Rural collaborative guideline implementation: Evaluation of a hub and spoke multidisciplinary team model of care for orthogeriatric inpatients - A before and after study of adherence to clinical practice guidelines

Exploring nurses' perceptions of clinical handover in regional health care facilities: A exploratory qualitative study

AIM

This study sought to explore nurses' perceptions of clinical handover in a regional health care facility to better understand the local context and identify the most appropriate clinical handover models.

BACKGROUND

Clinical handover is an essential aspect of clinical care, and yet using accurate spoken and written communication can be neglected in nursing, potentially resulting in patient harm. Although much information is available on clinical handover in metropolitan settings, few studies have examined the regional context.

METHODS

This study was an exploratory qualitative study based at one small regional health care facility located 100 km from a metropolitan Australian centre. The study utilized an Appreciative Inquiry approach to identify how nurses perceive the use of standardized oral and written clinical handover. Focus groups were engaged to explore the perceptions of nurses "handing over" in the smaller regional facility.

RESULTS

Through focus group interviews with Registered and Enrolled Nurses, the data revealed that the cultural context of the ward influenced perceptions of clinical handover and that handover served as a light in the dark for all nursing staff; as an evolving communication tool illuminating patient care needs.

CONCLUSION

This study facilitated understanding of the handover needs of smaller Australian regional hospitals. This study identified gaps in perception about handover practices between junior and senior nurses. New graduate nurses develop confidence in supportive clinical environments. A transition to practice programme would need to address the challenges new graduates face in the regional setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers in regional facilities can champion supportive senior nurses to mentor new graduate nurses and enhance the transition to practice for the new nurse.

Impact of a Comprehensive Guideline Dissemination Strategy on Diabetes Diagnostic Test Rates: an Interrupted Time Series

BACKGROUND

Diabetes Canada launched a comprehensive Dissemination and Implementation (D&I) strategy to optimize uptake of their 2013 Clinical Practice Guidelines; the strategy involved continuing professional development courses, webinars, an interactive website, applications for mobile devices, point-of-care decision support tools, and media awareness campaigns. It included a focus on promoting HbA1c as the recommended diagnostic test for diabetes.

OBJECTIVE

To determine the impact of Diabetes Canada's 2013 D&I strategy on physician test-ordering behavior, specifically HbA1c testing, for the diagnosis of diabetes, using provincial healthcare administrative data.

DESIGN

Population-based interrupted time series.

SETTING

Ontario, Canada.

PARTICIPANTS

Ontario residents aged 40-79 not previously diagnosed with diabetes.

MEASUREMENTS

For each quarter between January 2005 and December 2014, we conducted an interrupted time series analysis on the first-order difference of the proportion of patients receiving HbA1c tests per quarter with an autoregressive integrated moving average model with the intervention step occurring in quarter 2 of 2013. Subgroup analyses by rurality, physician graduation year, and practice size were also conducted.

RESULTS

There were 32 quarters pre-intervention and 6 post-intervention; average sample size per quarter was 5,298,686 individuals. Pre-intervention, the quarter-to-quarter growth was 1.51 HbA1c tests per quarter per 1000 people. Post-intervention, the quarter-to-quarter growth increased by 8.45 tests per 1000 people (p < 0.005). Growth of HbA1c ordering differed significantly by region, years since physician graduation, and practice size.

LIMITATIONS

Incomplete data collection, inadequate stratification, and other unidentified confounders.

CONCLUSION

The D&I strategy resulted in a significant increase in the growth of HbA1c tests. The successful uptake of this recommendation may be due to its simplicity; guideline developers should consider this when drafting recommendations. Furthermore, differential uptake by user groups suggests that future strategies should include targeted barrier analysis and interventions to these groups.

Age-friendly care for older adults within rural Australian health systems: An integrative review

OBJECTIVES

To identify the core elements of interventions and models that facilitate age-friendly care for older adults within rural Australian health systems, and assess the extent to which these align with core elements of the Institute for Health Improvement's (IHI) Age-Friendly Health Systems 4Ms Model.

METHODS

Peer-reviewed journal articles examining core elements of Australian rural geriatric care models were collected and analysed using an integrative review methodology.

RESULTS

Identified models and interventions addressed all four core elements of the IHI model-what matters, medications, mobility and mentation. There was more evidence relating to mobility and mentation, with lesser evidence relating to medications and what matters. A series of core elements not aligned with the model were also identified.

CONCLUSION

The IHI 4Ms Model appears to be applicable in the rural Australian context. More high-quality, systematic evidence is needed to investigate the core elements of age-friendly care across diverse rural contexts.

Nurses' Perspectives on Interprofessional Communication in the Prevention of Functional Decline in Hospitalized Older People

Older people present with complex health issues on admission to hospital and are at high risk for functional decline and related complications. Thus, they require the services of diverse health-care professionals working in concert to support their functioning. Despite nurses' central role in caring for this patient population, and evidence indicating that interprofessional communication is a persistent challenge for nurses in acute-care settings, little is known about nurses' views on interprofessional communication in care preserving functioning in acutely admitted older people. To fill this knowledge gap, we gathered acute-care staff nurses' perspectives on interprofessional communication in a function-focused, interprofessional approach to hospital care for older adults. Thirteen focus groups were conducted with a purposeful, criterion-based sample of 57 nurses working in acute-care hospitals. Thematic analysis revealed two overarching themes capturing nurses' perspectives on key factors shaping interprofessional communication in a function-focused interprofessional approach to care (1) context of direct communication and (2) context of indirect communication. The first theme demonstrates that nurses preferred synchronous modes of communication, but some ascribed greater importance to unstructured forms of direct information-sharing, while others stressed structured direct communication, particularly interprofessional rounds. The second theme also documents divergence in nurses' views on asynchronous communication, with some emphasizing information technology and others analog tools. Perceptions of some modes of interprofessional communication were found to vary by practice setting. Theoretical and pragmatic conclusions are drawn that can be used to optimize interprofessional communication processes supporting hospitalized older people's functioning.

CE: Original Research: Exploring Clinicians' Perceptions About Sustaining an Evidence-Based Fall Prevention Program

: Purpose: This study aimed to address the knowledge gap between implementing and sustaining evidence-based fall prevention practices for hospitalized patients by exploring perspectives of the interprofessional health care team.

DESIGN

A qualitative design was used to capture insights from clinicians across disciplines in a large midwestern academic medical center.

METHODS

Four homogenous semistructured focus groups and three individual interviews involving a total of 20 clinicians were conducted between October 2013 and March 2014. Audio-recorded data were transcribed and analyzed using inductive qualitative analysis.

FINDINGS

Two primary themes emerged from participants regarding the sustainability of an evidence-based fall prevention program: communication patterns within the interprofessional health care team and influences of hospital organizational practices and elements. Several subthemes also emerged. Participants gave nursing staff primary responsibility for fall risk assessment and prevention.

CONCLUSIONS

Individual professional perceptions and practices, as well as organizational characteristics, affect the sustainability of evidence-based fall prevention practices. While all team members recognized patient falls as a significant quality and safety issue, most believed that direct care nurses hold primary responsibility for leading fall prevention efforts. The data support the importance of effective interprofessional team communication and organizational practices in sustaining an evidence-based fall prevention program across inpatient units. Furthermore, the data call into question the wisdom in labeling quality indicators as "nursing sensitive"; the evidence indicates that a team approach is best.

The impact of patient safety culture on handover in rural health facilities

BACKGROUND

Effective handover is crucial for patient safety. Rural health care organisations have particular challenges in relation to handover of information, placing them at higher risk of adverse events. Few studies have examined the relationship between handover and patient safety in rural contexts, particularly in Australia. This study aimed to explore the effect of handover on overall perceptions of patient safety and the effect of other patient safety dimensions on handover in a rural Australian setting.

METHODS

A cross-sectional online survey using The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was implemented across six rural Local Health Districts in NSW, Australia and resulted in 1587 respondents. Hierarchical multiple linear regression analysis was conducted to account for the nested nature of the data. Models were developed to assess the effect of handover on patient safety perceptions, and the effect of other patient safety culture composites on handover variables. Open-ended questions about patient safety were inductively analyzed for themes. Quotes from the handover theme are presented.

RESULTS

All models were significant overall (p < .001), with explanatory powers ranging from 29 to 48%. Within rural health settings, effective handover is significantly related to patient safety perceptions (R2 = .29). A strong teamwork culture and management support culture was found to enhance effective handover of patient information (R2 = .47), and effective handover of personal responsibility (R2 = .37). A strong teamwork, management support, and open communication culture enhances handover of department accountability (R2 = .41). Despite the implementation of standardised communication tools and frameworks for handover, patient safety is compromised by inadequate coordination, poor or absent documentation between departments, between other health care agencies and in transfer of care from acute facilities to primary/community care.

CONCLUSION

Approaches to handover need to consider the particular challenges associated with rurality and strengthening elements found to be associated with increased safety, such as a strong teamwork and management culture and good reporting practices. Research is required to examine how communication at transition of care, particularly between facilities, is conducted and ways in which to enhance patients' and families' participation.

Age-related trends in injury and injury severity presenting to emergency departments in New South Wales Australia: Implications for major injury surveillance and trauma systems

OBJECTIVES

To describe population based trends and clinical characteristics of injury related presentations to Emergency Departments (EDs).

DESIGN AND SETTING

A retrospective, descriptive analysis of de-identified linked ED data across New South Wales, Australia over five calendar years, from 2010 to 2014.

PARTICIPANTS

Patients were included in this analysis if they presented to an Emergency Department and had an injury related diagnosis. Injury severity was categorised into critical (triage category 1-2 and admitted to ICU or operating theatre, or died in ED), serious (admitted as an in-patient, excluding above critical injuries) and minor injuries (discharged from ED).

MAIN OUTCOME MEASURES

The outcomes of interest were rates of injury related presentations to EDs by age groups and injury severity.

RESULTS

A total of 2.09 million injury related ED presentations were analysed. Minor injuries comprised 85.0%, and 14.1% and 1.0% were serious and critical injuries respectively. There was a 15.8% per annum increase in the rate of critical injuries per 1000 population in those 80 years and over, with the most common diagnosis being head injuries. Around 40% of those with critical injuries presented directly to a major trauma centre.

CONCLUSION

Critical injuries in the elderly have risen dramatically in recent years. A minority of critical injuries present directly to major trauma centres. Trauma service provision models need revision to ensure appropriate patient care. Injury surveillance is needed to understand the external causes of injury presenting to hospital.

Analysis of the barriers and enablers to implementing lifestyle management practices for women with PCOS in Singapore

BACKGROUND

Polycystic ovary syndrome (PCOS) is a condition that affects women of reproductive age and manifests with adverse reproductive, metabolic and psychological consequences. Evidence-based PCOS guidelines recommend lifestyle management first line for infertility. In Singapore women with PCOS can attend the PCOS Clinic at the Kandang Kerbau Women and Children's Hospital for infertility treatment. However lifestyle integration into infertility management is currently limited and barriers and enablers to progress remain unclear.

METHODS

All PCOS clinic staff undertook semi-structured interviews to investigate perceived barriers for staff and consumers for the integration of lifestyle into infertility management. This study utilised various tools including an 8P Ishikawa diagram model to identify and categorise barriers. A modified Hanlon method was then used to prioritise barriers within the Singaporean context considering organisational, cultural and financial constraints. Propriety, economics, acceptability, resources and legality (PEARL) criteria were also incorporated into this decision-making tool.

RESULTS

In the 8P model, there were five factors contributing to the 'procedure (consultations and referral processes)' barrier, one 'policy (government and hospitals)' factor, five 'place' factors, two 'product (lifestyle management programme)' barriers, two 'people (programme capacity)' factors, four 'process (integration)' factors, three 'promotion' barriers and three 'price' factors. Of the prioritised barriers, two were identified across each of 'procedures', 'place', 'product' and 'people' and four related to 'processes'. There were no barriers identified that for 'policies', 'promotion' and 'price' that can be addressed.

CONCLUSIONS

There is a clear need to integrate lifestyle into infertility management in PCOS, in line with current national and international evidence-based guidelines. The highest priority identified improvement opportunity was to develop a collaborative lifestyle management programme across hospital services. Reductions in variation of delivery and strengthening support within the lifestyle programme are other identified priorities. The strength of this study is that this is the first study to utilise a pragmatic quality improvement method for barriers identification and prioritisation in the area of lifestyle management for women with PCOS. This project identified factors that may provide easy improvements, but also identified some local factors that may be very difficult to change. The major limitation of this study is that it is only looking at the Singapore setting, so may have limited applicability to other countries. However, results from quality improvement projects are meant to be context specific.