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>

Protocol for a mixed methods exploratory study of success factors to escalation of care: the SUFFICE study

Background: In the United Kingdom, hospital patients suffer preventable deaths (failure to rescue) and delayed admission to the Intensive Care Unit because of poor illness recognition. This problem has consistently been identified in care reviews. Strategies to improve deteriorating ward patient care, such as early warning systems and specialist care teams (critical care outreach or rapid response), have not reliably demonstrated reductions to patient deaths. Current research focuses on failure to rescue, but further reductions to patient deaths are possible, by examining care of unwell hospital patients who are rescued (successfully treated). Our primary objective is to develop a framework of care escalation success factors that can be developed into a complex intervention to reduce patient mortality and unnecessary admissions to the Intensive Care Unit (ICU). Methods and Analysis: SUFFICE is a multicentre mixed-methods, exploratory sequential study examining rescue events in the acutely unwell ward patient in two National Health Service Trusts with Teaching Hospital status. The study will constitute four key phases. Firstly, we will observe ward care escalation events to generate a theoretical understanding of the process of rescue. Secondly, we review care records from unwell ward patients in whom an ICU admission was avoided to identify care success factors. Thirdly we will conduct staff interviews with expert doctors, nurses, and Allied Health Professionals to identify how rescue is achieved and further explore care escalation success factors identified in the first two study phases. The final phase involves integrating the study data to generate the theoretical basis for the framework of care escalation success factors. Ethics and Dissemination: Ethical approval has been obtained through the Queen Square London Research and Ethics committee (REC Ref 20/HRA/3828; CAG-20CAG0106). Study results will be of interest to critical care, nursing and medical professions and results will be disseminated at national and international conferences.

Case Report on Tuberculosis Meningitis-A Nurses Perspective

Mycobacterium tuberculosis is the bacteria that cause tuberculosis. If the infection is not treated immediately the bacterium passes via the circulatory system and spread other organs and tissues. Pathogen will travel to the meninges and causes inflammation of membranes called as tubercular meningitis. Here, the authors report a case of tuberculous meningitis a 42- years-old male patient with the chief complaints of low grade fever with chills since 1 month, headache in frontal region since 5-6 days, altered sensorium, breathing difficulty, reduced speech and left side weakness of the body since 1 day. After admitting in the ward all investigation done like MRI brain, ECG, lumbar puncture, blood tests etc. and he diagnosed as tuberculous meningitis. Patient admitted in AVBRH in ICU, investigations done, where patient was on NIV support, nasogastric tube, foleys catheter and it has been removed as patient was improving the condition and shifted in ward. Patient medical treatment in the ward was inj. C-tri 2 gm, Inj.levoflox 500 mg, inj. thimine 100 mg, Inj.Dexamethasone 10 mg, tab. Pan 40 mg, tab. Akt4 3, Inj.manitol, tab. Lorazepam. History collection, Physical examination, neurological assessment and nursing care plan were done after all treatment patient condition has been improved.

OBSERVATION OF PROSTATE SPECIFIC ANTIGEN LEVEL ON ENLARGED PROSTATE IN RIMS RANCHI.

Aim and objective- To differentiate between physiological and pathological elevation of of PSA, importance of PSA level in various prostatic diseases, and monitoring the efcacy of therapy. Patient And Method- study conducted in department of surgery, Rajendra institute of medical sciences, Ranchi. Study in 60 patients in OPD and in ward patient. Result And Conclusion- There is physiological increase in serum PSA Level with increase in age in absence of any prostatic disease and symptom. Increase in PSA level in carcinoma prostate, monitoring of response of treatment and disease recurrence

Significance of MPV, RDW and PDW with the Severity and Mortality of COVID-19 and Effects of Acetylsalicylic Acid Use

We aimed to investigate association between mean platelet volume (MVP), platelet distribution width (PDW) and red cell distribution width (RDW) and mortality in patients with COVID-19 and find out in which patients the use of acetylsalicylic acid (ASA) affects the prognosis due to the effect of MPV on thromboxan A2. A total of 5142 patients were divided into those followed in the intensive care unit (ICU) and those followed in the ward. Patient medical records were examined retrospectively. ROC analysis showed that the area under curve (AUC) values were 0.714, 0.750, 0.843 for MPV, RDW and D-Dimer, the cutoff value was 10.45fl, 43.65fl, 500.2 ng/mL respectively. (all P < .001). Survival analysis showed that patients with MPV >10.45 f/l and D-Dimer >500.2 ng/mL, treatment with ASA had lower in-hospital and 180-day mortality than patients without ASA in ICU patients (HR = 0.773; 95% CI = 0.595-0.992; P = .048, HR = 0.763; 95% CI = 0.590-0.987; P = .036). Administration of low-dose ASA in addition to anti-coagulant according to MPV and D-dimer levels reduces mortality.

Liver Cirrhosis, Etiology and Clinical Characteristics Disparities among Minority Population

Background: Liver cirrhosis (LC) is a common disease with varied primary causes and ethnic disparities. We aimed to determine the frequency, clinical characteristics, and outcomes of LC among the Arab Bedouin (AB) population in southern Israel. Methods: This retrospective and follow-up study enrolled all patients diagnosed with LC at the gastroenterology and hepatology department or the internal medicine ward. Patient records were reviewed for demographic, clinical data, and mortality. Clinical primary outcomes were defined as death, hepatocellular carcinoma or liver transplantation. Results: We included 820 patients 69 (8.4%) AB and 752 (91.6%) Jewish patients. Incidence of cirrhosis found in our study was much lower among AB patients, 5-10/100,000/year, compared with 20-40/100,000 per year in Jewish patients. Age at diagnosis was 42.6±16.9 years among Bedouins compared to 61±13 years (p<0.001) among Jews. The study included 25 (36.2%) male AB and 472 (63%) male Jewish patients (p<0.001). The most frequent causes of LC among AB were cryptogenic (24.6%), hepatitis B (18.8%) and autoimmune hepatitis (17.4%), while hepatitis C (41.7%), fatty liver (16.5%) and alcoholic liver disease (15.5%) were most common among Jewish patients. An all-cause mortality of 41.8% was found in AB patients compared to 63.4% in Jewish patients (p<0.001). Primary clinical outcomes were found by 34 (49%) AB patients and by 510 (67.9%) Jewish patients (p=0.002), with 46 and 608 events, retrospectively. Conclusions: The incidence of liver cirrhosis among Arab Bedouin is lower than that in the Jewish population, with disparities in etiology, age at diagnosis, presence of complications and mortality.

2894. Metrics of Antimicrobial Use Within Inpatient Settings: Impacts of Statistical Methods and Case-Mix Adjustments

Background The necessary data elements and optimal statistical methods for benchmarking hospital-level antimicrobial use are still being debated. We aimed to describe the relative influence of case-mix adjustment and different statistical methods when ranking hospitals on antimicrobial use (AU) within inpatient settings. Methods Using administrative data from the Veterans Health Administration (VHA) system in October 2016, we calculated total antimicrobial days of therapy (DOT) and days present according to the National Healthcare Safety Network (NHSN) protocol. Patient-level demographics, comorbidities, and recent procedures were used for case-mix adjustments. We compared hospital rankings across 4 different methods: (A) crude antimicrobial DOT per 1,000 days present, aggregated at the hospital-level; (B) observed/expected (O/E) AU ratio with risk adjustment for ward-level variables (analogous to NHSN’s Standardized Antimicrobial Administration Ratio); (C) O/E AU ratio with risk adjustment for ward-/patient-level variables; (D) predicted/expected (P/E) AU ratio with risk adjustment for ward-/patient-level variables, based on a multilevel model accounting for clustering effects at hospital- and ward-levels. Results The cohort included 165,949 DOTs and 318,321 days present at 122 acute care hospitals within VHA. Crude DOTs per 1,000 days present ranged from 153.6 to 900.8 (Figure A), and ward-level risk adjustment only modestly changed rankings (Figure B). When adjusted for ward- and patient-level variables (including demographics, 14 comorbidities and 22 procedures), rankings changed substantially (Figure C). Risk-adjustment by a multilevel model changed rankings even further, while shrinking variabilities (Figure D). Ten hospitals in the lowest and 11 hospitals in the highest quartiles by O/E risk adjustment for only ward-level variables were classified to different quartiles on P/E risk adjustment. Conclusion We observed that the selection of variables and statistical methods for case-mix adjustment had a substantial impact on hospital rankings for antimicrobial use within inpatient settings. Careful consideration of methodologies is warranted when providing benchmarking metrics for hospitals. Disclosures All Authors: No reported Disclosures.

Liver Cirrhosis, Etiology and Clinical Characteristics Disparities among Minority Population

Background Liver cirrhosis (LC) is a common disease with varied primary causes and ethnic disparities. We aimed to determine the frequency, clinical characteristics, and outcomes of liver cirrhosis among the Arabs population in southern Israel.Methods This retrospective and follow-up study enrolled all patients diagnosed with liver cirrhosis at the gastroenterology and hepatology department or the internal medicine ward. Patient records were reviewed for demographic, clinical data, and mortality. Clinical primary outcomes were defined as death, hepatocellular carcinoma or liver transplantation.Results We included 820 patients 69 (8.4%) Arabs and 752 (91.6%) Jewish patients. Incidence of cirrhosis was much lower among Arabs patients, 5-10/100,000/year, compared with 20-40/100,000 per year in Jewish patients. Age at diagnosis was 42.6±16.9 years among Bedouins compared to 61±13 years (p<0.001) among Jews. The study included 25 (36.2%) male Bedouins and 472 (63%) male Jews (p<0.001). The most frequent causes of liver cirrhosis among Arabs were cryptogenic (24.6%), hepatitis B (18.8%) and autoimmune hepatitis (17.4%), while hepatitis C (41.7%), fatty liver (16.5%) and alcoholic liver disease (15.5%) were most common among Jewish patients. An all-cause mortality of 41.8% was found in Arabs patients, compared to 63.4% in Jewish patients (p<0.001). Primary clinical outcomes were found by 34 (49%) Arabs patients and by 510 (67.9%) Jewish patients (p=0.002), with 46 and 608 events, retrospectively.Conclusions The incidence of liver cirrhosis among Arabs is lower than that in the Jewish population, with disparities in etiology, age at diagnosis, presence of complications and mortality.