an observational analytic study using multiple data sources. Four models of nurse practitioner service were chosen from a competitive field of applications that were evaluated according to efficacy, feasibility, and sustainability across specified selection criteria. Each model in the trial included a clinical support team, with the nurse practitioner candidate 'working-into-the-role' and collecting demographic, clinical practice, patient outcome, and health service and consumer survey data over a 10 month period.

Findings. The trial identified the broad potential of the nurse practitioner role, its breadth and limitations, and its impact on selected health services in the Australian Capital Territory. Data from individual models were compared highlighting generic elements, and formed the basis for the development of the scope of practice for the Australian Capital Territory nurse practitioner models.

Conclusions. This study has validated a research-based, iterative process for initial development of nurse practitioner scope of practice for any Australian specialization. Importantly, the study concluded with the scope of practice as a finding, rather than commencing with it a priori. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles.

Tensions and constraints for nurses in hospital-in-home programmes

Economic necessity constrains health-care expenditure and waiting lists for hospital treatments remain high. As a result, more care is delivered via alternative means, such as same-day surgery initiatives and home-care programmes. Acute care delivered in the home to patients who would otherwise require hospitalization is becoming an increasingly acceptable means of treatment. These Hospital-in-the-Home programmes offer increased comfort while delivering comparable outcomes to many patient groups. The purpose of this paper is to generate discussion concerning the tensions that exist for nurses who practice in the home under the auspices of acute-care institutions. Data drawn from field work that formed part of a critical ethnography is used to generate the discussion. The larger research project explored the constructions of the role of the nurse in four Hospital-in-the-Home programmes in Victoria, Australia. It will be argued that there is significant pressure exerted upon nurses to support the imperative to reduce bed days in acute hospitals by transferring people to their home. At times, this agenda clashes with the nurses’ professional commitment to provide holistic patient care yet the dilemmas are largely unacknowledged and/or unrecognized by the nurses despite the tension they generate.

Nurses' perceptions of discharge planning

The present paper investigates what the term discharge planning actually means to nurses working in the acute care environment. A qualitative approach was used for this study. Twelve volunteer registered nurses (RNs) working in a large metropolitan Victorian public hospital were interviewed. All participants stated emphatically that they were involved in the discharge planning process although differing levels of involvement existed. ‘Organizing’ and ‘planning’ were key words used by participants to define the term discharge planning. All but one participant considered the nurse to be the coordinator of the discharge planning process. How participants communicated with other nursing staff regarding the discharge planning needs of individual patients depended on the policy of each individual ward. Communication was perceived to be a major factor that either enhanced or impeded the discharge planning process.

Mismanagement of delerium places patients at risk

Objective: This paper discusses the problem of delirium and the challenges of accurately assessing, preventing and managing patients with delirium in an acute care setting.

Primary Argument: Acute confusion, also known as delirium, is misdiagnosed and under-treated in up to 94% of older patients in hospitals. With the ageing population, this problem will increase dramatically in the Australian setting. Managing patients with delirium is challenging not only for the management of their basic nursing care needs but also because they are prone to adverse events such as falls and medication problems. In order to address this issue it is vital that health care professionals routinely assess patients for signs of delirium. The current 'gold standard' for assessing delirium is the use of the Confusion Assessment Method (CAM) which has been developed based on the diagnostic criteria set by the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and can be used by non-psychiatrists. Further, increased attention should be given to the prevention and management of delirium and the use of orientation and validation therapy.

Conclusion: Research indicates that early identification and intervention can help to limit any negative effects or adverse events. Increasing knowledge and awareness of early detection and efficient management of delirium is the first step toward prevention.