Factors Affecting the Care of Acutely Unwell Ward Patients: A Multiple Case Study

<p>Suboptimal care of acutely unwell ward patients is of growing concern internationally. As empirical study of the problem is underdeveloped this thesis explores factors affecting suboptimal care of acutely unwell ward patients. In order to bring a theoretical understanding to this area, a concept analysis of the term suboptimal care was undertaken. The results of this concept analysis were then used to inform the design and analysis of this multiple case study. The cases for this study were two general surgical and two general medical wards located in two hospitals in the North Island of New Zealand. Interviews and focus groups with nurses, doctors, and managerial staff were undertaken using a semi structured interview approach informed by the concept analysis. Organisational and ward documentation was also reviewed. Using categorical aggregation and pattern matching, an analytical framework emerged from the data. This framework was then used to conduct within, cross case, and hospital analyses. Key findings of this research reveal that workload, teamwork, communication, leadership, skills and knowledge deficit, and organisational systems and processes are significant factors affecting care of acutely unwell ward patients and that these factors are not unique to specific contexts. Polarised views about workload were expressed by those who manage organisations and those who deliver care at ward level. Current approaches to improving care of the acutely unwell ward patient have involved the introduction of service initiatives. However, this study demonstrates that service initiatives alone are insufficient to improve care for acutely unwell ward patients. Recommendations from this study are that strategies should be put in place to support and develop clinical shift leaders and that staffing resources should be reviewed in the context of contemporary acute care settings. These must be informed by the views of organisational managers and ward staff leading to an integrated hospital-wide understanding of factors affecting care of the acutely unwell ward patient.</p>

Factors Affecting the Care of Acutely Unwell Ward Patients: A Multiple Case Study

<p>Suboptimal care of acutely unwell ward patients is of growing concern internationally. As empirical study of the problem is underdeveloped this thesis explores factors affecting suboptimal care of acutely unwell ward patients. In order to bring a theoretical understanding to this area, a concept analysis of the term suboptimal care was undertaken. The results of this concept analysis were then used to inform the design and analysis of this multiple case study. The cases for this study were two general surgical and two general medical wards located in two hospitals in the North Island of New Zealand. Interviews and focus groups with nurses, doctors, and managerial staff were undertaken using a semi structured interview approach informed by the concept analysis. Organisational and ward documentation was also reviewed. Using categorical aggregation and pattern matching, an analytical framework emerged from the data. This framework was then used to conduct within, cross case, and hospital analyses. Key findings of this research reveal that workload, teamwork, communication, leadership, skills and knowledge deficit, and organisational systems and processes are significant factors affecting care of acutely unwell ward patients and that these factors are not unique to specific contexts. Polarised views about workload were expressed by those who manage organisations and those who deliver care at ward level. Current approaches to improving care of the acutely unwell ward patient have involved the introduction of service initiatives. However, this study demonstrates that service initiatives alone are insufficient to improve care for acutely unwell ward patients. Recommendations from this study are that strategies should be put in place to support and develop clinical shift leaders and that staffing resources should be reviewed in the context of contemporary acute care settings. These must be informed by the views of organisational managers and ward staff leading to an integrated hospital-wide understanding of factors affecting care of the acutely unwell ward patient.</p>

EP.FRI.461 Management of acutely ill surgical patients NICE guidance CG50: a complete audit cycle

Aim NICE CG50 guidelines are a response to evidence suggesting patients who are, or become, acutely unwell may receive suboptimal care. The guidelines suggest: After previously unsuccessful audits a fourth re-audit was designed to re-assess compliance with the CG 50 guidelines. Method After implementing previous recommendations like, keeping a poster of recommendations in the handover room and making these guidelines as part of surgical induction, a re-audit was planned. A prospective random sample of 40 patients admitted during the general surgery was taken. Using the audit tool the following parameters were recorded for each patient in the sample: Results The compliance was 100% for patients who have had their physiological observations recorded at the time of admission or initial assessment, the percentage of patients monitored using a physiological track and trigger system, and the percentage whose physiological observations were monitored at least every 12 hours. The compliance was 95% for the percentage of patients with a clear written monitoring plan. Conclusions Following the interventions detailed above, there is now 95 to 100% compliance with NICE guidelines in the documentation.

800 The Impact of the COVID-19 Pandemic on The Management of Patients with Vascular Conditions: The Vascular and Endovascular Research Network (VERN) COVID-19 Vascular Service (COVER) Tier 3 Study

Introduction The COVID-19 pandemic has had significant impact on healthcare delivery internationally. The aim of this study was to evaluate the changes in the management of vascular conditions during the COVID-19 pandemic compared to pre-pandemic standards. Method An international multicentre prospective cohort study was conducted over a 4-week period from March 2020. All patients referred to vascular services with acute vascular conditions were eligible to participate. Data on patient demographics, diagnosis and treatment delivered during the pandemic were collected. If there was a deviation from the pre-pandemic management plan, this ‘ideal’ plan was recorded, and the severity of modification scored on a 5-point scale. Results A total of 1801 patients from 52 centres in 19 countries were included in the study, most commonly referred with lower limb conditions (54.4%). Only 2.3% of patients had a confirmed diagnosis of COVID-19. A deviation from the pre-pandemic treatment standard occurred in 35% of unruptured ≥5.5cm diameter abdominal aortic aneurysms, 24.7% of patients with carotid disease, 17% with acute or chronic limb-threatening ischaemia and 12.7% with diabetic foot conditions. Of these modifications, 40.7% were significant, such as endovascular instead of open aneurysm repair or treatment delays, 38.1% major, such as non-operative management of carotid and lower limb disease, and 4.9% life-changing/ending including major amputation or palliation. Conclusions The COVID-19 pandemic has significantly impacted upon the management decisions for vascular conditions, independent of COVID status, with 17% of all-referred patients receiving suboptimal care due to limited resources and difficulty accessing services.

Survey of Nurses’ Experiences Applying The Joint Commission’s Medication Management Titration Standards

Background Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses’ autonomous decision-making. Objectives To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. Methods A survey of nurses’ experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. Results The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. Conclusions Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

Italian physiotherapists’ knowledge of and adherence to osteoarthritis clinical practice guidelines: a cross-sectional study

Introduction Implementation of clinical practice guidelines (CPGs) to manage musculoskeletal conditions among physiotherapists appears suboptimal. Osteoarthritis is one of the most disabling conditions worldwide and several studies showed a lack of knowledge of and adherence to osteoarthritis CPGs in physiotherapists’ clinical practice. However, those studies are not conclusive, as they examine the knowledge of and adherence to CPGs only in isolation, or only by focussing on a single treatment. Thus, analysis of the knowledge of and adherence to CPGs in the same sample would allow for a better understanding of the evidence-to-practice gap, which, if unaddressed, can lead to suboptimal care for these patients. This study aims at assessing Italian physiotherapists’ evidence-to-practice gap in osteoarthritis CPGs. Methods An online survey divided into two sections investigating knowledge of and adherence to CPGs was developed based on three high-quality, recent and relevant CPGs. In the first section, participants had to express their agreement with 24 CPG statements through a 1 (completely disagree) to 5 (completely agree) scale. We defined a ≥ 70% agreement with a statement as consensus. In the second section, participants were shown a clinical case, with different interventions to choose from. Participants were classified as ‘Delivering’ (all recommended interventions selected), ‘Partially Delivering’ (some recommended interventions missing) and ‘Non-Delivering’ (at least one non-recommended interventions selected) the recommended intervention, depending on chosen interventions. Results 822 physiotherapists (mean age (SD): 35.8 (13.3); female 47%) completed the survey between June and July 2020. In the first section, consensus was achieved for 13/24 statements. In the second section, 25% of the participants were classified as ‘Delivering’, 22% as ‘Partially Delivering’ and 53% as ‘Non-Delivering’. Conclusions Our findings revealed an adequate level of knowledge of osteoarthritis CPGs regarding the importance of exercise and education. However, an adequate level of adherence has yet to be reached, since many physiotherapists did not advise weight reduction, but rest from physical activity, and often included secondary treatments (e.g. manual therapy) supported by low-level evidence. These results identify an evidence-to-practice gap, which may lead to non-evidence based practice behaviours for the management of patients with osteoarthritis.

Methodological and Measurement Advances in Social Determinants of HIV: View from NIH

Social determinants are increasingly understood as key contributors to patterns of heightened risk for HIV acquisition and suboptimal care and treatment outcomes. Yet, the ability to rigorously model, map and measure these nuanced social dynamics has been a challenge, resulting in limited examples of effective interventions and resource allocation. In 2016, the United States National Institute of Mental Health (NIMH) and the National Institute of Allergy and Infectious Diseases (NIAID) issued a Request for Applications calling for methodological innovations around the social determinants of HIV. In May of 2019, NIMH, in collaboration with American University’s Center on Health, Risk and Society and the DC Center for AIDS Research, sponsored a symposium to bring together the funded teams to share accomplishments, distill lessons learned and reflect on the state of the science with other key stakeholders. Presentations focused on causal inference, multi-level analysis and mathematical modeling (Models); geospatial analytics and ecological momentary assessments (Maps); and measurement of social and structural determinants including inequalities and stigmas (Measures). Cross-cutting and higher-level themes were discussed and largely focused on the importance of critical and careful integration of social theory, community engagement and mixed methodologies into research on the social determinants of HIV.

Negotiating Social Diversity in Residential Care for Older Persons

Studies have long noted challenges of diversity in the workplace. Growing evidence suggests that both the aging population and the workforce needed for health and social care will be more diverse than in previous decades. The confluence of older person and care worker diversity can result in suboptimal care. Drawing on 44 interviews, observations of 62 meetings, and a five-year immersion, this organizational ethnography examines the impact of social diversity at a large, urban, multi-level, residential care organization for older persons. The impact of diversity is delineated on three levels such as among care workers, between care workers and residents, and in terms of personal and organizational responsibility for diversity work. Strengths of diversity are mainly with regard to connectivity between care workers and residents. Diversity challenges include implications for care processes, care workers’ identities, and organizational health.