Tim Schultz

Failures in transition: learning from incidents relating to clinical handover in acute care.

&NA; The appropriate handover of patients, whereby responsibility and accountability of care is transferred between healthcare providers, is a critical component of quality healthcare delivery. This paper examines data from recent incidents relating to clinical handover in acute care settings, in order to provide a basis for the design and implementation of preventive and corrective strategies. A sample of incidents (n = 459) relating to clinical handover was extracted from an Australian health services incident reporting system using a manual search function. Incident narratives were subjected to classification according to the system safety and quality concepts of failure type, error type, and failure detection mechanism. The most prevalent failure types associated with clinical handover were those relating to the transfer of patients without adequate handover 28.8% (n = 132), omissions of critical information about the patients condition 19.2% (n = 88), and omissions of critical information about the patients care plan during the handover process 14.2% (n = 65). The most prevalent failure detection mechanisms were those of expectation mismatch 35.7% (n = 174), clinical mismatch 26.9% (n = 127), and mismatch with other documentation 24.0% (n = 117). The findings suggest the need for a structured approach to handover with a recording of standardized sets of information to ensure that critical components are not omitted. Limitations of existing reporting processes are also highlighted.

Nurse-led clinics as an effective service for cardiac patients: results from a systematic review.

AIM The article summarises results of a systematic review on the effectiveness of nurse-led clinics for patients with coronary heart disease. The objective was to present the best available evidence related to effective interventions in nurse-led cardiac clinics including patient education, risk factor assessment and continuity of care. METHODS Following the principles of the Cochrane Collaboration for systematic reviews on effectiveness, this is an update to a previously published review. Thirty databases, relevant journals and hand searching of reference lists were the basis for a comprehensive literature search for the period September 2002 to March 2008. Assessment of methodological quality, data extraction and synthesis was undertaken using a systematic review management tool (JBI-SUMARI). When possible, data was pooled in a meta-analysis. RESULTS The systematic review is based on seven randomised controlled trials. Inconsistencies of interventions executed in nurse-led clinics and various effects on the outcomes make a comparison difficult. The major nurse-led intervention applied in the clinics consisted of health education, counselling behaviour change and promotion of a healthy lifestyle. There were no harmful effects on patients with coronary heart disease identified when exposed to a nurse-led clinic. A few risk factors were significantly reduced in the short term by attending nurse-led clinics, but long-term changes were less apparent. The success of modifying behaviour such as smoking cessation and diet adherence was limited. However, nurse-led clinics may positively influence perceived quality of life and general health status. CONCLUSION The results indicated that care was equivalent to non-nurse-managed clinics, and there was no greater risk of poorer outcomes in the nurse-led clinics. The effectiveness of clinics might be dependent on the intensity of the nursing support. Before establishing a nurse-led clinic appropriate qualification and responsibilities, as well as the particular structure of the healthcare system and funding possibilities have to be considered. The combination of counselling and regular assessment of risk factors and health status delivered at nurse-led clinics is supported by the available research, and given that outcomes were in general equivalent between nurse-led and other clinics, further research should investigate the cost-effectiveness of the different models of care.

Energetic consequences of metabolic depression in tropical and temperate-zone lizards

One response of ectothermic animals to periods of inactivity is inverse acclimation, or metabolic depression, which results in the conservation of energy. Most studies of metabolic depression and acclimation have involved temperate-zone species, and the information from tropical species has been largely restricted to laboratory studies that failed to demonstrate thermal acclimation of metabolism. Recently, metabolic depression has been shown in several species of reptiles from the wet-dry tropics of northern Australia during the dry season. We review existing data on the energy budgets of temperate and tropical species during periods of inactivity and make calculations of energy saved due to metabolic depression across a range of temperatures. Because tropical species experience relatively high temperatures during periods of inactivity, they have a greater potential for energy savings, any enhancement of their metabolic depression is disproportionately advantageous with respect to energy savings, and in some species metabolic depression is probably essential for survival. Thus, we would expect metabolic depression to be well developed in some tropical reptiles. The lack of thermal acclimation in laboratory studies indicates that environmental parameters other than temperature (such as food or water) may initiate metabolic depression in tropical species. Higher temperatures, however, magnify the energy savings accomplished by metabolic depression.

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

OBJECTIVE To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. METHODS 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. RESULTS Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). CONCLUSION The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings. ADVANCES IN KNOWLEDGE Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

Establishing National Medical Imaging Incident Reporting Systems: Issues and Challenges

Radiology incident reporting systems provide one source of invaluable patient safety data that, when combined with appropriate analysis and action, can result in significantly safer health care, which is now an urgent priority for governments worldwide. Such systems require integration into a wider safety, quality, and risk management framework because many issues have global implications, and they also require an international classification scheme, which is now being developed. These systems can be used to inform global research activities as identified by the World Health Organization, many of which intersect with the activities of and issues seen in medical imaging departments. How to ensure that radiologists (and doctors in general) report incidents, and are engaged in the process, is a challenge. However, as demonstrated with the example of the Australian Radiology Events Register, this can be achieved when the reporting system is integrated with their professional organization and its other related activities (such as training and education) and administered by a patient safety organization.

The Physiological Cost of Pregnancy in a Tropical Viviparous Snake

Abstract During pregnancy, the metabolic rate of females may increase above basal levels to support metabolically active tissues and developing embryos. In mammals, this energetic cost of supporting the pregnancy (MCP) is an important component of reproductive effort, but less is known about the magnitude of this cost in ectothermic vertebrates. We estimated the metabolic cost of supporting pregnancy in a tropical viviparous snake, the Northern Death Adder, Acanthophis praelongus. We measured the metabolic rates of non-gravid and gravid females throughout gestation and following parturition. We also measured the oxygen consumption of a sample of neonates from each clutch within 24 h of birth. The metabolic rate of gravid females rose slowly during pregnancy, but was significantly elevated during the last three weeks of gestation. Considering the late term metabolism of gravid females as 100%, then the baseline metabolism of female Death Adders represented 36.6%, embryo metabolism accounted for 37.0%, and the cost of supporting the pregnancy was 26.4% of the total metabolic rate. Neonate metabolism during the first 24 h of birth was 2.9 times higher than the estimate for embryo metabolism. Thus, our results do not support the assumption that the metabolism of embryos (prior to birth) and neonates is similar in this species. Although gravid female Death Adders maintain high and constant body temperatures during late gestation, the energetic cost of supporting the pregnancy is only a minor component of the total reproductive effort for females of this species.

Effects of Seasonal Variation in Prey Abundance on Field Metabolism, Water Flux, and Activity of a Tropical Ambush Foraging Snake

The responses of animals to seasonal food shortages can have important consequences for population dynamics and the structure and function of food webs. We investigated how an ambush foraging snake, the northern death adder Acanthophis praelongus, responds to seasonal fluctuations in prey availability in its tropical environment. In the dry season, field metabolic rates and water flux, as measured by doubly labeled water, were significantly lower than in the wet season. Unlike some other reptiles of the wet‐dry tropics, death adders showed no seasonal difference in their resting metabolism. About 94% of the decrease in energy expended in the dry season was due to a decrease in activity and digestion, with lower body temperatures accounting for the remainder. In the dry season, death adders were less active and moved shorter distances between foraging sites than in the wet season. Analysis of energy expenditure suggested that adders fed no more than every 2–3 wk in the dry season but fed more frequently during the wet season. Unlike many lizards that cease feeding during the dry season, death adders remain active and attempt to maximize their energy intake year‐round.

Where Failures Occur in the Imaging Care Cycle: Lessons From the Radiology Events Register

Adverse events contribute to significant patient morbidity and mortality on a global scale, and this has been documented in a number of international studies. Despite this, there is limited understanding of medical imagings involvement in such events. Incident reporting is a key feature of high-reliability organizations because, understandably, it is essential to know where things go wrong and why as the very first step in formulating preventative and corrective strategies. Although anesthesiology has led the way, health care in general has been slow to adopt this technique, and this includes medical imaging. Knowledge as to where medical imaging incidents are initiated and detected, and why, is not well documented or appreciated, although this is critical information in relation to quality improvement. Using an online radiology reporting system, the authors therefore sought to gain further insight and also ascertain where failures are located in the imaging cycle, and whether different incidents sources provide different information. Last, the authors sought to examine the resilience of the imaging system using these incident data.

Energetics and water flux of the marbled velvet gecko (Oedura marmorata) in tropical and temperate habitats

Abstract The gecko Oedura marmorata was studied in two different climatic zones: the arid zone of central Australia and in the wet-dry tropics of northern Australia. Doubly labelled water was used to measure field metabolic rate (FMR) and water flux rates of animals in the field during the temperate seasons of spring, summer and winter, and during the tropical wet and dry seasons. FMRs were highest in the tropical wet season and lowest in the temperate winter. The geckos in central Australia expended less energy than predicted for a similarly sized iguanid lizard, but geckos from the tropics expended about the same amount of energy as predicted for an iguanid. Water flux rates of geckos from the arid zone were extremely low in all seasons compared to other reptiles, and although water flux was higher in tropical geckos, the rates were low compared to other tropical reptiles. The standard metabolic rates (SMRs) of geckos were similar between the two regions and among the seasons. Geckos selected higher body temperatures (Tbs) in a laboratory thermal gradient in the summer (33.5°C) and wet (33.8°C) seasons compared to the winter (31.7°C) and dry (31.4°C) seasons. The mean Tbs selected in the laboratory thermal gradient by geckos from the two regions were not different at a given time of year. The energy expended during each season was partitioned into components of resting metabolism, Tb and activity. Most of the energy expended by geckos from central Australia could be attributed to the effects of temperature on resting lizards in all three seasons, but the energy expended by tropical geckos includes a substantial component due to activity during both seasons. This study revealed variability in patterns of ecological energetics between populations of closely related geckos, differences which cannot be entirely attributed to seasonal or temperature effects.

The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project).

BackgroundMalnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.Methods/DesignA pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.DiscussionUnplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.Trial registrationACTRN12611000020987