Do multidisciplinary integrated care pathways improve interprofessional collaboration?

This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning. Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork. In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care. Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care. Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings. Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital. This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital. Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization. The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase. Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway. The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced. Furthermore, key factors in discharge delays appeared to be organizational rather than professional.     

Are scoop stretchers suitable for use on spine-injured patients?

Introduction

In the prehospital setting, spine-injured patients must be transferred to a spine board to immobilize the spine. This can be accomplished using both manual techniques and mechanical devices.

Objectives

The study aimed to evaluate the effectiveness of the scoop stretcher to limit cervical spine motion as compared to 2 commonly used manual transfer techniques.

Methods

Three-dimensional angular motion generated across the C5-C6 spinal segment during execution of 2 manual transfer techniques and the application of a scoop stretcher was recorded first on cadavers with intact spines and then repeated after C5-C6 destabilization. A 3-dimensional electromagnetic tracking device was used to measure the maximum angular and linear motion produced during all test sessions.

Results

Although not statistically significant, the execution of the log roll maneuver created more motion in all directions than either the lift-and-slide technique or with scoop stretcher application. The scoop stretcher and lift-and-slide techniques were able to restrict motion to a comparable degree.

Conclusion

The effectiveness of the scoop stretcher to limit spinal motion in the destabilized spine is comparable or better than manual techniques currently being used by primary responders.     

Are emergency care staff prepared for disaster?

When disasters occur, nurses of all specialties require the appropriate knowledge and skills to respond effectively and efficiently. To assess the extent to which nurses in the US are prepared for emergencies, researchers have developed the Emergency Preparedness Information Questionnaire (EPIQ), in which participants are invited to assess their familiarity with aspects of emergency preparedness. This article discusses a pilot study of the use of the EPIQ among minor injury unit nurses and healthcare assistants in the UK. The results suggest that the principle of the EPIQ is sound but that it should be adapted to cater for different disaster situations and the needs of individual nurses. Terms that describe disasters and large-scale emergency situations are often used interchangeably so, to avoid confusion, this article uses 'disaster' to refer to all such events.     

Are critical pathways effective for reducing postoperative length of stay?

BACKGROUND: Many hospitals use critical pathways to attempt to reduce postoperative length of stay (PLOS) for diverse conditions and procedures. OBJECTIVE: To evaluate whether critical pathways were associated with reductions in postoperative PLOS after accounting for prepathway trends in PLOS. RESEARCH DESIGN: Retrospective cohort study, from 1988 to 1998. SETTING: Academic medical center department of surgery. SUBJECTS: A total of 10,960 admissions eligible for 1 of 26 critical pathways implemented from 1990 to 1996, from 2 years before to 2 years after each pathway implementation date. Coding definitions were developed and validated to identify admissions eligible for each pathway, and data were abstracted from the hospital's discharge database. MEASURE: A pathway was considered effective if, after its implementation, there was a statistically significant decrease in the prepathway trend for PLOS. RESULTS: Median number of annual eligible admissions per pathway was 59 (range, 18-706). Median PLOS for the prepathway periods was 8 days (interquartile range, 5-10 days). For 16 (62%) pathways, PLOS was already declining in the prepathway period. After adjusting for demographics, comorbidity, admission characteristics, and prepathway time trends in PLOS, 7 (27%) pathways were associated with a significant postimplementation decrease in the rate of change in PLOS (range among the 7 pathways, 5-45% decrease) and none with a significant increase from the prepathway trend for PLOS. CONCLUSION: Critical pathways may decrease postoperative stay for some, but not all, surgeries. Trends toward decreasing length of stay over time may reduce the impact of critical pathways on this outcome.     

Are care workers appropriate mentors for nursing students in residential aged care?

Background

The aged care sector is increasingly dominated by a less-qualified workforce at a time of increasing prevalence of complex health concerns, such as dementia. An Australian program to develop teaching aged care facilities is being undertaken to build the sector’s capacity and provide nursing students with positive experiences of engaging with vulnerable clients. This research aimed to examine care staff potential to facilitate nursing student engagement with clinically relevant knowledge in the performance of hygiene care in a residential aged care facility.

Methods

This study was designed as an action research study. A cycle of reflection, planning, action, and evaluation is described to illustrate the carer mentor capacity to engage with and contribute to the learning of nursing students. Participants were second year student nurses (n = 10) on a four-week placement in a Tasmanian aged care facility in 2013 and their nurse/carer mentors (n = 17). Mentors participated in six action research meetings, and nursing students engaged in a parallel series of four feedback meetings during the placement.

Results

At the beginning of the placement, nursing students exhibited a disregard for the clinical value of care provision. Students considered provision of hygiene care, in particular, the preserve of care workers and an inappropriate training exercise in the context of an undergraduate nursing qualification. To assist students to make links between core nursing competencies and hygiene care as well as to engender respect for their role within the aged care facility, carer mentors developed the Carer Assessment and Reporting Guide. Once implemented during the final weeks of the placement, the Guide improved student perceptions of resident hygiene care (reframed as assessment) and the role of facility care workers, as well as reinforcing carer self-esteem.

Conclusion

Hygiene care is replete with nursing competencies that are valuable for undergraduate learners, including assessments of skin integrity, mobility, cognitive function, bowels and urine, and basic hygiene. Nurse education programs should strive to address student misconceptions about care work in facilities to account for population level increases in care needs.

     

Are special ethical guidelines needed for palliative care research?

Recent studies have made it clear that there are substantial opportunities to improve end-of-life care. Doing so will require solid evidence on which to base clinical and policy decisions and this, in turn, will require a focused research effort. However, research that involves patients near the end of life creates numerous ethical challenges. Moreover, the inclusion of dying patients in research may make many providers uncomfortable. In short, there seems to be something ethically unique, and uniquely challenging, about palliative care research. This paper considers 4 arguments for this unique status: 1) dying patients are especially vulnerable; 2) adequate informed consent may be difficult to obtain; 3) balancing research and clinical roles is particularly difficult; and 4) the risks and benefits of palliative research are difficult to assess. We conclude that the first three of these arguments are weak, and that special guidelines are not needed. We suggest, however, that the fourth argument may have some merit, and should be the focus of discussion among investigators, providers, and patients.     

A decade on: has the use of integrated care pathways made a difference in Lanarkshire?

This article aimed to: (1) review the work carried out in Lanarkshire between 1996 and 1999 on a Scottish Executive funded project and (2) to discuss the situation from 1999 to 2006. (1) This 3-year project led to the successful development and implementation of over 100 integrated care pathways in an urban teaching hospital (Glasgow) and a district general hospital (Lanarkshire) and was the first in-depth study of integrated care pathways to be undertaken in Scotland. The main report on the project was produced in 1999 (Clinical Audit and Quality using Integrated Pathways of Care) and reported increased adherence to British Thoracic Society and Scottish Intercollegiate Guidelines Network guidelines and multiple best practice statements, and improved standards of documentation. The general findings were that process indicators were improved by integrated care pathway use and there was some suggestion of improved length of stay with no apparent effect on outcome. Evidence was found that integrated care pathways have made a difference for both patients and staff. (2) This provides an update of integrated care pathway development in a changing environment within NHS Lanarkshire and examines some of the key factors for success.     

Are low-income elderly patients at risk for poor diabetes care?

OBJECTIVE: Diabetes is common among low-income elderly, dual-eligible (DE) Medicare/Medicaid patients resulting in significant morbidity, mortality, and cost. However, the quality of diabetes care delivered to these patients has not been evaluated. The aims of this study were to describe the quality of diabetes care provided to DE patients and compare it with non-DE patients. RESEARCH DESIGN AND METHODS: This was a cross-sectional analysis of administrative claims from 1 January 1997 through 31 December 1998. A total of 9,453 patients aged 65-75 years with diabetes participated in the study. These were Colorado Medicare fee-for-service (FFS) outpatients. The main outcome measures consisted of a proportion of patients receiving an annual hemoglobin A1c test, biennial eye examination, biennial lipid test, and all three of these care processes. RESULTS: The mean patient age was 71 +/- 2.8 years. Over 22% of patients were identified as dual eligible, and they were significantly more likely to be younger, female, and of minority race/ethnicity; reside in a rural location; and have comorbid conditions compared with the non-DE population. DE patients had more visits to primary care physicians, emergency departments, and hospitalizations but were less likely to visit endocrinologists. DE patients were significantly less likely to receive an annual A1c test (73 vs. 81%; P < 0.0001), biennial ophthalmologic examination (63 vs. 75%; P < 0.0001), and biennial lipid testing (43 vs. 57%; P < 0.0001). The adjusted odds ratio of urban DE patients receiving all three care measures was 0.60 (95% CI 0.52-0.69) compared with urban non-DE patients. Minority race/ethnicity and emergency department use were significantly associated with not receiving diabetes care, whereas endocrinology visits were associated with an increased odds of receiving diabetes care. CONCLUSIONS: DE Medicare/Medicaid status was independently associated with not receiving diabetes care, especially among those in urban areas.     

Are plants vectors for transmission of infection in acute care?

This article reviews relevant research that sheds light on the role of plants and flowers in hospital-acquired infections. After a review of a survey of acute care hospital policies, evidence-based practice recommendations intended to reduce nosocomial infections in acute and critical care are provided.     

Are link-nurse systems an effective means for improving patient care?

Link nurses are part of a system that shares information and provides formal, two-way communication between specialist teams and nurses in the clinical area. Many different clinical areas might employ such nurses, including tissue viability and diabetes. Link-nurse systems have the potential to promote and enhance clinical effectiveness and disseminate research findings.     

Is pericardium a suitable calibration reference in integrated backscatter analysis?

To evaluate if pericardium is a suitable calibration reference in the integrated backscatter (IBS) analysis, the grossly normal pericardial specimens from 23 patients without a history of pericarditis were mounted on a steel platform and immersed in a 0.9% saline bath. The 2-D IBS images acquired at the uniform time gain compensation settings of 50 and 70 dB were analyzed. For the pericardial IBS, the limits of agreement for intraobserver and interobserver measurements were -1.2 to 1.4 dB and -1.6 to 2.2 dB, respectively. However, the calibrated IBS intensity of the pericardium presented a rather wide range of variation and was -13 +/- 5 (-5 to -29) and -10 +/- 4 (-4 to -22) dB at the overall gain settings of 50 and 70 dB, respectively. Conclusively, pericardium may not be an ideal IBS calibration reference in a population study of cardiac tissue characterization.     

Carotid stenting for impending carotid blowout: suitable supportive care for head and neck cancer patients?

BACKGROUND: Carotid blowout (CB) represents a dramatic end-of-life situation for palliative head and neck cancer patients, their relatives and caregivers. Recently, endovascular therapy has been proposed for head and neck surgical patients. Preliminary reports showed a better outcome with less morbidity compared to the previous treatment modalities. However, the specific use of such techniques for palliative head and neck cancer patients has not been previously described. METHOD: Retrospective review of two cases of head and neck cancer patients receiving palliative care, presenting with a CB, managed with endovascular stent placement. RESULTS: Bleeding was effectively stopped by the procedure in both cases. Both patients developed a post-procedure thromboembolism, which was immediately treated by appropriate anticoagulation therapy. Neurological symptoms resolved within 24 hours allowing rapid hospital discharge. One patient died at home seven months later. The second patient is alive five months after the procedure. No recurrence of CB occurred in either patient. CONCLUSIONS: Endovascular stent placement for CB allows a rapid arrest of bleeding and permits the use of anticoagulation therapy in order to avoid long-term neurological injury. In our view, carotid stenting should be considered as valid supportive care for palliative head and neck patients presenting with a CB.     

Should nurses be leaders of integrated health care?

AIM(S): To examine the role of nurses within integrated health care. BACKGROUND: Healthcare planners are overly concerned with the treatment of diseases and insufficiently focused on social cohesion vertical rather than horizontal integration of healthcare effort. These domains need to be better connected, to avoid medicalization of social problems and socialisation of medical problems. EVALUATION: Published literature, related to theories of whole system integration. *When conceptualizing whole system integration it helps to consider research insights to be snapshots of more complex stories-in-evolution, and change to be the result of ongoing community dance where multiple players adapt their steps to each other. *One image that helps to conceptualize integration is that of a railway network. Railway tracks and multiple journeys are equally needed; each requiring a different approach for success. *Traditional nursing values make nurses more attuned to the issues of combined vertical and horizontal integration than medical colleagues. CONCLUSION(S): Nurses should lead integration at the interface between horizontal and vertical activities. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers and universities should support the development of nurses as leaders of whole system integration, in partnership with local healthcare organizations.     

Do pathways lead to better organized care processes?

Aim  Clinical pathways are used worldwide to (re)organize care processes. They are used by multidisciplinary teams in their search towards excellence. The goal of this study is (1) to assess differences in the perception of health professionals in their evaluation of care processes; (2) to assess whether care processes supported by clinical pathways perform better than those not supported by clinical pathways; and (3) to assess the sensitivity and specificity of clinical pathways in predicting well-organized care processes.
Methods  A cross-sectional, multi-centre study was performed comprising 309 healthcare workers, 103 care processes and 49 hospitals. The Care Process Self Evaluation Tool (CPSET) was used to score care processes according to their organization. Processes were also scored according to the level of pathway implementation.
Results  (1) Significant differences between healthcare professionals were found on two of five CPSET subscales. No significant differences were found among the overall CPSET scores. (2) Care processes supported by pathways had the highest CPSET scores. Nonetheless, continuous follow-up is necessary. (3) Clinical pathways have significant impact on the coordination of care (odds ratio: 8.92), follow-up (odds ratio: 6.65) and overall CPSET score (odds ratio: 4.26). Clinical pathways have a positive impact on the organization of care processes. Not all pathways have high CPSET scores, and care processes without pathways can also be well organized. Continuous evaluation is essential. This is the first study to analyse how healthcare teams perceive the organization of care processes with respect to clinical pathways. Our findings are important for other quality improvement methods.     

Are terminally ill patients dying in the ICU suitable for non-heart beating organ donation?

Objective To evaluate the feasibility of implementing a program of controlled non-heart beating organ donation, in patients undergoing the withdrawal of intensive care treatment.Design and setting Prospective observational study. Medical and Surgical ICUs in a tertiary university hospital.Patients Consecutive patients younger than 70 years dying in the ICU after treatment withdrawal for dire neurological prognosis.Measurements and results We analyzed prospectively collected data from the ICU clinical information system. Seventy-three of 516 ICU deaths (13%) were identified, equally distributed among traumatic, stroke, and anoxic brain injury. The management and the course in these three diagnostic categories were similar. All patients underwent withdrawal of mechanical ventilation and half were extubated. Median time to death was of 4.8 h (IQR 1.4–11.5). In 70% of cases the patient received analgesia and 30% sedation. Such treatment was not related to earlier death. Hypotension was observed in 50% of patients during the 30 min preceding cardiac death.Conclusions With our current management of terminal patients controlled non-heart beating organ procedure may be difficult due to the duration and variability of the dying process. This observation suggests that we can perform better by evaluating this process moreclosely.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.René Chioléro and Luca Imperatori are members of the SwissFoundation to Support Organ Donation.     

Is integrated nursing home care cheaper than traditional care? A cost comparison

Background

It is generally assumed that integrated care has a cost-saving potential in comparison with traditional care. However, there is little evidence on this potential with respect to integrated nursing home care.

Aims and objectives

• • 

  To portray the costs of traditional and integrated nursing home care.

• • 

  To explore the cost-saving potential of integrated care.

Design/methods/settings/participants

Between 1999 and 2003, formal and informal caregivers of different nursing homes in the Netherlands recorded activities performed for residents with somatic or psycho-social problems. In total, 23,380 lists were analysed to determine the average costs of formal and informal care per activity, per type of resident and per nursing home care type. For formal care activities, the total personnel costs per minute (in Euro) were calculated. For informal care costs, two shadow prices were used.

Results

Compared to traditional care, integrated care had lower informal direct care costs per resident and per activity and lower average costs per direct activity (for a set of activities performed by formal caregivers). The total average costs per resident per day and the costs of formal direct care per resident, however, were higher as were the costs of delivering a set of indirect activities to residents with somatic problems.

Conclusions

The general assumption that integrated care has a cost-saving potential (per resident or per individual activity) was only partially supported by our research. Our study also raised issues which should be investigated in future research on integrated nursing home care.