Visual identifier systems for patients with cognitive impairment in healthcare settings: A survey of practice in UK hospitals

Exploring end of life care provision during medical imaging in hospitals: Analysis of survey data from the UK radiography workforce

INTRODUCTION

Patients receiving end-of-life care often undergo medical imaging examinations in hospitals to inform symptom management and care. Yet little is known about the experiences of the radiography workforce who deliver it. This study aims to describe and explore experiences of the UK radiography workforce delivering medical imaging as part of patients' end-of-life care.

METHODS

A mixed method cross-sectional online survey disseminated via social media and national organisations from September 2023 to January 2024. Diagnostic radiographers, assistant practitioners and radiology assistants involved in the medical imaging of patients receiving end-of-life care in UK hospitals.

RESULTS

120 valid responses were received. Most respondents received no education/training (91.6%) on the role of medical imaging in end-of-life care, despite 87.7% expressing a need for education, particularly around adopting supportive/palliative-centric communication techniques. Although most respondents (89.2%) had heard of end-of-life care, some had difficulty understanding the role of medical imaging in end-of-life care. Insufficient information provided on imaging requests hindered the workforces' ability to determine and understand the appropriate use of medical imaging during end-of-life care. These uncertainties exacerbated negative emotions, with 80.8% of respondents indicating that they felt emotional during or after imaging patients on end-of-life care.

CONCLUSION

Educational and policy needs were identified around facilitating more supportive/palliative-centric communication techniques and providing the radiography workforce with the knowledge to better understand, explain, deliver and where necessary, challenge the use of medical imaging in end-of-life care.

IMPLICATIONS FOR PRACTICE

This study has evidenced the important role the radiography workforce play in generalist end-of-life care. However, there is a need for training to support practitioners as well as appropriate policies to develop supportive and high-quality end-of-life care in medical imaging.

A Principle-Based Approach to Visual Identification Systems for Hospitalized People with Dementia

A large proportion of hospital inpatients are affected by cognitive impairment, posing challenges in the provision of their care in busy, fast-paced acute wards. Signs and symbols, known as visual identifiers, are employed in many U.K. hospitals with the intention of helping healthcare professionals identify and respond to the needs of these patients. Although widely considered useful, these tools are used inconsistently, have not been subject to full evaluation, and attract criticism for acting as a shorthand for a routinized response. In order for visual identifiers to be used effectively in acute care settings, thorough consideration must be given to the ethical and legal issues that are engaged in this context, and their potential benefits and harms must be weighed and balanced. This paper proposes a set of legal and ethical principles that can be used to guide the implementation of visual identifiers. Together, these principles provide a framework applicable in the design and implementation phases to systematically identify relevant considerations arising from the use of these tools. We outline some tensions that arise between principles and conclude that selecting a preferred moral framework could help to guide decision-making, as does clarity around the purpose and objectives of the identifier.

Visual identifiers for people with dementia in hospitals: a qualitative study to unravel mechanisms of action for improving quality of care

BACKGROUND

Hospitalised people with dementia (PwD) experience worse care and more patient safety incidents than non-dementia patients. Visual identifiers are commonly used to identify patients who have a diagnosis of dementia, with the aim of promoting more personalised care. However, little is known about how they work in practice, nor about the potential unintended consequences that might arise from their use. We aim to identify the mechanisms through which visual identifiers could support good care for PwD, how and why their use may have negative consequences and the conditions for their effective use.

METHODS

We conducted interviews with 21 dementia leads and healthcare professionals, 19 carers and two PwD, and produced case studies of visual identification systems in four UK acute hospital trusts between 2019 and 2021. Analysis drew on the concept of classification to identify and explore mechanisms of action.

RESULTS

We identified four mechanisms through which visual identifiers could help towards providing good care for PwD: enabling coordination of care at organisational level; signalling eligibility for dementia-specific interventions; informing prioritisation of resources on wards; and acting as a quick reference cue for staff. But identifier effectiveness could be undermined by: lack of standardisation and consistency; a lack of closely coupled information about individual needs; and stigma associated with a dementia diagnosis. Identifier effectiveness was dependent on their implementation being supported through staff training, resources directed and efforts to develop a supportive culture for caring for this patient group.

CONCLUSION

Our research highlights the potential mechanisms of action of visual identifiers and their possible negative consequences. Optimising the use of identifiers requires consensus on the rules of classification and the symbols used, and closely coupled patient information. Organisations need to provide support, offer the right resources and training and engage meaningfully with carers and patients about the use of identifiers.

Using experience-based co-design (EBCD) to develop high-level design principles for a visual identification system for people with dementia in acute hospital ward settings

OBJECTIVES

We tested a modified co-design process to develop a set of high-level design principles for visual identification systems (VIS) for hospitalised people with dementia.

DESIGN

We designed and ran remote workshops in three phases with carers of people with dementia and healthcare staff. In phase 1 we presented participants with scenarios based on findings from prior research, prompting participants to discuss their own experiences of VIS. Phase 2 used more future-focused scenarios, prompting participants to co-design improved VIS. In phase 3, a set of provisional design principles developed from our analysis of phases 1 and 2 data were discussed.

SETTING

Online workshops.

PARTICIPANTS

A total of 26 carers and 9 healthcare staff took part in a pilot and three separate workshops.

RESULTS

We identified a set of six dementia-friendly design principles for improving the effectiveness of VIS: (1) The hospital trust provides a professionally-trained workforce and an appropriate culture of care; (2) the symbol is easily recognisable and well understood; (3) key personal information is readily available and accessible; (4) key personal information is integrated into the electronic patient record; (5) relatives and carers are involved in providing key information and monitoring care; (6) the principles need to function as a system to be successful. Participants suggested that, in addition to the use of an identifier and key personal information, professional standards training, effective information and records management and improved means to involve carers and/or families were key to the effective operation of VIS, leading us to expand a narrow understanding of a VIS.

CONCLUSION

Using a scenario-led co-design approach can help trigger useful discussions with staff and carer groups, identify current problems with VIS and develop a set of high-level design principles for their improvement. These principles reveal day-to-day frictions that require further attention and resolution.

QI initiative to reduce the number of inpatient falls in an acute hospital Trust

Inpatient falls are one of the most frequent concerns to patient safety within the acute hospital environment, equating to 1700 falls per year in an 800-bed general hospital. They are predicted to cost approximately £2600 per patient, however, this estimate does not capture the costs and impact that inpatient falls have on the wider health and social care system. It also does not take into the account loss of confidence and delays in functional recovery.This report shares the learning from a quality improvement (QI) initiative that took place in a District General Hospital (DGH) in the UK. The initiative started in February 2020, was paused November 2020 due to wave 2 of the pandemic and restarted in March 2021. Improvement was achieved in January 2021.Data for falls within the Trust identified that falls were within common cause variation. A system change was needed to achieve an improvement.A QI project was commenced with the aim to achieve a 5% reduction in falls per 1000 bed days in a care of the elderly ward.Two primary drivers were identified: recognising patients at high risk of falls and preventing them from falling. Change ideas to address these primary drivers were tested using Plan Do Study Act (PDSA) cycles. Changes tested included: the development of an assessment tool to identify patients at high risk of falls, use of a wristband to identify patients at high risk of a fall, and increased observation.Change ideas achieved some success with the process measures but did not achieve an improvement with the outcome measures. A Trust wide change idea relating to the falls prevention service did lead to a sustained improvement in falls reduction.The barriers to the improvement included changing Trust priorities during the pandemic, and limited opportunities to fully engage the ward-based team with systems thinking and changing mental models.