Every patient should be enabled to stop the line

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

BACKGROUND

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

METHODS

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

RESULTS

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

CONCLUSIONS

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention

AIM

To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital.

BACKGROUND

Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability.

DESIGN

A narrative inquiry.

METHODS

Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data.

RESULTS

The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation.

CONCLUSION

Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly.

REPORTING METHOD

The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

The consumer researcher was involved in design, data analysis and publication preparation.

Film production during the Covid-19 pandemic

BACKGROUND

The COVID-19 pandemic created unprecedented challenges for the film industry. Following a shutdown of productions, The Safe Way Forward document was developed to outline disease mitigation protocols. Despite this framework, many unanticipated scenarios arose during reopening of film production with the ongoing pandemic.

AIMS

To identify and document promising practices for mitigating COVID-19 transmission in the film industry that can inform future pandemics and other industries.

METHODS

We conducted a literature search to review research regarding COVID-19 disease mitigation efforts in the film industry. Through client-facing consultancy and consultant group meetings, we identified those factors most important for disease mitigation in the film industry and applicable to future pandemics and other industries. The Delphi Method enabled experts to review lessons learned as studio consultants during the COVID-19 pandemic; learnings were coded and analyzed for recurring themes.

RESULTS

We identified anxiety, mistrust, and poor communication as key contributors to decreased compliance with COVID-19 protocols. In response, our team demonstrated multi-specialty expertise, provided scientific explanations, and developed trust by listening empathetically and responding with clear, consistent messaging. These measures served to alleviate anxiety, improve compliance, and provide a safe return to production.

CONCLUSIONS

This study demonstrates the ability and agility of multi-disciplinary experts acting in the absence of clear guidance to support a safe return to film production. Workplace anxiety and non-compliance can be alleviated through effective communication by trusted experts. Lessons learned by our consultancy group can help protect workers across diverse industries in future pandemics.

Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system

OBJECTIVE

Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients' medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented.

DESIGN

This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis.

SETTING

Community pharmacies and medical centres in Geneva, Switzerland.

PARTICIPANTS

This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases.

METHODS

Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants' perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3).

RESULTS

Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers.

CONCLUSION

The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

Patient Voices in Hospital Safety during the COVID-19 Pandemic

Hospitalized patients and their families may be reluctant to express safety concerns. We aimed to describe safety and quality concerns experienced by hospitalized patients and families and factors and outcomes surrounding decisions about voicing concerns, including those related to the COVID-19 pandemic. We conducted semi-structured interviews with 19 discharged inpatients or family members in a qualitative descriptive design. Some participants reported concern about staff competency or knowledge, communication and coordination, potential treatment errors, or care environment. Factors influencing feeling safe included healthcare team member characteristics, communication and coordination, and safe care expectations. Reasoning for voicing concerns often included personal characteristics. Reasons for not voicing concerns included feeling no action was needed or the concern was low priority. Outcomes for voicing a concern were categorized as resolved, disregarded, and unknown. These findings support the vital importance of open safety communication and trustworthy response to patients and family members who voice concerns.

Perspectives of hospital leaders and staff on patient education for the prevention of healthcare-associated infections

OBJECTIVE

Device-related healthcare-associated infections (HAIs), such as catheter-associated urinary tract infections (CAUTIs) and central-line-associated bloodstream infections (CLABSIs), are largely preventable. However, there is little evidence of standardized approaches to educate patients about how they can help prevent these infections. We examined the perspectives of hospital leaders and staff about patient education for CAUTI and CLABSI prevention to understand the challenges to patient education and the opportunities for improvement.

METHODS

In total, 471 interviews were conducted with key informants across 18 hospitals. Interviews were analyzed deductively and inductively to identify themes around the topic of patient education for infection prevention.

RESULTS

Participants identified patient education topics specific to CAUTI and CLABSI prevention, including the risks of indwelling urinary catheters and central lines, the necessity of hand hygiene, the importance of maintenance care, and the support to speak up. Challenges, such as lack of standardized education, and opportunities, such as involvement of patient and family advisory groups, were also identified regarding patient education for CAUTI and CLABSI prevention.

CONCLUSIONS

Hospital leaders and staff identified patient education topics, and ways to deliver this information, that were important in the prevention of CAUTIs and CLABSIs. By identifying both challenges and opportunities related to patient education, our results provide guidance on how patient education for infection prevention can be further improved. Future work should evaluate the implementation of standardized approaches to patient education to better understand the potential impact of these strategies on the reduction of HAIs.

Do Patients and Relatives Have Different Dispositions When Challenging Healthcare Professionals About Patient Safety? Results Before and After an Educational Program

BACKGROUND

There is a universal interest in evaluating the new roles of patients to improve patient safety. However, relatively little is known about the contribution of family caregivers. The purposes of this study was to determine whether patients and relatives (P&Rs) have different dispositions when challenging healthcare professionals about patient safety and to measure the influence of an educational program.

METHODS

An interventional before-and-after design was used to determine the P&Rs' basal level of willingness and the influence of a training program. One hundred thirty-six participants were recruited, 90 patients and 46 relatives, from the Day Hospital of a Tertiary Hospital in Spain, in 2018.The safe practices selected were as follows: patient identification, hand hygiene, blood or chemotherapy identification, and secondary effects of treatment. The educational materials comprised brochures and story-type videos. A questionnaire measured participants' willingness to speak up before and after the training.

RESULTS

One hundred thirty-six P&Rs (63% response rate) agreed to participate. The hypothesis that relatives are more willing to challenge healthcare professionals could not be proven. Their willingness to speak up depended on the type of safe practice both before and after training, ranging from 42% to 87%. The percentage of items that P&Rs were willing to challenge increased after the training among both the patients and the relatives, but statically significant differences were only seen among patients.

CONCLUSIONS

After the training, participants' willingness to challenge healthcare workers was high for all safe practices analyzed but hand hygiene. Patients and relatives had very similar willingness. After the training, participants felt confident with their knowledge about safe practices, thereby increasing their challenging attitude.

You're Worried, We're Listening: Online Testing of the Effectiveness of Education Materials to Improve Consumer Knowledge and Confidence in Reporting Patient Deterioration

OBJECTIVES

Early identification of patient deterioration in hospital is important to reduce mortality, avoidable morbidity, length of stay, and associated healthcare costs. By closely observing physical and behavioral changes, deteriorating patients are more likely to be identified. Patients and family at the bedside can play an important role in reporting deterioration if made aware of how to do so. Therefore, the objective of this study was to undertake an online evaluation of educational materials designed to improve consumers' knowledge and confidence to report patient deterioration.

METHODS

A convenience sample was used to recruit community-based participants for an online survey. A self-designed validated instrument was used to undertake a preintervention and postintervention test involving 3 types of educational materials. Quantitative data were analyzed with Wilcoxon signed rank test to compare participants' knowledge and confidence before and after exposure to the intervention. Conventional content analyses examined responses on key messages and recommendations to improve the educational materials.

RESULTS

A total of 84 respondents completed both prequestionnaires and postquestionnaires. After exposure to the education materials, analyses confirmed that knowledge and confidence scores were significantly higher than baseline measures. Content analyses indicated a clear understanding of the key messages presented in the materials. Four main recommendations were made regarding the education materials.

CONCLUSIONS

Participants readily identified the key messages in the educational materials and demonstrated increased knowledge and confidence to report concerns about deterioration. Further research is required to determine the efficacy of the educational materials in relation to consumer behavior.

Honesty and Transparency, Indispensable to the Clinical Mission-Part III: How Leaders Can Prevent Burnout, Foster Wellness and Recovery, and Instill Resilience

The hidden epidemic of burnout exacts a staggering toll on professionals and patients, reflected in increased risk of medical errors, complications, and staff turnover. For surgeons, nurses, and other team members working at the sharp end of care, adverse events can amplify work exhaustion, interpersonal disengagement, and risk of moral adversity. Visionary leaders are not content to mitigate burnout and moral injury; they elevate the human experience throughout health care by modeling wellness, fostering moral courage, promoting safety of professionals, and restoring joy in work. Part 3, Health Professional Wellness and Resilience, introduces the final pillar for advancing the clinical mission.

Informatics opportunities to involve patients in hospital safety: a conceptual model

Objective

Inpatients could play an important role in identifying, preventing, and reporting problems in the quality and safety of their care. To support them effectively in that role, informatics solutions must align with their experiences. Thus, we set out to understand how inpatients experience undesirable events (UEs) and to surface opportunities for those informatics solutions.

Materials and Methods

We conducted a survey with 242 patients and caregivers during their hospital stay, asking open-ended questions about their experiences with UEs. Based on our qualitative analysis, we developed a conceptual model representing their experiences and identified informatics opportunities to support patients.

Results

Our 4-stage conceptual model illustrates inpatient experiences, from when they first encounter UEs, when they could intervene, when harms emerge, what types of harms they experience, and what they do in response to harms.

Discussion

Existing informatics solutions address the first stage of inpatients’ experiences by increasing their awareness of potential UEs. However, future researchers can explore new opportunities to fill gaps in support that patients experience in subsequent stages, especially at critical decision points such as intervening in UEs and responding to harms that occur.

Conclusions

Our conceptual model reveals the complex inpatient experiences with UEs, and opportunities for new informatics solutions to support them at all stages of their experience. Investigating these new opportunities could promote inpatients’ participation and engagement in the quality and safety of their care, help healthcare systems learn from inpatients’ experience, and reduce these harmful events.

Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review

BACKGROUND

Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas.

OBJECTIVES

To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual.

SEARCH STRATEGY

MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019.

INCLUSION CRITERIA

Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care.

RESULTS

We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment.

CONCLUSION

This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility.

RELEVANCE TO PRACTICE

These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.

Bias and Racism Teaching Rounds at an Academic Medical Center

Racism and events of racial violence have dominated the US news in 2020 almost as much as the novel coronavirus pandemic. The resultant civil unrest and demands for racial justice have spawned a global call for change. As a subset of a society that struggles with racism and other explicit biases, it is inescapable that some physicians and health-care employees will have the same explicit biases as the general population. Patients who receive care at academic medical centers interact with multiple individuals, some of whom may have explicit and implicit biases that influence patient care. In fact, multiple reports have documented that some physicians, health-care workers, and health professional students have negative biases based on race, ethnicity, obesity, religion, and sexual identity, among others. These biases can influence decision-making and aggravate health-care disparities and patient-physician mistrust. We review four actual cases from academic medical centers that illustrate how well-intended physicians and health-care workers can be influenced by bias and how this can put patients at risk. Strategies to mitigate bias are discussed and recommended. We introduce what we believe can be a powerful teaching tool: periodic "bias and racism rounds" in teaching hospitals, in which real patient interactions are reviewed critically to identify opportunities to reduce bias and racism and to attenuate the impact of bias and racism on patient outcomes.

The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation

OBJECTIVE

To describe the clinimetric validation of the I-DECIDED tool for peripheral intravenous catheter assessment and decision-making.

DESIGN AND SETTING

I-DECIDED is an eight-step tool derived from international vascular access guidelines into a structured mnemonic for device assessment and decision-making. The clinimetric evaluation process was conducted in three distinct phases.

METHODS

Initial face validity was confirmed with a vascular access working group. Next, content validity testing was conducted via online survey with vascular access experts and clinicians from Australia, the UK, the USA and Canada. Finally, inter-rater reliability was conducted between 34 pairs of assessors for a total of 68 peripheral intravenous catheter (PIVC) assessments. Assessments were timed to ensure feasibility, and the second rater was blinded to the first's findings. Content validity index (CVI), mean item-level CVI (I-CVI), internal consistency, mean proportion of agreement, observed and expected inter-rater agreements, and prevalence-adjusted bias-adjusted kappas (PABAK) were calculated. Ethics approvals were obtained from university and hospital ethics committees.

RESULTS

The I-DECIDED tool demonstrated strong content validity among international vascular access experts (n=7; mean I-CVI=0.91; mean proportion of agreement=0.91) and clinicians (n=11; mean I-CVI=0.93; mean proportion of agreement=0.94), and high inter-rater reliability in seven adult medical-surgical wards of three Australian hospitals. Overall, inter-rater reliability was 87.13%, with PABAK for each principle ranging from 0.5882 ('patient education') to 1.0000 ('document the decision'). Time to complete assessments averaged 2 min, and nurse-reported acceptability was high.

CONCLUSION

This is the first comprehensive, evidence-based, valid and reliable PIVC assessment and decision tool. We recommend studies to evaluate the outcome of implementing this tool in clinical practice.

TRIAL REGISTRATION NUMBER

12617000067370.

Using online patient feedback to improve NHS services: the INQUIRE multimethod study

Background

Online customer feedback has become routine in many industries, but it has yet to be harnessed for service improvement in health care.

Objectives

To identify the current evidence on online patient feedback; to identify public and health professional attitudes and behaviour in relation to online patient feedback; to explore the experiences of patients in providing online feedback to the NHS; and to examine the practices and processes of online patient feedback within NHS trusts.

Design

A multimethod programme of five studies: (1) evidence synthesis and stakeholder consultation; (2) questionnaire survey of the public; (3) qualitative study of patients’ and carers’ experiences of creating and using online comment; (4) questionnaire surveys and a focus group of health-care professionals; and (5) ethnographic organisational case studies with four NHS secondary care provider organisations.

Setting

The UK.

Methods

We searched bibliographic databases and conducted hand-searches to January 2018. Synthesis was guided by themes arising from consultation with 15 stakeholders. We conducted a face-to-face survey of a representative sample of the UK population (n = 2036) and 37 purposively sampled qualitative semistructured interviews with people with experience of online feedback. We conducted online surveys of 1001 quota-sampled doctors and 749 nurses or midwives, and a focus group with five allied health professionals. We conducted ethnographic case studies at four NHS trusts, with a researcher spending 6–10 weeks at each site.

Results

Many people (42% of internet users in the general population) read online feedback from other patients. Fewer people (8%) write online feedback, but when they do one of their main reasons is to give praise. Most online feedback is positive in its tone and people describe caring about the NHS and wanting to help it (‘caring for care’). They also want their feedback to elicit a response as part of a conversation. Many professionals, especially doctors, are cautious about online feedback, believing it to be mainly critical and unrepresentative, and rarely encourage it. From a NHS trust perspective, online patient feedback is creating new forms of response-ability (organisations needing the infrastructure to address multiple channels and increasing amounts of online feedback) and responsivity (ensuring responses are swift and publicly visible).

Limitations

This work provides only a cross-sectional snapshot of a fast-emerging phenomenon. Questionnaire surveys can be limited by response bias. The quota sample of doctors and volunteer sample of nurses may not be representative. The ethnographic work was limited in its interrogation of differences between sites.

Conclusions

Providing and using online feedback are becoming more common for patients who are often motivated to give praise and to help the NHS improve, but health organisations and professionals are cautious and not fully prepared to use online feedback for service improvement. We identified several disconnections between patient motivations and staff and organisational perspectives, which will need to be resolved if NHS services are to engage with this source of constructive criticism and commentary from patients.

Future work

Intervention studies could measure online feedback as an intervention for service improvement and longitudinal studies could examine use over time, including unanticipated consequences. Content analyses could look for new knowledge on specific tests or treatments. Methodological work is needed to identify the best approaches to analysing feedback.

Study registration

The ethnographic case study work was registered as Current Controlled Trials ISRCTN33095169.

Funding

This project was funded by the National institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 38. See the NIHR Journals Library website for further project information.