Ronan O’Sullivan

Advance care planning: A systematic review of randomised controlled trials conducted with older adults.

Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.

Drivers for inappropriate fever management in children: a systematic review

Background Fever is one of the most common childhood symptoms and accounts for numerous consultations with healthcare practitioners. It causes much anxiety amongst parents as many struggle with managing a feverish child and find it difficult to assess fever severity. Over- and under-dosing of antipyretics has been reported. Aim of the review The aim of this review was to synthesise qualitative and quantitative evidence on the knowledge, attitudes and beliefs of parents regarding fever and febrile illness in children. Method A systematic search was conducted in ten bibliographic databases from database inception to June 2014. Citation lists of studies and consultation with experts were used as secondary sources to identify further relevant studies. Titles and abstracts were screened for inclusion according to pre-defined inclusion and exclusion criteria. Quantitative studies using a questionnaire were analysed using narrative synthesis. Qualitative studies with a semi-structured interview or focus group methodology were analysed thematically. Results Of the 1565 studies which were screened for inclusion in the review, the final review comprised of 14 studies (three qualitative and 11 quantitative). Three categories emerged from the narrative synthesis of quantitative studies: (i) parental practices; (ii) knowledge; (iii) expectations and information seeking. A further three analytical themes emerged from the qualitative studies: (i) control; (ii) impact on family; (iii) experiences. Conclusion Our review identifies the multifaceted nature of the factors which impact on how parents manage fever and febrile illness in children. A coherent approach to the management of fever and febrile illness needs to be implemented so a consistent message is communicated to parents. Healthcare professionals including pharmacists regularly advise parents on fever management. Information given to parents needs to be timely, consistent and accurate so that inappropriate fever management is reduced or eliminated. This review is a necessary foundation for further research in this area.

The Community Assessment of Risk and Treatment Strategies (CARTS): An Integrated Care Pathway to Manage Frailty and Functional Decline in Community Dwelling Older Adults

The Community Assessment of Risk & Treatment Strategies (CARTS) is an evolving integrated care pathway for community-dwelling older adults, designed to screen for and prevent frailty through the use of innovative, novel targeted risk screening instruments, comprehensive geriatric assessment, tailored interventions and integrated patient-centred multi-disciplinary monitoring. This multimodal service aims to positively affect risk and frailty transitions, to reduce adverse healthcare outcomes and achieve the European Innovation Partnerships on Active and Healthy Ageing’s (EIP-AHA) goal of improved healthy life years. The CARTS programme builds on the activities and deliverables defined within Action Plan A3 of the EIP-AHA ‘Prevention and early diagnosis of frailty, both physical and cognitive, in older people’, aiming to use information and communications technology (ICT) to facilitate its implementation in clinical practice. The CARTS instruments have been piloted in Ireland as well as in Portugal, Spain and Australia. An update on the research conducted to date and future plans are presented.

The knowledge, attitudes and beliefs of carers (parents, guardians, healthcare practitioners, crèche workers) around fever and febrile illness in children aged 5 years and under: protocol for a qualitative systematic review

BackgroundMany parents consider fever a disease in itself and feel disempowered when their child is ill. Numerous guidelines have been produced; however, their target audience remains healthcare professionals and not carers of children in general. A reliable source of information will decrease worry in parents and carers when managing a febrile child.Methods/DesignA systematic search will be conducted in nine electronic databases. Articles published in English, or with an abstract published in English, will be eligible for inclusion in the review. Unpublished literature, grey literature and consultation with experts in the area will be used to supplement database searching. Titles and abstracts of studies will be screened for inclusion in the study by two independent reviewers against pre-determined inclusion and exclusion criteria. A data extraction form will be designed and data will be extracted to provide detail of the included studies by a further two reviewers. Quality assessment of studies will be conducted by two additional independent reviewers and results will be used to moderate included studies. All disagreements will be resolved through discussion until consensus is reached. Thematic synthesis will be used to analyse results.DiscussionCorrect management of fever in children is not well understood in the general population. Although carers can identify fever and febrile illness in children, determination of the severity of fever proves challenging. Research is needed to cohere existing evidence and identify knowledge gaps. It is envisaged that results of this review will contribute to the development of trustworthy, accessible guidelines for parents and carers of children with fever or febrile illness.Systematic review registrationPROSPERO CRD42014009812

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach

BackgroundEarly detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED).MethodsA novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of ‘Plan Do Study Act’ (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed.DiscussionOver 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

287Long Term Care Staff’s Educational Needs and Confidence in Providing End of Life Care Before and After an Educational Initiative

Background: Rising life expectancy, a growing older population and societal trends, have led to increasing numbers of older people residing and ultimately dying in long term care (LTC). It is essential therefore that LTC staff be knowledgeable, skilled and supported in providing high quality end of life (EoL) care. Research has found those dying in LTC have unmet palliative care needs and suboptimal palliative care education amongst LTC staff. Education is optimised if staff ’s training needs are considered. This study aimed to assess these needs and the impact of a general palliative care educational programme on staff perceptions and confidence in providing EoL care for residents in three LTC facilities. Methods: In this qualitative descriptive study, LTC staff completed detailed questionnaires before, and after delivery of a palliative care educational programme tailored to the educational needs identified by staff, which included advance care planning (ACP) training. Results: There were 179 completed questionnaires. Before the programme, up to 58% of staff had no prior palliative care training, this fell to 32% in the period after the educational initiative, which 92% of attendees found useful. There were many common learning needs for nurses and healthcare assistants (HCAs), but nurses looked more for training on pain and symptom management whilst HCAs highlighted symptom assessment, recognising dying and addressing the emotional needs of the patient. Staff who had received palliative care training (and staff overall in the “after” period) were more confident in discussing end of life issues, dealing with bereaved families and nurses were more confident and knowledgeable in using a syringe driver. Interestingly the barriers to ACP changed amongst staff engaged in the process. Delivering education was challenging due to staff turnover and difficulties releasing staff to attend. Conclusions: The tailored palliative care training was well received and had a beneficial effect.