Una Kyriacos

The critical care nursing workforce in Western Cape hospitals - a descriptive survey

Background. A global shortage of registered nurses (RNs) has been reported internationally, and confirmed in South Africa by the National Audit of Critical Care services. Critical care nurses (CCNs) especially are in great demand and short supply. Purpose. The purpose of this study was to quantify the nursing workforce and compare it with requirements of critical care units (CCUs) in hospitals of the Western Cape province as at 1 January 2005, and to quantify potential recruits from nursing education institutions. Design. A descriptive survey conducted on site in CCUs of the private and public sector hospitals of the Western Cape, using a structured questionnaire. Results. Data were obtained from questionnaires (96.5% return rate) from 77 of the 80 CCUs surveyed in 35 hospitals (12 public; 23 private). Intensive care units (ICUs) and high-care units (HCUs) were classified in the questionnaire. Findings revealed: 39 adult ICUs (12; 27), 2 paediatric ICUs (public), 14 neonatal ICUs (4; 10), 13 adult HCUs (11, 2), 1 paediatric HCU (public), 3 neonatal HCUs (public) and 5 high-dependency units (HDUs) for adults (public), with 720 functional unit beds in total (359; 361). A registered nurse/ventilated patient ratio of 1:1 was used in 5.26% of public sector units but in all private sector units. Of the 768 nurses of all categories in public sector units 118 (15.4%) were trained CCNs and 289 were RNs (37.6%). In private sector units 204 (38.1%) of 535 nurses were trained CCNs and 204 (38.1%) were RNs. According to a consensus-driven method developed in Australia to measure the required number of ICU nurses, the Western Cape has a deficit of 72% and 80% RNs respectively in public and private sector CCUs, amounting to an actual total shortage of 2 711 RNs. Data from 7 educational institutions revealed that during 2004, 300 undergraduate nurses and 80 postgraduate CCNs graduated. Conclusion. The current supply of nurses does not meet the needs of CCUs in the Western Cape, and the number of educators and clinical mentors is inadequate Southern African Journal of Critical Care Vol. 22 (2) 2006: pp. 50-56

Monitoring Vital Signs: Development of a Modified Early Warning Scoring (Mews) System for General Wards in a Developing Country

Objective The aim of the study was to develop and validate, by consensus, the construct and content of an observations chart for nurses incorporating a modified early warning scoring (MEWS) system for physiological parameters to be used for bedside monitoring on general wards in a public hospital in South Africa. Methods Delphi and modified face-to-face nominal group consensus methods were used to develop and validate a prototype observations chart that incorporated an existing UK MEWS. This informed the development of the Cape Town ward MEWS chart. Participants One specialist anaesthesiologist, one emergency medicine specialist, two critical care nurses and eight senior ward nurses with expertise in bedside monitoring (N = 12) were purposively sampled for consensus development of the MEWS. One general surgeon declined and one neurosurgeon replaced the emergency medicine specialist in the final round. Results Five consensus rounds achieved ≥70% agreement for cut points in five of seven physiological parameters respiratory and heart rates, systolic BP, temperature and urine output. For conscious level and oxygen saturation a relaxed rule of <70% agreement was applied. A reporting algorithm was established and incorporated in the MEWS chart representing decision rules determining the degree of urgency. Parameters and cut points differed from those in MEWS used in developed countries. Conclusions A MEWS for developing countries should record at least seven parameters. Experts from developing countries are best placed to stipulate cut points in physiological parameters. Further research is needed to explore the ability of the MEWS chart to identify physiological and clinical deterioration.

Early warning scoring systems versus standard observations charts for wards in South Africa: a cluster randomized controlled trial

BackgroundOn South African public hospital wards, observation charts do not incorporate early warning scoring (EWS) systems to inform nurses when to summon assistance. The aim of this trial was to test the impact of a new chart incorporating a modified EWS (MEWS) system and a linked training program on nurses’ responses to clinical deterioration (primary outcome). Secondary outcomes were: numbers of patients with vital signs recordings in the first eight postoperative hours; number of times each vital sign was recorded; and nurses’ knowledge.Methods/designA pragmatic, parallel-group, cluster randomized, controlled clinical trial of intervention versus standard care was conducted in three intervention and three control adult surgical wards in an 867-bed public hospital in Cape Town, between March and July 2010; thereafter the MEWS chart was withdrawn. A total of 50 out of 122 nurses in full-time employment participated. From 1,427 case notes, 114 were selected by randomization for assessment.The MEWS chart was implemented in intervention wards. Control wards delivered standard care, without training. Case notes were reviewed two weeks after the trial’s completion. Knowledge was assessed in both trial arms by blinded independent marking of written tests before and after training of nurses in intervention wards. Analyses were undertaken with IBM SPSS software on an intention-to-treat basis.ResultsPatients in trial arms were similar. Introduction of the MEWS was not associated with statistically significant changes in responses to clinical deterioration (50 of 57 received no assistance versus 55 of 57, odds ratio (OR): 0.26, 95% confidence interval (CI): 0.05 to 1.31), despite improvement in nurses’ knowledge in intervention wards. More patients in intervention than control wards had recordings of respiratory rate (27 of 57 versus 2 of 57, OR: 24.75, 95% CI: 5.5 to 111.3) and recordings of all seven parameters (5 of 57 versus 0 of 57 patients, risk estimate: 1.10, 95% CI: 1.01 to 1.2).ConclusionsA MEWS chart and training program enhanced recording of respiratory rate and of all parameters, and nurses’ knowledge, but not nurses’ responses to patients who triggered the MEWS reporting algorithm.Trial registrationThis trial was registered with the Pan African Clinical Trials Registry (identifier: PACTR201309000626545) on 9 September 2013.

Record Review to Explore the Adequacy of Post-Operative Vital Signs Monitoring Using a Local Modified Early Warning Score (Mews) Chart to Evaluate Outcomes

Objectives 1) To explore the adequacy of: vital signs’ recordings (respiratory and heart rate, oxygen saturation, systolic blood pressure (BP), temperature, level of consciousness and urine output) in the first 8 post-operative hours; responses to clinical deterioration. 2) To identify factors associated with death on the ward between transfer from the theatre recovery suite and the seventh day after operation. Design Retrospective review of records of 11 patients who died plus four controls for each case. Participants We reviewed clinical records of 55 patients who met inclusion criteria (general anaesthetic, age >13, complete records) from six surgical wards in a teaching hospital between 1 May and 31 July 2009. Methods In the absence of guidelines for routine post-operative vital signs’ monitoring, nurses’ standard practice graphical plots of recordings were recoded into MEWS formats (0 = normal, 1–3 upper or lower limit) and their responses to clinical deterioration were interpreted using MEWS reporting algorithms. Results No patients’ records contained recordings for all seven parameters displayed on the MEWS. There was no evidence of response to: 22/36 (61.1%) abnormal vital signs for patients who died that would have triggered an escalated MEWS reporting algorithm; 81/87 (93.1%) for controls. Death was associated with age, ≥61 years (OR 14.2, 3.0–68.0); ≥2 pre-existing co-morbidities (OR 75.3, 3.7–1527.4); high/low systolic BP on admission (OR 7.2, 1.5–34.2); tachycardia (≥111–129 bpm) (OR 6.6, 1.4–30.0) and low systolic BP (≤81–100 mmHg), as defined by the MEWS (OR 8.0, 1.9–33.1). Conclusions Guidelines for post-operative vital signs’ monitoring and reporting need to be established. The MEWS provides a useful scoring system for interpreting clinical deterioration and guiding intervention. Exploration of the ability of the Cape Town MEWS chart plus reporting algorithm to expedite recognition of signs of clinical and physiological deterioration and securing more skilled assistance is essential.

A nontraditional curriculum for the preparation of nurse educators.

The purpose of this article is to describe a bold and innovative program for the preparation of nurse educators in a developing country. This program was designed to anticipate the competing demands for radical change in both the health care system and the nursing educational system. Consideration was given to the need for a curriculum model that was flexible and broad enough to accommodate the educational and professional needs of a very diverse group of students regarding academic ability, culture, and language. The aim of the curriculum was to achieve the desire for meaningful, lifelong learning and personal growth, while maintaining academic excellence within a transformative and democratizing context.

Renal unit practitioners’ knowledge, attitudes and practice regarding the safety of unfractionated heparin for chronic haemodialysis

Background Chronic haemodialysis for adult patients with end-stage kidney failure requires a patent extracorporeal circuit, maintained by anticoagulants such as unfractionated heparin (UFH). Incorrect administration of UFH has safety implications for patients. Objectives Firstly, to describe renal practitioners’ self-reported knowledge, attitudes and practice (KAP) regarding the safe use of UFH and its effects; secondly, to determine an association between KAP and selected independent variables. Method A cross-sectional descriptive survey by self-administered questionnaire and non-probability convenience sampling was conducted in two tertiary hospital dialysis units and five private dialysis units in 2013. Results The mean age of 74/77 respondents (96.1%), was 41.1 years. Most (41/77, 53.2%) had 0–5 years of renal experience. The odds of enrolled nurses having poorer knowledge of UFH than registered nurses were 18.7 times higher at a 95% Confidence Interval (CI) (1.9–187.4) and statistically significant (P = 0.013). The odds of delivering poor practice having ≤ five years of experience and no in-service education were 4.6 times higher at a 95% CI (1.4–15.6), than for respondents who had ≥ six years of experience (P = 0.014) and 4.3 times higher (95% CI 1.1–16.5) than for respondents who received in-service education (P = 0.032), the difference reaching statistical significance in both cases. Conclusion Results suggest that the category of the professional influences knowledge and, thus, safe use of UFH, and that there is a direct relationship between years of experience and quality of haemodialysis practice and between having in-service education and quality of practice.

CRITICAL APPRAISAL: ADEQUACY OF REPORTING STUDIES ON EARLY WARNING SCORE SYSTEMS

Background : Routine monitoring of patients’ clinical and physiological status by nurses includes the use of vital signs (observations) charts for recording findings. Charts that incorporate early warning score (EWS) systems are designed to ‘track’ signs of deterioration and ‘trigger’ a rapid response. Published studies of EWS systems are of limited benefit if reporting of these studies is inadequate. Reporting guidelines are recommended to improve the quality of reporting. Objective: To assess the adequacy of reporting studies on EWS systems. Methods: All study designs published between 1 May 2007 and 23 May 2015 describing the use of EWS systems for detecting deterioration in adult patients on general medical and surgical wards were included. Data extraction was undertaken by one researcher. Results: Of the 657 references identified from search terms, 596 articles were excluded leaving 61 articles for assessment. Most studies were published in non-nursing journals (47/61, 77.0%). Six of the 61 (9.8%) studies were reviews. The remaining 55 clinical studies on the use of EWS/MEWS systems were mostly observational (46/55, 83.6%) rather than experimental (9/55, 16.4%). Reporting guidelines were used in 9.8% (6/61) of reviewed studies. Only the reviews but no clinical studies reported a search strategy. Electronic searches included mostly CINAHL (5/6, 83.3%), MEDLINE and The Cochrane Library (4/6, 66.7%). No meta-analyses were performed. Inclusion and exclusion criteria and reasons for exclusion of references were well reported in the reviews. The most frequently reported range of physiological parameters (12/61, 19.7%) were respiratory rate, oxygen saturation, supplemental oxygen, heart rate, systolic blood pressure, temperature and level of consciousness. Conclusion: Reporting of published studies on EWS systems reviewed for this critical appraisal, with the exception of reviews, was inadequate as most did not use reporting guidelines, limiting the use of study findings for developing clinical guidelines and in further research.