Commissioning Clinical Spaces During a Pandemic: Merging Methodologies of Human Factors and Simulation

Objectives: The objective of this case study is to demonstrate the value of applying tabletop and simulation techniques to highlight high-risk, high-impact outcomes and organizational recommendations in the commissioning of a new clinical spaces. Purpose/Aim: Generalizability of lessons learned from this case study aim to support other health organizations in commissioning of clinical spaces during communicable disease outbreaks. Background: COVID-19 challenged our healthcare system, requiring teams to prepare in a short span of time. Bridging expertise of human factor and simulation teams provided a novel, interdisciplinary, and timely approach to evaluate and commission spaces. Methods: Human factors and simulation teams were enlisted to conduct an evaluation of a new space prior to readiness for delivery of safe patient care. An adapted tabletop evaluation and subsequent systems integration simulation was conducted. The goal of the tabletop exercise was to identify and define processes and risks to tested in the physical space using simulation. Results: Applying both human factors science and systems simulation proactively identified the highest risk, highest impact outcomes, validated existing processes and allowed for refining of potential solutions and recommendations of the new space. A strong working relationship between teams fostered an opportunity to share information, debrief, evaluate, and adapt methods while applying timely changes based on emergent findings. Conclusions: These combined methodologies are important tools that can be learned and applied to healthcare commissioning of new clinical spaces in the identification of high-risk, high-impact outcomes affecting staff and organizational preparedness and safety.

What educational and other experiences assist recently qualified nurses to understand and deal with clinical risk and patient safety?

<p>This research was undertaken to investigate how newly graduated nurses recognise and develop skills relating to clinical risk and patient safety. I set out to understand how and where new graduates learn those skills and what would help future undergraduate nurses better prepare for the complexities of the clinical setting. A qualitative research study using Appreciative Inquiry (AI) was the chosen methodology. This was selected for its aspirational outlook, which allows positive conclusions to be drawn from the study’s findings. Nine nurses in their first year of clinical practice participated in the study and they were interviewed on a one-to-one basis. The key findings demonstrated that the approaches to teaching clinical risk and safe patient care and experiences of these in the undergraduate setting were variable, with many participants describing that they were ill prepared for the rigours of the clinical environment. They identified workplace culture, clinical role models, exposure to the clinical environment; experiential learning, narrative story sharing, debriefing and simulation as contributing factors to their ability to learn and understand clinical risk and safe patient care. Despite their initial uncertainty, the participants were able to describe safe patient care and clinical risk. They identified cultures of safe patient care, safe teaching and safe learning. The participants further identified their preferred learning styles and recommended strategies that educationalists and clinical stakeholders employ to facilitate their professional development and understanding of clinical risk and patient safety. The participants identified a more thoughtful, structured and overt approach to teaching the subject of clinical risk and patient safety to prepare for the clinical environment. They desired more experiential exposure, either clinical or simulated. They highlighted the need for effective preceptors and role models, alongside opportunities for sharing their clinical experiences and debriefing critical incidents. Furthermore, they recognised aspects of workplace cultures that facilitated or hindered effective clinical practice and safe patient care.</p>

What educational and other experiences assist recently qualified nurses to understand and deal with clinical risk and patient safety?

<p>This research was undertaken to investigate how newly graduated nurses recognise and develop skills relating to clinical risk and patient safety. I set out to understand how and where new graduates learn those skills and what would help future undergraduate nurses better prepare for the complexities of the clinical setting. A qualitative research study using Appreciative Inquiry (AI) was the chosen methodology. This was selected for its aspirational outlook, which allows positive conclusions to be drawn from the study’s findings. Nine nurses in their first year of clinical practice participated in the study and they were interviewed on a one-to-one basis. The key findings demonstrated that the approaches to teaching clinical risk and safe patient care and experiences of these in the undergraduate setting were variable, with many participants describing that they were ill prepared for the rigours of the clinical environment. They identified workplace culture, clinical role models, exposure to the clinical environment; experiential learning, narrative story sharing, debriefing and simulation as contributing factors to their ability to learn and understand clinical risk and safe patient care. Despite their initial uncertainty, the participants were able to describe safe patient care and clinical risk. They identified cultures of safe patient care, safe teaching and safe learning. The participants further identified their preferred learning styles and recommended strategies that educationalists and clinical stakeholders employ to facilitate their professional development and understanding of clinical risk and patient safety. The participants identified a more thoughtful, structured and overt approach to teaching the subject of clinical risk and patient safety to prepare for the clinical environment. They desired more experiential exposure, either clinical or simulated. They highlighted the need for effective preceptors and role models, alongside opportunities for sharing their clinical experiences and debriefing critical incidents. Furthermore, they recognised aspects of workplace cultures that facilitated or hindered effective clinical practice and safe patient care.</p>

400. Impact of SARS-CoV-2 Test-based Strategy to Reduce Quarantine Days Among Asymptomatic Healthcare Workers After Household Exposure

Background Appropriate staffing is essential to provide safe patient care. During the COVID-19 pandemic, healthcare workers (HCWs) are missing work days due to illness or high-risk exposure (HRE) to an infected person. To avoid staffing shortages, we implemented a SARS-CoV-2 test-based strategy among asymptomatic HCWs after HRE to facilitate early return to work. Methods In July 2020, our institution implemented a SARS-CoV-2 RT-PCR test-based strategy among HCWs within 7 days of HRE. HCWs were defined as any paid or unpaid persons directly or indirectly involved in patient care. HRE was defined as close contact &lt; 6 feet with an infected household member without use of mask and lasting for ≥ 15 minutes. Contact with a patient or coworker was not considered high-risk due to universal masking and eye protection use. HCWs underwent SARS-CoV-2 RT PCR testing of a nasopharyngeal swab at least once (1-2 days post-exposure) or twice (5-7 days post-exposure). HCWs with symptoms at baseline were excluded. HCWs who were asymptomatic during evaluation were considered as truly asymptomatic (TA). Saved work-days (SWD) were calculated based on number of days saved due to testing strategy compared to the Centers for Disease Control and Prevention’s recommended 14-day quarantine. HCWs were allowed to return to work within 7 days of HRE if they tested negative, or after completing 10-day isolation period ± improvement in symptoms from symptom onset if they tested positive. Results Between 07/01/2020 to 12/31/2020, 450 unique asymptomatic HCWs underwent SARS-CoV-2 testing. Of those, 84% were women and median age was 36 years, 347 tested negative and 103 tested positive. Of those positives, 33% of HCWs tested positive on day 2 after HRE with 141 SWDs (average 2 days/person). Only 37% were TA positives. Of those negatives, 94% were TA SARS-CoV-2 negative with 2620 SWDs (average 7.5 days/person). There were no healthcare outbreaks related to HCWs allowed to return to work following this strategy. Asymptomatic healthcare workers commonly tested positive for SARS-CoV-2 on day 2 from household exposure compared to other days Conclusion Test-based strategy among asymptomatic HCWs with HRE reduced loss of workdays and helped limit staffing shortages. Majority of positive HCWs developed symptoms after positive SARS-CoV-2 testing, which may support allowing most fully vaccinated HCWs with no COVID-like symptoms to continue to work unless symptomatic. Disclosures All Authors: No reported disclosures

Improving handover competency in preclinical medical and health professions students: establishing the reliability and construct validity of an assessment instrument

Background As part of the worldwide call to enhance the safety of patient handovers of care, the Association of American Medical Colleges (AAMC) requires that all graduating students “give or receive a patient handover to transition care responsibly” as one of its Core Entrustable Professional Activities (EPAs) for Entering Residency. Students therefore require educational activities that build the necessary teamwork skills to perform structured handovers. To date, a reliable instrument designed to assess teamwork competencies, like structured communication, throughout their preclinical and clinical years does not exist. Method Our team developed an assessment instrument that evaluates both the use of structured communication and two additional teamwork competencies necessary to perform safe patient handovers. This instrument was utilized to assess 192 handovers that were recorded from a sample of 229 preclinical medical students and 25 health professions students who participated in a virtual course on safe patient handovers. Five raters were trained on utilization of the assessment instrument, and consensus was established. Each handover was reviewed independently by two separate raters. Results The raters achieved 72.22 % agreement across items in the reviewed handovers. Krippendorff’s alpha coefficient to assess inter-rater reliability was 0.6245, indicating substantial agreement among the raters. A confirmatory factor analysis (CFA) demonstrated the orthogonal characteristics of items in this instrument with rotated item loadings onto three distinct factors providing preliminary evidence of construct validity. Conclusions We present an assessment instrument with substantial reliability and preliminary evidence of construct validity designed to evaluate both use of structured handover format as well as two team competencies necessary for safe patient handovers. Our assessment instrument can be used by educators to evaluate learners’ handoff performance as early as their preclinical years and is broadly applicable in the clinical context in which it is utilized. In the journey to optimize safe patient care through improved teamwork during handovers, our instrument achieves a critical step in the process of developing a validated assessment instrument to evaluate learners as they seek to accomplish this goal.

SP3.1.10 Surgical Emergency Assessment Unit and Emergency Surgeon of the Week’ : A Paradigm shift to providing Emergency Surgical Care

Aims Ever increasing number of A&E attendance and admissions cause immense strain on hospital beds with drainage of our finite health resources. This prompted the need for implementation and review of alternative schemes: Surgical Emergency Assessment Unit (SEAU) and ‘Emergency Surgeon of the Week’ (ESW) and its impact on our depleted health system. Patients and Method Retrospective analysis of a prospectively collected data from SEAU activity logs, patient information center and friends and family questionnaire following implementation of SEAU (November 2014) and ESW (November 2017) in a large DGH.SEAU operates on a five day policy (Monday – Friday, 0800-2000) aided by dedicated imaging pathway and ESW works on a 1:5 (Monday – Thursday, 0800-1800) rota with full complement of the surgical team. Results SEAU has attended to 16057 patients (New 9811; Follow Up 6246) from November 2014-October 2019. Emergency general surgical admission pre and post SEAU implementation was 309* and 202*/month respectively, a drop of 35% with a further reduction after introduction of ESW by another 24% to 153*/month. Thus, a total reduction of emergency admission by almost 60%. Stay in SEAU was 4* hours and re-admission rate was 6%. SEAU received 98% friends and family recommendation to others. Conclusions A paradigm shift in providing emergency surgical care is required in the face of a strained health care system; the positive outcome achieved after implementation of SEAU and ESW could be the answer to relieving bed capacity and financial pressures, possibly a solution to providing high quality and safe patient care.

Nurse staffing levels and patient outcomes: a systematic review of longitudinal studies

Background: The contribution of registered nurses (RN) towards safe patient care has been demonstrated by several studies. However, most of the evidence is cross-sectional, hence the inability to demonstrate that staffing levels precede patient outcomes. No reviews have summarised longitudinal studies considering nurse staffing and patient outcomes. Objectives: To synthesise longitudinal studies focusing on associations between nurse staffing levels and patient outcomes. Methods: Systematic review. We conducted our search in 2020 and updated it in July 2021. We searched Medline, CINAHL, Embase and the Cochrane Library. We used the ROBINS-I tool for assessing risk of bias. We reported results narratively grouped by outcome. Results: 28 papers were included. Most studies were either at serious (n=12) or critical (n=6) risk of bias, with 3 studies at low risk of bias. Studies were conducted in a variety of settings and populations. Notwithstanding the limitations, findings are consistent with an overall picture of a beneficial effect from higher RN staffing on preventing patient death. Studies with the greatest risk of bias were judged as most likely to underestimate the effect of higher RN staffing. The evidence is less clear for other patient outcomes, but estimates, though at moderate or serious risk of bias, indicate that higher RN staffing is likely to lead to better patient outcomes. Evidence about the contribution of other nursing staff groups and skill mix of the team is unclear. Conclusion: There is a likely causal relationship between low RN staffing and harm to patients, although uncertainties remain regarding the magnitude of effect. To address these uncertainties, future studies should be conducted in more than one hospital and using standardised measures when reporting staffing levels.

Physicochemical Stability and Compatibility Testing of Voriconazole in All-in-One Parenteral Nutrition Admixtures

(1) Drug compatibility with all-in-one (AiO) parenteral nutrition (PN) admixtures is a very important pharmaceutical quality issue to be answered based on appropriate laboratory testing. We assessed voriconazole (V), a poorly water-soluble (logP ≈ 1) single-daily dosed antifungal drug monitored in patients and thus candidate for AiO PN admixing for convenient and safe patient care. We evaluated V compatibility and stability in AiO PN admixtures through adapted therapeutic drug monitoring method (drug stability) and visual microscopic emulsion stability by lipid droplets analysis improved by an automated microscopic digital assessment. (2) V was added in concentrations of 0.05/0.25/0.5 mg/mL (143.1/715.7/1431.5 µM), correlating to daily therapeutic dosing, to three commercially available industrial AiO PN admixtures. Three aliquots were stored in the refrigerator (4 °C), at room temperature (24 °C) and under stress conditions in a water bath (37 °C). Samples taken at 0/24/48/72/168 h after admixing were subjected to a stability-indicating one-week analysis. Assessment included visual examination, lipid droplet measurement according to an established and validated method (bright-field microscopy using oil immersion), pH measurement (glass electrode) and V identification/quantification (LC–MS/MS). (3) After one week, all samples at 37 °C showed slight yellow discoloration. The pH values remained stable. All samples met specifications for lipid droplets according to size (upper size ≤8µm, mean size <4.5 ± 2 µm) and number (n ≤ 9 lipid droplets >5 µm). V concentrations were within an acceptable range, calculated for every timepoint as percent of the theoretical concentration spiked into the AiO PN. The median recovery was 98.2% (min–max, 90–112%). (4) At therapeutic doses, commercial V formulations were compatible and stable within specifications over one week in commonly used volumes of commercial AiO PN admixtures at 4–37 °C.

Periprocedural Management of Electroconvulsive Therapy in Pregnancy during COVID-19 Outbreak: The First Case Report in Thailand

Objective: To described the periprocedural electroconvulsive therapy (ECT) management of a patient in the 3rd trimester of pregnancy, the ECT complications, and their treatment. Materials and Methods: A retrospective chart review was conducted of a 26-year-old parturient with bipolar I disorder with psychotic features during the coronavirus disease 2019 (COVID-19) outbreak. Case Report: The patient was admitted and scheduled for ECT. Fifteen ECT sessions (eight on her first admission, and another seven on a second admission) were performed. General anesthesia with endotracheal intubation was conducted after sufficient preoxygenation. Complications were observed: prolonged seizure, decreased fetal heart rate, and hypersecretion. Nonetheless, good outcomes were achieved after treated with thiopental to terminate the seizure, intravenous crystalloid loading and left uterine displacement to stabilize the fetus, and suctioning and an antisialagogue for secretion clearance. Conclusion: In ECT during pregnancy, it can be challenging to apply electrical current, induce anesthesia and airway management to achieve safe patient care and ensure adequate seizure duration. Moreover, the ECT is conducted in a non-operating room setting where equipment may be deficient. A prerequisite is good periprocedural collaboration among members of the multidisciplinary team which include a psychiatrist, an anesthesiologist, and an obstetrics-gynecologist, as well as proper protective equipment to prevent the contamination to the environment. Keywords: Coronavirus disease 2019 (COVID-19); Electroconvulsive therapy (ECT); Multidisciplinary team; Periprocedural management; Pregnancy