Kathryn Zeitz

What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing

AIM To identify the common, core elements of patient-centred care in the health policy, medical and nursing literature. BACKGROUND Healthcare reform is being driven by the rhetoric around patient-centred care yet no common definition exists and few integrated reviews undertaken. DESIGN Narrative review and synthesis. DATA SOURCES Key seminal texts and papers from patient organizations, policy documents, and medical and nursing studies which looked at patient-centred care in the acute care setting. Search sources included Medline, CINHAL, SCOPUS, and primary policy documents and texts covering the period from 1990-March 2010. REVIEW METHODS A narrative review and synthesis was undertaken including empirical, descriptive, and discursive papers. Initially, generic search terms were used to capture relevant literature; the selection process was narrowed to seminal texts (Stage 1 of the review) and papers from three key areas (in Stage 2). RESULTS In total, 60 papers were included in the review and synthesis. Seven were from health policy, 22 from medicine, and 31 from nursing literature. Few common definitions were found across the literature. Three core themes, however, were identified: patient participation and involvement, the relationship between the patient and the healthcare professional, and the context where care is delivered. CONCLUSION Three core themes describing patient-centred care have emerged from the health policy, medical, and nursing literature. This may indicate a common conceptual source. Different professional groups tend to focus on or emphasize different elements within the themes. This may affect the success of implementing patient-centred care in practice.

Forecasting medical work at mass-gathering events: predictive model versus retrospective review

INTRODUCTION Mass-gathering events are dynamic and challenge traditional medical management systems. To improve the system for the provision of first aid at mass-gathering events, an evaluation of two models that assist in forecasting the number of patients presenting for first-aid services was conducted. METHOD A prospective evaluation of a recurrent, mass-gathering event was undertaken comparing predicted patient presentations and ambulance transfers generated by a predictive model developed by Arbon et al and a retrospective review of seven years of historical, event data as described by Zeitz et al. RESULTS Patient presentation rate (per 1,000 patrons) for this event was 1.6 and the transport to hospital rate (per 1,000 patrons) was 0.07. The retrospective review closely predicted the actual overall attendance. Both methods forecast the number of patients presenting on a daily basis. The prediction proved to be more accurate, on a day-by-day basis, using the Zeitz method. CONCLUSION The Arbon method is particularly useful for events where there is no or limited information about previous medical work. Retrospective review of data generated from specific events (Zeitz method) considers the unique and individual variability that can occur from event to event and is more accurate at predicting patient presentations when the data are available. Both methods have the potential to be used more frequently to adequately and efficiently plan for the resources required for specific events.

Improving the fundamentals of care for older people in the acute hospital setting: facilitating practice improvement using a Knowledge Translation Toolkit

This paper reports on a structured facilitation program where seven interdisciplinary teams conducted projects aimed at improving the care of the older person in the acute sector. Aims  To develop and implement a structured intervention known as the Knowledge Translation (KT) Toolkit to improve the fundamentals of care for the older person in the acute care sector. Three hypotheses were tested: (i) frontline staff can be facilitated to use existing quality improvement tools and techniques and other resources (the KT Toolkit) in order to improve care of older people in the acute hospital setting; (ii) fundamental aspects of care for older people in the acute hospital setting can be improved through the introduction and use of specific evidence-based guidelines by frontline staff; and (iii) innovations can be introduced and improvements made to care within a 12-month cycle/timeframe with appropriate facilitation. Methods  Using realistic evaluation methodology the impact of a structured facilitation program (the KT Toolkit) was assessed with the aim of providing a deeper understanding of how a range of tools, techniques and strategies may be used by clinicians to improve care. The intervention comprised three elements: the facilitation team recruited for specific knowledge, skills and expertise in KT, evidence-based practice and quality and safety; the facilitation, including a structured program of education, ongoing support and communication; and finally the components of the toolkit including elements already used within the study organisation. Results  Small improvements in care were shown. The results for the individual projects varied from clarifying issues of concern and planning ongoing activities, to changing existing practices, to improving actual patient outcomes such as reducing functional decline. More importantly the study described how teams of clinicians can be facilitated using a structured program to conduct practice improvement activities with sufficient flexibility to meet the individual needs of the teams. Conclusions  The range of tools in the KT Toolkit were found to be helpful, but not all tools needed to be used to achieve successful results. Facilitation of the teams was a central feature of the KT Toolkit and allowed clinicians to retain control of their projects; however, finding the balance between structuring the process and enabling teams to maintain ownership and control was an ongoing challenge. Clinicians may not have the requisite skills and experience in basic standard setting, audit and evaluation and it was therefore important to address this throughout the project. In time this builds capacity throughout the organisation. Identifying evidence to support practice is a challenge to clinicians. Evidence-based guidelines often lack specificity and were found to be difficult to assimilate easily into everyday practice. Evidence to inform practice needs to be provided in a variety of forms and formats that allow clinicians to easily identify the source of the evidence and then develop local standards specific to their needs. The work that began with this project will continue - all teams felt that the work was only starting rather than concluding. This created momentum, motivation and greater ownership of improvements at local level.

Policies that drive the nursing practice of postoperative observations

Postoperative nursing care traditionally has involved the utilisation of regulated, routine patient observation to monitor patient progress. This study was designed to review the policy/procedure documentation that drives this practice and to determine who contributes to policy development. In all, 75 surgical hospitals were surveyed, producing 47 procedures for content analysis. Findings suggest that there is a great diversity in procedures between organisations. The most common pattern of postoperative vital sign collection is hourly for 4 h and then 4 hourly in 27% of the regimes. On average a patient receives 10 sets of observation in the first 24 h, with neurovascular, wound and drain checks the most frequent observations collected in addition to vital signs.

Assessing the psychosocial elements of crowds at mass gatherings.

INTRODUCTION The environmental aspects of mass gatherings that can affect the health and safety of the crowd have been well described. Although it has been recognized that the nature of the crowd will directly impact the health and safety of the crowd, the majority of research focuses on crowd behavior in a negative context such as violence or conflict. Within the mass gathering literature, there is no agreement on what crowd behavior, crowd mood and crowd type actually mean. At the same time, these elements have a number of applications, including event management and mass gathering medicine. These questions are worthy of exploration. METHODS This paper will report on a pilot project undertaken to evaluate how effective current crowd assessment tools are in understanding the psychosocial domain of a mass gathering event. RESULTS The pilot project highlighted the need for a more consistent descriptive data set that focuses on crowd behavior. CONCLUSIONS The descriptive data collected in this study provide a beginning insight into the science of understanding crowds at a mass gathering event. This pilot has commenced a process of quantifying the psychosocial nature of an event. To maximize the value of this work, future research is required to understand the interplay among the three domains of mass gatherings (physical, environmental and psychological), along with the effects of each element within the domains on safety and health outcomes for participants at mass gatherings.

The reality of multiple casualty triage: putting triage theory into practice at the scene of multiple casualty vehicular accidents

Objectives: The project investigated the experiences of ambulance paramedics in applying the principles and protocols of prehospital multiple casualty triage at the scene of motor vehicle accidents. Key objectives included investigation of the situational cues and other contextual factors influencing triage practice and the development of recommendations for the future education of ambulance paramedics. Methods: A triangulated approach was used incorporating demographic data, the use of focus groups and in-depth interviews. A thematic analysis was undertaken following the well established practices of human science research. Results and conclusions: The research describes an extended and broadened triage process returning to a more authentic definition of triage as the practice of sorting of casualties to determine priority. The findings highlight the need to consider triage as an extended and complex process that incorporates evidence based physiological cues to assist decision making and the management of the process of triage from call out to conclusion including assessment of contextual and situational variables.

Tradition, rituals and standards, in a realm of evidenced based nursing care

Abstract Evidenced-based nursing is seen as the future of nursing but the real world in which practice occurs is limiting the possibilities for change. The practice of post-operative (PO) vital sign collection in the general ward setting is described as an example of the complexities that surround practice. Despite the ongoing work around evidenced-based practice, elements of nursing practice remain based on tradition. Routines and rituals are driving care rather than clinical judgement. The complexities of practice limit the possibilities for change. These complexities include the systems in which nurses’ practice, the fear of medico-legal repercussions, and the sense of security that rituals provide. This paper discusses these themes including the barriers to change and the implications for practice. The development of evidenced-based practice is only one component of the solution to the provision of best practice. Care is required to ensure that the evidenced-based movement does not lead to recipe book care rather than patient centred practice.

Does hospital occupancy impact discharge rates

OBJECTIVE To understand what impact hospital inpatient occupancy levels have on patient throughput by analysing one hospitals occupancy levels and the rate of patient discharge. METHODS A four-stage model was fit to hospital admission and separation data and used to analyse the per-capita separation rate according to the patient load and the impact of hospital over-census actions. RESULTS Per-capita separation rates are significantly higher on days when the hospital declares an over-census due to emergency department crowding. Per-capita separation rates are also higher or lower on days with 8-10% higher or lower patient loads, respectively, but the response is not nearly as strong as the response to an over-census declaration, and is limited to patients with an elapsed stay of 10 days or more. Within the medical division there is an increase in per-capita separation rates on over-census days, but no significant difference in per-capita release rates for different patient loads. Within the surgical division there is no significant difference in per-capita separation rates on over-census days compared with other days, but the patient load does make a significant difference. CONCLUSION Staff do discharge a greater proportion of long-stay patients when the hospital is experiencing high demand and a lower proportion when occupancy is low, but the reasons driving those changes remains unclear.

Out-of-hospital cardiac arrest-review of demographics in South Australia to inform decisions about the provision of automatic external defibrillators within the community.

INTRODUCTION Sudden, out-of-hospital cardiac arrest (OHCA) has an annual incidence of approximately 50 per 100,000 population. Public access defibrillation is seen as one of the key strategies in the chain-of-survival for OHCA. Positioning of these devices is important for the maximization of public health outcomes. The literature strongly advocates widespread public access to automated external defibrillatiors (AEDs). The most efficient placement of AEDs within individual communities remains unclear. METHODS A retrospective case review of OHCAs attended by the South Australia Ambulance Service in metropolitan and rural South Australia over a 30-month period was performed. Data were analyzed using Utstein-type indicators. Detailed demographics, summative data, and clinical data were recorded. RESULTS A total of 1,305 cases of cardiac arrest were reviewed. The annual rate of OHCA was 35 per 100,000 population. Of the cases, the mean value for the ages was 66.3 years, 517 (39.6%) were transported to hospital, 761 (58.3%) were judged by the paramedic to be cardiac, and 838 (64.2%) were witnessed. Bystander cardiopulmonary resuscitation (CPR) was performed in 495 (37.9%) of cases. The rhythm on arrival was ventricular fibrillation (VF) or ventricular tachycardia (VT) in 419 (32.1%) cases, and 315 (24.1%) of all arrests had return of spontaneous circulation (ROSC) before or on arrival at the hospital. For cardiac arrest cases that were witnessed by the ambulance service (n=121), the incidence of ROSC was 47.1%. During the 30-month period, there only was one location that recorded more than one cardiac arrest. No other location recorded recurrent episodes. CONCLUSIONS This study did not identify any specific location that would justify defibrillator placement over any other location without an existing defibrillator. The impact of bystander CPR and the relatively low rate of bystander CPR in this study points to an area of need. The relative potential impact of increasing bystander CPR rates versus investing in defibrillators in the community is worthy of further consideration.

The ebbs and flows of changing acute bed capacity delays

OBJECTIVE This case study provides a summary of changes in acute hospital bed delays that have occurred over a 4-year period as identified through a Capacity Audit process. BACKGROUND Royal Adelaide Hospital (RAH) designed a Capacity Audit process and tool that provides a systematic method to evaluate factors limiting access to inpatient bed capacity. The aim of the audit is to improve understanding of bed capacity by identifying key causes of delay for hospital inpatients and quantify the most frequent causes of blocked bed capacity. This can then be used to underpin targeted improvement work. The Capacity Audit has been undertaken at the RAH over three cycles. METHOD The Capacity Audit involves a survey of every open and staffed bed, identifying how the bed is being used: for acute care or treatment, if there was a delay to the patient for discharge, or if the bed was unavailable. The first and second cycle of the audit (2007-2008) involved a twice-daily survey over a 2-week period and the third audit cycle in 2010 occurred once daily for 1 week. RESULTS On average, 620 beds were surveyed daily with an audit compliance rate ranging from 85-97%. This process has revealed almost 75% of beds are used positively for care. Of the remaining 25% of hidden capacity identified, non-clinical discharge delays account for 10% of total beds surveyed. Waiting for post-acute beds has consistently remained the main cause of acute bed delay. CONCLUSION The Capacity Audit process and tool has been used to track progress, trends and change resulting from service improvement efforts, and to provide the evidence to commence strategies to reduce the hidden capacity issues. This case study has shown that whilst overall bed stock usage for positive care has not changed significantly there are various ebbs and flows over time in relation to the reasons for bed delays.