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Gamborg ML, Mehlsen M, Paltved C, Tramm G, Musaeus P. Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine. BMC Emerg Med 2020; 20:73. [PMID: 32928158 PMCID: PMC7489001 DOI: 10.1186/s12873-020-00367-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/31/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM. OBJECTIVE A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM. METHODS A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized. RESULTS Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM. CONCLUSIONS This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.
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Affiliation(s)
- Maria Louise Gamborg
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark.
- Corporate HR MidtSim, Central Region of Denmark & Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Mimi Mehlsen
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Charlotte Paltved
- Corporate HR MidtSim, Central Region of Denmark & Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Gitte Tramm
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Peter Musaeus
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark
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Rance S, Westlake D, Brant H, Holme I, Endacott R, Pinkney J, Byng R. Admission Decision-Making in Hospital Emergency Departments: The Role of the Accompanying Person. Glob Qual Nurs Res 2020; 7:2333393620930024. [PMID: 32596418 PMCID: PMC7303774 DOI: 10.1177/2333393620930024] [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: 08/02/2019] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 11/15/2022] Open
Abstract
In resource-stretched emergency departments, people accompanying patients
play key roles in patients’ care. This article presents analysis of
the ways health professionals and accompanying persons talked about
admission decisions and caring roles. The authors used an ethnographic
case study design involving participant observation and
semi-structured interviews with 13 patients, 17 accompanying persons
and 26 health care professionals in four National Health Service
hospitals in south-west England. Focused analysis of interactional
data revealed that professionals’ standardization of the patient–carer
relationship contrasted with accompanying persons’ varied connections
with patients. Accompanying persons could directly or obliquely
express willingness, ambivalence and resistance to supporting
patients’ care. The drive to avoid admissions can lead health
professionals to deploy conversational skills to enlist accompanying
persons for discharge care without exploring the meanings of their
particular relationship with the patients. Taking a
relationship-centered approach could improve the attention to
accompanying persons as co-producers of health care and participants
in decision-making.
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Affiliation(s)
| | | | - Heather Brant
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | | | - Ruth Endacott
- University of Plymouth, Plymouth, United Kingdom.,Monash University, Frankston, Victoria, Australia
| | | | - Richard Byng
- University of Plymouth, Plymouth, United Kingdom
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3
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Redwood S, Simmonds B, Fox F, Shaw A, Neubauer K, Purdy S, Baxter H. Consequences of 'conversations not had': insights into failures in communication affecting delays in hospital discharge for older people living with frailty. J Health Serv Res Policy 2020; 25:213-219. [PMID: 32013572 DOI: 10.1177/1355819619898229] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Older people living with frailty (OPLWF) are often unable to leave hospital even if they no longer need acute care. The aim of this study was to elicit the views of health care professionals in England on the barriers to effective discharge of OPLWF. METHODS We conducted semi-structured interviews with hospital-based doctors and nurses with responsibility for discharging OPLWF from one large urban acute care hospital in England. The data were analysed using the constant comparative method. RESULTS We conducted interviews with 17 doctors (12 senior doctors or consultants and 5 doctors in training) and six senior nurses. Some of our findings reflect well-known barriers to hospital discharge including service fragmentation, requiring skilled coordination that was often not available due to high volumes of work, and poor communication between staff from different organizations. Participants' accounts also referred to less frequently documented factors that affect decision making and the organization of patient discharges. These raised uncomfortable emotions and tensions that were often ignored or avoided. One participant referred to 'conversations not had', or failures in communication, because difficult topics about resuscitation, escalation of treatment and end-of-life care for OPLWF were not addressed. CONCLUSIONS The consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients' quality of life and care. As the population of older people is rising, this becomes a key priority for all practitioners in health and social care. Evidence to support practitioners, OPLWF and their families is needed to ensure that these vital conversations take place so that care at the end of life is humane and compassionate.
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Affiliation(s)
- Sabi Redwood
- Senior Research Fellow in Ethnography, Bristol Medical School - Population Health Sciences, University of Bristol, UK.,Deputy Director, National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West, University of Bristol NHS Foundation Trust, UK
| | - Bethany Simmonds
- Senior Lecturer in Sociology, School of Social, Historical and Literar Studies, University of Portsmouth, UK
| | - Fiona Fox
- Senior Research Associate in Ethnography, Bristol Medical School - Population Health Sciences, University of Bristol, UK.,Senior Research Associate in Ethnography, National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West at University of Bristol NHS Foundation Trust, UK
| | - Alison Shaw
- Senior Research Fellow in Primary Care Research, Bristol Medical School - Population Health Sciences, University of Bristol, UK
| | - Kyra Neubauer
- Consultant - Care of the Elderly, Clinical Lead Complex Assessment and Liaison Service, North Bristol NHS Trust, UK
| | - Sarah Purdy
- Head of School, Bristol Medical School - Population Health Sciences, University of Bristol, UK.,Director, National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West at University of Bristol NHS Foundation Trust, UK
| | - Helen Baxter
- NIHR Knowledge Mobilisation Research Fellow, Bristol Medical School - Population Health Sciences, University of Bristol, UK
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Hurley E, McHugh S, Browne J, Vaughan L, Normand C. A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland's hospitals. BMC Health Serv Res 2019; 19:766. [PMID: 31665004 PMCID: PMC6819558 DOI: 10.1186/s12913-019-4629-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation. METHODS We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation. DISCUSSION This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.
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Affiliation(s)
- E Hurley
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.
| | - S McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - J Browne
- School of Public Health, University College Cork, Cork, Ireland
| | | | - C Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
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Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, Kurtev S, Phelps K, Regen E, Rogers S, Waring J. Understanding variation in unplanned admissions of people aged 85 and over: a systems-based approach. BMJ Open 2019; 9:e026405. [PMID: 31289067 PMCID: PMC6615796 DOI: 10.1136/bmjopen-2018-026405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIM To examine system characteristics associated with variations in unplanned admission rates in those aged 85+. DESIGN Mixed methods. SETTING Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three 'improving' sites where rates had declined by more than 4% and three 'deteriorating' sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care. PARTICIPANTS A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey's 7S framework was used as a structure for investigation and analysis. RESULTS In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission. CONCLUSIONS Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions.
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Affiliation(s)
- Andrew Wilson
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Health Sciences, University of Leicester, Leicester, UK
| | - John Bankart
- Health Sciences, University of Leicester, Leicester, UK
| | - Jay Banerjee
- Emergency Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, UK
| | - Ran Bhamra
- WolfsonSchool of Mechanical, Electrical & Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Simon Conroy
- Health Sciences, University of Leicester, Leicester, UK
| | - Stoyan Kurtev
- Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Health Sciences, University of Leicester, Leicester, UK
| | | | - Justin Waring
- Centre for Health Innovation, Leadership & Learning / Nottingham University Business School, University of Nottingham, Nottingham, UK
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Walthall H, Dolan B, Jackson D. Trapped in care: Recognising and responding to frailty as a cause of delayed transfers of care. J Clin Nurs 2018; 28:5-6. [PMID: 29683525 DOI: 10.1111/jocn.14356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Helen Walthall
- Oxford Brookes University, Oxford, UK.,Oxford Institute of Nursing, Midwifery& Allied Health Research (OxINMAHR), Oxford, UK
| | - Brian Dolan
- Oxford Institute of Nursing, Midwifery& Allied Health Research (OxINMAHR), Oxford, UK.,University of Salford, Manchester, UK
| | - Debra Jackson
- University of Technology, Sydney (UTS), Sydney, NSW, Australia
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Abstract
Background Increasing pressure in the United Kingdom (UK) urgent care system has led to Emergency Departments (EDs) failing to meet the national requirement that 95% of patients are admitted, discharged or transferred within 4-h of arrival. Despite the target being the same for all acute hospitals, individual Trusts organise their services in different ways. The impact of this variation on patient journey time and waiting is unknown. Our study aimed to apply the Lean technique of Value Stream Mapping (VSM) to investigate care processes and delays in patient journeys at four contrasting hospitals. Methods VSM timing data were collected for patients accessing acute care at four hospitals in South West England. Data were categorised according to waits and activities, which were compared across sites to identify variations in practice from the patient viewpoint. We included Public and Patient Involvement (PPI) to fully interpret our findings; observations and initial findings were considered in a PPI workshop. Results One hundred eight patients were recruited, comprising 25,432 min of patient time containing 4098 episodes of care or waiting. The median patient journey was 223 min (3 h, 43 min); just within the 4-h target. Although total patient journey times were similar between sites, the stage where the greatest proportion of waiting occurred varied. Reasons for waiting were dominated by waits for beds, investigations or results to be available. From our sample we observed that EDs without a discharge/clinical decision area exhibited a greater proportion of waiting time following an admission or discharge decision. PPI interpretation indicated that patients who experience waits at the beginning of their journey feel more anxious because they are ‘not in the system yet’. Conclusions The novel application of VSM analysis across different hospitals, coupled with PPI interpretation, provides important insight into the impact of care provision on patient experience. Measures that could reduce patient waiting include automatic notification of test results, and the option of discharge/clinical decision areas for patients awaiting results or departure. To enhance patient experience, good communication with patients and relatives about reasons for waits is essential.
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