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Canetta C, Accordino S, La Boria E, Arosio G, Cacco S, Formagnana P, Masotti M, Provini S, Passera S, Viganò G, Sozzi F. Effects of a medical admission unit on in-hospital patient flow and clinical outcomes. Eur J Intern Med 2024; 127:105-111. [PMID: 38735801 DOI: 10.1016/j.ejim.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/28/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND the burden of acute complex patients, increasingly older and poli-pathological, accessing to Emergency Departments (ED) leads up hospital overcrowding and the outlying phenomenon. These issues highlight the need for new adequate patients' management strategies. The aim of this study is to analyse the effects on in-hospital patient flow and clinical outcomes of a high-technology and time-limited Medical Admission Unit (MAU) run by internists. METHODS all consecutive patients admitted to MAU from Dec-2017 to Nov-2019 were included in the study. The admissions number from ED and hospitalization rate, the overall in-hospital mortality rate in medical department, the total days of hospitalization and the overall outliers bed days were compared to those from the previous two years. RESULTS 2162 patients were admitted in MAU, 2085(95.6%) from ED, 476(22.0%) were directly discharged, 88(4.1%) died and 1598(73.9%) were transferred to other wards, with a median in-MAU time of stay of 64.5 [0.2-344.2] hours. Comparing the 24 months before, despite the increase in admissions/year from ED in medical department (3842 ± 106 in Dec2015-Nov2017 vs 4062 ± 100 in Dec2017-Nov2019, p<0.001), the number of the outlier bed days has been reduced, especially in surgical department (11.46 ± 6.25% in Dec2015-Nov2017 vs 6.39 ± 3.08% in Dec2017-Nov2019, p=0.001), and mortality in medical area has dropped from 8.74 ± 0.37% to 7.29 ± 0.57%, p<0.001. CONCLUSIONS over two years, a patient-centred and problem-oriented approach in a medical admission buffer unit run by internists has ensured a constant flow of acute patients with positive effects on clinical risk and quality of care reducing medical outliers and in-hospital mortality.
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Affiliation(s)
- Ciro Canetta
- High Care Internal Medicine Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Italy
| | - Silvia Accordino
- High Care Internal Medicine Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Italy.
| | - Elisa La Boria
- Internal Medicine and Medical Admission Unit, Ospedale Maggiore of Crema, ASST Crema, Italy
| | - Gianpiero Arosio
- Internal Medicine and Medical Admission Unit, Ospedale Maggiore of Crema, ASST Crema, Italy
| | - Silvia Cacco
- Post Acute Medicine Unit, Foundation IRCCS Istituti Clinici Scientifici Salvatore Maugeri of Milan, Italy
| | - Pietro Formagnana
- Internal Medicine and Medical Admission Unit, Ospedale Maggiore of Crema, ASST Crema, Italy
| | - Michela Masotti
- Internal Medicine and Medical Admission Unit, Ospedale Maggiore of Crema, ASST Crema, Italy
| | - Stella Provini
- Internal Medicine Unit, Ospedale Civico of Codogno, ASST Lodi, Italy
| | - Sonia Passera
- Internal Medicine and Medical Admission Unit, Ospedale Maggiore of Crema, ASST Crema, Italy
| | - Giovanni Viganò
- Internal Medicine and Medical Admission Unit, Ospedale Maggiore of Crema, ASST Crema, Italy
| | - Fabiola Sozzi
- Cardiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Italy
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Torri E, Rigoni M, Dorigoni S, Peterlana D, Cozzio S, Nollo G, Spagnolli W. A model based on intensity of medical care may improve outcomes for internal medicine patients in Italy. PLoS One 2019; 14:e0211548. [PMID: 30703156 PMCID: PMC6354996 DOI: 10.1371/journal.pone.0211548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In medical wards, to guarantee safe, sustainable and effective treatments to heterogeneous and complex patients, care should be graduated into different levels of clinical intensity based on a standardised assessment of acute-illness severity. To support this assumption, we conducted a prospective observational study on all unselected admissions of 3,381 patients to a medium size internal Italian Medicine Unit by comparing Standard Medical Care model (SMC) to a new paradigm of patient admission based on Intensity of Medical Care (IMC). METHODS The SMC operated during 2013, while an IMC organizational model started in 2014. In SMC, patient's admission was performed according to bed availability only. In IMC, after the stratification of clinical instability performed using the National Early Warning Score (NEWS) and clinical judgment, patients were allocated to three different ward areas (high, middle, and post-acute medical care). We compared clinical and organizational outcomes of IMC patients (2015) to SMC patients (2013), performing adjusted logistic regression model. RESULTS We managed 1,609 and 1,772 patients using SMC and IMC, respectively. The IMC seemed to be associated to a lower risk of clinical worsening for patients. Comparing IMC to SMC, the odds ratio (aOR) for urgent transfers to intensive care units was 0.69 (p = 0.03), and for combination of urgent transfers and early deaths was 0.68 (p<0.01). CONCLUSIONS Redesigning the configuration of internal medicine ward to support urgency and competency of the clinical response by applying IMC paradigm based on the NEWS, improved outcomes in patients with acute illness and enhanced ward performances.
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Affiliation(s)
- Emanuele Torri
- Autonomous Province of Trento, Dipartimento Salute e Politiche Sociali, Trento, Italy
- Fondazione Bruno Kessler, Healthcare Research and Innovation Program – HTA Unit, Trento, Italy
| | - Marta Rigoni
- Fondazione Bruno Kessler, Healthcare Research and Innovation Program – HTA Unit, Trento, Italy
- * E-mail:
| | - Stefania Dorigoni
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
| | - Dimitri Peterlana
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
| | - Susanna Cozzio
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
| | - Giandomenico Nollo
- Fondazione Bruno Kessler, Healthcare Research and Innovation Program – HTA Unit, Trento, Italy
- Università degli Studi di Trento, Dipartimento di Ingegneria Industriale – BIOtech Labs, Trento, Italy
| | - Walter Spagnolli
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
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Uemura K, Inoue S, Kawaguchi M. The unnecessary application of central venous catheterization in surgical patients. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29631881 PMCID: PMC9391795 DOI: 10.1016/j.bjane.2018.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and objectives Methods Results Conclusions
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Affiliation(s)
- Keiko Uemura
- Nara Medical University, Department of Anesthesiology and Division of Intensive Care, Kashihara, Japão
| | - Satoki Inoue
- Nara Medical University, Department of Anesthesiology and Division of Intensive Care, Kashihara, Japão.
| | - Masahiko Kawaguchi
- Nara Medical University, Department of Anesthesiology and Division of Intensive Care, Kashihara, Japão
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[The unnecessary application of central venous catheterization in surgical patients]. Rev Bras Anestesiol 2018; 68:336-343. [PMID: 29631881 DOI: 10.1016/j.bjan.2018.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 11/04/2017] [Accepted: 01/01/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement. METHODS Using data from institutional perioperative central venous catheter surveillance, we analysed data from 1,141 patients who underwent central venous catheter placement. We reviewed the central venous catheter registry and medical charts and allocated registered patients into those with the proper or with unnecessary application of central venous catheter according to standard indications. Multivariate analysis was used to identify factors associated with the unnecessary application of central venous catheter placement. RESULTS In 107 patients, representing 9.38% of the overall population, we identified the unnecessary application of central venous catheter placement. Multivariate analysis identified emergencies at night or on holidays (odds ratio [OR] 2.109, 95% confidence interval [95% CI] 1.021-4.359), low surgical risk (OR=1.729, 95% CI 1.038-2.881), short duration of anesthesia (OR=0.961/10min increase, 95% CI 0.945-0.979), and postoperative care outside of the intensive care unit (OR=2.197, 95% CI 1.402-3.441) all to be independently associated with the unnecessary application of catheterization. Complications related to central venous catheter placement when the procedure consequently turned out to be unnecessary were frequently observed (9/107) compared with when the procedure was necessary (40/1034) (p=0.032, OR=2.282, 95% CI 1.076-4.842). However, the subsequent multivariate logistic model did not hold this significant difference (p=0.0536, OR=2.115, 95% CI 0.988-4.526). CONCLUSIONS More careful consideration for the application of central venous catheter is required in cases of emergency surgery at night or on holidays, during low risk surgery, with a short duration of anesthesia, or in cases that do not require postoperative intensive care.
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McGregor C, Chohan S, O’Reilly J. Collaborative approach to reducing cardiac arrests in an acute medical unit. BMJ Open Qual 2017; 6:e000026. [PMID: 29450266 PMCID: PMC5699152 DOI: 10.1136/bmjoq-2017-000026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 07/11/2017] [Accepted: 09/21/2017] [Indexed: 12/27/2022] Open
Abstract
Cardiac arrests are often preceded by a period of physiological deterioration. Preventing potentially avoidable cardiac arrests therefore depends on reliable recognition of, and response to, those deteriorations. Our hospital's acute medical unit had one of the highest rates of cardiac arrest in our organisation at baseline. The aim was to reduce our unit's cardiac arrest rate by over 50%. Pareto chart analysis identified unreliable processes in the recognition and response to deteriorating patients. Process mapping exercises were performed, then the model for improvement and rapid cycle tests of change were used to develop standardised processes for clinical observations, recognising deteriorating patients and responding to hypoxia. Multidisciplinary learning from what went well, incorporating resilience engineering principles, helped to identify good practice and then test ways of making good practice happen more reliably. Learning from success also addressed some of the psychological barriers to change by encouraging pride in work and a positive focus within our unit. The cardiac arrest rate reduced from 4.3/1000 (October 2014 to February 2016) to 1.1/1000 (March 2016 to end of 2016), associated with improved reliability of the following process measures: reliability of clinical observations, documentation of target oxygen saturations, identification of hypoxia and completion of structured response to hypoxia. This study is an example of a multidisciplinary team engaging in quality improvement, identifying their own local problems and testing their solutions scientifically. Learning from what went well had a positive impact on the project, and the team plans to spread the successful interventions across the organisation.
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Affiliation(s)
- Calum McGregor
- Emergency Care unit, Wishaw General Hospital, Wishaw, UK
| | - Sanjiv Chohan
- Department of Anaesthesia, Monklands Hospital, Coatbridge, UK
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Johnson M, Whyte M, Loveridge R, Yorke R, Naleem S. A Unified Electronic Tool for CPR and Emergency Treatment Escalation Plans Improves Communication and Early Collaborative Decision Making for Acute Hospital Admissions. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:bmjquality_uu213254.w6626. [PMID: 28469900 PMCID: PMC5411716 DOI: 10.1136/bmjquality.u213254.w6626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 03/02/2017] [Indexed: 11/04/2022]
Abstract
The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report 'Time to Intervene' (2012) stated that in a substantial number of cases, resuscitation is attempted when it was thought a 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision should have been in place. Early decisions about CPR status and advance planning about limits of care now form part of national recommendations by the UK Resuscitation Council (2016). Treatment escalation plans (TEP) document what level of treatment intervention would be appropriate if a patient were to become acutely unwell and were not previously formally in place at King's College Hospital. A unifying paper based form was successfully piloted in the Acute Medical Unit, introducing the TEP and bringing together decision making around both treatment escalation and CPR status. Subsequently an electronic order-set for CPR status and treatment escalation was launched in April 2015 which led to a highly visible CPR and escalation status banner on the main screen at the top of the patient's electronic record. Ultimately due to further iterations in the electronic process by December 2016, all escalation decisions for acutely admitted patients now have high quality supporting, explanatory documentation with 100% having TEPs in place. There is now widespread multidisciplinary engagement in the process of defining limits of care for acutely admitted medical patients within the first 14 hours of admission and a strategy for rolling this process out across all the divisions of the hospital through our Deteriorating Patient Group (DPG). The collaborative design with acute medical, palliative and intensive care teams and the high visibility provided by the electronic process in the Electronic Patient Record (EPR) has enhanced communication with these teams, patients, nursing staff and the multidisciplinary team by ensuring clarity through a universally understood process about escalation and CPR. Clarity and openness about these discussions have been welcomed by patient focus groups facilitated via our acute medicine patient experience committee. There has been a shift in medical culture where transparency about limits of care has contributed to improving patient safety and quality of care through reducing unnecessary CPR supported by focus groups of staff.
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Patella M, Papagiannopoulos K, Milton R, Chaudhuri N, Kefaloyannis E, Brunelli A. Operating room scheduling is not associated with early outcome following elective anatomic lung resections: a propensity score case-matched analysis. Eur J Cardiothorac Surg 2017; 51:660-666. [PMID: 28007872 DOI: 10.1093/ejcts/ezw371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/10/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives To investigate the effect of operating room scheduling on the outcome of patients undergoing elective lung resection. Methods In total, 420 patients submitted to anatomical pulmonary resections (363 lobectomies, 35 pneumonectomies, 22 segmentectomies) (April 2014-November 2015) were analysed. Ninety-two patients (22%) were operated on during weekends (Friday or Saturday) and 161 patients (38%) in the afternoon. Propensity score matching was performed to account for possible selection bias between the groups. The matched groups (weekdays versus weekends; morning versus afternoon) were compared in terms of cardiopulmonary complications, in-hospital mortality and length of stay (LOS). Results In total, 102 (24%) patients developed cardiopulmonary complications and 56 (13%) patients developed major complications. In-hospital mortality was 3.1% (13 patients). The case-matched comparison between patients operated on during the week versus those operated on during weekends (92 pairs) showed no differences of cardiopulmonary morbidity (22 vs 24, P = 0.8), major complications (14 in both groups), mortality (2 vs 4, P = 0.7) and LOS (7 vs 7.5 days, P = 0.6). The case-matched comparison between patients operated on in the morning versus those operated on in the afternoon (161 pairs) showed no differences of cardiopulmonary morbidity (32 vs 33, P = 0.9), major morbidity (17 vs 19, P = 1), mortality (7 vs 4, P = 0.5) and LOS (7.2 vs 5.9 days, P = 0.2). Conclusions In our setting, operating room scheduling did not affect early outcome following elective lung resections, confirming the appropriate structural and procedural characteristics of a dedicated Thoracic Unit.
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Affiliation(s)
- Miriam Patella
- Department of Thoracic Surgery, St James's University Hospital, Leeds, UK
| | | | - Richard Milton
- Department of Thoracic Surgery, St James's University Hospital, Leeds, UK
| | | | - Emmanuel Kefaloyannis
- Department of Thoracic Surgery, St James's University Hospital, Leeds, UK,Department of Thoracic Surgery, Leeds Teaching Hospitals, Leeds, UK
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Spagnolli W, Rigoni M, Torri E, Cozzio S, Vettorato E, Nollo G. Application of the National Early Warning Score (NEWS) as a stratification tool on admission in an Italian acute medical ward: A perspective study. Int J Clin Pract 2017; 71. [PMID: 28276182 DOI: 10.1111/ijcp.12934] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 01/20/2017] [Indexed: 11/30/2022] Open
Abstract
AIM We aimed to assess the performance of the National Early Warning Score (NEWS) as tool for patient risk stratification at admission in an acute Internal Medicine ward and to ensure patient placement in ward areas with the required and most appropriate intensity of care. As secondary objective, we considered NEWS performance in two subgroups of patients: sudden cardiac events (acute coronary syndromes and arrhythmic events), and chronic respiratory insufficiency. METHODS We conducted a perspective cohort single centre study on 2,677 unselected patients consecutively admitted from July 2013 to March 2015 in the Internal Medicine ward of the hospital of Trento, Italy. The NEWS was mandatory collected on ward admission. We defined three risk categories for clinical deterioration: low score (NEWS 0-4), medium score (NEWS 5-6), and high score (NEWS≥7). Following adverse outcomes were considered: total and early (<72 hours) in-hospital mortality, urgent transfers to a higher intensity of care. A logistic regression model quantified the association between outcomes and NEWS. RESULTS For patients with NEWS >4 vs patients with NEWS <4, the risk of early death increased from 12 to 36 times, total mortality from 3.5 to 9, and urgent transfers from 3.5 to 7. In patients with sudden cardiac events, lower scores were significantly associated with higher risk of transfer to a higher intensity of care. In patients affected by chronic hypoxaemia, adverse outcomes occurred less in medium and high score categories of NEWS. CONCLUSIONS National Early Warning Score assessed on ward admission may enable risk stratification of clinical deterioration and can be a good predictor of in-hospital serious adverse outcomes, although sudden cardiac events and chronic hypoxaemia could constitute some limits.
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Affiliation(s)
- Walter Spagnolli
- Azienda Provinciale per i Sevizi Sanitari, Ospedale Sanata Chiara U.O. Medicina Interna, Trento, Italy
| | - Marta Rigoni
- Healthcare Research and Innovation Program, Fondazione Bruno Kessler, Trento, Italy
| | - Emanuele Torri
- Healthcare Research and Innovation Program, Fondazione Bruno Kessler, Trento, Italy
- Dipartimento Salute e Solidarietà Sociale, Autonomous Province of Trento, Trento, Italy
| | - Susanna Cozzio
- Azienda Provinciale per i Sevizi Sanitari, Ospedale Sanata Chiara U.O. Medicina Interna, Trento, Italy
| | - Elisa Vettorato
- Azienda Provinciale per i Sevizi Sanitari, Ospedale Sanata Chiara U.O. Medicina Interna, Trento, Italy
| | - Giandomenico Nollo
- Healthcare Research and Innovation Program, Fondazione Bruno Kessler, Trento, Italy
- Dipartimento di Ingegneria Industriale, Università degli studi di Trento, Trento, Italy
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Khan A, Baird J, Rogers JE, Furtak SL, Williams KA, Allair B, Litterer KP, Sharma M, Smith A, Schuster MA, Landrigan CP. Parent and Provider Experience and Shared Understanding After a Family-Centered Nighttime Communication Intervention. Acad Pediatr 2017; 17:389-402. [PMID: 28143793 PMCID: PMC5438159 DOI: 10.1016/j.acap.2017.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/13/2017] [Accepted: 01/22/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess parent and provider experience and shared understanding after a family-centered, multidisciplinary nighttime communication intervention (nurse-physician brief, family huddle, family update sheet). METHODS We performed a prospective intervention study at a children's hospital from May 2013 to October 2013 (preintervention period) and May 2014 to October 2014 (postintervention period). Participants included 464 parents, 176 nurses, and 52 resident physicians of 582 hospitalized 0- to 17-year-old patients. Pre- versus postintervention, we compared parent/provider top-box scores (eg, "excellent") for experience with communication across several domains; and level of agreement (shared understanding) between parent, nurse, and resident reports of patients' reason for admission, overnight medical plan, and overall medical plan, as rated independently by blinded clinician reviewers (agreement = 74.7%, kappa = .60). RESULTS Top-box parent experience improved for 1 of 4 domains: Experience and Communication With Nighttime Doctors (23.6% to 31.5%). Top-box provider experience improved for all 3 domains, including Communication and Shared Understanding With Families (resident rated, 16.5% to 35.1%; nurse rated, 32.2% to 37.9%) and Experience, Communication, and Shared Understanding With Other Providers (resident rated, 20.3% to 35.0%; nurse rated, 14.7% to 21.5%). Independently rated shared understanding remained unchanged for most domains but improved for parent-nurse composite shared understanding (summed agreement for reason for admission, overall plan, and overnight plan; 36.2% to 48.2%) and nurse-resident shared understanding regarding reason for admission (67.1% to 71.2%) and regarding overall medical plan (45.0% to 58.6%). All P <.05. CONCLUSIONS A family-centered, multidisciplinary nighttime communication intervention was associated with improvements in some, but not all, domains of parent/provider experience and shared understanding, particularly provider experience and nurse-family shared understanding. The intervention was promising but requires further refinement.
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Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | | | - Jayne E. Rogers
- Department of Nursing, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Stephannie L. Furtak
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Kathryn A. Williams
- Clinical Research Center, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02215
| | - Brenda Allair
- Family Advisory Council, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Katherine P. Litterer
- Center for Families, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | | | - Alla Smith
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Christopher P. Landrigan
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA
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Basey AJ, Kennedy TD, Mackridge AJ, Krska J. Delays and interruptions in the acute medical unit clerking process: an observational study. JRSM Open 2016; 7:2054270415619323. [PMID: 26877881 PMCID: PMC4737975 DOI: 10.1177/2054270415619323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES It is recommended that patients are seen within 4 h of arrival in Acute Medical Units in English hospitals. This study explored the frequency and nature of interruptions and delays potentially affecting the duration of the Acute Medical Unit admission process and the quality of care provided. DESIGN The admission process was directly observed for patients admitted to the Acute Medical Unit over four one-week periods, November 2009 to April 2011. SETTING UK teaching hospital Acute Medical Unit. PARTICIPANTS Hospital staff n = 36. MAIN OUTCOME MEASURES Patient waiting times, duration of clerking, number of interruptions and/or delays. RESULTS Thirty-five doctors and one nurse practitioner were observed admitting 71 medical patients, 48/71 (68%) patients were clerked within 4 h of arrival. A delay and/or interruption affected 49/71 (69%) patients. Sixty-six interruptions were observed in 36/71 (51%) of admissions, of these 19/36 (53%) were interrupted more than once. The grade of doctor had no bearing on the frequency of interruption; however, clerking took significantly longer when interrupted; overall doctors grade ST1 and above were quicker at clerking than foundation doctors. Delays affected 31/71 (44%) of admissions, 14/31 (45%) involved X-rays or ECGs; other causes of delays included problems with equipment and computers. CONCLUSION Interruptions and delays regularly occurred during the admission process in the study hospital which impacts adversely on patient experience and compliance with the recommended 4-h timeframe, further work is required to assess the impact on patient safety. Data obtained from this observational study were used to guide operational changes to improve the process.
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Affiliation(s)
- Avril J Basey
- Royal Liverpool University Hospital, Liverpool, L7 8XP, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | | | - Adam J Mackridge
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | - Janet Krska
- Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Anson Building, Central Avenue, Chatham Maritime, Chatham, Kent, ME4 4TB, UK
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Alansari MA, Althenayan EA, Hijazi MH, Maghrabi KA. The rapid response team in outpatient settings identifies patients who need immediate intensive care unit admission: A call for policy maker. Saudi J Anaesth 2015; 9:428-32. [PMID: 26543462 PMCID: PMC4610089 DOI: 10.4103/1658-354x.159469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Caregivers in the ambulatory care setting with differing clinical background could encounter a patient at high risk of deterioration. In the absence of a dedicated acute care team, the response to an unanticipated medical emergencies in these settings is likely to have a poor outcome. Objective: To describe our experience in implementing an intensivist-led rapid response team (RRT) in the outpatient settings that identified patients who needed immediate Intensive Care Unit (ICU) admission. The effect on in hospital arrests, mortality, and ICU outcome is not the scope of this study. Materials and Methods: This retrospective descriptive study was performed from January 1, 2009 to December 31, 2011 in a tertiary hospital. Data from hospital records were used (none from patients’ records). Consent was not needed. Measurements: Direct ICU admissions from the outpatient areas. Results: There were 90 patients cared for by RRT in the outpatient's settings, 76 adult, and 14 pediatric patients. A total of12 adult patients were transferred directly to ICU. Among the patient who were transferred to the emergency department, additional four patients required to be transferred to ICU (total 16 patients [17.7%], 15 adult, and one pediatric patient). Follow-up at 24 h in the ICU showed death of one adult oncology patient (6.25%), and discharge of two patients (12.5%). Nine patients (81%) were still sick to require longer ICU stay. Conclusion: Intensivist-led RRT in outpatient settings identifies patients who are critically ill and in need of immediate ICU admission. Thus, an intensivist-led RRT policy in the outpatient settings needs to be implemented hospital wide.
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Affiliation(s)
- Mariam A Alansari
- Department of Adult Critical Care Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Eyad A Althenayan
- Neuro-Critical Care, London Health Sciences Centre, University of Western London, Ontario, Canada
| | - Mohammed H Hijazi
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Khalid A Maghrabi
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
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Dagar S, Sahin S, Yilmaz Y, Durak U. Emergency Department During Long Public Holidays. Turk J Emerg Med 2014; 14:165-71. [PMID: 27331186 PMCID: PMC4909941 DOI: 10.5505/1304.7361.2014.20438] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 07/31/2014] [Indexed: 11/30/2022] Open
Abstract
Objectives The purpose of this study is to determine the impact of the expected increase in the volume of patient visits in the emergency department during holiday periods on physicians' tendencies regarding test and consultation requests as well as on the length of time patients stay in the emergency department. Methods The study groups included all of the patients who visited the emergency department during the nine-day public holiday (Eid al-Adha, a religious festival of sacrifice) celebrations and a nine-day non-holiday “normal” period. The patients' demographic information, reasons for their visits, comorbid diseases, whether or not they had undergone laboratory and screening tests, consultations, length of stay, and the way their visits ended were compared statistically. Results Of the 6353 patients enrolled in the study, 3523 (55.5%) were seen in the emergency department during the holiday period, while 2830 (45.5%) were seen during the non-holiday period (p≤0.001). During the holiday period, there was a 1.9% decrease in laboratory test requests (p=0.108), a 7.7% increase in radiology examination requests (p≤0.001), and a 1.2% increase in consultation requests (p=0.063). The patients' length of stay during the holiday period was 55.9±75.3 minutes and was 56.3±71.9 minutes during the non-holiday period (p=0.819). The length of time for the patients who underwent tests or consultations was 88.6±92.8 minutes during the holiday period and 92.6±87.5 minutes during the non-holiday period (p=0.224). Conclusions As expected, the number of patient visits to the emergency department increased during the holiday period, but this increase did not lead to a similar increase in test and consultation requests by the physicians, except for radiology examination requests. In addition, the length of time that patients stayed in the emergency department was not affected by the increase in the volume of patient visits during the holiday period.
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Affiliation(s)
- Seda Dagar
- Department of Emergency Medicine, Kars State Hospital, Kars
| | - Sibel Sahin
- Department of Emergency Medicine, Artvin State Hospital, Artvin
| | - Yunus Yilmaz
- Department of Pediatric Service, Kars State Hospital, Kars
| | - Ugur Durak
- Department of Emergency Medicine, Kars State Hospital, Kars
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Turkington P, Power M, Hunt C, Ward C, Donaldson E, Bellerby J, Murphy P. There is another way: empowering frontline staff caring for acutely unwell adults. Int J Qual Health Care 2013; 26:71-8. [PMID: 24257161 DOI: 10.1093/intqhc/mzt084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
QUALITY PROBLEM OR ISSUE It is estimated that only 17% of patients survive an in-hospital cardiac arrest. Medical evidence indicates that many patients show signs of deterioration during the 24 h period prior to their cardiac arrest. INITIAL ASSESSMENT At Salford Royal NHS Foundation Trust (SRFT) 135 patients (outside critical care areas) suffered a cardiac arrest between March 2007 and April 2008. CHOICE OF SOLUTION Quality improvement method-The breakthrough series (BTS) collaborative approach, change package-reliable manual vital signs, nurse-led response to the deteriorating patient, code red, structured ward round, ceilings of care, nurse-led do not attempt cardiopulmonary resuscitation (DNA-CPR) protocol and allocated roles. IMPLEMENTATION The project was delivered over two phases with a total of 23 wards (12 wards in Phase One and 11 wards in Phase Two). Frontline teams worked to develop changes with the aim of reducing cardiac arrests by 50%. EVALUATION The primary outcome measure was the number of cardiac arrests per 1000 admissions outside of critical care areas. Process and balancing measures were also used to evaluate the impact of the intervention. LESSONS LEARNED The results showed a positive relationship between the change package and a reduction of 41% in cardiac arrests outside of critical care areas from the baseline period (April 2007-March 2008) to December 2012. The BTS model has the potential to reduce cardiac arrests without the need for initial large-scale financial investment.
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Affiliation(s)
- Peter Turkington
- Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK;
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Bell D, Lambourne A, Percival F, Laverty AA, Ward DK. Consultant input in acute medical admissions and patient outcomes in hospitals in England: a multivariate analysis. PLoS One 2013; 8:e61476. [PMID: 23613858 PMCID: PMC3629209 DOI: 10.1371/journal.pone.0061476] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 03/10/2013] [Indexed: 12/01/2022] Open
Abstract
Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An 'all inclusive' pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting.
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Affiliation(s)
- Derek Bell
- Imperial College, London, United Kingdom.
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15
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Al-Lawati JA, Al-Zakwani I, Sulaiman K, Al-Habib K, Al Suwaidi J, Panduranga P, Alsheikh-Ali AA, Almahmeed W, Al Faleh H, Al Saif S, Hersi A, Asaad N, Al-Motarreb A, Mikhailidis DP, Amin H. Weekend versus weekday, morning versus evening admission in relationship to mortality in acute coronary syndrome patients in 6 middle eastern countries: results from gulf race 2 registry. Open Cardiovasc Med J 2012; 6:106-12. [PMID: 23002404 PMCID: PMC3447162 DOI: 10.2174/1874192401206010106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 07/15/2012] [Indexed: 12/04/2022] Open
Abstract
We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their management on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.
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Affiliation(s)
- Jawad A Al-Lawati
- Department of Non-Communicable Diseases Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
- Gulf Health Research, Muscat, Oman
| | | | - Khalid Al-Habib
- King Fahad Cardiac Centre, King Khalid University Hospital, College of Medicine, Riyadh, Saudi Arabia
| | - Jassim Al Suwaidi
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | | | - Alawi A Alsheikh-Ali
- Department of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- Tufts Clinical and Translational Science Institute and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Wael Almahmeed
- Department of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Husam Al Faleh
- King Fahad Cardiac Centre, King Khalid University Hospital, College of Medicine, Riyadh, Saudi Arabia
| | | | - Ahmad Hersi
- King Fahad Cardiac Centre, King Khalid University Hospital, College of Medicine, Riyadh, Saudi Arabia
| | - Nidal Asaad
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
- Weill Cornell Medical School, Doha, Qatar
| | | | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital, University College London Medical School, University College London, London, England, UK
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Findlay J, Boulton C, Forward D, Moran C. 'Hospital-at-Night' expedites review of trauma patients without affecting outcome from hip fracture. J Perioper Pract 2011; 21:346-351. [PMID: 22132478 DOI: 10.1177/175045891102101003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The UK Hospital at Night (H@N) programme is hypothesised to improve efficiency of out-of-hours care. No studies have assessed a surgical programme or mechanisms of effect. This prospective study aimed to do so in a trauma and orthopaedic department over 10 weeks. Senior house officers recorded night shift activity. Mean time to attend referrals reduced from 29 to 15 minutes as a result of the programme (p = 0.007). Workload and 30 day mortality and morbidity for hip fracture remained unchanged. The mechanisms underlying improvements are unclear, but may represent central organisation of workload.
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Affiliation(s)
- John Findlay
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, RG1 5RN.
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Brims FJH, Asiimwe A, Andrews NP, Prytherch D, Higgins BR, Kilburn S, Chauhan AJ. Weekend admission and mortality from acute exacerbations of chronic obstructive pulmonary disease in winter. Clin Med (Lond) 2011; 11:334-9. [PMID: 21853828 PMCID: PMC5873741 DOI: 10.7861/clinmedicine.11-4-334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Historically, acute medical staffing numbers have been lower on weekends and in winter numbers of medical admissions rise. An analysis of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) admissions to Portsmouth Hospitals over a seven-year period was undertaken to examine the effects of admission on a weekend, of winter, and with the opening of a medical admissions unit (MAU). In total, 9,915 admissions with AECOPD were identified. Weekend admissions accounted for 2,071 (20.9%) of cases, winter accounted for 3,026 (30.5%) admissions, and 522 (34.4%) deaths. Adjusted odds ratio (OR) for death on day 1 after winter weekend admission was 2.89 (95% confidence interval (CI) 1.035 to 8.076). After opening the MAU, the OR for death day 1 after weekend winter admission fell from 3.63 (95% CI 1.15 to 11.5) to 1.65 (95% CI 0.14 to 19.01). AECOPD patients have an increased risk of death after admission over a weekend in winter and this effect was reduced by opening a MAU. These findings have implications for the planning of acute care provision in different seasons.
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Affiliation(s)
- F J H Brims
- Centre for Respiratory Research, University College London.
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Quirke S, Coombs M, McEldowney R. Suboptimal care of the acutely unwell ward patient: a concept analysis. J Adv Nurs 2011; 67:1834-45. [PMID: 21545636 DOI: 10.1111/j.1365-2648.2011.05664.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM This paper presents a concept analysis of suboptimal care of the acutely unwell ward patient. BACKGROUND Acutely unwell patients exhibit abnormal vital signs which are either not recognized or are treated inappropriately. This is frequently termed 'suboptimal care'. However, use of the term 'suboptimal care' is ambiguous and not clearly defined. Critical review of this concept is required to ensure nurses have a better understanding of why and how suboptimal care occurs. DATA SOURCES Electronic databases (CINAHL, Medline, Cochrane) were searched for literature related to suboptimal care of acutely unwell ward patients. Reference lists from relevant publications were reviewed. No date or language restrictions were imposed. Only articles relevant to suboptimal care of the acutely unwell adult ward patient were included. All literature reviewed was in English and was published between 1990 and 2009. METHOD The Walker and Avant approach was used. RESULTS The attributes of suboptimal care are delays in diagnosis, treatment or referral, poor assessment and inadequate or inappropriate patient management. These attributes are preceded by contextual antecedents which can be categorized into patient complexity, healthcare workforce, organization and education factors. Suboptimal care may have catastrophic consequences for patients such as death, Intensive Care Unit admission or cardiac arrests which are preventable or avoidable. CONCLUSION For future research, investigators need to develop more objective measures which capture delays in the treatment and inappropriate or inadequate management of acutely unwell patients. This should occur through critical focus on the antecedents to suboptimal care.
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Affiliation(s)
- Sara Quirke
- School of Nursing Midwifery and Health, Victoria University of Wellington, New Zealand.
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Clunas S, Whitaker R, Ritchie N, Upton J, Isbister GK. Reviewing deaths in the emergency department: deaths in the department or deaths within 48 h. Emerg Med Australas 2010; 21:117-23. [PMID: 19422408 DOI: 10.1111/j.1742-6723.2009.01166.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate an ED death audit process that included deaths occurring within 48 h of admission in addition to deaths in the ED. METHODS The study was a review of a prospective audit process undertaken in routine clinical practice that included auditing deaths in the ED and deaths of admitted patients within 48 h of ED presentation. Data were extracted from the audit database and included demography, clinical information and medical recommendations. The hospital incident investigation and monitoring system (IIMS) was searched for major incident reports involving death. The main outcome was the number of medical record audits from each group reported to the clinical governance unit for review, and whether the 48 h audit identified relevant cases to the ED in addition to those identified in the ED audit alone. Secondary outcomes were the number of audits resulting in other actions: ED policy review, education, case discussion or review with the inpatient team. RESULTS Over a 2 year period, 303 deaths were reviewed, including 75 deaths in the ED and 228 deaths within 48 h. The ED auditor recommended no further action in 66/75 (88%) ED deaths and 195/228 (86%) 48 h deaths. A major hospital review was recommended in 4/75 (5%) ED deaths and 11/228 (5%) 48 h deaths, with only 3 and 7 of these, respectively, having been detected by the hospital's IIMS. The audit identified 10 of 13 deaths notified to the IIMS and the remaining 3 did not involve error relevant to the ED. Internal review was recommended in one ED death and eight 48 h deaths. CONCLUSIONS The present study demonstrates that auditing both ED deaths and 48 h deaths identifies additional issues relevant to the ED compared with auditing ED deaths alone or relying on standard hospital incident reporting.
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Affiliation(s)
- Sally Clunas
- Emergency Department, John Hunter Hospital, Newcastle, NSW, Australia
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20
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Timing and interventions of emergency teams during the MERIT study. Resuscitation 2010; 81:25-30. [DOI: 10.1016/j.resuscitation.2009.09.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 08/18/2009] [Accepted: 09/26/2009] [Indexed: 11/23/2022]
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Ward D, Potter J, Ingham J, Percival F, Bell D. Acute medical care. The right person, in the right setting--first time: how does practice match the report recommendations? Clin Med (Lond) 2009; 9:553-6. [PMID: 20095297 PMCID: PMC4952293 DOI: 10.7861/clinmedicine.9-6-553] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An acute medicine Royal College of Physicians report makes key recommendations. This study reviews organisational issues and consultant working patterns against these recommendations. Thirty-nine trusts in England and Wales were asked to participate in an online survey, which 27 completed. Twenty-six sites had an acute medical unit (AMU) and all had a lead consultant. Two trusts had no written operational policy. Of the 26 AMUs, 22 had at least level 1 facilities and 21 used an early warning score at point of entry to care. Ten reported a minimum of twice daily ward rounds seven days a week. Consultant of the day was the most common pattern of work. Ten trusts cancelled other clinical duties for consultants responsible for acute take. The pilot shows evidence of good practice in leadership and operational policies. Further work to standardise and improve acute care is needed including a more consistent twice daily consultant review.
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Affiliation(s)
- David Ward
- Clinical Effectiveness Evaluation Unit, Royal College of Physicians
- Clinical Standards, Royal College of Physicians
- Imperial College, London
| | - Jonathan Potter
- Clinical Effectiveness Evaluation Unit, Royal College of Physicians
| | - Jane Ingham
- Clinical Standards, Royal College of Physicians
| | - Fran Percival
- Clinical Effectiveness Evaluation Unit, Royal College of Physicians
- Clinical Standards, Royal College of Physicians
- Imperial College, London
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Chaponda M, Borra M, Beeching NJ, Almond DS, Williams PS, Hammond MA, Price VA, Tarry L, Taegtmeyer M. The value of the post-take ward round: are new working patterns compromising junior doctor education? Clin Med (Lond) 2009; 9:323-6. [PMID: 19728503 PMCID: PMC4952497 DOI: 10.7861/clinmedicine.9-4-323] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This prospective observational study assessed the impact of the changes in junior doctors' working hours and waiting-time initiatives on teaching and learning opportunities for junior doctors in acute medicine. An audit cycle of post-take ward rounds including all medical admissions to an urban teaching hospital was conducted. During two seven-day periods in July 2006 and 2008, 317 and 354 patients were admitted respectively. In the two-year interval a number of changes were implemented resulting in a significant increase in patients reviewed by a consultant within 24 hours of admission. Target waiting times were being met but there were many missed learning opportunities for junior staff. Senior doctors continue to perform the majority of post-take reviews in the absence of the doctors who had admitted the patient. Similar patterns are likely to be found in other hospitals attempting to balance training with government targets for waiting times and junior doctors' working hours.
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Affiliation(s)
- M Chaponda
- Infectious Diseases and Clinical Pharmacology, Royal Liverpool University Hospital, Liverpool.
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Beckett DJ, Gordon CF, Paterson R, Chalkley S, Stewart C, Jones MC, Young M, Bell D. Improvement in out-of-hours outcomes following the implementation of Hospital at Night. QJM 2009; 102:539-46. [PMID: 19465374 DOI: 10.1093/qjmed/hcp056] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period. AIM To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes. DESIGN An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh. METHODS Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS). RESULTS Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU. CONCLUSION This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.
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Affiliation(s)
- D J Beckett
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK.
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UK Consensus Conference on Acute Medicine. Br J Hosp Med (Lond) 2009. [DOI: 10.12968/hmed.2009.70.1.38004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The ageing population and the growth in numbers of patients suffering from long-term conditions demands an adequate response from the health service to provide care and support. This is particularly true when individuals experience an acute deterioration in their health: they have a right to expect prompt, effective treatment from competent clinicians who are properly equipped. This pressure on the NHS has been reflected in the increasing numbers of acute admissions to medical beds and the increasing percentage of acute bed days occupied by patients aged over 80 years. Recognizing the need to provide good care at the front door, the NHS looked for solutions and appointed a number of doctors to manage acute medical units. None of these doctors had been trained specifically for this task but, subsequently, training programmes were developed. However, the place of acute medicine remains the subject of debate.
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Bell D, Jones M. Emergency Admissions— A time for action and improving patient outcomes. Med Chir Trans 2007; 100:487-8. [DOI: 10.1177/014107680710001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Derek Bell
- Professor of Acute Medicine, Imperial College, Chelsea and Westminster Campus, London SW10 9NH, UK
| | - Mike Jones
- Consultant Physician, Edinburgh Royal Infirmary, Edinburgh EH16 4SA, UK
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Papiernik E, Pibarot ML, Vidal-Trécan G, Christoforov B. [Improving patient safety: decreasing adverse events associated with medical care]. Presse Med 2007; 36:1255-61. [PMID: 17408913 DOI: 10.1016/j.lpm.2007.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Awareness of the importance of what were previously called iatrogenic accidents is not new, but recent publications have demonstrated the frequency and severity of the accidents and incidents associated with care, which are now known simply as "adverse events". Research has helped us to understand the principal mechanisms underlying them and the circumstances that promote them. It shows that root causes, often linked to the organization of care, should be sought beneath the initial appearance of mistakes. Institutions providing health care must ascertain how to develop a new culture that makes it possible to improve patient safety by implementing new policies, that is, a group of several coordinated measures intended to decrease patient risk. These policies should use accepted techniques, such as reports and appropriate information management for events for which reporting is mandatory, but extended to medical accidents; critical activity analyses must also be used, for comparison with a standard, following the model used for evaluations of professional practices. New techniques are also necessary, such as operational feedback in the form of morbidity-mortality reviews and in-depth analyses of the most serious events. Institutions must establish indicators to prove the effectiveness of this new policy.
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Baker M, Clancy M. Can mortality rates for patients who die within the emergency department, within 30 days of discharge from the emergency department, or within 30 days of admission from the emergency department be easily measured? Emerg Med J 2007; 23:601-3. [PMID: 16858089 PMCID: PMC2564158 DOI: 10.1136/emj.2005.028134] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Death rates are an outcome that can be used to describe a service. We measured three death rates that can be used to describe an emergency department (ED): death rates for those seen in the ED and discharged, those that die within the ED, and those that die after admission. We also wanted to establish how easy it was to obtain these rates and how frequently autopsy was performed. SETTING ED within a large teaching hospital. RESULTS Between 1 December 2003 and 1 December 2004, 76,060 patients attended the ED of which 205 died within the department. A total of 16,489 were admitted of which 876 died within 30 days. A total of 59,366 were discharged home of which 111 subsequently died over the next 30 days. The rates were 0.19% (111/59,366) for those discharged, 4.6% (766/16,489) for those admitted, and 0.27% (205/76,060) for those patients attending the ED who died within it. The autopsy rate was low (20%) and was more likely if the patient died in the department, died within the first few days of admission, or was young. The data were easy to collect. CONCLUSIONS These three death rates were easy to calculate and could be used to describe the outcome of an ED service. Further research to establish the range of rates for different departments is now required to determine their potential use.
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Affiliation(s)
- M Baker
- Emergency Department, Southampton General Hospital, Tremona Road, Southampton, UK.
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Adverse Events in Patients With Community-Acquired Pneumonia at an Academic Tertiary Emergency Department. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2006. [DOI: 10.1097/01.idc.0000227713.81012.ae] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lu TC, Tsai CL, Lee CC, Ko PCI, Yen ZS, Yuan A, Chen SC, Chen WJ. Preventable deaths in patients admitted from emergency department. Emerg Med J 2006; 23:452-5. [PMID: 16714507 PMCID: PMC2564342 DOI: 10.1136/emj.2004.022319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2005] [Indexed: 11/03/2022]
Abstract
BACKGROUND There is limited data about how appropriate medical care is in the emergency department (ED). OBJECTIVES To investigate the rate and types of preventable deaths among patients with early mortality after emergency admission from the ED. METHODS We retrospectively reviewed charts of early mortality (defined as mortality which occurred within 24 hours after admission from the ED) over a 3 year period. Those patients with terminal cancer or out of hospital cardiac arrest (OHCA) at presentation were excluded. Two independent assessors reviewed each eligible chart and determined whether early mortality was preventable. Any disagreements were resolved through discussion between the investigators. A mortality event was considered preventable if actions or missed actions were identified that would have prevented the death. The types of preventability were categorised as misdiagnosis, delayed diagnosis, and inappropriate medical management. Interrater reliability in the initial determination was assessed using Cohen kappa statistic. RESULTS Over a 3 year period, 210 early mortality cases were identified. Excluding patients with terminal cancer or OHCA, the rate of preventable deaths was 25.8% (32/124). The types of preventability were inappropriate medical management (17 patients), delayed diagnosis (eight), and misdiagnosis (seven). There was good agreement between assessors with a Cohen kappa statistic of 0.81. CONCLUSIONS Preventable deaths in emergency admitted patients with early mortality are not uncommon. Analysis and identification of preventability early mortality by using a chart based method may be used as a quality assurance index in emergency medical care.
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Affiliation(s)
- T-C Lu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Rankin J, Bush J, Bell R, Cresswell P, Renwick M. Impacts of participating in confidential enquiry panels: a qualitative study. BJOG 2006; 113:387-92. [PMID: 16553650 DOI: 10.1111/j.1471-0528.2006.00883.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the impacts of participating in confidential enquiry panels for the Confidential Enquiry into Stillbirths and Deaths in Infancy. DESIGN Qualitative interview study. SETTING The former northern health region of England. SAMPLE Eighteen health professionals who had participated in at least one confidential enquiry panel. METHODS Semistructured one-to-one interviews using purposive sampling; transcripts were analysed by identifying recurring themes. Data were organised and coded using NUD*IST. MAIN OUTCOME MEASURES Views on the impacts of participation on clinical practice and views on the strengths and limitations of confidential enquiries. RESULTS Participants valued attendance at panels as a learning experience that provoked reflection on their own clinical practice. Participants felt that taking part had a positive impact on their clinical thinking and practice by increasing their awareness of standards of care. These impacts occurred through both the detailed examination of cases and the interaction with colleagues from different disciplines and hospitals. Learning impacts were cascaded to colleagues through informal discussion and teaching. Concrete examples of changes in practice at the organisational level, stimulated by panel attendance, were reported. CONCLUSIONS The confidential enquiry approach was supported not only as an effective way of assessing care but also as a valuable learning experience that motivated change in clinical practice. Local benefits of nationally coordinated confidential enquiries should be valued and supported in their future development. Wide multidisciplinary participation in enquiry panels coordinated through regional clinical networks should be promoted.
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Affiliation(s)
- J Rankin
- School of Population and Health Sciences, University of Newcastle, Newcastle Upon Tyne, UK.
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Daud-Gallotti R, Dutilh Novaes HM, Lorenzi MC, Eluf-Neto J, Namie Okamura M, Tadeu Velasco I. Adverse events and death in stroke patients admitted to the emergency department of a tertiary university hospital. Eur J Emerg Med 2005; 12:63-71. [PMID: 15756081 DOI: 10.1097/00063110-200504000-00005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To identify the occurrence of adverse events in stroke patients presenting to the emergency department of a tertiary university facility, and to disclose the categories of adverse events associated with death. METHODS This matched case-control study enrolled 468 patients admitted with stroke to the emergency department from March 1996 to September 1999. The cases comprised 234 consecutive deaths and the controls 234 discharged patients, matched for primary diagnosis and admission period. Adverse events, detected by chart review, were classified according to the degree of severity, immediate causes, and professional category. The association with death was analysed by conditional logistic regression. RESULTS Adverse events totaled 1218 and occurred in 295 patients: 932 events (76.5%) in 170 cases and 286 (23.5%) in 125 controls. Major adverse events equaled 54.1% of all events (659 episodes): 538 events in 143 cases and 121 in 65 controls. Diagnostic or therapeutic procedures and nursing activities accounted for 55.2% of events. Nursing (38.4%) and medical (31%) adverse events represented the most common related professional categories. A significant association with death was found for major adverse events, medical adverse events, and nosocomial infections, with adjusted odds ratio estimates of 3.74 [95% confidence interval (CI) 1.64-8.54], 3.71 (95% CI 1.61-8.53), and 3.22 (95% CI 1.21-8.59), respectively. CONCLUSION Adverse events, mostly severe, predominated among deceased patients, resulting mainly from diagnostic or therapeutic procedures and nursing activities. In spite of limitations concerning the observational retrospective nature of this study, we found that severe adverse events, medical adverse events, and nosocomial infections were significantly associated with death in stroke patients.
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Affiliation(s)
- Renata Daud-Gallotti
- Department of Medical Emergency Medicine, School of Medicine, University of São Paulo, São Paulo, SP, Brazil.
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Abstract
Severity-of-illness assessment is now an accepted part of clinical practice and clinical research for the management of adults who have community-acquired pneumonia. Several approaches to this issue have been devised based on severity-of-illness scores or rules, some related to site of management. No single approach has been found to be superior to others, but further research into their effect on outcome in clinical practice is required. It is likely that different approaches may suit different populations and health care systems.
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Affiliation(s)
- Mark Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
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