Ruth Endacott

Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM).

ObjectivesTo define a set of indicators that could be used to improve quality in intensive care medicine.MethodologyAn European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes.ResultsA total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes.ConclusionThis document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

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.

Generic qualitative research: a design for qualitative research in emergency care?

The frequency of qualitative studies in the Emergency Medicine Journal, while still low, has increased over the last few years. All take a generic approach and rarely conform to established qualitative approaches such as phenomenology, ethnography and grounded theory. This generic approach is no doubt selected for pragmatic reasons but can be weakened by a lack of rigor and understanding of qualitative research. This paper explores qualitative approaches and then focuses on “best practice” for generic qualitative research.

Physical restraint use in intensive care units across Europe: the PRICE study.

The use of physical restraint has been linked to delirium in ICU patients and a range of physical and psychological outcomes in non-ICU patients. However, the extent of restraint practice in ICUs is largely unknown. This study was designed to examine physical restraint practices across European ICUs. A prospective point prevalence survey was conducted in adult ICUs across European countries to examine: physical and chemical restraint use during the weekend and weekdays, reasons for physical restraint use, timing of restraint use, type of restraint used and availability of restraint policies. Thirty-four general (adult) ICUs in nine countries participated in the study providing information on 669 patients with details of physical and chemical restraint use in 566 patients. Prevalence of physical restraint use in individual units ranged from 0 to 100% of patients. Thirty-three per cent of patients were physically restrained; those that were restrained were more likely to be ventilated (χ(2)=87.56, p<0.001), sedated (χ(2)34.66, p<0.001), managed in a larger unit (χ(2)=10.741, p=.005) and managed in a unit with a lower daytime nurse:patient ratio (χ(2)=17.17, p=0.001). Larger units were more likely to use commercial wrist restraints and smaller units were more likely to have a restraint policy, although these results did not reach significance. As an initial exploration, this study provides evidence of the range of restraint practice across Units in Europe. Variation in the number of units per country limits generalization of findings. However, further examination is needed to determine whether there is a causal element to these relationships. Attention should be paid to developing evidence based guidelines to underpin restraint practices.

The incidence and significance of accidental hypothermia in major trauma—A prospective observational study

BACKGROUND Serious sequelae have been associated with injured patients who are hypothermic (<35°C) including coagulopathy, acidosis, decreased myocardial contractility and risk of mortality. AIM Establish the incidence of accidental hypothermia in major trauma patients and identify causative factors. METHOD Prospective identification and subsequent review of 732 medical records of major trauma patients presenting to an Adult Major Trauma Centre was undertaken between January and December 2008. Multivariate analysis was performed using logistic regression. Significant and clinically relevant variables from univariate analysis were entered into multivariate models to evaluate determinants for hypothermia and for death. Goodness of fit was determined with the use of the Hosmer-Lemeshow statistic. MAIN RESULTS Overall mortality was 9.15%. The incidence of hypothermia was 13.25%. The mortality of patients with hypothermia was 29.9% with a threefold independent risk of death: OR (CI 95%) 3.44 (1.48-7.99), P = 0.04. Independent determinants for hypothermia were pre-hospital intubation: OR (CI 95%) 5.18 (2.77-9.71), P < 0.001, Injury Severity Score (ISS): 1.04 (1.01-1.06), P = 0.01, Arrival Systolic Blood Pressure (ASBP) < 100 mm Hg: 3.04 (1.24-7.44), P = 0.02, and winter time: 1.84 (1.06-3.21), P = 0.03. Of the 87 hypothermic patients who had repeat temperatures recorded in the Emergency Department, 77 (88.51%) patients had a temperature greater than the recorded arrival temperature. There was no change in recorded temperature for four (4.60%) patients, whereas six (6.90%) patients were colder at Emergency Department discharge. CONCLUSION Seriously injured patients with accidental hypothermia have a higher mortality independent of measured risk factors. For patients with multiple injuries a coordinated effort by paramedics, nurses and doctors is required to focus efforts toward early resolution of hypothermia aiming to achieve a temperature >35 °C.

Using portfolios in the assessment of learning and competence: the impact of four models

This paper discusses the diversity of portfolio use highlighted in a study funded by the English National Board for Nursing, Midwifery and Health Visiting exploring the effectiveness of portfolios in assessing learning and competence (). Data collection was undertaken in two stages: through a national telephone survey of Higher Education Institutions (HEIs) delivering nursing programmes (stage 1); and through four in-depth case studies of portfolios use (stage 2). Data collection for stage two was undertaken through field work in four HEIs purporting to use portfolios as an assessment strategy, and their associated clinical placement settings. Four approaches to the structure and use of portfolios were evident from the stage 2 case study data; these were characterised as: the shopping trolley; toast rack; spinal column and cake mix. The case study data also highlighted the evolutionary nature of portfolio development and a range of additional factors influencing the effectiveness of their use, including language of assessment, degree of guidance and expectations of clinical and academic staff.

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.

Impact of an ICU Liaison Nurse Service on major adverse events in patients recently discharged from ICU

AIM To identify the effect of an ICU Liaison Nurse (LN) on major adverse events in patients recently discharged from the ICU. METHODS Case-control study using a chart audit protocol to assess controls retrospectively and cases prospectively. Controls did not receive ICU-based follow-up care. Cases received at least three visits over 3 days from the ICU LN. The LN service operated 7 days/week 0800-1800. Data on a range of predictors and three major adverse events (unexpected death, surgical procedure needed, and transfer to a higher level of care) were collected using a purpose built audit form. RESULTS A total of 388 patients (201 controls and 187 cases) were included in the study. Demographic and clinical characteristics were similar for both groups. A total of 165 major adverse events were identified in 129 patients. After controlling for all other potential predictors, patients who received the LN intervention were 1.82 times more likely to be transferred to a higher level of care (P=0.028) and 2.11 times more likely to require a surgical procedure (P=0.006). Surgical patients were 7.20 times as likely to require a surgical procedure (P<0.001). CONCLUSIONS Our results support the claim that ICU LN has a role in preventing adverse events. However as the control data was retrospective and the study was conducted at one site, other unknown factors may have influenced the results.

Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial.

Objective: To evaluate whether enhanced secondary prevention more significantly influences readiness to change health behaviour after minor stroke/transient ischaemic attack, compared with conventional stroke secondary prevention. Design: Single-blind randomized control trial. Setting: Rural district general hospital outpatient clinic. Subjects: Fifteen women and 37 men with a mean age of 68.3 years with first minor stroke or transient ischaemic attack. Interventions: The intervention group received ‘enhanced secondary prevention’ (additional advice, motivational interviewing and telephone support) to change health behaviour. Both groups received ‘conventional care’ which included advice given during routine care. Main measures: The primary outcome was ‘readiness to change behaviour’ measured using a validated stroke specific score based on the transtheoretical model. Secondary outcomes were the Hospital Anxiety and Depression Scale, and self-reported alcohol consumption, smoking behaviour, exercise frequency, and fruit and vegetable consumption. Results: Analysis of the data for the 52 participants showed no statistical difference in the groups for the primary outcome of readiness to change behaviour. Statistically significant improvements for change in self-reported exercise were demonstrated (P = 0.007); to 2—3 times per week in the intervention group compared to 0—1 times per week in the control group, and in fruit and vegetable consumption (P = 0.033); to 10 portions of fruit and vegetables consumed per week in the intervention group compared to 1 or 2 portions a week for the control group. No evidence of a difference between groups was seen for alcohol consumption or Hospital Anxiety and Depression Scale. Conclusions: While no difference was demonstrated between the groups for readiness to change behaviour, a clinically significant effect in reported exercise behaviour and diet were demonstrated in the intervention group. This interesting finding indicates a dissonance between the behaviour scale and actual behaviour change, potentially indicating a lack of sensitivity of the scale to detect a change in this patient group.

Models of portfolios

The use of portfolios to assess the clinical competence of nurses, midwives, health visitors and other health care professionals is now common practice across the UK. But does a portfolio provide educators and employers with real insight into practitioners’ clinical ability or does it simply show that they are good at writing about what they do? We are carrying out a study for the English National Board for Nursing, Midwifery and Health Visiting to evaluate The use of portfolios in the assessment of learning and competence . Research has indicated that the make-up of portfolios can be very different and so far we have identified four different models of portfolio use in our case studies of nursing programmes. These are: