Tim Stephens

Nursing intensive care skills training: A nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting☆

PURPOSE To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting. METHODS A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires. RESULTS In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P < .0001). More than 95% passed the post-course Objective Structured Clinical Assessment (patient assessment) and SOE 1 (arterial blood gas analysis), whereas 76.9% passed SOE 2 (3-lead electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience. CONCLUSIONS Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings.

Capacity building for critical care training delivery: Development and evaluation of the Network for Improving Critical care Skills Training (NICST) programme in Sri Lanka

OBJECTIVES To deliver and evaluate a short critical care nurse training course whilst simultaneously building local training capacity. RESEARCH METHODOLOGY A multi-modal short course for critical care nursing skills was delivered in seven training blocks, from 06/2013-11/2014. Each training block included a Train the Trainer programme. The project was evaluated using Kirkpatricks Hierarchy of Learning. There was a graded hand over of responsibility for course delivery from overseas to local faculty between 2013 and 2014. SETTING Sri Lanka. MAIN OUTCOME MEASURES Participant learning assessed through pre/post course Multi-Choice Questionnaires. RESULTS A total of 584 nurses and 29 faculty were trained. Participant feedback was consistently positive and each course demonstrated a significant increase (p≤0.0001) in MCQ scores. There was no significant difference MCQ scores (p=0.186) between overseas faculty led and local faculty led courses. CONCLUSIONS In a relatively short period, training with good educational outcomes was delivered to nearly 25% of the critical care nursing population in Sri Lanka whilst simultaneously building a local faculty of trainers. Through use of a structured Train the Trainer programme, course outcomes were maintained following the handover of training responsibility to Sri Lankan faculty. The focus on local capacity building increases the possibility of long term course sustainability.

Closing the theory to practice gap for newly qualified doctors: evaluation of a peer-delivered practical skills training course for newly qualified doctors in preparation for clinical practice

Purpose The Good Intern Programme (GIP) in Sri Lanka has been implemented to bridge the ’theory to practice gap’ of doctors preparing for their internship. This paper evaluates the impact of a 2-day peer-delivered Acute Care Skills Training (ACST) course as part of the GIP. Study design The ACST course was developed by an interprofessional faculty, including newly graduated doctors awaiting internship (pre-intern), focusing on the recognition and management of common medical and surgical emergencies. Course delivery was entirely by pre-intern doctors to their peers. Knowledge was evaluated by a pre- and post-course multiple choice test. Participants’ confidence (post-course) and 12 acute care skills (pre- and post-course) were assessed using Likert scale-based questions. A subset of participants provided feedback on the peer learning experience. Results Seventeen courses were delivered by a faculty consisting of eight peer trainers over 4 months, training 320 participants. The mean (SD) multiple choice questionnaire score was 71.03 (13.19) pre-course compared with 77.98 (7.7) post-course (p<0.05). Increased overall confidence in managing ward emergencies was reported by 97.2% (n=283) of respondents. Participants rated their post-course skills to be significantly higher (p<0.05) than pre-course in all 12 assessed skills. Extended feedback on the peer learning experience was overwhelmingly positive and 96.5% would recommend the course to a colleague. Conclusions A peer-delivered ACST course was extremely well received and can improve newly qualified medical graduates’ knowledge, skills and confidence in managing medical and surgical emergencies. This peer-based model may have utility beyond pre-interns and beyond Sri Lanka.

An interprofessional training course in crises and human factors for perioperative teams

ABSTRACT Improving patient safety and the culture of care are health service priorities that coexist with financial pressures on organisations. Research suggests team training and better team processes can improve team culture, safety, performance, and clinical outcomes, yet opportunities for interprofessional learning remain scarce. Perioperative practitioners work in a high pressure, high-risk environment without the benefits of stable team membership: this limits opportunities and momentum for team-initiated collaborative improvements. This article describes an interprofessional course focused on crises and human factors which comprised a 1-day event and a multifaceted sustainment programme for perioperative practitioners, grouped by surgical specialty. Participants reported increased understanding and confidence to enact processes and behaviours that support patient safety, including: team behaviours (communication, coordination, cooperation and back-up, leadership, situational awareness); recognising different perspectives and expectations within the team; briefing and debriefing; after action review; and using specialty-specific incident reports to generate specialty-specific interprofessional improvement plans. Participants valued working with specialty colleagues away from normal work pressures. In the high-pressure arena of front-line healthcare delivery, improving patient safety and theatre efficiency can often be erroneously considered conflicting agendas. Interprofessional collaboration amongst staff participating in this initiative enabled general and specialty-specific interprofessional learning that transcended this conflict.

Pathways to professionalism? Quality improvement, care pathways, and the interplay of standardisation and clinical autonomy

Care pathways are a prominent feature of efforts to improve healthcare quality, outcomes and accountability, but sociological studies of pathways often find professional resistance to standardisation. This qualitative study examined the adoption and adaptation of a novel pathway as part of a randomised controlled trial in an unusually complex, non-linear field - emergency general surgery - by teams of surgeons and physicians in six theoretically sampled sites in the UK. We find near-universal receptivity to the concept of a pathway as a means of improving peri-operative processes and outcomes, but concern about the impact on appropriate professional judgement. However, this concern translated not into resistance and implementation failure, but into a nuancing of the pathways-as-realised in each site, and their use as a means of enhancing professional decision-making and inter-professional collaboration. We discuss our findings in the context of recent literature on the interplay between managerialism and professionalism in healthcare, and highlight practical and theoretical implications.

A retrospective study of physiological observation-reporting practices and the recognition, response, and outcomes following cardiopulmonary arrest in a low-to-middle-income country

Background and Aims: In Sri Lanka, as in most low-to-middle-income countries (LMICs), early warning systems (EWSs) are not in use. Understanding observation-reporting practices and response to deterioration is a necessary step in evaluating the feasibility of EWS implementation in a LMIC setting. This study describes the practices of observation reporting and the recognition and response to presumed cardiopulmonary arrest in a LMIC. Patients and Methods: This retrospective study was carried out at District General Hospital Monaragala, Sri Lanka. One hundred and fifty adult patients who had cardiac arrests and were reported to a nurse responder were included in the study. Results: Availability of six parameters (excluding mentation) was significantly higher at admission (P < 0.05) than at 24 and 48 h prior to cardiac arrest. Patients had a 49.3% immediate return of spontaneous circulation (ROSC) and 35.3% survival to hospital discharge. Nearly 48.6% of patients who had ROSC did not receive postarrest intensive care. Intubation was performed in 46 (62.2%) patients who went on to have ROSC compared with 28 (36.8%) with no ROSC (P < 0.05). Defibrillation, performed in eight (10.8%) patients who had ROSC and eight (10.5%) in whom did not, was statistically insignificant (P = 0.995). Conclusions: Observations commonly used to detect deterioration are poorly reported, and reporting practices would need to be improved prior to EWS implementation. These findings reinforce the need for training in acute care and resuscitation skills for health-care teams in LMIC settings as part of a program of improving recognition and response to acute deterioration.

Capacity building for critical care skills training provision in resource limited settings: the nursing intensive care skills training (nicst) project

The availability of high quality critical care is increasingly recognised as a global health problem [1, 2]. The ability of any health system to scale-up delivery of effective critical care services will be limited by critical care training capacity.

A COLLABORATIVE APPROACH TO TRAINING WARD NURSES IN ACUTE CARE SKILLS IN RESOURCE LIMITED SETTINGS: THE NURSING INTENSIVE CARE SKILLS TRAINING (NICTS) PROJECT

Early recognition and prevention of deterioration of ward patients can improve patient outcomes and reduce critical care admissions [1]. In low and middle income countries (LMICs), with often minimal access to critical care therapies, the benefit may be even greater. However training to assist ward nurses develop acute care skills remains limited in such settings. As part of the NICST portfolio of acute care training, the Sri Lankan nursing faculty sought assistance to deliver a 2 day course for ward nurses [2].

1040 The emergency laparotomy collaborative: scaling up an improvement bundle for high risk surgical patients

Background Emergency intra-abdominal laparotomy is a common surgical procedure. Mortality is high with 11%–15% of patients dying within 30 days of surgery. Complication rates are also high and >25% of patients remain in hospital for >20 days. A previous study, ELPQuIC, successfully used a care bundle to reduce mortality in four hospitals. Objectives The aim of the Emergency Laparotomy Collaborative was to scale implementation of the ELPQuIC bundle to 24 NHS Trusts within three Academic Networks to reduce mortality, complications and length of stay. Methods We used the IHI Breakthrough Series Collaborative Model to bring 100+ staff together over two years with 5 large events and 4 local quality improvement events. Data collection was through the National Emergency Laparotomy Audit (NELA). Economic analysis was undertaken. Using NELA data we distributed comparative dashboards showing care bundle adherence and patient outcomes quarterly. The collaborative model enabled Trusts to share progress through dialogue, group reflection and celebration of success. Results 5793 patients had an emergency laparotomy between October 2015 and December 2016. Crude mortality decreased from 9.8% to 8.7% and length of stay decreased by 1.3 days. There were significant improvements in delivery of care bundle components. Economic analysis showed potential savings of £2 M in 15 months, primarily through decreased length of stay. The collaborative promoted innovation with ideas such as ‘virtual peer review’ emerging. Conclusions Implementation of the ELPQuIC care bundle improved process delivery resulting in better outcomes for emergency laparotomy patients across 25 NHS Trusts. QI promotion through a BTS model fostered collaboration and innovation.Abstract 1040 Figure 1 Diagram of the ‘ELPQuIC’ Care BundleAbstract 1040 Figure 2 Run charts of mortality and length of stay from all hospitals. Intervention began October 2015.Abstract 1040 Figure 3 SPC charts from one hospital showing improvement in senior anaesthetist presence in theater and increase in number of patients going to critical care after surgery. Dotted line marks start of intervention.Abstract 1040 Figure 4 Odds ratios showing the increased likelihood of a patient receiving the implementation or outcome. Where the horizontal line is no longer in touch with the vertical line, a significant change has taken place. This charts shows how the change in post-op critical care has been replicated across the majority of hospitals. The chart includes analysis of historic data and the first 15 months of prospective collected data. References 1. National Emergency Laparotomy Audit. The Second Patient Report 2016. Availablefrom NELA 2016. http://www.nela.org.uk/reports. 2. Al-Temimi, Griffee M, Ennis TM et al. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012;215:503–11. 3. Saunders D, Murray D, Varley S, Pichel A, Peden CJ. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. BJA 2012;109:368–375. 4. Huddart S, Peden CJ, Swart M et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. BJS 2015;102:57–66.

Practices and perspectives in cardiopulmonary resuscitation attempts and the use of do not attempt resuscitation orders: A cross-sectional survey in Sri Lanka

Objective: The objective of this study is to describe the characteristics of in-hospital cardiopulmonary resuscitation (CPR) attempts, the perspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders. Methods: A cross-sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective. Results: A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were “not at all” or “only a little bit surprised” by the arrest. Conclusions: CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon.