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Batterbury A, Douglas C, Coyer F. The illness severity of ward remaining patients reviewed by the medical emergency team: A retrospective cohort study. J Clin Nurs 2023; 32:6450-6459. [PMID: 36894523 DOI: 10.1111/jocn.16678] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/14/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Although progress has been made in identifying and responding to acutely deteriorating ward patients, judgements about the level of care required for patients after medical emergency team review are complex, rarely including a formal assessment of illness severity. This challenges staff and resource management practices and patient safety. OBJECTIVE This study sought to quantify the illness severity of ward patients after medical emergency team review. RESEARCH DESIGN AND SETTING This retrospective cohort study examined the clinical records of 1500 randomly sampled adult ward patients following medical emergency team review at a metropolitan tertiary hospital. Outcome measures were the derivation of patient acuity and dependency scores using sequential organ failure assessment and nursing activities score instruments. Findings are reported using the STROBE guideline for cohort studies. NO PATIENT OR PUBLIC CONTRIBUTION No direct patient contact was made during the data collection and analysis phases of the study. RESULTS Patients were male (52.6%), unplanned (73.9%) medical admissions (57.5%), median age of 67 years. The median sequential organ failure assessment score was 4% and 20% of patients demonstrated multiple organ system failure requiring non typical monitoring and coordination arrangements for at least 24 h. The median nursing activities score was 86% suggestive of a near 1:1 nurse-to-patient ratio. More than half of all patients required enhanced levels of assistance with mobilization (58.8%) and hygiene (53.9%) activities. CONCLUSIONS Patients who remain on the ward following medical emergency team review had complex combinations of organ dysfunction, with levels of dependency similar to those found in intensive care units. This has implications for ward and patient safety and continuity of care arrangements. RELEVANCE TO CLINICAL PRACTICE Profiling illness severity at the conclusion of the medical emergency team review may help determine the need for special resource and staffing arrangements or placement within the ward environment.
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Affiliation(s)
- Anthony Batterbury
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Clint Douglas
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Fiona Coyer
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
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Geisler A, Hedegaard S, Bucknall TK. Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4214. [PMID: 36901225 PMCID: PMC10001841 DOI: 10.3390/ijerph20054214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.
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Affiliation(s)
- Anja Geisler
- Department of Anesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Susanne Hedegaard
- Department of Anesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
| | - Tracey K. Bucknall
- School of Nursing & Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
- Centre for Quality and Patient Safety—Alfred Health Partnership, Institute of Health Transformation, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004, Australia
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Parra Cubides SL. The good death. Colomb Med (Cali) 2022; 53:e4005472. [PMID: 37305224 PMCID: PMC10252043 DOI: 10.25100/cm.v53i4.5472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 06/13/2023] Open
Abstract
Que gran compromiso es hablar de la buena muerte. Desde el ejercicio clínico es posible tener una mirada distante muy enfocada en los dominios biológicos del proceso, pero indiscutiblemente la visión más acertada y completa es unir el componente biológico con el componente humano, es decir como parte de un proceso que será también parte de mi propia existencia.
Siempre que nos enfrentamos de manera reflexiva al tema de la muerte propia o de un ser amado, aflora nuestro deseo innato que este momento este libre de sufrimiento innecesario, reconociendo esto como un derecho básico para cualquier ser humano. Y este derecho siempre estará regido por la dignidad del ser humano, la dignidad es el marco básico que ampara este deseo.
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Koenig JFL, Asendorf T, Simon A, Bleckmann A, Truemper L, Wulf G, Overbeck TR. "SpezPat"- common advance directives versus disease-centred advance directives: a randomised controlled pilot study on the impact on physicians' understanding of non-small cell lung cancer patients' end-of-life decisions. BMC Palliat Care 2022; 21:167. [PMID: 36167565 PMCID: PMC9516789 DOI: 10.1186/s12904-022-01057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The advance directive represents patients' health care choices and fosters patients' autonomy. Nevertheless, understanding patients' wishes based on the information provided in advance directives remains a challenge for health care providers. Based on the ethical premises of positive obligation to autonomy, an advanced directive that is disease-centred and details potential problems and complications of the disease should help health care providers correctly understand patients' wishes. To test this hypothesis, a pilot-study was conducted to investigate whether physicians could make the correct end-of-life decision for their patients when patients used a disease-centred advance directive compared to a common advance directive. MATERIAL AND METHODS: A randomised, controlled, prospective pilot study was designed that included patients with non-small cell lung cancer (NSCLC) stage VI from the Department of Haematology and Medical Oncology, University Medical Centre, Goettingen. Patients were randomised into intervention and control groups. The control group received a common advance directive, and the intervention group received a disease-centred advance directive. Both groups filled out their advance directives and returned them. Subsequently, patients were asked to complete nine medical scenarios with different treatment decisions. For each scenario the patients had to decide whether they wanted to receive treatment on a 5-point Likert scale. Four physicians were given the same scenarios and asked to decide on the treatment according to the patients' wishes as stated in their advance directives. The answers by patients and physicians were then compared to establish whether physicians had made the correct assumptions. RESULTS Recruitment was stopped prior to reaching anticipated sample target. 15 patients with stage IV NSCLC completed the study, 9 patients were randomised into the control group and 6 patients in the intervention group. A total of 135 decisions were evaluated. The concordance between physicians' and patients' answers, was 0.83 (95%-CI 0.71-0.91) in the intervention group, compared to 0.60 (95%-CI 0.48-0.70) in the control group, and the difference between the two groups was statistically significant (p = 0.005). CONCLUSION This pilot study shows that disease-centred advance directives help physicians understand their NSCLC patients' wishes more precisely and make treatment choices according to these wishes. TRIAL REGISTRATION The study is registered at the German Clinical Trial Register (no. DRKS00017580, registration date 27/08/2019).
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Affiliation(s)
- Julia Felicitas Leni Koenig
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany.
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Centre, Von-Siebold-Str. 3, Goettingen, Germany
| | - Alfred Simon
- Academy of Ethics in Medicine, Robert-Koch-Str. 40, Goettingen, Germany
| | - Annalen Bleckmann
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany.,Department of Medicine A; Hematology, Oncology and Pneumology, University Hospital Muenster; Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Lorenz Truemper
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
| | - Gerald Wulf
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
| | - Tobias R Overbeck
- Department of Haematology and Medical Oncology, University Medical Centre, Robert-Koch-Str. 40, Goettingen, Germany
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Sarangi RK, Rajamani A, Lakshmanan R, Srinivasan S, Arvind H. A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration. Indian J Crit Care Med 2022; 26:457-463. [PMID: 35656047 PMCID: PMC9067487 DOI: 10.5005/jp-journals-10071-24166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Patients with terminal illnesses hospitalized with acute deteriorations often suffer from unnecessary/inappropriate therapies at the end of their lives. Appropriate advance care planning (ACP) practices aligned to patients’ goals of care may mitigate this. Materials and methods To explore the rationale for clinical decision-making in hospitalized patients with terminal illnesses and formulate a practice pathway to streamline care. Between May and December 2018, a questionnaire survey with three case vignettes derived from intensive care unit (ICU) patients was emailed to ICU, respiratory and renal doctors, and nurses in two Sydney hospitals. Respondents chose various management options ranging from all active therapies to palliation. The primary outcome was the proportion of responses for each management option. With these and a thematic analysis of responses to identify barriers to ACP practice, a practice pathway was formulated. Results Of the 310 invited clinicians, 178 responded (57.4%). About 89.2% of respondents reported caring for dying patients frequently. Sixty percent saw patients suffering from prolonged therapies. Most respondents deemed patients in the case vignettes to be terminally ill, warranting ACP discussions. However, many still wanted to treat the acute deterioration with active ICU-level interventions. Most respondents reported being comfortable in having ACP discussions. Conclusion The survey showed discordance between the stated opinions and the choice of management options for terminally ill patients with acute deteriorations; possibly due to the lack of a considered approach in choosing management options that align with medical consensus and the patient's/family's wishes, a practice pathway is suggested to improve management. How to cite this article Sarangi RK, Rajamani A, Lakshmanan R, Srinivasan S, Arvind H. A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration. Indian J Crit Care Med 2022;26(4):457–463.
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Affiliation(s)
- Rishi K Sarangi
- Department of ICU, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Arvind Rajamani
- University of Sydney, Nepean Clinical School and Nepean Hospital, Kingswood, New South Wales, Australia
- Arvind Rajamani, University of Sydney, Nepean Clinical School and Nepean Hospital, Kingswood, New South Wales, Australia, Phone: +61247342490, e-mail:
| | | | - Saradha Srinivasan
- Department of ICU, Fairfield Hospital, Sydney, New South Wales, Australia
| | - Hemamalini Arvind
- Department of Ophthalmology, University of Sydney, Sydney, New South Wales, Australia
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An Exploratory Investigation into the Roles of Critical Care Response Teams in End-of-Life Care. Crit Care Res Pract 2021; 2021:4937241. [PMID: 34336279 PMCID: PMC8324371 DOI: 10.1155/2021/4937241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 04/29/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Critical Care Response Teams (CCRTs) represent an important interface between end-of-life care (EOLC) and critical care medicine (CCM). The aim of this study was to explore the roles and interactions of CCRTs in the provision of EOLC from the perspective of CCRT members. Methods Twelve registered nurses (RNs) and four respiratory therapists (RTs) took part in focus groups, and one-on-one interviews were conducted with six critical care physicians. Thematic coding using a modified constructivist grounded theory approach was used to identify emerging themes through an iterative process involving a four-member coding team. Results Three main perspectives were identified that spoke to CCRT interactions and perceptions of EOLC encounters. CCRT members felt that they provide a unique skill set of multidisciplinary expertise in treating critically ill patients and evaluating the utility of intensive care treatments. However, despite feeling that they possessed the skills and resources to deliver quality EOLC, CCRT members were ambivalent with respect to whether EOLC was a part of their mandate. Challenges were also identified that impacted the ability of CCRTs to deliver quality EOLC. Conclusions This research aids in understanding for the first time CCRT roles in EOLC from the perspectives of individual CCRT members themselves. While CCRTs provide unique multidisciplinary expertise to evaluate the utility of intensive care treatments, opportunities exist to support CCRTs in EOLC, such as dedicated EOLC training, protocols for advance care planning, documentation, and transitions to palliative care.
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Bielinska AM, Archer S, Obanobi A, Soosipillai G, Darzi LA, Riley J, Urch C. Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study. PLoS One 2021; 16:e0247874. [PMID: 33667272 PMCID: PMC7935239 DOI: 10.1371/journal.pone.0247874] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/16/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. METHOD This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. RESULTS There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, "Planning for health and wellbeing in the spectrum of illness". Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. CONCLUSION Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care.
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Affiliation(s)
- Anna-Maria Bielinska
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
| | - Stephanie Archer
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- The University of Cambridge, Cambridge, United Kingdom
| | | | - Gehan Soosipillai
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lord Ara Darzi
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julia Riley
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Catherine Urch
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Street M, Dunning T, Bucknall T, Hutchinson AM, Rawson H, Hutchinson AF, Botti M, Duke MM, Mohebbi M, Considine J. Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: A multi-site prospective cohort study. J Clin Nurs 2020; 29:1302-1311. [PMID: 31793121 DOI: 10.1111/jocn.15125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital. BACKGROUND Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%). DESIGN This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. METHODS Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. FINDINGS Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care. CONCLUSIONS Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients. RELEVANCE TO CLINICAL PRACTICE As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.
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Affiliation(s)
- Maryann Street
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Australia
| | - Trisha Dunning
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Barwon Health Partnership, Deakin University, Geelong, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Alfred Health Partnership, Deakin University, Geelong, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Monash Health Partnership, Deakin University, Geelong, Australia
| | - Helen Rawson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Monash Health Partnership, Deakin University, Geelong, Australia
| | - Anastasia F Hutchinson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Deakin University, Geelong, Australia
| | - Mari Botti
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Deakin University, Geelong, Australia
| | - Maxine M Duke
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong, Australia
| | | | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Australia
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