Learning from Patient Safety Incidents in the Emergency Department: A Systematic Review

BackgroundPatient safety incidents are commonly observed in critical and high demanding care settings, including the emergency department. There is a need to understand what causes patient safety incidents in emergency departments and determine the implications for excellence in practice.ObjectiveOur aim was to systematically review the international literature on patient safety incidents in emergency departments and determine what can be learned from reported incidents to inform and improve practice.DiscussionPatient safety incidents in emergency departments have a number of recognized contributing factors. These can be used as groundwork for the development of effective tools to systematically identify incident risk. Participation in efforts to diminish risk and improve patient safety through appropriate incident reporting is critical for removing barriers to safe care.ConclusionsThis review enhances our awareness of contributing factors to patient safety incidents within emergency departments and encourages researchers from different disciplines to investigate the causes of practice errors and formulate safety improvement strategies.     

Witnessed resuscitation: A concept analysis

BackgroundThe advance in the practice of resuscitation is globally recognised and fully sanctioned in scientific world. However, practicing family presence during resuscitation, also known as witnessed resuscitation, is yet to be endorsed by healthcare professionals. Many professional nursing and physician organisations have endorsed the practice of witnessed resuscitation by issuing guidelines. These organisations support family presence during resuscitation due to the research proving its benefit for patients and families.PurposeThe purpose of this paper is to analyse the concept of witnessed resuscitation.MethodA concept analysis was undertaken using Rodger’s (2000) evolutionary method.FindingsThe concept analysis suggests that witnessed resuscitation refers to the presence of a family member or relative during a resuscitation procedure, mostly in emergency and complex critical care areas. The defining attributes are family centred care approach, exercising patients and family rights and autonomy in end of life care decisions and involvement of family as active and passive observers during a resuscitation event.ConclusionClarity surrounding witnessed resuscitation will guide the development of a conceptual framework, expand nursing knowledge and identify the research required to advance understanding of witnessed resuscitation in practice.     

El valor del recurso humano: experiencia de profesionales enfermeros de cuidados críticos durante la pandemia por COVID-19

The COVID-19 pandemic has caused an unprecedented health crisis. Pressure on the National Health System has created unique demand particularly in certain services and care units like the critical care units.ObjectiveTo learn about the experience of nurses in caring for people with coronavirus in critical care units.MethodA qualitative phenomenological study that constitutes the second phase of a mixed methodology project. We conducted interviews with 17 nurses caring for patients affected by COVID-19 in critical care units. The interviews were audio-recorded, transcribed, and analysed using thematic discourse analysis.ResultsThis article shows the findings around the theme “the value of human resources” which is nuanced through sub-themes “it's not the beds, it's the expert staff”, “shouldering the patient's burden”, and suffering because “they have not cared well”.DiscussionExpert nurses have emerged as leading professionals in the care of the critical patient during the COVID-19 pandemic. This leadership is executed from a profile framed in an inclusive philosophy where wisdom, agility and intuition are the key elements underpinning problem identification and solving in a creative way, while adapting to the needs of the patient and healthcare team as they emerge.ConclusionsExpert nurses have played an advanced role in the management of care and human resources by exercising effective leadership in the clinical setting. Care has been hampered due to the crisis, which causes nurses moral distress because they have been unable to meet standards of quality and excellence in care.     

La percepción del paciente crítico sobre los cuidados enfermeros: una aproximación al concepto de satisfacción

IntroductionLevel of satisfaction is a key indicator of quality of care. There are many tools that measure satisfaction with nursing care, however they do not respond to the reality of the critical care patient or to our context.ObjectivesTo define and to identify the dimensions of the satisfaction of patients admitted to the intensive care unit of a tertiary hospital with nursing cares and to define and identify the dimensions of the concept of satisfaction from their point of view.Material and methodsA qualitative research study was conducted according to the Grounded Theory Method in three Intensive Care Units with 34 individual boxes, with theoretical sampling. Nineteen patients remained after data saturation sampling. Data collection was obtained through recorded in-depth interviews and field logbook. Contents analysis was made according to the Grounded Theory. Guba and Lincoln rigor's criteria were followed. There was a favorable report from the Hospital's Ethics Committee and informed consent was obtained from the patients.ResultsFour categories were found: The definition and dimensions of the satisfaction concept, expectations and life experiences. The participants included the following dimensions in their satisfaction definition: professional competences, human, technical and continuous cares. The combination of these elements produces feelings of security, calmness, being monitored, feeling like a person, perceiving a close relationship and trustfulness with the nurse who performs the individualized cares.ConclusionsThe definition and dimensions of satisfaction concept from the patient's point of view show the important aspects of the person and also clarify their dimensions, allowing the construction of tools more in line with the context and real perception.     

The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study

BackgroundIntensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call.ObjectiveThe study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team.MethodA constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews.FindingsA substantive theory was developed that ‘keeping patient's safe’ is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety.ConclusionThis study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.     

Care Models Preventing Readmission

ObjectivesThis article aims to identify the steps necessary to evaluate the clinical need for innovative coverage models within the oncology setting to help prevent hospital readmissions.Data SourcesMultiple published studies suggest alternative methods for patient care delivery that are safe and cost effective.ConclusionImproving care transitions for the oncology patient is necessary to be able to provide low-cost, high-quality, and patient-centered care. Many of the review studies in this article suggest that emergency room visits and subsequent readmission could be decreased with the use of innovative care models.Implications for Nursing PracticeNurses are critical to the care of medically fragile patients. Nurse-led activities such as telephone triage, post discharge phone calls, or telehealth visits can reduce patient emergency department utilization and readmissions through early recognition of symptoms and oncologic emergencies by prompting timely referrals/consultations and quick interventions.     

Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock

PurposeThe purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU).Materials and methodsFive multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach.ResultsThe major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated.ConclusionsOur study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.     

Importance Ranking of Electrocardiogram Rhythms: A Primer for Curriculum Development

IntroductionElectrocardiogram interpretation is an essential skill for emergency and critical care nurses and physicians. There remains a gap in standardized curricula and evaluation strategies used to achieve and assess competence in electrocardiogram interpretation. The purpose of this study was to develop an importance ranking of the 120 American Heart Association electrocardiogram diagnostic labels with interdisciplinary perspectives to inform curriculum development.MethodsData for this mixed methods study were collected through focus groups and individual semi-structured interviews. A card sort was used to assign relative importance scores to all 120 American Heart Association electrocardiogram diagnostic labels. Thematic analysis was used for qualitative data on participants' rationale for the rankings.ResultsThe 18 participants included 6 emergency and critical care registered nurses, 5 cardiologists, and 7 emergency medicine physicians. The 5 diagnoses chosen as the most important by all disciplines were ventricular tachycardia, ventricular fibrillation, atrial fibrillation, complete heart block, and normal electrocardiogram. The “top 20” diagnoses by each discipline were also reported. Qualitative thematic content analysis revealed that participants from all 3 disciplines identified skill in electrocardiogram interpretation as clinically imperative and acknowledged the importance of recognizing normal, life threatening, and time-sensitive electrocardiogram rhythms. Additional qualitative themes, identified by individual disciplines, were reported.DiscussionThis mixed-methods approach provided valuable interdisciplinary perspectives concerning electrocardiogram curriculum case selection and prioritization. Study findings can provide a foundation for emergency and critical care educators to create local ECG educational programs. Further work is recommended to validate the list amongst a larger population of emergency and critical care frontline nurses and physicians.     

Family support liaison in the witnessed resuscitation: A phenomenology study

BackgroundFamily-witnessed resuscitation remains controversial among clinicians from implementation to practice and there are a number of countries, such as Iran, where that is considered a low priority.ObjectiveTo explore the lived experience of resuscitation team members with the presence of the patient's family during resuscitation.DesignThe hermeneutic phenomenology.SettingsThe emergency departments and critical care units of 6 tertiary hospitals in Tabriz, Iran.ParticipantsThere were potentially 380 nurses and physicians working in the emergency departments and acute care settings of 6 tertiary hospitals in Tabriz. A purposive sample of these nurses and physicians was used to recruit participants who had at least 2 years of experience, had experienced an actual family witnessed resuscitation event, and wanted to participate. The sample size was determined according to data saturation. Data collection ended when the data were considered rich and varied enough to illuminate the phenomenon, and no new themes emerged following the interview of 12 nurses and 8 physicians.MethodsSemi-structured, face- to- face interviews were held with the participants over a period of 6 months (April 2015 to September 2015), and Van Manen’s method of data analysis was adopted.ResultsThree main themes emerged from the data analysis, including ‘Futile resuscitation’, ‘Family support liaison’, and ‘Influence on team’s performance’. A further 9 sub-themes emerged under the 3 main themes, which included ‘futile resuscitation in end-stage cancer patients’, ‘when a patient dies’, ‘young patients’, ‘care of the elderly’, ‘accountable person’, ‘family supporter’, ‘no influence’, ‘positive influence’, and ‘negative influence’.ConclusionsParticipants noted both positive and negative experiences of having family members present during cardiopulmonary resuscitation. Welltrained and expert resuscitation team members are less likely to be stressed in the presence of family. A family support liaison would act to decrease family anxiety levels and to de-escalate any potentially aggressive person during the resuscitation. It is recommended that an experienced health care professional be designated to be responsible for explaining the process of resuscitation to the patient’s family.     

The meaning of being triaged to non-emergency ambulance care as experienced by patients

BackgroundThe levels of care in the Swedish healthcare system comprise self-care, primary care as well as accident and emergency care. The Swedish system of specialist ambulance nurses enables referral by prehospital triage. However, little is known about patients' experiences of not being triaged to the emergency department.AimTo explore the subjective meaning of non-emergency ambulance care among patients who were triaged to levels of care below that of the Accident and Emergency Department.Approach/MethodsAn inductive design inspired by phenomenological hermeneutics. Twelve patients were interviewed using an open-ended method.FindingsTwo structural analyses resulted in three themes covering the subjective meaning of being taken seriously or not being taken seriously. When taken seriously, the patient was empowered irrespective of the outcome of the medical assessment and triage process. When not taken seriously the patient doubted her/his own judgement and felt guilty and ashamed about bothering the ambulance service.ConclusionN-EAC involves a strong need to be taken seriously and listened to when describing one's illness experience. When taken seriously, the patient feels as a competent person. Spending time with the patient is vital as well as listening to and inviting her/him to participate in the decision-making process. However not being taken seriously constitutes an infringement of personal autonomy.     

Clinical decision-making in the intensive care unit: A concept analysis

AimTo operationally define clinical decision-making as it relates to intensive care unit nursing.BackgroundClinical decision-making is an intricate cognitive process that is demanding on intensive care nurses due to the severity of their patients’ illnesses, consistent exposure to high-stakes situations, and prevalent patient mortality. When compromised, it can lead to adverse patient events. However, clinical decision-making specific to the intensive care unit is a concept seldom defined in nursing research.DesignConcept analysis.MethodsUsing Walker and Avant’s eight-step method, nursing databases were searched for studies between 1980 and 2022 describing the antecedents, defining attributes, consequences, and empirical referents of clinical decision-making in the intensive setting.FindingsIntensive care unit clinical decision-making is a complex cognitive process in which nurses recognize a clinical problem in their patient and respond promptly by implementing interventions to improve their patient’s rapidly and frequently changing health status to a more favorable condition in an intensive care setting. The defining attributes are: assessment of the patient situation, prompt recognition of cues, efficient comprehension of patient data abnormalities, prior knowledge and experience, prompt response to the clinical problem(s), colleague collaboration, formulation of interventions to treat clinical problem(s), and appraisal of risks/benefits.ConclusionIntensive care unit clinical decision-making is a skill that is different from traditional clinical decision-making in nursing. Prompt action characterizes this concept due to the unstable health status of these patients. More research on this concept is needed to enhance nurse performance and patient outcomes in intensive care.Implications for clinical practiceA definition of this concept opens doors for potential studies on promoting effective decision-making among intensive care nurses. This can improve the safety and outcomes of critically ill patients. Additionally, it generates new questions regarding how nursing schools and hospital orientation programs can promote and develop competent decision-making skills in future intensive care nurses.     

A qualitative multicase study of the trajectories of prolonged critical illness: Patient,family, and healthcare professionals’ experiences

BackgroundContemporary intensive care enables many critically ill patients to survive their initial illness; however, a small group of patients require a protracted stay in the intensive care unit (ICU), experiencing many complications throughout their illness. It is only when we understand the total illness experience from patients' and families’ perspectives, as well as the complexity of care for healthcare professionals, that we can fully engage in developing services and promoting evidence-based practice to improve broad health outcomes and experiences for all groups.ObjectiveThe objective of this study was to explore the trajectories of a prolonged critical illness in an ICU from the experiences of the patient, their family, and the healthcare professionals who provide care.MethodsThis was a longitudinal, qualitative, multicase study of six cases from four New Zealand ICUs. Theoretical underpinnings were informed by the Chronic Illness Trajectory Framework. Each case consisted of the patient, their family members, and nurses and other healthcare professionals who provided care. Data collection methods included observations, conversations, interviews, and document review. Data were analysed using thematic analysis and trajectory mapping.ResultsRegardless of the patient's admitting diagnosis, the trajectory of a prolonged critical illness is made up of common phases, determined by the patient's physiological condition. However, all subphases represented different psychosocial needs. The patients' debilitated state made them susceptible to complications and added to the complexity of their trajectory. The family's trajectory was informed by the patient's trajectory, and uncertainty dominated throughout. Each phase of the illness presented different challenges for healthcare professionals as they cared for this complex group of patients.ConclusionThe study highlights the distinct phases of a prolonged critical illness. Knowledge of these phases provides the ground work for improving care, not only for patients but also for their family and the healthcare professionals who provided care.