Frances Lin

Redesigning the ICU Nursing Discharge Process: A Quality Improvement Study

PURPOSE To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality, and ICU readmission within 72 hours. METHODS A quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, and designing a daily ICU discharge alert sheet that included an expected date of discharge. RESULTS A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention). CONCLUSIONS Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed the new process into practice.

Reducing the risk of surgical site infection using a multidisciplinary approach: an integrative review

Purpose To identify and describe the strategies and processes used by multidisciplinary teams of health care professionals to reduce surgical site infections (SSIs). Materials and methods An integrative review of the research literature was undertaken. Searches were conducted in April 2015. Following review of the included studies, data were abstracted using summary tables and the methodological quality of each study assessed using the Standards for Quality Improvement Reporting Excellence guidelines by two reviewers. Discrepancies were dealt with through consensus. Inductive content analysis was used to identify and describe the strategies/processes used by multidisciplinary health care teams to prevent SSI. Results and discussion In total, 13 studies met the inclusion criteria. Of these, 12 studies used quantitative methods, while a single study used qualitative interviews. The majority of the studies were conducted in North America. All quantitative studies evaluated multifaceted quality-improvement interventions aimed at preventing SSI in patients undergoing surgery. Across the 13 studies reviewed, the following multidisciplinary team-based approaches were enacted: using a bundled approach, sharing responsibility, and, adhering to best practice. The majority of studies described team collaborations that were circumscribed by role. None of the reviewed studies used strategies that included the input of allied health professionals or patient participation in SSI prevention. Conclusion Patient-centered interventions aimed at increasing patient participation in SSI prevention and evaluating the contributions of allied health professionals in team-based SSI prevention requires future research.

Relocating an intensive care unit: An exploratory qualitative study

BACKGROUND As new hospitals are built to replace old and ageing facilities, intensive care units are being constructed with single patient rooms rather than open plan environments. While single rooms may limit hospital infections and promote patient privacy, their effect on patient safety and work processes in the intensive care unit requires greater understanding. Strategies to manage changes to a different physical environment are also unknown. OBJECTIVES This study aimed to identify challenges and issues as perceived by staff related to relocating to a geographically and structurally new intensive care unit. METHODS This exploratory ethnographic study, underpinned by Donabedians structure, process and outcome framework, was conducted in an Australian tertiary hospital intensive care unit. A total of 55 participants including nurses, doctors, allied health professionals, and support staff participated in the study. We conducted 12 semi-structured focus group and eight individual interviews, and reviewed the hospitals documents specific to the relocation. After sorting the data deductively into structure, process and outcome domains, the data were then analysed inductively to identify themes. FINDINGS Three themes emerged: understanding of the relocation plan, preparing for the uncertainties and vulnerabilities of a new work environment, and acknowledging the need for change and engaging in the relocation process. DISCUSSION AND CONCLUSIONS A systematic change management strategy, dedicated change leadership and expertise, and an effective communication strategy are important factors to be considered in managing ICU relocation. Uncertainty and staff anxiety related to the relocation must be considered and supports put in place for a smooth transition. Work processes and model of care that are suited to the new single room environment should be developed, and patient safety issues in the single room setting should be considered and monitored. Future studies on managing multidisciplinary work processes during intensive care unit relocation will add to the learnings we report here.

Dressing and securement for central venous access devices (CVADs): a Cochrane systematic review

OBJECTIVES To compare the available dressing and securement devices for central venous access devices (CVADs). DESIGN Systematic review of randomised controlled trials. DATA SOURCES Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews and of Effects, NHS Economic Evaluation Database, Ovid MEDLINE, CINAHL, EMBASE, clinical trial registries and reference lists of identified trials. REVIEW METHODS Studies evaluated the effects of dressing and securement devices for CVADs. All types of CVADs were included. Outcome measures were CVAD-related bloodstream infection, CVAD tip colonisation, entry and exit site infection, skin colonisation, skin irritation, failed CVAD securement, dressing condition and mortality. We used standard methodological approaches as expected by The Cochrane Collaboration. RESULTS We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. It is unclear whether there is a difference in the rate of CVAD-related bloodstream infection between securement with gauze and tape and standard polyurethane (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated dressings and standard polyurethane (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93). There is moderate quality evidence that chlorhexidine gluconate-impregnated dressings reduce the frequency of CVAD-related bloodstream infection per 1000 patient days compared with standard polyurethane dressings (RR 0.51, 95% CI 0.33 to 0.78). There is moderate quality evidence that catheter tip colonisation is reduced with chlorhexidine gluconate-impregnated dressings compared with standard polyurethane dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and standard polyurethane are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). CONCLUSIONS Medication-impregnated dressing products reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types. There is some evidence that chlorhexidine gluconate-impregnated dressings, relative to standard polyurethane dressings, reduce CVAD-related bloodstream infection for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of CVAD-related bloodstream infection. Most studies were conducted in intensive care unit settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVADs.

Patient perceptions of nurse mentors facilitating the Aussie Heart Guide: A home‐based cardiac rehabilitation programme for rural patients.

To explore and describe long‐term thoughts and perceptions of the Aussie Heart Guide Programme including the role of the mentor, held by patients recovering from myocardial infarction.

Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide

BACKGROUND Peripheral intravenous catheter (PIVC) use in health care is common worldwide. Failure of PIVCs is also common, resulting in premature removal and replacement. OBJECTIVE To investigate the characteristics, management practices, and outcomes of PIVCs internationally. DESIGN SETTING/PATIENTS Cross-sectional study. Hospitalized patients from rural, regional, and metropolitan areas internationally. MEASUREMENTS Hospital, device, and inserter characteristics were collected along with assessment of the catheter insertion site. PIVC use in different geographic regions was compared. RESULTS We reviewed 40,620 PIVCs in 51 countries. PIVCs were used primarily for intravenous medication (n = 28,571, 70%) and predominantly inserted in general wards (n = 22,167, 55%). Two-thirds of all devices were placed in non-recommended sites such as the hand, wrist, or antecubital veins. Nurses inserted most PIVCs (n = 28,575, 71%); although there was wide regional variation (26% to 97%). The prevalence of iIn this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.dle PIVCs was 14% (n = 5,796). Overall, 10% (n = 4,204) of PIVCs were painful to the patient or otherwise symptomatic of phlebitis; a further 10% (n = 3,879) had signs of PIVC malfunction; and 21% of PIVC dressings were suboptimal (n = 8,507). Over one-third of PIVCs (n = 14,787, 36%) had no documented daily site assessment and half (n = 19,768, 49%) had no documented date and time of insertion. CONCLUSIONS In this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.

Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review

Effective communication among healthcare professionals in the intensive care unit (ICU) is a particular imperative, with accurate and efficient interdisciplinary communication being a critical prerequisite for high-quality care. Nurses and physicians are highly important parts of the healthcare system workforce. Thus, identifying strategies that would improve communication between these two groups can provide evidence for practical improvement in the ICU, which will ultimately improve patient outcomes. This integrative literature review aimed to identify interventions that improve communication between nurses and physicians in ICUs. Three databases (Medline, CINAHL, and Science Direct) were searched between September 2014 and June 2016 using 11 search terms, namely, nurse, doctor, physician, resident, clinician, ICU, intensive care unit, communication, teamwork, collaboration, and relationship. A manual search of the reference lists of found papers was also conducted. Eleven articles met the inclusion criteria. These studies reported on the use of communication tools/checklists, team training, multidisciplinary structured work shift evaluation, and electronic situation–background–assessment–recommendation documentation templates to improve communication. Although which intervention strategies are most effective remains unclear, this review suggests that these strategies improve communication to some extent. Future studies should be rigorously designed and outcome measures should be specific and validated to capture and reflect the effects of effective communication.

Quality appraisal of clinical guidelines for surgical site infection prevention: A systematic review

Background Surgical site infections (SSI) occur in up to 10% of surgeries. Wound care practices to prevent infections are guided by Clinical Practice Guidelines (CPGs), yet their contribution to improving patient outcomes relies on their quality and adoption in practice. We critically evaluated the quality of CPGs for SSI prevention during pre-, intra- and post-operative phases of care. Methods We systematically reviewed the literature from 1990–2018 using the Cochrane Library, CINAHL, EMBASE, MEDLINE, ProQuest databases and five guidelines repositories. We extracted characteristics of each guideline using purposely-developed data collection tools. We assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Results Combined searches of databases and repositories yielded 5,910 citations. Of these, we reviewed 215 full text documents. The final sample included 15 documents: 6 complete CPGs, 3 CPG updates, and 6 supplementary documents. The overall %mean scores across AGREE II domains for CPGs were: 1) scope and purpose (%mean ± SD = 86.3±23.5); 2) stakeholder involvement (%mean ± SD = 64±31.0); 3) rigour of development (%mean ± SD = 68.7±30.6); 4) clarity and presentation (%mean ± SD = 88.5±16.7); 5) applicability (%mean ± SD = 44±30.2); and, 5) editorial independence (%mean ± SD = 61±37.6). Based on individual AGREE II domains and overall scores, we appraised 4 out of 6 CPGs (inclusive of updates) as “recommended” for use in practice. Overall agreement among appraisers was excellent (ICC 0.86 [95%CI 0.73–0.94] - 0.98 [95%CI 0.96–0.99]; p <0.001). Discussion International interest in CPG development has resulted in refinements to methodologies, which has led to improvements in the overall quality of the product. Implications for translation Given the domains that received the lowest scores, it is clear that we need more consumer involvement and better consideration of the implementation challenges with CPG uptake and sustainability.

Development of a position statement for Australian critical care nurse education

Position statements are used by large organisations such as the Australian College of Critical Care Nurses to publically present an official philosophy or beliefs and to propose recommendations. Position statements are increasingly used by health departments and healthcare facilities to allocate resources and to guide and audit nursing practice, yet there are limited resources on the process of their development. A position statement should help readers better understand the issue, communicate solutions to problems, and inform decision-making. It should be supported by the highest level of evidence available and reflect the organisations governing objectives and goals. In this article, we describe the structured approach used to develop a position statement for Australian critical care nurse education. The formation of an expert advisory panel, synthesis of available evidence using Whittemore and Knafls integrative review methodology, use of Donabedians structure-process-outcomes quality framework as a theoretical approach, and multiple layers of consensus building and consultation enabled the development of an important critical care document and informed an implementation plan. The framework and processes we have outlined in this discussion article may provide a useful starting point for other professional organisations wishing to develop similar position statements.

Nurse mentor perceptions in the delivery of a home-based cardiac rehabilitation program to support patients living in rural areas: An interpretive study

Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with heart disease. Mentoring of patients by nurses trained in CR has been proposed as an innovative model of cardiac care. Little is known however, about the experience of mentors facilitating such programs and adapting to this new role. The aim of this qualitative study was to explore nurse mentor perceptions of their role in the delivery of a home-based CR program for rural patients unable to attend a hospital or outpatient CR program. Seven nurses mentored patients by telephone providing patients with education, psychosocial support and lifestyle advice during their recovery. An open-ended survey was administered to mentors by email and findings revealed mentors perceived their role to be integral to the success of the program. Nurses were satisfied with the development of their new role as patient mentors. They believed their collaborative skills, knowledge and experience in coronary care, timely support and guidance of patients during their recovery and use of innovative audiovisual resources improved the health outcomes of patients not able to attend traditional programs. Cardiac nurses in this study perceived that they were able to successfully transition from their normal work practices in hospital to mentoring patients in their homes.