Patient deterioration education: Evaluation of face-to-face simulation and e-simulation approaches

Background: Simulation-based education is one strategy that may be used to teach nursing students to recognize and manage patient deterioration. Method: Final-year preregistration nursing students (n=97) completed three face-to-face laboratory-based team simulations with a simulated patient (actor) and 330 students individually completed a three-scenario Web-based simulation program: FIRST2ACTWeb™. Results: Both groups achieved moderate performance scores (means: face to face, 49%; e-simulation, 69%). Course evaluations were positive, skill gain showing a greater effect size in the face-to-face program than for e-simulation, and higher satisfaction and more positive appraisal. Conclusion: Face-to-face simulation and e-simulation are effective educational strategies with e-simulation offering greater feasibility. Either strategy is likely to add value to the learning experience.

IPA: Integrated predictive gene signature from gene expression based breast cancer patient samples

Background: Novel predictive markers are needed to accurately diagnose the breast cancer patients so they do not need to undergo any unnecessary aggressive therapies. Various gene expression studies based predictive gene signatureshave generated in the recent past to predict the binary estrogen-receptor subclass or to predict the therapy response subclass. However, the existing algorithms comes with many limitations, including low predictive performances over multiple cohorts of patients and non-significant or limited biological roles associated with thepredictive gene signatures. Therefore, the aim of this study is to develop novel predictive markers with improved performances.Methods: We propose a novel prediction algorithm called IPA to construct a predictive gene signature for performing multiple prediction tasks of predicting estrogen-receptor based binary subclass and predicting chemotherapy response (neoadjuvantly) based binary subclass. The constructed gene signature with considering multiple classification techniques was used to evaluate the algorithm performance on multiple cohorts of breast cancer patients.Results: The evaluation on multiple validation cohorts demonstrated that proposed algorithm achieved stable and high performance to perform prediction tasks, with consideration given to any classification techniques. We show that the predictive gene signature of our proposed algorithm reflects the mechanisms underlying the estrogen-receptors or response to therapy with significant greater biological interpretations, compared with the other existing algorithm.

Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease.

Depression is common but frequently undetected in patients with coronary artery disease (CAD). Self-report screening instruments for assessing depression such as the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9) are available but their validity is typically determined in depressed patients without comorbid somatic illness. We investigated the validity of these instruments relative to a referent diagnostic standard in recently hospitalized patients with CAD.

A metasynthesis of patient-provider communication in hospital for patients with severe communication disabilities: informing new translational research

Poor patient-provider communication in hospital continues to be cited as a possible causal factor in preventable adverse events for patients with severe communication disabilities. Yet to date there are no reports of empirical interventions that investigate or demonstrate an improvement in communication in hospital for these patients. The aim of this review was to synthesize the findings of research into communication in hospital for people with severe communication disabilities arising from lifelong and acquired stable conditions including cerebral palsy, autism, intellectual disability, aphasia following stroke, but excluding progressive conditions and those solely related to sensory impairments of hearing or vision. Results revealed six core strategies suggested to improve communication in hospital: (a) develop services, systems, and policies that support improved communication, (b) devote enough time to communication, (c) ensure adequate access to communication tools (nurse call systems and communication aids), (d) access personally held written health information, (e) collaborate effectively with carers, spouses, and parents, and (f) increase the communicative competence of hospital staff. Currently there are no reports that trial or validate any of these strategies specifically in hospital settings. Observational and evaluative research is needed to investigate the ecological validity of strategies proposed to improve communication.

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.

Effectiveness of patient feedback as an educational intervention to improve medical student consultation (PTA Feedback Study): study protocol for a randomized controlled trial.

Oral feedback from clinical educators is the traditional teaching method for improving clinical consultation skills in medical students. New approaches are needed to enhance this teaching model. Multisource feedback is a commonly used assessment method for learning among practising clinicians, but this assessment has not been explored rigorously in medical student education. This study seeks to evaluate if additional feedback on patient satisfaction improves medical student performance.

Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications

Introduction: The National Emergency Access Target was implemented to ensure 90% of patients leave emergency departments (EDs) within 4h. The impact of time driven performance on the number of physiologically unstable ward-based patients is unknown. An increase in clinical deterioration episodes potentially leading to adverse events will have resource implications for intensive care units (ICUs).
Objectives: To compare the characteristics and outcomes of patients who required an emergency response for clinical deterioration (cardiac arrest team or rapid response system activation) within and beyond 24 h of emergency admission to general medical and surgical units.
Methods: A retrospective exploratory design was used. The study site was a 365 bed urban hospital in Melbourne. Emergency responses for clinical deterioration during 2012 were examined.
Results: Of 819 emergency responses for clinical deterioration, 587 patients were admitted via ED. The median time to first responsewas59h, 28.4% of patients required this <24 h after admission. One in eight patients required ICU admission. Comparison of patients requiring a response within and beyond 24h of admission showed no significant differences in age, gender, waiting times, ED length of stay or in-hospital mortality rates. Patients in whom first emergency response occurred <24h after admission were less likely to be admitted to ICU immediately following the emergency response (7.6% vs 13.9%, p-0.039), less likely to have recurrent emergency responses during their hospitalisation (9.7% vs 34.0%, p<0.001), and had shorter median hospital length of stay (7 vs 11 days, p<0.001).
Conclusions: Considerable ICU resources were utilised given one in eight patients required ICU admission following emergency response, and patients admitted via the ED constituted 55% of all rapid response system activations. Exploring potential antecedents to clinical deterioration in this cohort may assist in establishing risk management strategies to reduce utilisation of ICU resources.

Understanding the experience of inpatient rehabilitation: insights into patient-centred care from patients and family members

The aim of the study was describe the experiences, needs and preferences of recent inpatients of a rehabilitation centre, and the needs of their families. Data were collected in four focus groups, two with patients (n = 13) who had recently completed inpatient rehabilitation following an illness, injury or elective surgery, and two with family members (n = 11). During the focus groups, two researchers facilitated discussion on any topic that participants considered important to the experience of inpatient rehabilitation; participants were encouraged to describe their care, needs and preferences. The focus group discussions were audio-taped and transcribed verbatim. Field notes were hand recorded. Data were analysed and collated into themes. Six key themes emerged. Participants wanted: interactions with friendly, empathetic staff; regular contact with senior staff and all staff to introduce themselves by name and profession; timely communication of accurate information; and rehabilitation services seven days a week. The physical environment had both positive and negative effects on patient well-being. Patients with complex or atypical circumstances required special attention to ensure their needs were met. In conclusion, patients and families identified six important issues that need to be considered during inpatient rehabilitation.

Symptoms and distress in children with advanced cancer: prospective patient-reported outcomes from the PediQUEST Study

PURPOSE: Thousands of children are living with advanced cancer; yet patient-reported outcomes (PROs) have rarely been used to describe their experiences. We aimed to describe symptom distress in 104 children age 2 years or older with advanced cancer enrolled onto the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) Study (multisite clinical trial evaluating an electronic PRO system).

METHODS: Symptom data were collected using age- and respondent-adapted versions of the PediQUEST Memorial Symptom Assessment Scale (PQ-MSAS) at most once per week. Clinical and treatment data were obtained from medical records. Individual symptom scores were dichotomized into high/low distress. Determinants of PQ-MSAS scores were explored using linear mixed-effects models.

RESULTS: During 9 months of follow-up, PQ-MSAS was administered 920 times: 459 times in teens (99% self-report), 249 times in children ages 7 to 12 years (96% child/parent report), and 212 times in those ages 2 to 6 years (parent reports). Common symptoms included pain (48%), fatigue (46%), drowsiness (39%), and irritability (37%); most scores indicated high distress. Among the 73 PQ-MSAS surveys administered in the last 12 weeks of life, pain was highly prevalent (62%; 58% with high distress). Being female, having a brain tumor, experiencing recent disease progression, and receiving moderate- or high-intensity cancer-directed therapy in the prior 10 days were associated with worse PQ-MSAS scores. In the final 12 weeks of life, receiving mild cancer-directed therapy was associated with improved psychological PQ-MSAS scores.

CONCLUSION: Children with advanced cancer experience high symptom distress. Strategies to promote intensive symptom management are indicated, especially with disease progression or administration of intensive treatments.

Malnutrition: significance, prevalence and management of the hospitalised surgery patient

Malnutrition is prevalent and poorly diagnosed in hospitalised patients, with high rates of malnutrition seen in surgical patients. The administration of a specialised immuno-nutrition supplement is beneficial for malnourished patients undergoing gastrointestinal surgery, and a multidisciplinary team approach improves nutritional care for patients.

Cancer patients' perceptions of the barriers and facilitators to patient participation in symptom management during an episode of admission

BACKGROUND:: Symptoms by definition are subjective, and patients' role in their assessment and management will impact on patient outcomes; thus, symptom management is an area of acute care practice where facilitation of patient participation is vital if quality outcomes are to be achieved. OBJECTIVE:: This study originated from a large multimethod research program exploring patient participation in symptom management in an acute oncology setting. The purpose of this article is to explore patients' perceptions of the barriers and facilitators to participating in their symptom management during an episode of admission to an acute oncology ward and the relationships between these perceptions and patients' preference for participation. METHODS:: One hundred seventy-one cancer inpatients consented and completed an interview-administered questionnaire. Patients' preference for participation was measured using the Control Preference Scale. Responses to open-ended survey questions were evaluated using content analysis. RESULTS:: Ten categories were identified in the analyses of patient perceptions of the barriers and facilitators to participating in care decisions relating to their symptoms. Patients, irrespective of their Control Preference, reported multiple barriers and facilitators to participating in their symptom management. CONCLUSIONS:: Patients overall perceived information as the most critical component of participation. Irrespective of patients' preference for participation, there were similarities in the barriers and facilitators to the operationalization of participation in the acute care setting reported. IMPLICATIONS FOR PRACTICE:: Understanding patient perceptions of barriers and facilitators of participating in symptom management has provided important insights into person and system factors in the acute care sector impacting quality patient symptom outcomes.

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.

Patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery.

BACKGROUND: Clinical interventions aimed at reducing the incidence of postoperative pulmonary complications necessitate patient engagement and participation in care. Patients' ability and willingness to participate in care to reduce postoperative complications is unclear. Further, nurses' facilitation of patient participation in pulmonary interventions has not been explored. OBJECTIVE: To explore patients' ability and willingness to participate in pulmonary interventions and nurses' facilitation of pulmonary interventions. DESIGN: Single institution, case study design. Multiple methods of data collection were used including preadmission (n=130) and pre-discharge (n=98) patient interviews, naturalistic observations (n=48) and nursing focus group interviews (n=2). SETTING: A cardiac surgical ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. PARTICIPANTS: One hundred and thirty patients admitted for cardiac surgery via the preadmission clinic during a 1-year period and 40 registered nurses who were part of the permanent workforce on the cardiac surgical ward. OUTCOME MEASURES: Patients' understanding of their role in pulmonary interventions and patients' preference for and reported involvement in pulmonary management. Nurses' facilitation of patients to participate in pulmonary interventions. RESULTS: Patients displayed a greater understanding of their role in pulmonary interventions after their surgical admission than they did at preadmission. While 55% of patients preferred to make decisions about deep breathing and coughing exercises, three-quarters of patients (75%) reported they made decisions about deep breathing and coughing during their surgical admission. Nurses missed opportunities to engage patients in this aspect of pulmonary management. CONCLUSIONS: Patients appear willing to take responsibility for pulmonary management in the postoperative period. Nurses could enhance patient participation in pulmonary interventions by ensuring adequate information and education is provided. Facilitation of patients' participation in their recovery is a fundamental aspect of care delivery in this context.