The impact of nurse staffing levels on nursing-sensitive patient outcomes: a multilevel regression approach

The goal of this study is to provide empirical evidence of the impact of nurse staffing levels on seven nursing-sensitive patient outcomes (NSPOs) at the hospital unit level. Combining a very large set of claims data from a German health insurer with mandatory quality reports published by every hospital in Germany, our data set comprises approximately 3.2 million hospital stays in more than 900 hospitals over a period of 5 years. Accounting for the grouping structure of our data (i.e., patients grouped in unit types), we estimate cross-sectional, two-level generalized linear mixed models (GLMMs) with inpatient cases at level 1 and units types (e.g., internal medicine, geriatrics) at level 2. Our regressions yield 32 significant results in the expected direction. We find that differentiating between unit types using a multilevel regression approach and including postdischarge NSPOs adds important insights to our understanding of the relationship between nurse staffing levels and NSPOs. Extending our main model by categorizing inpatient cases according to their clinical complexity, we are able to rule out hidden effects beyond the level of unit types.

Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes

BACKGROUND

Despite nurses' responsibilities in recognition and treatment of sepsis, little evidence documents whether patient-to-nurse staffing ratios are associated with clinical outcomes for patients with sepsis.

METHODS

Using linked data sources from 2017 including MEDPAR patient claims, Hospital Compare, American Hospital Association, and a large survey of nurses, we estimate the effect of hospital patient-to-nurse staffing ratios and adherence to the Early Management Bundle for patients with Severe Sepsis/Septic Shock SEP-1 sepsis bundles on patients' odds of in-hospital and 60-day mortality, readmission, and length of stay. Logistic regression is used to estimate mortality and readmission, while zero-truncated negative binomial models are used for length of stay.

RESULTS

Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. Adherence to SEP-1 bundles is associated with lower in-hospital mortality and shorter lengths of stay; however, the effects are markedly smaller than those observed for staffing.

DISCUSSION

Improving hospital nurse staffing over and above implementing sepsis bundles holds promise for significant improvements in sepsis patient outcomes.

Rapid tranquillisation: an issue for all nurses in acute care settings

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

Nurses' perceptions, experiences and involvement in the provision of end-of-life care in acute hospitals: A mapping review of research output, quality and effectiveness

BACKGROUND

Safe and high-quality end of life care is not always achieved in acute care hospitals. Nurses represent a key source of information about current practice, and active participants in interventions to improve end of life care in these settings. Examining the volume, type and quality of publications in this field can help to determine whether research is following a natural scientific progression to inform best-practice end of life care.

AIMS

To systematically review: (i) whether the volume and type of publications (i.e. measurement, descriptive or interventions studies) examining nurses' perceptions of, and involvement in, end-of-life care delivered in acute hospitals changed over time (i.e. since 2000); (ii) the proportion of intervention studies involving nurses that meet Risk of Bias research design criteria; and (iii) the effectiveness of intervention studies that met minimum Risk of Bias criteria.

METHODS

MEDLINE, Embase, CINAHL, and PsychInfo were searched for data-based papers published in English between Jan 2000 and Dec 2020. Studies were included if they focused on nurses' perceptions of, or role in, the provision of end-of-life care in hospitals. Eligible papers were classified as descriptive, measurement or intervention studies. Intervention studies were assessed against the Risk of Bias methodological criteria for research design, and their effectiveness examined.

RESULTS

A total of 131 papers met eligibility criteria for inclusion in the review. The number increased by 31% in each time period (p < 0.0001). Most studies were descriptive (n = 70; 53%), 11 were measurement studies (8%), and the remainder were intervention studies (n = 50; 38%). Thirteen intervention studies (26%) met eligibility criteria. Methodological quality of the eligible intervention studies was variable. Randomisation and blinding of outcome assessors were the domains of greatest concern. Results were variable, with larger, system-wide interventions that incorporated the expertise of the multidisciplinary healthcare team showing the most promise.

CONCLUSION

There is an increasing number of studies examining nurses' perceptions of, and involvement in, end-of-life care delivered in acute hospitals. The difficulties of conducting intervention research in this field mean that many studies are descriptive in nature. Given the importance of intervention research in establishing causal relationships, larger-scale intervention studies are essential to improving the quality of end-of-life care provided to patients dying in hospital.

Hospital-based, acute care within 30 days following discharge for acute burn injury

BACKGROUND

While the acute management of burn injury has received substantial attention, patients may undergo additional hospital based, acute care following initial management. We conducted this study to quantify and describe patients' full hospital based, acute care needs within 30 days following an acute burn injury.

METHODS

Using Florida, Nebraska, and New York state inpatient and emergency department databases, we identified adult patients discharged for an acute burn injury from January 1, 2010-November 30, 2014. The primary outcome was the frequency of hospital based, acute care (ED visit or hospital admission) within 30 days of initial discharge. Multivariable logistic regression modeling was used to identify patient factors associated with more frequent hospital based, acute care in the overall population.

RESULTS

The final sample included 126,685 patients who sustained an acute burn injury and were initially managed through the ED (88.3%) or by hospital admission (11.7%). Overall, 16.5% of patients experienced at least one hospital based, acute care encounter within 30 days of discharge of their initial encounter. Most commonly, these were ED visits not undergoing hospital admission for wound care, ongoing burn care, or infectious complications. Patient-level factors associated with more frequent encounters included a history of opioid misuse or abuse (Adjusted Odds Ratio = 2.23, [95% Confidence Interval 2.01-2.47]), chronic obstructive pulmonary disease (AOR = 1.25, [1.12-1.38]), diabetes mellitus (AOR = 1.13, [1.04-1.23]), and mental health diagnoses (AOR = 1.22, [1.11-1.34]).

CONCLUSIONS

Hospital based, acute care encounters are common after initial burn management. Further efforts are needed to improve the transition to outpatient care.

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

PURPOSE

Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC).

METHODS

A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods.

RESULTS

During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5).

CONCLUSIONS

This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.

A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol

Background

Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia.

Methods

A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers.

Discussion

The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives.

Trial registration

The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02294-8.

Understanding what matters most to patients in acute care in seven countries, using the flash mob study design

BACKGROUND

Truly patient-centred care needs to be aligned with what patients consider important, and is highly desirable in the first 24 h of an acute admission, as many decisions are made during this period. However, there is limited knowledge on what matters most to patients in this phase of their hospital stay. The objective of this study was to identify what mattered most to patients in acute care and to assess the patient perspective as to whether their treating doctors were aware of this.

METHODS

This was a large-scale, qualitative, flash mob study, conducted simultaneously in sixty-six hospitals in seven countries, starting November 14th 2018, ending 50 h later. One thousand eight hundred fifty adults in the first 24 h of an acute medical admission were interviewed on what mattered most to them, why this mattered and whether they felt the treating doctor was aware of this.

RESULTS

The most reported answers to "what matters most (and why)?" were 'getting better or being in good health' (why: to be with family/friends or pick-up life again), 'getting home' (why: more comfortable at home or to take care of someone) and 'having a diagnosis' (why: to feel less anxious or insecure). Of all patients, 51.9% felt the treating doctor did not know what mattered most to them.

CONCLUSIONS

The priorities for acutely admitted patients were ostensibly disease- and care-oriented and thus in line with the hospitals' own priorities. However, answers to why these were important were diverse, more personal, and often related to psychological well-being and relations. A large group of patients felt their treating doctor did not know what mattered most to them. Explicitly asking patients what is important and why, could help healthcare professionals to get to know the person behind the patient, which is essential in delivering patient-centred care.

TRIAL REGISTRATION

NTR (Netherlands Trial Register) NTR7538 .

Concurrent and Predictive Validity of FRAIL-NH in Hospitalized Older Persons: An Exploratory Study

OBJECTIVES

The FRAIL-NH was originally developed for frailty assessment of nursing home (NH) residents. We aimed to compare concurrent, predictive, and known-groups validity between FRAIL-NH and FRAIL, using the Frailty Index (FI) as gold standard reference. We also examined for ceiling effect of both measures in the detection of severe frailty.

DESIGN

A secondary analysis of a prospective cohort study.

SETTING & PARTICIPANTS

Older adults (mean age 89.4 years) hospitalized for an acute medical illness in a 1300-bed tertiary hospital.

MEASUREMENTS

Baseline data on demographics, comorbidities, severity of illness, functional status, and cognitive status were gathered. We also captured outcomes of mortality, length of stay (LOS), institutionalization, and functional decline. For concurrent validity, we compared areas under the operating characteristic curves (AUCs) for both measures against the FI. For predictive validity, univariate analyses and multiple logistic regression were used to compare both measures against the adverse outcomes of interest. For known-groups validity, we compared both measures against comorbidities and functional status via 1-way analysis of variance, and dementia diagnosis via independent t test. Box plots were also derived to investigate for possible ceiling effect.

RESULTS

Both measures had good concurrent validity (both AUC > 0.8 and P < .001), with FRAIL-NH detecting more frailty cases (79.5% vs 50.0%). Although FRAIL-frail was superior for in-hospital mortality [6.7% vs 1.0%, P = .031, odds ratio (OR) 9.29, 95% confidence interval (CI) 1.09-79.20, P < .042] and LOS (10 vs 8 days, P = .043), FRAIL-NH-frail better predicted mortality (OR 6.62, 95% CI 1.91-22.94, P = .003) and institutionalization (OR 6.03, 95% CI 2.01-18.09, P = .001) up to 12 months postenrollment. Known-groups validity was good for both measures with FRAIL-NH yielding greater F values for functional status and dementia. Lastly, box plots revealed a ceiling effect for FRAIL in the severely frail group.

CONCLUSIONS AND IMPLICATIONS

This exploratory study highlights the potential for expanding the role of FRAIL-NH beyond NH to acute care settings. Contrasted to FRAIL, FRAIL-NH had better overall validity with less ceiling effect in discrimination of severe frailty.

Avoidable Hospitalizations And Observation Stays: Shifts In Racial Disparities

Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.

Perceived roles and barriers to nurses' engagement in antimicrobial stewardship: A Thai qualitative case study

BACKGROUND

Antimicrobial stewardship is the practice of ensuring the optimal use of antibiotics to prevent antimicrobial resistance. A multidisciplinary approach is considered best practice; however, little is known about nurses' contribution.

OBJECTIVES

To explore how organisational multidisciplinary leaders and clinical nurses perceive nurses' roles in AMS in a single organisational site case study based in Thailand, within the current governance, educational and practice context, and the barriers to nurses' engagement in AMS.

METHODS

A qualitative descriptive study using thematic analysis approach was conducted in a 1000-bed university hospital in Bangkok, Thailand. The combined number of organisational leaders and nurses was 33 including 15 individual organisational leader interviews and three focus groups involving 18 nurses.

RESULTS

Nurses currently participate in AMS by supporting system processes, monitoring safety and optimal antibiotic use and patient education. A lack of clear articulation of nurses' role and traditional professional hierarchies limits active participation. Inconsistent engagement was perceived as due to a failure to prioritise AMS activities, a lack of formal policies and a need for further education.

CONCLUSION

Nurses do engage in AMS but there are significant governance, hierarchical and educational impediments. These gaps need to be addressed before clearly defined nurse roles in AMS can be developed and embedded into clinical practice.

How do nurses promote critical thinking in acute care? A scoping literature review

AIM

Critical thinking is essential to quality health care and patient outcomes in the acute care setting. It is important for educators to understand and apply teaching and learning strategies to promote critical thinking of nursing students and junior nurses in acute care.

DESIGN

We followed Arksey and O'Malley's 2005 framework to undertake a scoping literature review to find out how critical thinking is promoted among nursing learners (i.e., nursing students and junior nurses) in acute care.

METHODS

Between September and October 2018, four databases were searched: MEDLINE, CINAHL, ERIC, and Google Scholar. Search terms included: rapid, teaching, methods, nursing, promote, critical thinking and acute setting. A descriptive thematic analysis was undertaken.

RESULTS

Twenty-three articles were included for review. Three main themes were identified from the analysis: learner-teacher relationship, reflection, and inquiry. Strong relationships promoted positive role modelling and effective feedback - both contributing to the teaching of critical thinking. Reflection strategies such as concept mapping and journaling were frequently used, while active student inquiry further promoted critical thinking in the acute setting.

CONCLUSIONS

The acute setting affords opportunities and challenges to promote critical thinking. Teachers/clinicians should incorporate learner-centred pedagogy and encourage reflective practice to embed critical thinking in teaching and clinical practice.

A systematic review of interventions to improve acute hospital care for people with dementia

The aim of this study was to provide an overview of interventions targeting hospital care of patients with dementia. We conducted a systematic review, including interventional study designs. We searched five electronic databases, conducted a hand search and performed citation tracking. To assess risk of bias, we used Cochrane Collaboration's tool, ROBANS and AMSTAR. We narratively summarized the outcomes. The findings of twenty studies indicated a broad range of interventions and outcomes. We categorised the interventions into eight intervention types. Educational programmes were the most reported intervention type and resulted in improved staff outcomes. Family-/person-centred care programmes, use of specially trained nurses and delirium management programmes were effective in improving some patient-related outcomes. However, current evidence is insufficient to declare which interventions are effective in improving dementia care in acute hospitals. Future research should focus on relevant patient and family caregiver outcomes and must consider the complexity of the interventions when evaluating them.

Person-Centered Communication Between Health Care Professionals and COVID-19-Infected Older Adults in Acute Care Settings: Findings From Wuhan, China

Objectives

The current study aims to explore person-centered communication between health care professionals and COVID-19 infected older patients in acute care settings.

Methods

The current qualitative study explored the communication between professionals and COVID-19 infected older adults in the acute care setting through two rounds of interviews with physicians and nurses who provided direct care and treatment for COVID-19 infected older patients in Wuhan, China. We explored the possibilities and significance of facilitating effective communication despite multiple challenges in the pandemic. Conventional content analysis was adopted to analyze the rich data collected from our participants.

Results

It is possible and necessary to initiate and sustain person-centered communication despite multiple challenges brought by the pandemic. The achievement of person-centered communication can play significant roles in addressing challenges, building mutual trust, improving quality of care and relationships, and promoting treatment adherence and patients’ psychological wellbeing.

Discussion

It is challenging for healthcare professionals to provide care for COVID-19 infected older adults, especially for those with cognitive and sensory impairment, in acute care settings. Facilitating person-centered communication is a significant strategy in responding to the pandemic crisis and a core element of person-centered care.

Mental health nurses experience of the introduction and practice of the Safewards model: a qualitative descriptive study

BACKGROUND

A lack of safety experienced by patients and staff in acute psychiatric units is a major concern and containment methods used to manage conflict have the potential to cause harm and upset to both staff and patients. To ensure safety for all, it is highly desirable to reduce levels of conflict and containment and the Safewards model is an evidence-based model aimed at reducing conflict and containment rates by improving nurse-patient relationships and safety.

METHODS

The aim of this study was to explore mental health nurses' experience of the introduction and practice of three Safewards interventions; reassurance, soft words and discharge messages. A qualitative descriptive research design utilising a purposive sample (n = 21) of registered psychiatric nurses (n = 16) and managers (n = 5) in an acute psychiatric unit in Ireland. Following a 12-week implementation of Safewards, three focus groups were conducted, two with nursing staff and one with nurse managers. Data were analysed using Braun and Clarke thematic analysis framework which supported the identification of four themes: introducing Safewards, challenges of Safewards, impact of Safewards and working towards success.

RESULTS

The findings indicate that the process of implementation was inadequate in the training and education of staff, and that poor support from management led to poor staff adherence and acceptance of the Safewards interventions. The reported impact of Safewards on nursing practice and patient experience were mixed. Overall, engagement and implementation under the right conditions are essential for success and while some participants perceived that the interventions already existed in practice, participants agreed Safewards enhanced their communication skills and relationships with patients.

CONCLUSION

The implementation of Safewards requires effective leadership and support from management, mandatory training for all staff, and the involvement of staff and patients during implementation. Future research should focus on the training and education required for successful implementation of Safewards and explore the impact of Safewards on nursing practice and patient experience.

Acute day units for mental health crises: a qualitative study of service user and staff views and experiences

BACKGROUND

Acute Day Units (ADUs) provide intensive, non-residential, short-term treatment for adults in mental health crisis. They currently exist in approximately 30% of health localities in England, but there is little research into their functioning or effectiveness, and how this form of crisis care is experienced by service users. This qualitative study explores the views and experiences of stakeholders who use and work in ADUs.

METHODS

We conducted 36 semi-structured interviews with service users, staff and carers at four ADUs in England. Data were analysed using thematic analysis. Peer researchers collected data and contributed to analysis, and a Lived Experience Advisory Panel (LEAP) provided perspectives across the whole project.

RESULTS

Both service users and staff provided generally positive accounts of using or working in ADUs. Valued features were structured programmes that provide routine, meaningful group activities, and opportunities for peer contact and emotional, practical and peer support, within an environment that felt safe. Aspects of ADU care were often described as enabling personal and social connections that contribute to shifting from crisis to recovery. ADUs were compared favourably to other forms of home- and hospital-based acute care, particularly in providing more therapeutic input and social contact. Some service users and staff thought ADU lengths of stay should be extended slightly, and staff described some ADUs being under-utilised or poorly-understood by referrers in local acute care systems.

CONCLUSIONS

Multi-site qualitative data suggests that ADUs provide a distinctive and valued contribution to acute care systems, and can avoid known problems associated with other forms of acute care, such as low user satisfaction, stressful ward environments, and little therapeutic input or positive peer contact. Findings suggest there may be grounds for recommending further development and more widespread implementation of ADUs to increase choice and effective support within local acute care systems.

Antipsychotic Polypharmacy and High-Dose Antipsychotics in Involuntary Patients: a Seven-Year Audit of Discharge Prescriptions in an Acute Care Unit

Antipsychotic polypharmacy (APP) is a psychopharmacological practice in which two or more antipsychotics are prescribed simultaneously. Despite the absence of evidence to support it, it is highly prevalent in clinical settings. Another recurrent practice strongly associated with APP is the prescription of high-dose antipsychotics (HDAs). Compulsory treatment is a legal means to impose treatment on an individual suffering from mental illness who refuses therapeutic intervention. Compulsory treatment has been associated with APP and HDAs and rates of both have been proposed to represent indicators of the quality of prescribing. We aimed to perform an antipsychotic prescription audit in a vulnerable psychiatric population, at the psychiatry department of a district hospital in Portugal, across 7 years. We evaluated APP and HDAs in 403 compulsorily admitted patients by reviewing their files at discharge. We used logistic regression to search for factors associated with APP and HDAs. APP was found in 70.5% of individuals, whereas HDAs were found in 51.4%. After adjustment, APP was significantly associated with male gender (Odds Ratio[OR] = 1.85 [1.04; 3.30] 95% Confidence Interval [CI]), involuntary outpatient treatment (OR = .40 [.18; .82] 95% CI), activation of the hospital social services (OR = 1.91 [1.08; 3.38] 95%CI), prescription of antidepressants (OR = .43 [.22; .82] 95%CI) and long-acting injectables (LAI) (OR = 28.29 [13.13; 60.97] 95%CI). HDAs were associated with male gender (OR = 1.76 [1.06; 2.94] 95%CI), the prescription of LAI (OR = 12.92 [6.93; 24.09] 95%CI) and oral first-generation antipsychotics (OR = 2.90 [1.51; 5.60] 95%CI).

Evaluation of a blended learning approach to developing specialty-nursing practice. An exploratory descriptive qualitative study

BACKGROUND

An ageing population and a transitioning workforce is creating demands on healthcare workforces. Clinical and procedural knowledge deficits cause anxieties in new and experienced nurses alike when integrating into new teams. Overcoming these boundaries can be achieved with Introductory programs. These develop knowledge, technical skills and non-technical skills. Investigating nurses drive to undertake such programs, and the benefits they perceive for themselves, will help to tailor future programs.

OBJECTIVES

To explore post-registration nurses' motivations for undertaking an introductory program that utilised a blended learning methodology. Identifying changes in participants understanding and clinical behaviours.

METHODS

An exploratory descriptive qualitative study design was used to evaluate the Introduction to Specialty Practice (ISP) program that is run by a large private healthcare provider in Melbourne, Australia. The health service includes eight campuses and four intensive care units across the group. Twelve participants from a mixture of critical care and acute care clinical areas were consented. They were interviewed using a semi-structured questionnaire. Responses were transcribed verbatim and thematic analysis of the transcripts then occurred.

RESULTS

The study demonstrated intrinsic and extrinsic factors influenced participant's desires to undertake this program. Three major themes were evident: 1) that caring without knowledge was daunting, 2) that participants needed to create a clinical and professional identity and 3) that participant's perspective on their delivery of care improved, along with their professional aptitude.

CONCLUSION

Maintaining currency with knowledge, skills, and technological developments is crucial for nurses to consistently deliver high-level care. The demands that nurses' face within their clinical areas affects their intention to stay within the workforce and their ability to deliver care. Introductory programs that utilise blended learning strategies have a role to play in enabling nurses to create their professional identity, find their position in clinical teams, and meet the requirements of organisations.

[Analysis of injury incidences in a trauma surgery university hospital during the SARS-CoV‑2 pandemic]

Einleitung

Die Coronakrise 2020 stellte Kliniken vor schwere Herausforderungen. Neben der Behandlung von COVID(„coronavirus disease“)-19-Patienten war es die Aufgabe der Universitäts- und sonstigen Akutkliniken, eine notfallmedizinische Versorgung sicherzustellen. Aufgrund fehlender Planzahlen gestaltete sich eine genaue Ressourcenplanung schwierig. Daher war das Ziel dieser Arbeit, das Aufkommen von Polytraumata und sonstigen Verletzungen während der Pandemiekrise in einer universitären unfallchirurgischen Klinik zu erfassen und mit den Jahren 2017–2019 zu vergleichen.

Material und Methoden

Es wurde eine retrospektive Analyse unfallchirurgischer Patienten während der Kalenderwochen (KW) mit bestehender Ausgangsbeschränkung (12.–19. KW) im Jahr 2020 durchgeführt. Zunächst erfolgte eine tagesgenaue Erfassung der Behandlung von COVID‑19-Patienten. Zusätzlich wurden für die Auswertungsperiode vom 20.03.2020 bis zum 06.05.2020 die Anzahlen an 1. Polytrauma-, 2. Arbeitsunfall- und 3. Freizeitunfallpatienten erfasst und mit den Zahlen von 2017–2019 verglichen.

Ergebnisse

Maximal 43 COVID‑19-Patienten mussten gleichzeitig intensivmedizinisch betreut werden. Die Summe an unfallchirurgischen Patienten war im Jahr 2020 geringer als in den Vorjahren. Dennoch war mit einem Rückgang von nur −28 % (22 ± 4,9 vs. 16) ein beachtliches Aufkommen an Polytraumata zu verzeichnen, während v. a. die Arbeits- (44 %, 304 ± 31,3 vs. 170) und auch Freizeitunfälle (39 %, 173 ± 22,7 vs. 106) deutlich abnahmen.

Diskussion

Auch in Ausnahmesituationen wie der SARS-CoV‑2-Pandemie, war ein erhebliches Aufkommen von akut behandlungsbedürftigen Patienten zu verzeichnen, v. a. in puncto Polytraumapatienten. Dies sollte zukünftig bei ähnlichen Ausnahmesituationen im stationären Versorgungsrahmen bei der Vorhaltung unfallchirurgischer Versorgungskapazitäten bedacht werden.

Improving the assessment and documentation of patient mobility using a quality improvement framework

OBJECTIVE

To implement a system for assessing and documenting patient mobility in an inpatient geriatric unit using a quality improvement framework.

METHODS

Whiteboards incorporating the Johns Hopkins Highest Level of Mobility scale were placed on each door of the unit. Staff were trained to assess and document patient mobility, and documentation compliance was measured. Nurses were surveyed to assess perceived burden of the system. Fall rates were calculated and analyzed for change from baseline.

RESULTS

Median daily documentation rates reached 79% by the end of the project. Surveys indicated a low perceived burden of the system. Fall rates did not increase when compared to the previous year baseline (p = 0.80) and the analogous time frames during the previous two years (p = 0.84).

CONCLUSION

A quality improvement framework may be used to improve mobility assessment and documentation in a geriatric unit without increasing patient falls or nursing burden.

Nurses' experiences with an inpatient geriatric consulting service at a Midwestern Veterans' hospital: The elder veteran program

This qualitative project used conventional content analysis of interview data to examine nurses' experience with and perception of the Elder Veteran Program, an inpatient geriatric consulting service, at a midwestern Veterans' hospital. Nurses were recruited from nursing units utilizing the program and completed individual interviews (N = 10). Participants described the impact of the program within four categories: providing comprehensive care to patients, contributing to individual growth of nurses, promoting team-based care, and as a resource. Participants described several barriers and facilitators to implementation of the program on their unit, including workload and time, shifts and availability of program staff, perceived need, inclusion criteria, perception of program staff, education of nurses, communication, and the inpatient environment. This project provides opportunities for further examination of healthcare providers' experience with inpatient geriatric programs, how those experiences may relate to effectiveness of programs, and important areas of support for hospital staff.

A 3-Country Assessment of Traumatic Brain Injury Practices and Capacity

BACKGROUND

The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low- and middle-income countries, which have brain injury rates 3 times higher than high-income countries. The aim of this study was to identify current TBI practices and treatment capacity in 3 low- and middle-income countries: Republic of Armenia, Georgia, and Republic of Moldova.

METHODS

After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources.

RESULTS

All 3 countries follow international, national, and hospital protocols for TBI treatment, and the in-hospital management of patients with TBI is similar to international standards in all 3 countries. Although health care specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned as difficulties in interviews from all 3 countries.

CONCLUSIONS

Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.

Structure and processes of emergency observation units with a geriatric focus: a scoping review

BACKGROUND

Combining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs.

METHODS

The revised scoping methodology framework of Arksey and O'Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies.

RESULTS

Sixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies.

CONCLUSION

This scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of 'observation medicine' and 'CGA' can ideally be merged and successfully implemented in clinical care.

Physical performance measures and hospital outcomes among Italian older adults: results from the CRIME project

BACKGROUND

Older adults are a complex population, at risk of adverse events during and after hospital stay.

AIM

To investigate the association of walking speed (WS) and grip strength (GS) with adverse outcomes, during and after hospitalization, among older individuals admitted to acute care wards.

METHODS

Multicentre observational study including 1123 adults aged ≥ 65 years admitted to acute wards in Italy. WS and GS were measured at admission and discharge. Outcomes were length-of-stay, in-hospital mortality, 1-year mortality and rehospitalisation. Length-of-stay was defined as a number of days from admission to discharge/death.

RESULTS

Mean age was 81 ± 7 years, 56% were women. Compared to patients with WS ≥ 0.8 m/sec, those unable to perform or with WS < 0.8 m/sec had a higher likelihood of longer length-of-stay (OR 2.57; 95% CI 1.63-4.03 and 2.42; 95% CI 1.55-3.79) and 1-year mortality and rehospitalization (OR 1.47, 95% CI 1.07-2.01; OR 1.57, 95% CI 1.04-2.37); those unable to perform WS had a higher likelihood of in-hospital mortality (OR 9.59; 95% CI 1.23-14.57) and 1-year mortality (OR 2.60; 95% CI 1.37-4.93). Compared to good GS performers, those unable to perform had a higher likelihood of in-hospital mortality (OR 17.43; 95% CI 3.87-28.46), 1-year mortality ( OR 3.14; 95% CI 1.37-4.93) and combination of 1-year mortality and rehospitalisation (OR 1.46; 95% CI 1.01-2.12); poor GS performers had a higher likelihood of 1-year mortality (OR 1.39; 95% CI 1.03-2.35); participants unable to perform GS had a lower likelihood of rehospitalisation (OR 0.59; 95% CI 0.39-0.89).

CONCLUSION

Walking speed (WS) and grip strength (GS) are easy-to-assess predictors of length-of-stay, in-hospital and post-discharge death and should be incorporated in the standard assessment of hospitalized patients.

A consensus statement for trauma surgery capacity building in Latin America

BACKGROUND

Trauma is a significant public health problem in Latin America (LA), contributing to substantial death and disability in the region. Several LA countries have implemented trauma registries and injury surveillance systems. However, the region lacks an integrated trauma system. The consensus conference's goal was to integrate existing LA trauma data collection efforts into a regional trauma program and encourage the use of the data to inform health policy.

METHODS

We created a consensus group of 25 experts in trauma and emergency care with previous data collection and injury surveillance experience in the LA. region. Experts participated in a consensus conference to discuss the state of trauma data collection in LA. We utilized the Delphi method to build consensus around strategic steps for trauma data management in the region. Consensus was defined as the agreement of ≥ 70% among the expert panel.

RESULTS

The consensus conference determined that action was necessary from academic bodies, scientific societies, and ministries of health to encourage a culture of collection and use of health data in trauma. The panel developed a set of recommendations for these groups to encourage the development and use of robust trauma information systems in LA. Consensus was achieved in one Delphi round.

CONCLUSIONS

The expert group successfully reached a consensus on recommendations to key stakeholders in trauma information systems in LA. These recommendations may be used to encourage capacity building in trauma research and trauma health policy in the region.