The development and psychometric evaluation of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale

BackgroundValidated measures of ward nurses' safety cultures in relation to escalations of care in deteriorating patients are lacking.ObjectivesThis study aimed to develop and evaluate the psychometric properties of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients (CARED) scale for use among ward nurses.MethodsThe study was conducted in two phases: scale development and psychometric evaluation. The scale items were developed based on a systematic literature review, informant interviews, and expert reviews (n = 15). The reliability and validity of the scale were examined by administering the scale to 617 registered nurses with retest evaluations (n = 60). The factor structure of the CARED scale was examined in a split-half analysis with exploratory and confirmatory factor analyses. The internal consistency, test–retest reliability, convergent validity, and known-group validity of the scale were also analysed.ResultsA high overall content validity index of 0.95 was obtained from the validations of 15 international experts from seven countries. A three-factor solution was identified from the final 22 items: ‘beliefs about rapid response system’, ‘fears about escalating care’, and ‘perceived confidence in responding to deteriorating patients’. The internal consistency reliability of the scale was supported with a good Cronbach's alpha value of 0.86 and a Spearman-Brown split-half coefficient of 0.87. An excellent test–retest reliability was demonstrated, with an intraclass correlation coefficient of 0.92. The convergent validity of the scale was supported with an existing validated scale. The CARED scale also demonstrated abilities to discriminate differences among the sample characteristics.ConclusionsThe final 22-item CARED scale was tested to be a reliable and valid scale in the Singaporean setting. The scale may be used in other settings to review hospitals' rapid response systems and to identify strategies to support ward nurses in the process of escalating care in deteriorating ward patients.     

非公医院MDT院感管理查房新模式的探讨

目的 探讨多学科协作团队(multidisciplinary team, MDT)院感管理查房模式在医院感染管理中的应用, 旨在提高医院感染管理意识, 有效控制医院感染。方法 在做好医院感染预防控制的基础上,开展院感管理联合查房,比较2018年与2019年实施前后医院感染控制评价指标的变化及管理成效。结果 干预后,医护人员手卫生依从率与正确率、微生物标本采集合格率、抗菌药物使用前病原学送检率明显高于干预前,差异显著,具有统计学差异（P<0.01）;医院感染发生率、手术切口感染率及多重耐药菌感染率、ICU呼吸机相关肺炎（VAP）较干预前明显下降,差异显著,具有统计学意义（P<0.01）;ICU的CRBSI与CAUTI感染发生率,较干预前有所下降,具有统计学差异（P<0.05）。结论 以院感科主导的MDT院感管理查房模式,能达到部门协同、专业互补之目的,院感评价指标改善明显,管理成效显。     

How to Apply the Experience from the Diabetes Control and Complications Trial to Children and Adolescents?

The Diabetes Control and Complications Trial (DCCT) taught us to set target blood glucose (BG) and glycohaemoglobin (GHb) goals, to ensure safety regarding hypogly-caemia, to be flexible with insulin and meal planning and to offer frequent contact with diabetes educators, dieticians, psychologists and social workers as well as with diabe-tologists skilled in intensified management. Insulin dosage should be individualized based upon frequent BG monitoring results. Co-ordinated multidisciplinary health care teams provide optimum problem-solving rather than disaster control working with children, adolescents and their families. The patient and the family should form the central core of the diabetes team with outpatient follow-up every month and frequent telephone contact between visits. GHb should be obtained at least every 1–2 months to provide feedback as based on the DCCT intensified treatment cohort. Insulin lispro helps minimize hypoglycaemia and makes insulin administration more convenient and timely. Barriers to improvement should be identified: learning problems, concomitant significant illnesses (epilepsy, coeliac and thyroid disease, asthma) and family problems. Ensure age-appropriate transfer of self-care but continue adult supervision. Educate, motivate and re-educate. Meal planning includes not only carbohydrate counting but also maintaining normal lipids and energy needs for growth and development as well as strategies for activity compensation and hypoglycaemia prevention. Consideration of protein restriction may be required in adolescents with microalbuminuria. Individualized multidose insulin algorithms allow reactive (corrective) decisions based upon capillary BG results plus proactive (anticipatory) decisions to compensate for expected BG changes from changes in activity, food and/or illness using a multidose insulin schedule. The number of insulin injections does not define an intensified insulin treatment programme but rather the ability to target and achieve near-normal BG values as often as possible - without severe episodes of hypoglycaemia. Self BG monitoring is a key to success. Long-term monitoring should include not only frequent GHb but also at least annual fasting lipids, thyroid functions and microalbuminuria as well as dilated retinal exams, blood pressure, growth charting and Tanner staging.     

Organizational Structure,Team Process,and Future Directions of Interprofessional Health Care Teams

ABSTRACT

For a nationwide Geriatric Interdisciplinary Team Training (GITT) program evaluation of 8 sites and 26 teams, team evaluators developed a quantitative and qualitative team observation scale (TOS), examining structure, process, and outcome, with specific focus on the training function. Qualitative data provided an important expansion of quantitative data, highlighting positive effects that were not statistically significant, such as role modeling and training occurring within the clinical team. Qualitative data could also identify “too much” of a coded variable, such as time spent in individual team members' assessments and treatment plans. As healthcare organizations have increasing demands for productivity and changing reimbursement, traditional models of teamwork, with large teams and structured meetings, may no longer be as functional as they once were. To meet these constraints and to train students in teamwork, teams of the future will have to make choices, from developing and setting specific models to increasing the use of information technology to create virtual teams. Both quantitative and qualitative data will be needed to evaluate these new types of teams and the important outcomes they produce.     

Introducing an innovative method in team conferences

An innovative method to structure multidisciplinary team conferences in rehabilitation medicine was developed: Rehabilitation Activities Profile report system (RAP-TEAM). Experiences with introduction of RAP-TEAM and the study of its effects on the satisfaction of professionals are described. RAP-TEAM was introduced in three teams. RAP-TEAM did not influence the satisfaction of professionals in two teams; satisfaction in the third team even decreased. Nevertheless, professionals report more benefits than disadvantages of RAP-TEAM. Several possible explanations for these results and the methodological problems with this kind of evaluation study are discussed. The most important explanation is that introduction of an innovative method should be allowed sufficient time before it could become effective. Recommendations for a successful introduction of innovative changes are made. All people concerned must be aware that a process of change is not simple, and needs the full attention of all.     

Medical decision making for older patients during multidisciplinary oncology team meetings

Objectives

Multidisciplinary team meetings aim to facilitate efficient and accurate communication surrounding the complex process of treatment decision making for older patients with cancer. This process is even more complicated for older (≥70?years) patients as the lack of empirical evidence on treatment regimens in patients with age-related problems such as comorbidity and polypharmacy, necessitates a patient-centred approach.This study investigates the decision making process for older patients with cancer during multidisciplinary team meetings and the extent to which geriatric evaluation and geriatric expertise contribute to this process.

Experiences of returning to work after acquired brain injury

The purpose of this qualitative study was to explore experiences of returning to work after rehabilitation, from the viewpoint of people with acquired brain injury. A purposive sampling of eight informants was made, and data were collected through personal interviews with open questions. The data were then analysed through qualitative content analyses in five steps, resulting in four main categories of experiences: “A new person”, “Stimulants and fellowship”, “Understanding and support”, and “To reach insight” with appurtenant sub-categories. The overarching theme was “Returning to work after acquired brain injury is a long process”. The conclusion of this study is that returning to work after acquired brain injury requires motivated individuals, flexible work, accommodating labour management, and prolonged environmental support. This study also shows that the informants need support for a long period of time to reach a balance and to obtain a functional working role. In order to achieve this, client-centred rehabilitation, professional teamwork, and longer follow-up periods than those of today are required.     

以全科医生团队为基础的老年骨质疏松症健康教育效果分析

目的探讨以全科医生团队为基础的系统健康教育效果.方法在前期课题所积累得到的322例60～80岁骨质疏松症患者中,随机抽取参加系统健康教育的患者79例作为干预组,未参加系统健康教育的患者103例作为对照组,对两组患者进行“骨质疏松知识问卷”的现场问卷调查.结果在28项问答中,有23项回答正确率干预组明显高于对照组（P＜0.05）,5项回答正确率接近（P＞0.05）.结论以全科医生团队为基础的系统健康教育对提高骨质疏松症患者的相关知识具有较大帮助,但健康教育内容与方式有待进一步改善.