Bernice Redley

Staff attitudes towards family presence during resuscitation

The presence of family members in the resuscitation room of an Emergency Department (ED) is a controversial issue. This has been the subject of discussion in recent years and has received a lot of publicity. Allowing family to be present with their relative in the time leading up to their dying moments may help initiate the grieving process and dealings with subsequent death. This study found that there are occasions where families are present informally during resuscitation attempts in metropolitan hospitals around Melbourne. The experiences of staff have been given voice, with comments from those involved. A survey of ED workers was conducted to examine staff attitudes and to identify the major factors of concern about family presence during resuscitation. The willingness of staff to consider the option was revealed by this study. Examination of issues relevant to this proposal reveal many concerns for ED workers. These issues must be addressed in order to gain commitment and support from staff. The main concerns are discussed and possible solutions suggested. Ideas for developing guidelines to prepare staff and possible visitors into the resuscitation room are included for those wishing to develop and pilot such a project in their own department.

Reported medication errors after introducing an electronic medication management system

AIMS AND OBJECTIVES To explore the effects of introducing an electronic medication management system on reported medication errors. BACKGROUND Computerised medication management systems have been found to improve medication safety; however, introducing medication management system into healthcare environments can create unanticipated or new problems and opportunities for medication error. DESIGN Descriptive analysis of medication error reports. METHODS This was a retrospective analysis of 359 incident reports drawn from the period of 1 May 2005-30 April 2006 across two hospital sites of a single not-for-profit private health service located in metropolitan Melbourne. Site A used a conventional pen and paper system for medication management, and Site B had introduced a computerised medication management system. RESULTS Most medication errors occurred at the nurse administration (71·5%) and prescribing (16·4%) stages of delivery. The most common medication error type reported at Site A was omission (33%), and at Site B was wrong documentation (24·2%). A higher proportion of errors at the prescribing phase, and less nurse administration errors, were detected at Site B where the medication management system was in use. The incidence of other, less frequent errors was similar across the two hospital sites. CONCLUSIONS This examination of medication error reports suggests there are differences in the types of medication errors that are reported in association with the introduction of electronic medication management system compared to pen and paper system systems. The findings provide a new insight into the effects of introducing an electronic medication management system on the types of medication errors reported. RELEVANCE TO CLINICAL PRACTICE The findings provide a new insight into the types of medication errors that are reported during implementation of an electronic medication management system. Extra support for physicians prescribing practices should be considered.

Development of a Management Algorithm for Post-operative Pain (MAPP) after total knee and total hip replacement: study rationale and design

BackgroundEvidence from clinical practice and the extant literature suggests that post-operative pain assessment and treatment is often suboptimal. Poor pain management is likely to persist until pain management practices become consistent with guidelines developed from the best available scientific evidence. This work will address the priority in healthcare of improving the quality of pain management by standardising evidence-based care processes through the incorporation of an algorithm derived from best evidence into clinical practice. In this paper, the methodology for the creation and implementation of such an algorithm that will focus, in the first instance, on patients who have undergone total hip or knee replacement is described.MethodsIn partnership with clinicians, and based on best available evidence, the aim of the Management Algorithm for Post-operative Pain (MAPP) project is to develop, implement, and evaluate an algorithm designed to support pain management decision-making for patients after orthopaedic surgery. The algorithm will provide guidance for the prescription and administration of multimodal analgesics in the post-operative period, and the treatment of breakthrough pain. The MAPP project is a multisite study with one coordinating hospital and two supporting (rollout) hospitals. The design of this project is a pre-implementation-post-implementation evaluation and will be conducted over three phases. The Promoting Action on Research Implementation in Health Services (PARiHS) framework will be used to guide implementation. Outcome measurements will be taken 10 weeks post-implementation of the MAPP. The primary outcomes are: proportion of patients prescribed multimodal analgesics in accordance with the MAPP; and proportion of patients with moderate to severe pain intensity at rest. These data will be compared to the pre-implementation analgesic prescribing practices and pain outcome measures. A secondary outcome, the efficacy of the MAPP, will be measured by comparing pain intensity scores of patients where the MAPP guidelines were or were not followed.DiscussionThe outcomes of this study have relevance for nursing and medical professionals as well as informing health service evaluation. In establishing a framework for the sustainable implementation and evaluation of a standardised approach to post-operative pain management, the findings have implications for clinicians and patients within multiple surgical contexts.

Patient Participation in a Cardiac Rehabilitation Program

PURPOSE: Cardiac rehabilitation programs (CRPs) aim to help patients with cardiovascular disease achieve lifestyle changes. However, attendance and completion of programs are poor worldwide. The rationale for this study was to explore patterns of attendance and completion of a CRP located in a private hospital in metropolitan Melbourne, Victoria, Australia. METHODS: This exploratory descriptive study involved linking 2 databases to analyze demographic and cardiac characteristics of patients who did or did not attend the CRP. RESULTS: Only 11.9% of patients likely to benefit attended the CRP. Predictors of attendance included marital status, gender, age, and proximity of the program to home. The crucial area identified in need of improvement is the referral process to increase the rate of participation. CONCLUSION: The major finding is the need for improvement in referral and recruitment structures to increase awareness of the program and the participation rate. Practices such as automatic referral and followup of patients are recommended. The study outcomes will benefit future research on referral processes to the CRP at the hospital.

Nursing Roles and Strategies in End-of-Life Decision Making Concerning Elderly Immigrants Admitted to Acute Care Hospitals: An Australian Study.

Purpose: There is a lack of clarity regarding nursing roles and strategies in providing culturally meaningful end-of-life care to elderly immigrants admitted to Australian hospitals. This article redresses this ambiguity. Method: A qualitative exploratory descriptive approach was used. Data were obtained by conducting in-depth interviews with a purposeful sample of 22 registered nurses, recruited from four health services. Interview transcripts were analyzed using content and thematic analysis strategies. Results: Despite feeling underprepared for their role, participants fostered culturally meaningful care by “doing the ground work,” “facilitating families,” “fostering trust,” and “allaying fear.” Discussion and Conclusion: The Australian nursing profession has a significant role to play in leading policy, education, practice, and consumer engagement initiatives aimed at ensuring a culturally responsive approach to end-of-life care for Australia’s aging immigrant population. Implications for Practice: Enabling elderly immigrants to experience a “good death” at the end of their lives requires highly nuanced and culturally informed nursing care.

Using ANT to uncover the full potential of an intelligent operational planning and support tool (IOPST) for acute healthcare contexts

Based on initial pre-clinical data and results from focus group studies, proof of concept for an intelligent operational planning and support tool (IOPST) for nursing in acute healthcare contexts has been demonstrated. However, moving from a simulated context to a large scale clinical trial brings potential challenges associated with the many complexities and multiple people-technology interactions. To enable an in depth and rich analysis of such a context, it is the contention of this paper that incorporating an Actor-Network Theory (ANT) lens to facilitate analysis will be a prudent option as discussed below.

Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mixed methods study

Background Standard risk screening and assessment forms are frequently used in strategies to prevent harm to older people in hospitals. Little is known about good practices for their use. Objective Scope the preventable harms addressed by standard forms used to screen and assess older people and how standard forms are operationalised in hospitals across Victoria, Australia. Methods Mixed methods study: (1) cross-sectional audit of the standard risk screening and assessment forms used to assess older people at 11 health services in 2015; (2) nine focus groups with a purposive sample of 69 participants at 9 health services. Descriptive analysis examined the number of items on forms, preventable harms assessed and sources of duplication. Qualitative thematic analysis of focus group data identified themes explaining issues commonly affecting how health services used the forms. Results 152 standard assessment forms from 11 Victorian health services included over 3700 items with 17% duplicated across multiple forms. Assessments of skin integrity and mobility loss (including falls) were consistently included in forms; however, nutrition, cognitive state, pain and medication risks were inconsistent; and continence, venous thromboembolism risk and hospital acquired infection from invasive devices were infrequent. Qualitative analyses revealed five themes explaining issues associated with current use of assessment forms: (1) comprehensive assessment of preventable harms; (2) burden on staff and the older person, (3) interprofessional collaboration, (4) flexibility to individualise care and (5) information management. Examples of good practice were identified. Conclusions Current use of standard risk screening and assessment forms is associated with a high burden and gaps in assessment of several common preventable harms that can increase risk to older people in hospital. Improvement should focus on streamlining forms, increased guidance on interventions to prevent harm and facilitating front-line staff to manage complex decisions.

Nursing handover from ICU to cardiac ward: Standardised tools to reduce safety risks

BACKGROUND Standardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers. OBJECTIVES Adapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation. METHODS A three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses. RESULTS Stage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved. CONCLUSION Clinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.

Using Technology Solutions to Streamline Healthcare Processes for Nursing: The Case of an Intelligent Operational Planning Support Tool (IOPST) Solution

Identifying the value stream relating to healthcare processes primarily focuses around diagnosing and treating patients coupled with removing waste. This is now becoming a key priority for many healthcare organisations globally, yet remains an area that is significantly under researched especially with regard to nursing. Lean thinking, as a method to redesign processes in order to improve outcomes has been used with success especially in the manufacturing sector, and now, given the importance of identifying and creating value in healthcare processes, is becoming of increasing interest within various healthcare contexts. In this chapter, we discuss how lean thinking as a management approach, with focuses on operational aspects, can be used to facilitate effective and efficient nursing care. We illustrate with the example of an Intelligent Operational Planning Support Tool (IOPST) solution.

Interprofessional communication supporting clinical handover in emergency departments: An observation study

BACKGROUND Poor interprofessional communication poses a risk to patient safety at change-of-shift in emergency departments (EDs). The purpose of this study was to identify and describe patterns and processes of interprofessional communication impacting quality of ED change-of-shift handovers. METHODS Observation of 66 change-of-shift handovers at two acute hospital EDs in Victoria, Australia. Focus groups with 34 nurse participants complemented the observations. Qualitative data analysis involved content and thematic methods. RESULTS Four structural components of ED handover processes emerged represented by (ABCD): (1) Antecedents; (2) Behaviours and interactions; (3) Content; and (4) Delegation of ongoing care. Infrequent and ad hoc interprofessional communication and discipline-specific handover content and processes emerged as specific risks to patient safety at change-of-shift handovers. Three themes related to risky and effective practices to support interprofessional communications across the four stages of ED handovers emerged: 1) standard processes and practices, 2) teamwork and interactions and 3) communication activities and practices. CONCLUSIONS Unreliable interprofessional communication can impact the quality of change-of-shift handovers in EDs and poses risk to patient safety. Structured reflective analysis of existing practices can identify opportunities for standardisation, enhanced team practices and effective communication across four stages of the handover process to support clinicians to enhance local handover practices. Future research should test and refine models to support analysis of practice, and identify and test strategies to enhance ED interprofessional communication to support clinical handovers.