Elizabeth Manias

Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study

Objectives To investigate patients’ and family members’ perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure. Design Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members. Setting Nationwide multisite survey across Australia. Participants 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%). Main outcome measures Participants’ recurrent experiences and concerns expressed in interviews. Results Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure. Conclusions Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients’ (and family members’) needs and expectations.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

Objective:To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Design:Randomized, controlled trial. Setting:General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Patients:Adult, mechanically ventilated patients (n = 312). Interventions:Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). Measurements and Main Results:The median (95% confidence interval) duration of ventilation was 79 hrs (56–93 hrs) for patients in the protocol group compared with 58 hrs (44–78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2–1106] hrs vs. 88 (14–962) hrs, p = .58) and hospital (13 [1–113] days vs. 13 (1–365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. Conclusions:This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies.

Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review

AIM This paper is a report of a literature review to identify research involving interventions to improve medication adherence in people with multiple co-existing chronic conditions. Title. Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review. Background. The importance of managing co-existing, chronic conditions in people of all ages is critical to prevent adverse health outcomes. DATA SOURCES Databases, including Cumulative Index of Nursing and Allied Health Literature, Medline, PubMed and Web of Science were searched for the period January 1997-2007 using the combined keywords adherence, compliance, drug therapy, medication, clinical trial, randomized controlled trial, intervention, chronic condition, chronic disease, multiple morbidity and comorbidity. References of retrieved papers were also considered. METHODS The inclusion criteria were: English language, oral medication adherence, self-administered medications, multiple prescribed medications for three or more chronic conditions and randomized controlled trials lasting at least 3 months. RESULTS Studies examining medication adherence in people with multiple chronic conditions targeted people over 70 years of age, and were primarily focused on the management of polypharmacy and reducing healthcare costs. Adherence was measured using different tools and estimates of adherence, and interventions were predominantly delivered by pharmacists. The evidence for effective interventions to enhance medication adherence in multiple chronic conditions was weak, and psychosocial interventions were absent. CONCLUSION Interventions that improve medication adherence for people with multiple chronic conditions are essential, given the increased prevalence of these conditions in people of all ages. Outcomes of improved adherence, such as disease control and quality of life, require investigation. Psychosocial interventions engaging people in medication self-management offer potential for improved patient outcomes in complex diseases.

Impact of Medication Reconciliation and Review on Clinical Outcomes

Objective: To examine the evidence regarding the effectiveness of medication reconciliation and review and to improve clinical outcomes in hospitals, the community, and aged care facilities. Data Source: This systematic review was undertaken in concordance with the PRISMA statement. Electronic databases, including MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for relevant articles published between January 2000 and March 2014. Study Selection and Data Extraction: Randomized and nonrandomized studies rating the severity of medication discrepancies and medication-related problems identified during medication reconciliation and/or review were considered for inclusion. Data were extracted independently by 2 authors using a data collection form. Data Synthesis: Of the 5292 articles identified, 83 articles met the inclusion criteria. Medication reconciliation identified unintentional medication discrepancies in 3.4% to 98.2% of patients. There is limited evidence of the potential of these discrepancies to cause harm. Medication reviews identified medication-related problems or possible adverse drug reactions in 17.2% to 94.0% of patients. The studies reported conflicting findings regarding the impact of medication review on length of stays, readmissions, and mortality. Conclusions: The evidence demonstrates that medication reconciliation has the potential to identify many medication discrepancies and reduce potential harm, but the impact on clinical outcomes is less clear. Similarly, medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Overall, there is limited evidence that medication reconciliation and medication review processes, as currently performed, significantly improve clinical outcomes, such as reductions in hospital readmissions.

Eczema workshops reduce severity of childhood atopic eczema

An intervention study was conducted to assess the effectiveness of a nurse‐led eczema workshop in reducing the severity of atopic eczema in infants, children and adolescents. Ninety‐nine new patients referred to the Dermatology Department of The Royal Childrens Hospital in Melbourne, Australia, for the management of atopic eczema were randomized to receive care from an eczema workshop or a dermatologist‐led clinic. Patients were followed‐up 4 weeks after the intervention. The primary outcome was the severity of eczema as determined by scores obtained using the Scoring of Atopic Dermatitis (SCORAD) index at a 4‐week follow‐up visit. The secondary outcome was a comparison of treatments used in both clinics. At the 4‐week review the mean improvement in SCORAD was significantly greater in those patients attending the eczema workshop than those attending the dermatologist‐led clinic (−9.93, 95% confidence interval −14.57 to −5.29, P < 0.001). Significantly more patients from the eczema workshop improved from moderate severity eczema at baseline to mild at review. There was greater adherence to eczema management in the eczema workshop compared with the dermatologist‐led clinic. In this study, patients attending the eczema workshop had a greater improvement in eczema severity thanpatients attending a dermatologist‐led clinic, supporting collaborative models of service provision.

Interventions to reduce medication errors in adult intensive care: a systematic review

Critically ill patients need life saving treatments and are often exposed to medications requiring careful titration. The aim of this paper was to review systematically the research literature on the efficacy of interventions in reducing medication errors in intensive care. A search was conducted of PubMed, CINAHL EMBASE, Journals@Ovid, International Pharmaceutical Abstract Series via Ovid, ScienceDirect, Scopus, Web of Science, PsycInfo and The Cochrane Collaboration from inception to October 2011. Research studies involving delivery of an intervention in intensive care for adult patients with the aim of reducing medication errors were examined. Eight types of interventions were identified: computerized physician order entry (CPOE), changes in work schedules (CWS), intravenous systems (IS), modes of education (ME), medication reconciliation (MR), pharmacist involvement (PI), protocols and guidelines (PG) and support systems for clinical decision making (SSCD). Sixteen out of the 24 studies showed reduced medication error rates. Four intervention types demonstrated reduced medication errors post-intervention: CWS, ME, MR and PG. It is not possible to promote any interventions as positive models for reducing medication errors. Insufficient research was undertaken with any particular type of intervention, and there were concerns regarding the level of evidence and quality of research. Most studies involved single arm, before and after designs without a comparative control group. Future researchers should address gaps identified in single faceted interventions and gather data on multi-faceted interventions using high quality research designs. The findings demonstrate implications for policy makers and clinicians in adopting resource intensive processes and technologies, which offer little evidence to support their efficacy.

Assessment of Patient Pain in the Postoperative Context

Because of its subjective nature, the assessment of pain requires the use of comprehensive practices that accurately reflect a patient’s experiences of pain. The purpose of this study was to determine how nurses make decisions in their assessment of patients’ pain in the postoperative clinical setting. An observational design was chosen as the means of examining pain activities in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were selected. Each 2-hour observation period was examined 12 times thus resulting in 74 observations. In total, 316 pain activities were determined. Five themes relating to assessment were identified from the data analysis: simple questioning, use of a pain scale, complex assessment, the lack of pain assessment, and physical examination for pain. The study identified how nurses’ prioritization of work demands created barriers in conducting timely and comprehensive pain assessment decisions.

Interventions to improve medication adherence in adult kidney transplant recipients: a systematic review

BACKGROUND In kidney transplantation, adherence to immunosuppressive therapy is paramount for long-term graft survival. This systematic review aimed to assess the effectiveness of interventions to improve medication adherence in adult kidney transplantation. METHODS Eight electronic databases were searched from inception to November 2013. Only primary intervention studies, which reported measurement of adherence to immunosuppressive medications after kidney transplantation, were included. The quality of all studies was assessed using the Consolidated Standards of Reporting Trials and Transparent Reporting of Evaluations with Non-randomized Designs checklists. A synthesis was undertaken to tease out the domains targeted by interventions: (i) educational/cognitive, (ii) counselling/behavioural, (iii) psychologic/affective and (iv) financial support. For each study, key information, such as population, location, methods of measurements, comparison group, type of intervention and outcomes, were extracted and tabulated. RESULTS Twelve intervention studies were identified. Quality of studies ranged from 16.0 to 80.5%. Effective interventions were implemented for 3, 6 and 12 months. Medication adherence rates were greatly enhanced when multidimensional interventions were implemented whereas one-off feedback from a nurse and financial assistance programmes offered little improvement. Dose administration aids when used in conjunction with self-monitoring also improved adherence. The number of patients who had a drug holiday (at least 1-day interval without a dose) was higher in a once-daily regimen than a twice-daily regimen. CONCLUSIONS The findings of this review suggest an intervention targeting behavioural risk factors or a combination of behavioural, educational and emotional changes is effective in enhancing medication adherence. Effectiveness of an intervention may be further enhanced if patients are encouraged to participate in the development process.

Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery

BackgroundPeople who have complex health care needs frequently access emergency departments for treatment of acute illness and injury. In particular, evidence suggests that those who are homeless, or suffer mental illness, or have a history of substance misuse, are often repeat users of emergency departments. The aim of this study was to describe the socio-demographic and clinical characteristics of emergency department re-presentations. Re-presentation was defined as a return visit to the same emergency department within 28 days of discharge from hospital.MethodsA retrospective cohort study was conducted of emergency department presentations occurring over a 24-month period to an Australian inner-city hospital. Characteristics were examined for their influence on the binary outcome of re-presentation within 28 days of discharge using logistic regression with the variable patient fitted as a random effect.ResultsFrom 64,147 presentations to the emergency department the re-presentation rate was 18.0% (n = 11,559) of visits and 14.4% (5,894/40,942) of all patients. Median time to re-presentation was 6 days, with more than half occurring within one week of discharge (60.8%; n = 6,873), and more than three-quarters within two weeks (80.9%; n = 9,151). The odds of re-presentation increased three-fold for people who were homeless compared to those living in stable accommodation (adjusted OR 3.09; 95% CI, 2.83 to 3.36). Similarly, the odds of re-presentation were significantly higher for patients receiving a government pension compared to those who did not (adjusted OR 1.73; 95% CI, 1.63 to 1.84), patients who left part-way through treatment compared to those who completed treatment and were discharged home (adjusted OR 1.64; 95% CI, 1.36 to 1.99), and those discharged to a residential-care facility compared to those who were discharged home (adjusted OR 1.46: 95% CI, 1.03 to 2.06).ConclusionEmergency department re-presentation rates cluster around one week after discharge and rapidly decrease thereafter. Housing status and being a recipient of a government pension are the most significant risk factors. Early identification and appropriate referrals for those patients who are at risk of emergency department re-presentation will assist in the development of targeted strategies to improve health service delivery to this vulnerable group.

A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial

The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi‐layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex® Border Sacrum and Mepilex® Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi‐layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.