Patient participation in medication safety during an acute care admission

Background : Patient participation in medication management during hospitalization is thought to reduce medication errors and, following discharge, improve adherence and therapeutic use of medications. There is, however, limited understanding of how patients participate in their medication management while hospitalized.Objective : To explore patient participation in the context of medication management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease.Design : Single institution, case study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including pre-admission and pre-discharge patient interviews (n = 98), naturalistic observations (n = 48) and focus group interviews (n = 2).Results : All patients had changes made to their pre-operative cardiovascular medications as a consequence of surgery. More patients were able to list and state the purpose and side-effects of their cardiovascular medications at pre-admission than prior to discharge from hospital. There was very little evidence that nurses used opportunities such as medication administration times to engage patients in medication management during hospital admission.Discussion and Conclusions : Failure to engage patients in medication management and provide opportunities for patients to learn about changes to their medications has implications for the quality and safety of care patients receive in hospital and when managing their medications once discharged. To increase the opportunity for patients to participate in medication management, a fundamental shift in the way nurses currently provide care is required.

Improving the care of children with advanced cancer by using an electronic patient-reported feedback intervention : results from the PediQUEST randomized controlled trial.

This study aimed to determine whether feeding back patient-reported outcomes (PROs) to providers and families of children with advanced cancer improves symptom distress and health-related quality of life (HRQoL).

Determining criteria to assess patient readiness for discharge from postanaesthetic care: An international Delphi study

Aims and objectives: To obtain expert consensus on essential criteria required to assess patient readiness for discharge from the postanaesthetic care unit. Background: A patient's condition can deteriorate after surgery, and the immediate postoperative period is recognised internationally as a time of increased risk to patient safety. A recent systematic review identified evidence-based assessment criteria for the safe discharge of patients from the postanaesthetic care unit and identified gaps in the evidence. Design: Descriptive consensus study using the Delphi method. Methods: Members of international clinical specialist groups with expertise in anaesthesia or postanaesthetic care participated in three consultation rounds. Online surveys were used to determine expert consensus with regard to aspects of postanaesthetic care and specific criteria for assessing patient readiness for discharge. Three rounds of surveys were conducted from May 2011-September 2012. Results: Twenty-three experts contributed to the panel. Consensus, that is, at least 75% agreement, was reached in regard to 24 criteria considered essential (e.g. respiratory rate 100%; pain 100%; heart rate 95%; temperature 91%). Consensus was also reached for 15 criteria not considered essential (e.g. appetite 96%; headache 76%). Consensus was not obtained for a further 10 criteria. Participants (95%) agreed that a discharge tool was important to ensure safe patient discharge. Conclusion: Consensus was achieved by a panel of international experts on the use of a tool to assess patient readiness for discharge from postanaesthesia care unit and specific variables to be included or excluded from the tool. Further work is required to develop a tool and test its reliability and validity. Relevance to clinical practice: The findings of this study have informed the development of an evidence-based tool to be piloted in a subsequent funded study of nursing assessment of patient readiness for discharge from the postanaesthetic care unit.

Contributory factors to patient safety incidents in primary care: protocol for a systematic review

BACKGROUND: Organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting. METHODS/DESIGN: Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. The database search will be supplemented by additional search methodologies including citation searching and snowballing strategies which include reviewing reference lists and reviewing relevant journal table of contents, that is, BMJ Quality and Safety. Our search strategy will include search combinations of three key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies conducted in a primary care setting. They will include some description of the factors that contribute to patient safety. One reviewer (SG) will screen all the titles and abstracts, whilst a second reviewer will screen 50% of the abstracts. Two reviewers (SG and AH) will perform study selection, quality assessment and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), patient safety incident type and characteristics, practice characteristics and study outcomes. DISCUSSION: The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of health care.

In-reach nursing services improve older patient outcomes and access to emergency care

Aims: To identify the impact of in-reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care. Methods: Retrospective cohort study compared clinical outcomes of 2278 presentations from 2009 with 2051 presentations from 2011 before and after the implementation of in-reach services. Results: Median emergency department length of stay decreased by 24 minutes (7.0 vs 6.6 hours, P<0.001) and admission rates decreased by 23% (68 vs 45%, P<0.001). The proportion of people with repeat emergency department visits within six months decreased by 12% (27 vs 15%). The proportion of admitted patients who were discharged with an end of life palliative care plan increased by 13% (8 vs 21%, P=0.007). Conclusions: There was a significant reduction in the median length of stay, fewer hospital admissions and fewer repeat visits for people from residential aged care following implementation of in-reach services.

Chemosensory science in the context of cancer treatment: implications for patient care

Introduction: This collaborative commentary brings together both clinical and sensory science perspectives in an effort to explain the mechanisms of cancer treatment and the ensuing implications for the sensorium. Strategy: This paper makes the distinction between food hedonics and true chemosensory effects in the cancer context and describes the adverse effects cancer and its treatment have on the eating and drinking experience, including gastronomic, nutritional and emotional implications. Results from a prospective breast cancer cohort study, conducted by an interdisciplinary team of nurses, medical oncologists, dietitians and sensory science researchers shed new light on specific sensory symptomatology associated with chemotherapy treatment and the implications this has for informing reliable pre-treatment patient education. Findings: Two conceptual models are posed as frameworks for better understanding the determinants and consequences of altered eating and drinking experiences during chemotherapy, as well as the link between patient-reported symptoms and chemosensory or hedonic disturbances. Discussion: Application of evidence of cancer treatment and its sensory effects in the patient treatment context continues to be a challenge for cancer clinicians, especially where standardised testing of taste and smell function are not able to be practically administered. Conclusions: Recommendations are made for further research and practice pursuits to underpin improved food enjoyment and dietary quality throughout the cancer trajectory. Clinician education of sensory science is also encouraged.

Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study

BACKGROUND: Patients can have an important role in reducing harm in primary-care settings. Learning from patient experience and feedback could improve patient safety. Evidence that captures patients' views of the various contributory factors to creating safe primary care is largely absent. The aim of this study was to address this evidence gap. METHODS: Four focus groups and eight semistructured interviews were conducted with 34 patients and carers from south-east Australia. Participants were asked to describe their experiences of primary care. Audio recordings were transcribed verbatim and specific factors that contribute to safety incidents were identified in the analysis using the Yorkshire Contributory Factors Framework (YCFF). Other factors emerging from the data were also ascertained and added to the analytical framework. RESULTS: Thirteen factors that contribute to safety incidents in primary care were ascertained. Five unique factors for the primary-care setting were discovered in conjunction with eight factors present in the YCFF from hospital settings. The five unique primary care contributing factors to safety incidents represented a range of levels within the primary-care system from local working conditions to the upstream organisational level and the external policy context. The 13 factors included communication, access, patient factors, external policy context, dignity and respect, primary-secondary interface, continuity of care, task performance, task characteristics, time in the consultation, safety culture, team factors and the physical environment. DISCUSSION: Patient and carer feedback of this type could help primary-care professionals better understand and identify potential safety concerns and make appropriate service improvements. The comprehensive range of factors identified provides the groundwork for developing tools that systematically capture the multiple contributory factors to patient safety.

Developing a primary care patient measure of safety (PC PMOS): a modified Delphi process and face validity testing

BACKGROUND: Patients are a valuable source of information about ways to prevent harm in primary care and are in a unique position to provide feedback about the factors that contribute to safety incidents. Unlike in the hospital setting, there are currently no tools that allow the systematic capture of this information from patients. The aim of this study was to develop a quantitative primary care patient measure of safety (PC PMOS). METHODS: A two-stage approach was undertaken to develop questionnaire domains and items. Stage 1 involved a modified Delphi process. An expert panel reached consensus on domains and items based on three sources of information (validated hospital PMOS, previous research conducted by our study team and literature on threats to patient safety). Stage 2 involved testing the face validity of the questionnaire developed during stage 1 with patients and primary care staff using the 'think aloud' method. Following this process, the questionnaire was revised accordingly. RESULTS: The PC PMOS was received positively by both patients and staff during face validity testing. Barriers to completion included the length, relevance and clarity of questions. The final PC PMOS consisted of 50 items across 15 domains. The contributory factors to safety incidents centred on communication, access to care, patient-related factors, organisation and care planning, task performance and information flow. DISCUSSION: This is the first tool specifically designed for primary care settings, which allows patients to provide feedback about factors contributing to potential safety incidents. The PC PMOS provides a way for primary care organisations to learn about safety from the patient perspective and make service improvements with the aim of reducing harm in this setting. Future research will explore the reliability and construct validity of the PC PMOS.

Patient physiological status during emergency care and rapid response team or cardiac arrest team activation during early hospital admission

OBJECTIVES: The objective of this study was to examine the relationship between rapid response team (RRT) or cardiac arrest team (CAT) activation within 72 h of emergency admission and (i) physiological status in the emergency department (ED) and (ii) risk for ICU admission and in-hospital mortality.

METHODS: A retrospective matched cohort study was conducted in three hospitals in Melbourne, Australia. The exposed cohort (n=660) included randomly selected adults admitted to the medical or surgical ward through the ED who had RRT or CAT activation within 72 h of admission. Unexposed matched controls (n=1320) did not have RRT or CAT activation.

RESULTS: The exposed cohort was more likely to have physiological abnormalities fulfilling hospital RRT activation criteria during ED care (36.7 vs. 23.8%, P<0.001). After adjusting for confounders, tachypnoea (adjusted odds ratio=1.92, 95% confidence interval: 1.38-2.67) or hypotension (AOR=1.43, 95% confidence interval: 1.00-2.03), fulfilling RRT activation criteria during ED care, was associated with RRT or CAT activation within 72 h of admission. The exposed cohort had more in-hospital deaths (16.5 vs. 3.6%, P<0.001), more unexpected in-hospital deaths (2.05 vs. 0.2%, P<0.001), more ICU admissions (11.8 vs. 0.7%, P<0.001) and longer lengths of hospital stay (median=8 vs. 5 days, P<0.001).

CONCLUSION: CAT/RRT activations within 72 h of emergency admission are associated with higher mortality and increased length of stay. Factors associated with CAT/RRT activation in the wards are often identifiable when patients are in the ED. Further studies are required to determine whether early identification and intervention in patients at risk for RRT or CAT activation can improve their eventual outcomes.

Innovation practice using pervasive mobile technology solutions to improve population health management: a pilot study of gestational diabetes patient care in Australia

Healthcare service delivery is moving forward from individual care to population health management, because of the fast growth of health records. However, to improve population health performance, it is necessary to leverage relevant data and information using new technology solutions, such as pervasive diabetes mobile technology solution of Inet International Inc., which offers the potential to facilitate patient empowerment with gestational diabetic care. Hence, this article examines the pilot study outcomes of a small clinical trial focusing on pregnant patients affected by gestational diabetes mellitus, in an Australian not for profit healthcare context. The aims include establishing proof of concept and also assessing the usability, acceptability, and functionality of this mobile solution and thereby generate hypotheses to be tested in a large-scale confirmatory clinical trial.

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.

Ethically defensible decision-making in health care: challenges to traditional practice

The concept of paternalism is deeply entrenched in health care. Decision-making about health care can be extremely difficult at times, and many competing interests may influence the outcomes. However, ethically defensible practice aligns itself with acknowledging the patient's prima facie right to be treated as an autonomous individual. This includes the patient's right to make informed decisions or to decide that other(s), such as the close family, should make decisions on his or her behalf. (author abstract)