Long-term impact of COVID-19 on nursing and care delivery: A national survey among anaesthetic and critical care nurses

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has put an exceptional strain on intensive care delivery and has significantly impacted nursing practice in the intensive care unit, consequently affecting nurses' working environment and health. Little is known about the long-term impact on the nursing workforce and care delivery in intensive care and anaesthetic departments.

AIM/OBJECTIVE

This cross-sectional study aimed to describe the long-term impact of the COVID-19 pandemic on the nursing profession and nursing care from the perspectives of anaesthetic and critical care nurses.

METHODS

In this study, an online questionnaire with open- and close-ended questions was distributed to registered nurses working in anaesthesia and intensive care between February 8 and March 7, 2022. The data were analysed using content analysis and descriptive statistics.

RESULTS

Of the 514 registered nurses who responded to the questionnaire, 256 (50%) worked in anaesthesia care and 215 (42%) in intensive care. The long-term impact of COVID-19 was expressed in three categories: nursing care on hold, insights and experiences forming a new professional identity, and the impact of organisational conditions on the profession. Critical care nurses considered nursing care comparable to that before the COVID-19 pandemic. Nurse anaesthetics experienced changes in nursing tasks and activities compared to that before the COVID-19 pandemic.

CONCLUSIONS

Nursing care is still influenced by the pandemic due to the lack of resources and persistent high workload and needs to be reclaimed and prioritised. Re-establishing high-quality nursing care is a shared responsibility of the organisation and nursing profession, and the organisation needs to create prerequisites for this. Furthermore, nurses' views and insights into their profession developed both positively and negatively during the pandemic, which must be further considered, including the profession's values.

Missed nursing care in relation to registered nurses' level of education and self-reported evidence-based practice

BACKGROUND

Patient safety is one of the cornerstones of high-quality healthcare systems. Evidence-based practice is one way to improve patient safety from the nursing perspective. Another aspect of care that directly influences patient safety is missed nursing care. However, research on possible associations between evidence-based practice and missed nursing care is lacking.

AIM

The aim of this study was to examine associations between registered nurses' educational level, the capability beliefs and use of evidence-based practice, and missed nursing care.

METHODS

This study had a cross-sectional design. A total of 228 registered nurses from adult inpatient wards at a university hospital participated. Data were collected with the MISSCARE Survey-Swedish version of Evidence-Based Practice Capabilities Beliefs Scale.

RESULTS

Most missed nursing care was reported within the subscales Basic Care and Planning. Nurses holding a higher educational level and being low evidence-based practice users reported significantly more missed nursing care. They also scored significantly higher on the Evidence-based Practice Capabilities Beliefs Scale. The analyses showed a limited explanation of the variance of missed nursing care and revealed that being a high user of evidence-based practice indicated less reported missed nursing care, while a higher educational level meant more reported missed nursing care.

LINKING EVIDENCE TO ACTION

Most missed nursing care was reported within the subscales Planning and Basic Care. Thus, nursing activities are deprioritized in comparison to medical activities. Nurses holding a higher education reported more missed nursing care, indicating that higher education entails deeper knowledge of the consequences when rationing nursing care. They also reported varied use of evidence-based practice, showing that higher education is not the only factor that matters. To decrease missed nursing care in clinical practice, and thereby increase the quality of care, educational level, use of evidence-based practice, and organizational factors must be considered.

Differences between Registered Nurses and nurse assistants around missed nursing care-An observational, comparative study

BACKGROUND

From a nursing perspective, tasks that are not carried out, and the consequences of this, have been studied for over a decade. The difference between Registered Nurses (RNs) and nurse assistants (NAs) regarding qualifications and work tasks, and the profound knowledge around RN-to-patient ratios, warrants investigating missed nursing care (MNC) for each group rather than as one (nursing staff).

AIM

To describe and compare RNs and NAs ratings of and reasons for MNC at in-hospital wards.

METHODS

A cross-sectional study with a comparative approach. RNs and NAs at in-hospital medical and surgical wards for adults were invited to answer the MISSCARE Survey-Swedish version, including questions on patient safety and quality of care.

RESULTS

A total of 205 RNs and 219 NAs answered the questionnaire. Quality of care and patient safety was rated as good by both RNs and NAs. Compared to NAs, RNs reported more MNC, for example, in the item 'Turning patient every 2 h' (p < 0.001), 'Ambulation three times per day or as ordered' (p = 0.018), and 'Mouth care' (p < 0.001). NAs reported more MNC in the items 'Medications administered within 30 min before or after scheduled time' (p = 0.005), and 'Patient medication requests acted on within 15 min' (p < 0.001). No significant differences were found between the samples concerning reasons for MNC.

CONCLUSION

This study demonstrated that RNs' and NAs' ratings of MNC to a large extent differed between the groups. RNs and NAs should be viewed as separate groups based on their different knowledge levels and roles when caring for patients. Thus, viewing all nursing staff as a homogenous group in MNC research may mask important differences between the groups. These differences are important to address when taking actions to reduce MNC in the clinical setting.

Nurse staffing levels in critical care: The impact of patient characteristics

BACKGROUND

Intensive care is one of the most resource-intensive forms of care because seriously ill patients are cared for in units with high staffing levels. Studies show that the number of registered nurses (RNs) per patient and nurse education level affects patient outcome. However, there is a lack of studies that consider how nurses/patient ratio with an advanced educational level of specialized nurses in intensive care, affect the intensive care performed in different patient populations.

AIM

To investigate if differences in patient characteristics and nurse-patient ratio have an impact on the quality of care.

STUDY DESIGN

This is a retrospective observational study with a review of all patients >15 years receiving care at two general intensive care units with different nurse/patient ratio (unit A, 1:1 nurse/patient ratio and unit B, 0.5:1 nurse/patient ratio).

RESULTS

There was no significant difference in the initial severity of illness between the units. However, younger patients, male patients and patients requiring surgery entailed a higher workload and a longer intensive care unit (ICU) stay despite a 1:1 critical care nurse/patient ratio. A small difference, but not significant, with more unplanned re-intubations occurred at unit A compared with unit B.

CONCLUSION

The differences in the nurse/patient ratio did not reflect a difference in the severity of illness among admitted patients but might be explained by patient characteristics with different needs.

RELEVANCE TO CLINICAL PRACTICE

Health care managers should consider not only the number of nurses but also their educational level, specific competencies and skills mix and nursing-sensitive measures to provide high-quality ICU care in settings with different patient characteristics. Nursing-sensitive patient outcomes should be considered in relation to nurse/patient ratio, as important to measure to ensure a high quality of patient care in the ICU.

Patient safety, quality of care and missed nursing care at a cardiology department during the COVID-19 outbreak

Aim

To evaluate missed nursing care and patient safety during the first wave of the COVID‐19 pandemic at in‐patient cardiology wards.

Design

A cross‐sectional design with a comparative approach.

Method

Registered nurses and nurse assistants at a cardiology department were invited to answer the MISSCARE Survey‐Swedish version, and questions on patient safety and quality of care during the COVID‐19 pandemic. The data were compared with a reference sample.

Results

A total of 43 registered nurses and nurse assistants in the COVID‐19 sample and 59 in the reference sample participated. The COVID‐19 sample reported significantly more overtime hours and more absence from work due to illness in comparison with the reference sample. The patient safety and quality of care were perceived significantly worse, 76.7% (N = 33) versus 94.7% (N = 54), and 85.7% (N = 36) versus 98.3% (N = 58, respectively. The COVID‐19 sample reported more missed nursing care in wound care and in basic nursing.

Missed nursing care during the COVID-19 pandemic: A comparative observational study

Aim

To evaluate frequencies, types of, and reasons for missed nursing care during the COVID‐19 pandemic at inpatient wards in a highly specialized university hospital.

Background

Registered nurse/patient ratio and nursing competence is known to affect patient outcomes. The first wave of the COVID‐19 pandemic entailed novel ways for staffing to meet the expected increased acute care demand, which potentially could impact on quality of care.

Methods

A comparative cross‐sectional study was conducted, using the MISSCARE Survey. A sample of nursing staff during the first wave of the COVID‐19 pandemic (n=130) was compared with a reference sample (n=157).

Results

Few differences between samples concerning elements of missed care, and no significant differences concerning reasons for missed care were found. Most participants perceived the quality of care and the patient safety to be good.

Conclusion

The results may be explained by three factors: maintained registered nurse/patient ratio, patients’ dependency levels and that nursing managers could maintain the staffing needs with a sufficient skill mix.

Implications for nursing management

Nursing managers impact on the occurrence of MNC; to provide a sufficient registered nurse/patient ratio and skill mix when staffing. They play an important role in anticipatory planning, and during infectious diseases outbreaks.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma for Health Care Staff Working During COVID-19: Exploratory Pilot Study With Nurses

BACKGROUND

The COVID-19 pandemic has accelerated the worldwide need for simple remotely delivered (digital) scalable interventions that can also be used preventatively to protect the mental health of health care staff exposed to psychologically traumatic events during their COVID-19-related work. We have developed a brief behavioral intervention that aims to reduce the number of intrusive memories of traumatic events but has only been delivered face-to-face so far. After digitalizing the intervention materials, the intervention was delivered digitally to target users (health care staff) for the first time. The adaption for staff's working context in a hospital setting used a co-design approach.

OBJECTIVE

The aims of this mixed method exploratory pilot study with health care staff who experienced working in the pandemic were to pilot the intervention that we have digitalized (for remote delivery and with remote support) and adapted for this target population (health care staff working clinically during a pandemic) to explore its ability to reduce the number of intrusive memories of traumatic events and improve related symptoms (eg, posttraumatic stress) and participant's perception of their functioning, and to explore the feasibility and acceptability of both the digitalized intervention and digitalized data collection.

METHODS

We worked closely with target users with lived experience of working clinically during the COVID-19 pandemic in a hospital context (registered nurses who experienced intrusive memories from traumatic events at work; N=3). We used a mixed method design and exploratory quantitative and qualitative analysis.

RESULTS

After completing the digitalized intervention once with remote researcher support (approximately 25 minutes) and a brief follow-up check-in, participants learned to use the intervention independently. All 3 participants reported zero intrusive memories during week 5 (primary outcome: 100% digital data capture). Prior to study inclusion, two or more intrusions in the week were reported preintervention (assessed retrospectively). There was a general pattern of symptom reduction and improvement in perceived functioning (eg, concentration) at follow-up. The digitalized intervention and data collection were perceived as feasible and rated as acceptable (eg, all 3 participants would recommend it to a colleague). Participants were positive toward the digital intervention as a useful tool that could readily be incorporated into work life and repeated in the face of ongoing or repeated trauma exposure.

CONCLUSIONS

The intervention when delivered remotely and adapted for this population during the pandemic was well received by participants. Since it could be tailored around work and daily life and used preventatively, the intervention may hold promise for health care staff pending future evaluations of efficacy. Limitations include the small sample size, lack of daily intrusion frequency data in the week before the intervention, and lack of a control condition. Following this co-design process in adapting and improving intervention delivery and evaluation, the next step is to investigate the efficacy of the digitalized intervention in a randomized controlled trial.

Registered nurses' experiences of working in the intensive care unit during the COVID-19 pandemic

Background

During the pandemic, increased numbers of patients requiring intensive care unit (ICU) admission required an increase in ICU capacity, including ICU staffing with competence to care for critically ill patients. Consequently, nurses from acute care areas were called in to staff the ICU along with experienced intensive care nurses.

Aims and objectives

To describe Swedish registered nurses' experiences of caring for patients with COVID‐19 in ICUs during the pandemic.

Design

Mixed method survey design.

Methods

An online questionnaire was distributed through social media to registered nurses who had been working in the ICU during the COVID‐19 outbreak. Data were collected for 1 week (May 2020) and analysed using content analysis and descriptive statistics.

Results

Of the 282 nurses who participated, the majority were ICU nurses (n = 151; 54%). Half of the nurses specialized in ICU reported that they were responsible for the ICU care of three or more patients during the pandemic (n = 75; 50%). Among non‐intensive care nurses, only 19% received introduction to the COVID‐19 ICU (n = 26). The analysis of data regarding nurses' experiences resulted in three categories: tumbling into chaos, diminished nursing care, and transition into pandemic ICU care. Participants described how patient safety and care quality were compromised, and that nursing care was severely deprioritized during the pandemic. The situation of not being able to provide nursing care resulted in ethical stress. Furthermore, an increased workload and worsened work environment affected nurses' health and well‐being.

Conclusions

The findings from the present study indicate that nurses perceived that patient safety and quality of care were compromised during the pandemic. This resulted in ethical stress among nurses, which may have affected their physical and psychosocial well‐being.

Relevance to clinical practice

The COVID‐19 pandemic had a severe impact on nurses' work environment, which could result in burnout and staff turnover.

Translation, culture adaption and psychometric testing of the MISSCARE Survey-Swedish version

AIM

To translate the MISSCARE Survey into Swedish and establish its validity and reliability by evaluating its psychometric properties.

BACKGROUND

Missed nursing care is defined as any aspect of required nursing care that is omitted or delayed. The consequence of missed nursing care is a threat to patient safety. The MISSCARE Survey is an American instrument measuring missed nursing care activities (part A) and its reasons (part B).

METHODS

The translation was accomplished according to World Health Organization guidelines, focusing on a culture adaptation. Acceptability, construct validity, test-retest reliability and internal consistency were analysed. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) was used as reporting checklist.

RESULTS

The translation and culture adaptation needed several revisions. A total of 126 nurses answered the test and retest which showed acceptability of missing data. The factor analysis revealed a lack of fit to data for the original factorial structure in part B, while further analysis provided results suggesting a modification based on omitting six items. The internal consistency for part B and its subscales showed good results.

CONCLUSIONS

The MISSCARE Survey-Swedish version is a reliable and valid instrument, with good psychometric properties.

RELEVANCE TO CLINICAL PRACTICE

More reliable language versions of the instrument enable national and international comparisons that could be valuable for nursing managers and/or directors of nursing who are responsible for quality of care and patient safety in the strategic care planning process.

Patient experiences of initial trauma care

BACKGROUND

Correct initial treatment of trauma patients reduces mortality and morbidity. However, the initial examination may be perceived as traumatic because of the stressful situation, the unfamiliar setting and the shock of being seriously injured. To date, little is known about patient's experiences of initial trauma management. The aim of this study was to explore trauma patients' experiences of being exposed to initial full trauma team assessment at a Level 1 trauma centre.

METHODS

Interviews with 16 patients who had been exposed to initial trauma care were conducted at a Level 1 trauma centre, at a Swedish University Hospital. The interviews were transcribed verbatim and analysed with qualitative content analysis.

RESULTS

Patients' experiences of initial trauma care can be summarized as: feeling safe in a frightening situation. The trauma team members were mostly perceived as professional, well-organised, and efficient. Yet, the patients described an emotional response to the trauma, physical discomfort during the examination, and feeling prioritised or being ignored in the encounter with the trauma team members.

CONCLUSION

The initial trauma care may be improved if the trauma team members keep the patient's physical and emotional wellbeing in focus and maintain an informative dialogue with the patient during the whole process.

Prehospital emergency care nurses' strategies while caring for patients with limited Swedish-English proficiency

AIMS AND OBJECTIVES

To explore the strategies of nurses working in the ambulance service while caring for patients with limited Swedish-English proficiency.

BACKGROUND

Communication difficulties due to lack of mutual language is a challenge in healthcare systems around the world. Little is known about nurses' strategies while caring for patients with whom they do not share a mutual language in an unstructured, unplanned prehospital emergency environment, the ambulance service.

DESIGN AND METHOD

A qualitative study design based on interviews was used, and a purposeful sample and snowball technique were used to identify nurses with prehospital emergency experience of caring for patients with limited Swedish-English proficiency.

RESULTS

Eleven nurses were interviewed, and the main strategy they used was adapting to the patients' need and the caring situation. The nurses used their own body, and tone of voice for creating a sense of trust and security. The nurses also used structured assessment in accordance with medical guidelines. Translation devices and relatives/bystanders were used as interpreters when possible. Another strategy was to transport the patient directly to the emergency department as they had not found a secure way of assessing and caring for the patients in the ambulance.

CONCLUSION

The nurses used a palette of strategies while assessing and caring for patients when there was no mutual language between the caregiver and care seeker.

RELEVANCE TO CLINICAL PRACTICE

The nurses need to be prepared for how to assess and care for patients when there is a lack of mutual language; otherwise, there is a risk of increased unequal care in the ambulance service. To further explore and learn about this field of research, studies exploring the patients' perspective are needed.

Registered nurses' own experience of using a nurse-initiated pain protocol based on their working experience

AIMS AND OBJECTIVES

To explore registered nurses' (RNs) own experience of using the nurse-initiated pain protocol (NIPP) in the emergency department (ED) based on their working experience.

BACKGROUND

Pain is known to be one of the most common symptoms among adult patients seeking care at the ED. Several strategies aiming to improve pain management have been developed. Despite some improvements in pain management using NIPP, a large number of patients continue to have inadequate pain treatment when cared for in EDs.

DESIGN AND METHOD

A cross-sectional study design based on a questionnaire was used. The variable working experience was based on a theory that experience will make a change in RNs' knowledge. Descriptive statistics and Pearson's chi-square tests were used for analysing quantative data. Qualitative data were analysed by summative content analysis.

RESULTS

Seventy RNs answered the questionnaire (response rate 42%) and 61% considered the NIPP adequate to relieve patients' acute pain at the ED. No significant difference was found on how the RNs used the NIPP. However, qualitative data showed that more experienced RNs adapt the NIPP according to the patients' needs in a higher extent.

CONCLUSION

A majority of the RNs consider the NIPP to be adequate to relieve patients' acute pain in the ED. An increase in working experience showed an impact on how the NIPP was used, with an increase in pain management that is personalised depending on individual patients' needs. The RNs used several alternatives to both dosage and type of medication when the ED becomes crowded.

RELEVANCE TO CLINICAL PRACTICE

Registered nurses' working experience should be considered when planning nursing schedules to be better able to meet patients' needs. Guidelines should be developed and evaluated by both healthcare professionals and patients.

Teaching in the high-technological clinical setting- a new approach

This article was migrated. The article was not marked as recommended. Teaching in the clinical setting is demanding and a complex task that many clinicians carry out without preparation. It is clear that a clinical educator must be more than just a medical expert. We developed a supervision model based on student-centered learning inspired by adult learning theories. To achieve learning the student is treated as independent learner and that learning is self-directed based on previous knowledge. Aim: The purpose of this project was to evaluate the student´s experience of our developed student-centered supervision model. Method: We evaluated the project, with both qualitative interviews (n=6) and questionnaires (n=15), which were analyzed quantitively. Result: Student-centered learning is well suited to promoting self-directed learning in the clinical setting in critical care. Our student- and supervision model was found to enable a positive learning environment in which students and their skills were in focus. The clinical supervisor's educational ability to is crucial for the result.

Towards excellence in clinical education

This article was migrated. The article was marked as recommended. Background: The healthcare system has a growing need for knowledgeable and skilled health care personnel to meet the demands to support student learning in clinical training. One way to assess teachers' competence is to use a teacher portfolio; however, this has not been done with the mission of clinical health care personnel in focus. Therefore, the aim of this study was to develop a portfolio to assess clinical health care personnel´s pedagogical competence. Methods: Pedagogical active nurses and physicians from the anesthesia department, operating room and intensive care, and an educational expert with extensive experience of developmental work of pedagogical portfolios in the academic setting developed a qualifications portfolio for pedagogical competence in the clinical setting. Result: The assessment standards define five levels of teaching competence and include both experience and quality of the educational mission in the clinical setting. The pedagogical portfolio is congruent with the assessment tool and structured with headings to promote clinical teachers to document both quantitative and qualitative aspects of teaching. Conclusion: The portfolio enables clinicians and managers in academic hospitals to highlight the need for high-quality professional and the ability to identify needs for pedagogical skills among health care personnel.

Ambulance personnel's management of pain for patients with hip fractures; based on ambulance personnel's gender and years of experience

According to the World Health Organization (WHO) the goal of health care is for the entire general population to have good health and receive care on equal terms. Little is known about gender differences in the management of patients in the ambulance service. There is also a lack of studies investigating how the characteristics of health care personnel, such as gender and work experience, impact on patient care Therefore, the aim of this study was to describe ambulance personnel's assessments and the pain relief they provide for patients with hip fractures, based on the ambulance personnel's gender and years of experience.

METHOD

A retrospective study of patients (>65 years) with hip fracture who, during 2011, were transported by ambulance to hospital.

RESULT

Seven hundred and twenty two patients were included. Most patients reported experiencing pain and 50% received pain medication. Ambulance personnel with working experience of <10 years administered more pain medication compared to those with experience of >10 years. There was a tendency for male ambulance personnel to give pain medication more often compared to female personnel, but this tendency showed no significance.

CONCLUSION

The main finding of our study is that personnel with working experience of less than 10 years administer more pain relief, even though only half of the patients received pain medication during ambulance transportation.

The occurrence of pressure damage in the oral cavity caused by endotracheal tubes

The aim of this observational study was to investigate the occurrence of pressure damage caused by endotracheal tubes (ETT) when the tube is repositioned from one corner of the mouth to the other every third day. For the assessment of oral condition and the eventual damage caused by ETT, a modified version of the Oral Assessment Guide (OAG) was used. The oral condition was assessed once per day in all adult patients who were orally intubated with a tube for over 24 hours. Thirty-eight patients were included in the study. Most patients ( n = 33, 86.8%) had no pressure damage. Five patients (13.2%) had pressure damage on the oral mucosa and lip caused by endotracheal tubes. The group with damage to the oral mucosa was treated with noradrenaline, had bleeding problems and clotting disorders and had significantly more intubated and study days. The assessment of the oral mucosa according to the OAG reflected the worsening oral condition in the group with pressure damage. Endotracheal tubes may need to be repositioned more often than every third day to avoid pressure damage in patients with a high risk of complications, and individually tailored care may need to be implemented.

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients' satisfaction of pain management

BACKGROUND

Pain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients' own experience regarding pain management in ED.

OBJECTIVE

The aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED.

METHOD

An observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire.

RESULTS

A total of 160 patients answered the questionnaire. In the pre- (n=80) and post-intervention (n=80) groups, 91/95% experienced pain in the ED. A significant difference (p<0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p<0.03) in patients' own reported pain intensity at discharge was found between the groups. Patients' reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly.

CONCLUSION

Patients' satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain.

IMPLICATION

According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients' satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients' satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.

Barriers and opportunities in assessing calls to emergency medical communication centre--a qualitative study

INTRODUCTION

Previous studies have described the difficulties and the complexity of assessing an emergency call, and assessment protocols intended to support the emergency medical dispatcher's (EMD) assessment have been developed and evaluated in recent years. At present, the EMD identifies about 50-70 % of patients suffering from cardiac arrest, acute myocardial infarction or stroke. The previous research has primarily been focused on specific conditions, and it is still unclear whether there are any overall factors that may influence the assessment of the call to the emergency medical communication centre (EMCC).

AIM

The aim of the study was to identify overall factors influencing the registered nurses' (RNs) assessment of calls to the EMCC.

METHOD

A qualitative study design was used; a purposeful selection of calls to the EMCC was analysed by content analysis.

RESULTS

One hundred calls to the EMCC were analysed. Barriers and opportunities related to the RN or the caller were identified as the main factors influencing the RN's assessment of calls to the EMCC. The opportunities appeared in the callers' symptom description and the communication strategies used by the RN. The barriers appeared in callers' descriptions of unclear symptoms, paradoxes and the RN's lack of communication strategies during the call.

CONCLUSION

Barriers in assessing the call to the EMCC were associated with contradictory information, the absence of a primary problem, or the structure of the call. Opportunities were associated with a clear symptom description that was also repeated, and the RN's use of different communication strategies such as closed loop communication.

Has increased nursing competence in the ambulance services impacted on pre-hospital assessment and interventions in severe traumatic brain-injured patients?

OBJECTIVE

Trauma is one of the most common causes of morbidity and mortality in modern society, and traumatic brain injuries (TBI) are the single leading cause of mortality among young adults. Pre-hospital acute care management has developed during recent years and guidelines have shown positive effects on the pre-hospital treatment and outcome for patients with severe traumatic brain injury. However, reports of impacts on improved nursing competence in the ambulance services are scarce. Therefore, the aim of this study was to investigate if increased nursing competence level has had an impact on pre-hospital assessment and interventions in severe traumatic brain-injured patients in the ambulance services.

METHOD

A retrospective study was conducted. It included all severe TBI patients (>15 years of age) with a Glasgow Coma Score (GCS) of less than eight measured on admission to a level one trauma centre hospital, and requiring intensive care (ICU) during the years 2000-2009.

RESULTS

651 patients were included, and between the years 2000-2005, 395 (60.7%) severe TBI patients were injured, while during 2006-2009, there were 256 (39.3%) patients. The performed assessment and interventions made at the scene of the injury and the mortality in hospital showed no significant difference between the two groups. However, the assessment of saturation was measured more frequently and length of stay in the ICU was significantly less in the group of TBI patients treated between 2006-2009.

CONCLUSION

Greater competence of the ambulance personnel may result in better assessment of patient needs, but showed no impact on performed pre-hospital interventions or hospital mortality.

Age differences in brain injury characteristics

PURPOSE

Traumatic brain injury (TBI) is an important cause of morbidity and mortality in children. Despite the high incidence of head injury among children, the mortality rate is low. There is a lack of studies that describe children's age-specific symptoms in relation to outcome. The purpose is to investigate if other described symptoms could be used as a predictor of intracranial injury in children.

METHODS

Retrospective review of data from all children who during 1 year were admitted due to a brain injury.

RESULTS

During 1 year 724 children visited the ED due to a brain injury. A significant difference was found between age groups and other documented initial symptoms, but no single symptoms could be used as a predictor for intracranial injury.

CONCLUSION

Unconsciousness as a predictor for brain injury should be used with caution in children. Significant differences were found in other documented symptoms between age groups.

The specificity of post-concussive symptoms in the pediatric population

The study compared patterns of reported symptoms between a mild head injury group and a group of children with abdominal complaints visiting an emergency department. Children (0-15 years) admitted to an emergency department during a three-month period with a history of head injury and a comparison group of children were included. Medical records at the time of injury were reviewed and follow-up questionnaires focused on presumed symptoms related to concussion at three months post-visit. The comparison group reported significantly more change in behaviour than the head injury group. However, for the older children, higher intensity of symptoms was reported by the comparison group compared to the head injury group. Initial differences in the amount and presence of symptoms between the two groups did not reflect the findings at three months; both groups reported symptoms or changes at three months after the event. Evaluating children aged under five, their symptoms and recovery patterns after a head injury is recommended.

Evaluation of documentation in potential abusive head injury of infants in a Paediatric Emergency Department

AIM

The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI.

METHODS

A database search was performed to find all medical records over a period of one year relating to those children who had one AHI-related primary complaint and who had had a CT head-scan performed in conjunction with admission. Each medical record was reviewed, in order to assess whether potential abuse had been investigated and documented. Each CT-scan image was re-evaluated for missed indications of potential injuries attributable to AHI.

RESULTS

Forty-seven such medical records were found. Of these, 87% showed the diagnosis to be head injuries. The largest group of children was in the age group 0-3 months (38%). Of the children admitted to the Paediatric ED due to a head injury, 54% had a history deemed to raise suspicions of abuse but only five of them had had a documented investigation of child abuse. The re-evaluation of the CT-scans showed no missed cases.

CONCLUSION

In this study we found that among children with known risk factors for AHI, only a few had documentation regarding potential child abuse. The use of a standardized protocol could be helpful in the important work to help staff discover potential AHI.

Informational needs in families after their child's mild head injury

OBJECTIVE

When a child is hospitalized due to an illness or injury, the entire family may experience stress and/or anxiety. According to parents who have been in such a situation, providing adequate information is one of the most valuable ways to help the family deal with such feelings. Most mild head injuries suffered by children do not require hospitalisation and in such cases, their families should be provided with appropriate information in connection with their visit to the emergency ward. In the present study, family informational needs are characterized.

METHODS

The families of 57 children who had suffered a mild head injury at 0-15 years of age answered one open-ended question. The analysis was carried out using content analysis.

RESULTS

This analysis revealed two types of needs, i.e., a need for information concerning the head injury itself and how to provide care, as well as a need for reassurance and support in sharing and coping with the emotional burden.

CONCLUSION

Despite differences in the severity of the child's head injury and requirement for hospitalisation, all the families expressed the same informational needs but also the need for emotional support.

PRACTICE IMPLICATIONS

In connection with the treatment of children with head injuries, health-care personnel should provide the parents both with information concerning the injury and its treatment and with emotional support.

Current incidence and management of children with traumatic head injuries: the Stockholm experience

PURPOSE

A traumatic head injury is one of the most common causes of morbidity and mortality among children, however few population-based studies in this area have been reported. Therefore, the aim of this study was to evaluate the incidence and management of traumatic head injuries in children at a level-one trauma centre in Stockholm, Sweden.

PARTICIPANTS

All children (n = 3168) who visited the emergency department with a history of head injury during 1 year were included.

METHOD

The required information was collected retrospectively and the children's medical records were reviewed.

RESULTS

The overall incidences of head injury were 865 per 100 000 children with the highest incidence (2379/10(5) children) occurring among children younger than 18 months of age. Twelve per cent (n = 396) were admitted to a hospital ward and CT scans were performed in 13% (n = 412) of all children. During this year, 0.3% required a neurosurgical intervention and only 1% of all children had documentation of a planned follow-up appointment.

CONCLUSION

The findings indicate that clinical documentation as a part of the early management in children with a head injury is inconsistent and suffers from lack of valid criteria. Implementation of clinical guidelines during emergency care would help improve subsequent hospital care, as well as the planning of health care services for these children.

Are the symptoms and severity of head injury predictive of clinical findings three months later?

AIM

To describe symptoms and functional disabilities 3 mo after a minimal, mild or moderate head injury in children, and to analyse relationships between these and initial symptoms and management documented at the time of the injury.

METHODS

The sample consisted of all children (0-15 y) admitted to an emergency department during a 1-mo period with a history of head injury. Data were collected from the medical records at the time of the injury, and questionnaires about symptoms/change and functional problems 3 mo after the injury.

RESULTS

Symptoms and functional problems were reported in 35% of the children 3 mo after a head injury. Documented altered consciousness (in children less than 5 y) and disorientation (in children 5 y of age or older) at the emergency department were correlated with changes in behaviour at 3 mo. The initial duration of unconsciousness was not predictive of subsequent behaviour.

CONCLUSION

The difficulties in predicting outcomes in head-injured children, especially younger ones, indicate the need for a follow-up appointment in order to identify children with special needs. Further studies are needed regarding the early signs and symptoms in different age groups.