Leigh Kinsman

FIRST2ACT: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education.

Delayed assessment and mismanagement of patient deterioration is a substantial problem for which educational preparation can have an impact. This paper describes the development of the FIRST(2)ACT simulation model based on well-established theory and contemporary empirical evidence. The model combines evidence-based elements of assessment, simulation, self-review and expert feedback, and has been tested in undergraduate nurses, student midwives and post-registration nurses. Participant evaluations indicated a high degree of satisfaction and substantial self-rated increases in knowledge, confidence and competence. This evidence-based model should be considered for both undergraduate and post-registration education programs.

The Effects of Clinical Pathways on Professional Practice, Patient Outcomes, Length of Stay, and Hospital Costs: Cochrane Systematic Review and Meta-Analysis

This paper is a summary version of the previously published Cochrane review. It may increase the reach of the topic to health researchers and practitioners and encourage further discussion. The systematic review aims to summarize the evidence and assess the effect of clinical pathways on professional practice, patient outcomes, length of hospital stay, and hospital costs. The authors searched the Database of Abstracts of Reviews of Effectiveness, the Effective Practice and Organisation of Care Register, the Cochrane Central Register of Controlled Trials and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED, and Global Health. Twenty-seven studies considering a total of 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications (odds ratio 0.58: 95% CI [0.36, 0.94] and improved documentation (odds ratio 11.95: 95% CI [4.72, 30.30]) associated with clinical pathways. Considerable variation in study design and settings prevented statistical pooling of results for length of stay (LOS) and hospital costs. The authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation.

Forecasting Emergency Department presentations

OBJECTIVE To forecast the number of patients who will present each month at the emergency department of a hospital in regional Victoria. METHODS The data on which the forecasts are based are the number of presentations in the emergency department for each month from 2000 to 2005. The statistical forecasting methods used are exponential smoothing and Box-Jenkins methods as implemented in the software package SPSS version 14.0 (SPSS Inc, Chicago, Ill, USA). RESULTS For the particular time series, of the available models, a simple seasonal exponential smoothing model provides optimal forecasting performance. Forecasts for the first five months in 2006 compare well with the observed attendance data. CONCLUSIONS Time series analysis is shown to provide a useful, readily available tool for predicting emergency department demand. The approach and lessons from this experience may assist other hospitals and emergency departments to conduct their own analysis to aid planning.

Managing Deteriorating Patients: Registered Nurses’ Performance in a Simulated Setting

Aim: To examine, in a simulated environment, rural nurses’ ability to assess and manage patient deterioration using measures of knowledge, situation awareness and skill performance. Background: Nurses’ ability to manage deterioration and ‘failure to rescue’ are of significant concern with questions over knowledge and clinical skills. Simulated emergencies may help to identify and develop core skills. Methods: An exploratory quantitative performance review. Thirty five nurses from a single ward completed a knowledge questionnaire and two video recorded simulated scenarios in a rural hospital setting. Patient actors simulated deteriorating patients with an Acute Myocardial Infarction (AMI) and Chronic Obstructive Pulmonary Disease (COPD) as the primary diagnosis. How aware individuals were of the situation (levels of situation awareness) were measured at the end of each scenario. Results: Knowledge of deterioration management varied considerably (range: 27%-91%) with a mean score of 67%. Average situation awareness scores and skill scores across the two scenarios (AMI and COPD) were low (50%) with many important observations and actions missed. Participants did identify that ‘patients’ were deteriorating but as each patient deteriorated staff performance declined with a reduction in all observational records and actions. In many cases, performance decrements appeared to be related to high anxiety levels. Participants tended to focus on single signs and symptoms and failed to use a systematic approach to patient assessment. Conclusion: Knowledge and skills were generally low in this rural hospital sample with notable performance decrements as patients acutely declined. Educational models that incorporate high fidelity simulation and feedback techniques are likely to have a significant positive impact on performance.

The FIRST2ACT simulation program improves nursing practice in a rural Australian hospital

OBJECTIVE To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST(2) ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital. DESIGN Interrupted time series analysis. SETTING A rural Australian hospital. PARTICIPANTS All registered nurses (Division 1) employed on an acute medical/surgical ward. INTERVENTION The FIRST(2) ACT simulation program. OUTCOME MEASURES Appropriate frequency of a range of observations and administration of oxygen therapy. RESULTS Thirty-four nurses participated (83% of eligible nurses) in the FIRST(2) ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis. CONCLUSION FIRST(2) ACT was associated with measurable improvements in nursing practice.

Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol).

BackgroundLean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer’s needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited.MethodsThis is a protocol for a systematic review, following the Cochrane Effective Practice and Organisation of Care (EPOC) methodology. The review aims to document, catalogue and synthesize the existing literature on the effects of lean implementation in health care settings especially the potential effects on professional practice and health care outcomes. We have developed a Medline keyword search strategy, and this focused strategy will be translated into other databases. All search strategies will be provided in the review. The method proposed by the Cochrane EPOC group regarding randomized study designs, non-randomised controlled trials controlled before and after studies and interrupted time series will be followed. In addition, we will also include cohort, case–control studies, and relevant non-comparative publications such as case reports. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the reported types of implementation in the primary studies. We will present the results of studies in a tabular form.DiscussionOverall, the systematic review aims to identify, assess and synthesize the evidence to underpin the implementation of lean activities in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and implementation methodologies reported in health care.Systematic review registrationPROSPERO CRD42014008853

Mapping patient flow in a regional Australian emergency department: A model driven approach

Unified Modelling Language (UML) models of the patient journey in a regional Australian emergency department (ED) were used to develop an accurate, complete representation of ED processes and drive the collection of comprehensive quantitative and qualitative service delivery and patient treatment data as an evidence base for hospital service planning. The focus was to identify bottle-necks that contribute to over-crowding. Data was collected entirely independently of the routine hospital data collection system. The greatest source of delay in patient flow was the waiting time from a bed request to exit from the ED for hospital admission. It represented 61% of the time that these patients occupied ED cubicles. The physical layout of the triage area was identified as counterproductive to efficient triaging, and the results of investigations were often observed to be available for some time before clinical staff became aware. The use of independent primary data to construct UML models of the patient journey was effective in identifying sources of delay in patient flow, and aspects of ED activity that could be improved. The findings contributed to recent department re-design and informed an initiative to develop a business intelligence system for predicting impending occurrence of access block.

‘Making evidence count’: A framework to monitor the impact of health services research

OBJECTIVES The objective of this study is to develop a framework to measure the impact of primary health care research, describe how it could be used and propose a method for its validation. DESIGN Literature review and critical appraisal of existing models of research impact, and integration of three into a comprehensive impact framework. SETTING Centre of Research Excellence focusing on access to primary health care services in Australia. PARTICIPANTS Not applicable. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The Health Services Research Impact Framework, integrating the strengths of three existing models of research impact. CONCLUSION In order to ensure relevance to policy and practice and to provide accountability for funding, it is essential that the impact of health services research is measured and monitored over time. Our framework draws upon previously published literature regarding specific measures of research impact. We organise this information according to the main area of impact (i.e. research related, policy, service and societal) and whether the impact originated with the researcher (i.e. producer push) or the end-user (i.e. user pull). We propose to test the utility of the framework by recording and monitoring the impact of our own research and that of other groups of primary health care researchers.

An interdisciplinary, evidence-based process of clinical pathway implementation increases pathway usage.

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.

Managing patient deterioration: a protocol for enhancing undergraduate nursing students' competence through web-based simulation and feedback techniques

AimsTo describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.BackgroundThere are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.Design/MethodsA mixed methods triangulated convergent design.In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.ConclusionThis project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.