Michelle Beattie

Silver alloy vs. uncoated urinary catheters: a systematic review of the literature

AIMS AND OBJECTIVES This systematic review aimed to determine whether there was enough evidence to conclude that silver-alloy urinary catheters reduce catheter-associated urinary tract infections compared with silicone or latex urinary catheters in adult inpatients. BACKGROUND Previous systematic reviews into the effectiveness of silver-coated urinary catheters have offered limited opportunity to transfer their findings into practice. These studies have been on North American products only, of generally poor quality, or several years since their completion (Brosnahan J, Jull A & Tracy C 2004, Cochrane Database Systematic Reviews, Issue 1, Art. No.: CD004013). Design.  A systematic review of the literature was deemed the most appropriate research method to apply as there had already been several studies (Saint S, Veenstra DL, Sullivan SD, Chenoweth C & Fendrick AM 2000, Archives of International Medicine, 160, 2670-2675; Lai KK & Fontecchio SA 2002, American Journal of Infection Control, 30, 221-225; Schaeffer AJ 2005, The Journal of Urology, 173, 845-846) relating to the subject in question, although there were some queries regarding their methodological rigour. METHODS Randomised control trials, systematic reviews and meta-analyses were identified by searching relevant databases. Relevant papers were judged against predefined inclusion and exclusion criteria. Ten per cent of papers were assessed by a second reviewer. Following the application of a numerical filtering tool, six papers were rejected and eleven papers were retained. RESULTS Of the 11 papers retained, there were eight studies, as some studies published more than one paper. The integrated results did present a consistent pattern favourable towards the efficacy of silver-alloy urinary catheters to reduce catheter-associated urinary tract infection. CONCLUSION The collective evidence divulged an emerging pattern favouring the efficacy of silver-alloy urinary catheters to reduce catheter-associated urinary tract infection. Owing to the poor quality of some individual studies included in other systematic reviews and the inability to carry out meta-analysis because of significant heterogeneity, definitive conclusions cannot be drawn from the study. RELEVANCE TO CLINICAL PRACTICE Given the significant prevalence of catheter-associated urinary tract infection, early indications of improved infection rate outcomes using silver-alloy urinary catheters should not be dismissed.

Do the Institute of Medicine’s (IOM’s) dimensions of quality capture the current meaning of quality in health care? – An integrative review

Aims: The aim of this study was to determine whether the widely adopted Institute of Medicine’s dimensions of quality capture the current meaning of quality in health care literature. Design: An integrative review was utilised as there has been a multitude of published papers defining quality in relation to health care, therefore collective analysis may provide new insight and understanding. Method: Papers offering a definition or conceptual understanding of quality in relation to health care were identified by searching relevant databases. Papers were excluded according to predefined criteria. An integrative review was conducted and the Institute of Medicine’s dimensions were used as a framework for data extraction and analysis. Findings: The review identified two important additional dimensions of quality; namely caring and navigating the health care system and argues that they require recognition as dimensions in their own right. Conclusion: In the current climate of constrained finances there is a risk that the allocation of resources is directed to current explicit dimensions to the detriment of others. The result may be a reduction in health care quality, rather than improvement.

Continual improvement in ventilator acquired pneumonia bundle compliance: A retrospective case matched review

OBJECTIVES This study aimed to describe the population of people who acquired ventilator acquired pneumonia and determine the feasibility of a larger scale study to assess the degree to which bundle compliance reduces or even eliminates, the risk of ventilator acquired pneumonia. RESEARCH METHODOLOGY/DESIGN A retrospective matched case note review was conducted to scrutinise 10 VAP cases. Cases were matched with two controls for age, gender, APACHE score and number of ventilated days. Compliance with the VAP bundle was determined by extracting data on compliance from case notes. Binary logistic regression was used to calculate odds ratios with confidence intervals which were utilised to determine numbers needed for a larger study. SETTING A general intensive care unit within a 750 bedded district general hospital, serving a population of approximately 270,000 people in Scotland. MAIN OUTCOME MEASURE The outcome variable of interest was ventilator acquired pneumonia and the independent variable was ventilator acquired pneumonia bundle compliance. RESULTS Binary logistic regression suggested that cases which did not receive the bundle reliably were more likely to develop ventilator acquired pneumonia (OR 1.33, confidence interval (CI) 0.28-6.30). Statistical results should be interpreted with caution due to the small sample size, which is demonstrated with the wide ranging confidence intervals (CIs). CONCLUSION Wide confidence intervals enable only a cursory impression as to numbers that would be required for a full scale trial. Nonetheless, the effect size indicated in this paper contributes towards consideration as to numbers needed for future studies.

Development and preliminary psychometric properties of the Care Experience Feedback Improvement Tool (CEFIT)

Objective To develop a structurally valid and reliable, yet brief measure of patient experience of hospital quality of care, the Care Experience Feedback Improvement Tool (CEFIT). Also, to examine aspects of utility of CEFIT. Background Measuring quality improvement at the clinical interface has become a necessary component of healthcare measurement and improvement plans, but the effectiveness of measuring such complexity is dependent on the purpose and utility of the instrument used. Methods CEFIT was designed from a theoretical model, derived from the literature and a content validity index (CVI) procedure. A telephone population surveyed 802 eligible participants (healthcare experience within the previous 12 months) to complete CEFIT. Internal consistency reliability was tested using Cronbachs α. Principal component analysis was conducted to examine the factor structure and determine structural validity. Quality criteria were applied to judge aspects of utility. Results CVI found a statistically significant proportion of agreement between patient and practitioner experts for CEFIT construction. 802 eligible participants answered the CEFIT questions. Cronbachs α coefficient for internal consistency indicated high reliability (0.78). Interitem (question) total correlations (0.28–0.73) were used to establish the final instrument. Principal component analysis identified one factor accounting for 57.3% variance. Quality critique rated CEFIT as fair for content validity, excellent for structural validity, good for cost, poor for acceptability and good for educational impact. Conclusions CEFIT offers a brief yet structurally sound measure of patient experience of quality of care. The briefness of the 5-item instrument arguably offers high utility in practice. Further studies are needed to explore the utility of CEFIT to provide a robust basis for feedback to local clinical teams and drive quality improvement in the provision of care experience for patients. Further development of aspects of utility is also required.

Quality and safety in nurse education: are we in a state of readiness?

Internationally, improving the quality of health care remains challenging (Scottish Government, 2010; Department of Health, 2008; Institute of Medicine, 2001). Despite significant advances in evidence-based healthcare, patients are often in receipt of poor care. The evidence base suggests that 1 in 10 patients admitted to NHS hospitals will be unintentionally harmed and that around 50% of these events could have been avoided if lessons from previous incidents had been learned (National Audit Office, 2005). Patient safety incidents cost the NHS in the UK an estimated £2 billion a year in extra bed days alone (National Audit Office, 2005). Despite our best efforts, patient harm from healthcare has remained relatively common with little evidence of improvement over the last 10 years (Landrigan et al., 2010). A renewed focus to translate effective safety interventions into routine clinical practice, coupled with the monitoring of healthcare safety over time, has resulted in the emergence of Quality Improvement (QI). Batalden and Davidoff (2007, p2) defined QI as “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – tomake the changes thatwill lead to better patient outcomes (health), better systemperformance (care) and better professional development.” This focus onquality and safety aims to increase the reliability of optimum healthcare—ensuring the right care for the right patient, every time. Froman educational perspective, thismay sound intuitive, however, once translated into practice, it becomes increasingly complex. There is much that can be done to address the complexity of practice and create consistent high‐quality healthcare systems, or as James Reason (2000) termed ‘high reliability organisations.’ There are significant projects ongoing to improve quality and safety of healthcare across the world, from local quality improvement initiatives to breakthrough series collaboratives involving whole nations (e.g., Scottish Patient Safety Programme). Many of these initiatives are designed and delivered using various QI tools and techniques, such as the Model for Improvement, LEAN, Process Mapping, and driver diagrams amongst others. Importantly, they also require a different approach to doing things—a shift in culture. Don Berwick, the former President and CEO of the Institute for Healthcare Improvement (IHI), remarked that all healthcare professionals have two jobs to do—firstly to deliver the best care they can, and secondly, to constantly improve the care they deliver. Language contributes to this cultural transformation and subsequently new terminology has also emerged, namely ‘testing,’ ‘implementation,’ ‘spread,’ ‘checklists,’ ‘bundles’ and ‘briefs.’ Yet, many of these tools, techniques and even language have yet to find their way into nurse education. Old approaches to risk management, clinical audit and change management will not provide nurses with the necessary skills and knowledge needed for healthcare now, nor in the future. Recent curriculum plans to address these

“I know exactly what I'm going into”: recommendations for pre-nursing experience from an evaluation of a pre-nursing scholarship in rural Scotland.

To develop a model of pre‐nursing experience from evaluation of a pre‐nursing scholarship for school pupils in Scotland.

Improving wait time from referral to opiate replacement therapy in a drug recovery service

While the reported incidence of heroin use in the UK has reduced, related hospital admissions and associated mortality have continued to increase. Prompt access to treatment (opiate replacement therapy (ORT) and counselling support) have been shown to reduce risk and offer clients the optimal route to recovery. The Specialist Drug and Alcohol Recovery Service (Osprey House) within National Health Service Highland had lengthy delays from referral to commencing ORT (median wait 56 days), which this project aimed to reduce. A rapid process improvement workshop (RPIW) was undertaken to redesign the patient pathway from referral to recovery. The RPIW consisted of three phases: phase I, planning and preparation (12 weeks before the workshop week); phase II, the workshop week; and phase III, the follow-up. Metrics included the lead time from referral to initiating ORT and other process measures at baseline, and then repeated at 30, 60, 90 and 180 days, respectively. Additionally, data were routinely collected on the percentage of clients treated within 3 weeks, as was weekly data on the new process of screening clients within 1 day of referral. Multiple lean tools and techniques, including Plan, Do, Study, Act cycles, were used to test and implement new ways of working. Results at 180 days found the median time from referral to initiating ORT improved from a baseline of 56 to 21 days (63% improvement), room usage improved from 49% to 65% (32% increase) and standard work improved from level 1 to level 3. Increases in the number of clients treated within 3 weeks were demonstrated. Other metrics remained static or reported fluctuations too inconsistent to claim improvement at this point. By applying the Lean principles of removing waste and increasing value, we have redesigned our service, reducing the length of time clients with drug problems wait from referral to commencing ORT.

Implementing a non-steroidal anti-inflammatory drugs communication bundle in remote and rural pharmacies and dispensing practices

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with more emergency hospital admissions due to adverse drug reactions than any other class of medicine. One way to tackle this is to ensure that patients understand how to take their NSAIDs in the safest way possible. The aim of this project was to ensure that key safety information is given to every patient, every time an NSAID is sold or dispensed. The project started as part of the Scottish Patient Safety Programme’s Pharmacy in Primary Care Collaborative. An NSAIDs bundle was developed, tested and implemented using the Model for Improvement as a framework, including multiple Plan, Do, Study, Act cycles. The bundle, and associated improvement package, was developed during phase I of the project and tested by seven teams (five pharmacies and two dispensing practices). Phase II tested the spread of the defined improvement package across an additional five community pharmacies and eight dispensing general practitioner practices. The project has resulted in the development of a simple package to improve communication with patients about NSAIDs, which should enable patients to take NSAIDs safely. Three key safety messages were developed, typical for a care bundle approach, and simple tools were employed to ensure every patient received these three key messages every time. The project aim of 95% compliance with the NSAIDs bundle within the seven initial sites by December 2015 was achieved (when an exclusion was applied). The spread of the defined improvement package to a further 13 sites was achieved by December 2016. By December 2017, all 81 community pharmacies in National Health Service (NHS) Highland had agreed to implement the NSAIDs bundle. In June 2018, a national NSAIDs bundle, based on the NHS Highland work, was introduced in community pharmacies across Scotland. We also believe that the approach could be replicated for other high-risk medicines.

Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit

Managing pain is challenging in the intensive care unit (ICU) as often patients are unable to self-report due to the effects of sedation required for mechanical ventilation. Minimal sedative use and the utilisation of analgesia-first approaches are advocated as best practice to reduce unwanted effects of oversedation and poorly managed pain. Despite evidence-based recommendations, behavioural pain assessment tools are not readily implemented in many critical care units. A local telephone audit conducted in April 2017 found that only 30% of Scottish ICUs are using these validated pain instruments. The intensive care unit (ICU) at Raigmore Hospital, NHS Highland, initiated a quality improvement (QI) project using the Model for Improvement (MFI) to implement an analgesia-first approach utilising a validated and reliable behavioural pain assessment tool, namely the Critical-Care Pain Observation Tool (CPOT). Over a six-month period, the project deployed QI tools and techniques to test and implement the CPOT. The process measures related to (i) the nursing staff’s reliability to assess and document pain scores at least every four hours and (ii) to treat behavioural signs of pain or CPOT scores ≥ 3 with a rescue bolus of opioid analgesia. The findings from this project confirm that the observed trends in both process measures had reduced over time. Four hourly assessments of pain had increased to 89% and the treatment of CPOT scores ≥3 had increased to 100%.

Systematic reviews: inducting research students into scholarly conversations?

Systematic reviews: inducting research students into scholarly conversations? Janni Leung, Alize Ferrari, Amanda Baxter, Mariyana Schoultz, Michelle Beattie and Meredith Harris School of Public Health, The University of Queensland, Herston, QLD, Australia; Policy and Epidemiology Group, Queensland Centre of Mental Health Research, QLD, Australia; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; School of Health Sciences, University of Stirling, Stirling, UK