Acute Care Clinicians Research Articles

Developing a sociocultural framework of compliance: an exploration of factors related to the use of early warning systems among acute care clinicians.

BackgroundEarly warning systems (EWS) are most effective when clinicians monitor patients’ vital signs and comply with the recommended escalation of care protocols once deterioration is recognised.ObjectivesTo explore sociocultural factors influencing acute care clinicians’ compliance with an early warning system commonly used in Queensland public hospitals in Australia.MethodsThis interpretative qualitative study utilised inductive thematic analysis to analyse data collected from semi-structured interviews conducted with 30 acute care clinicians from Queensland, Australia.ResultsThis study identified that individuals and teams approached compliance with EWS in the context of 1) the use of EWS for patient monitoring; and 2) the use of EWS for the escalation of patient care. Individual and team compliance with monitoring and escalation processes is facilitated by intra and inter-professional factors such as acceptance and support, clear instruction, inter-disciplinary collaboration and good communication. Noncompliance with EWS can be attributed to intra and inter-professional hierarchy and poor communication.ConclusionsThe overarching organisational context including the hospital’s embedded quality improvement and administrative protocols (training, resources and staffing) impact hospital-wide culture and influence clinicians’ and teams’ compliance or non-compliance with early warning system’s monitoring and escalation processes. Successful adoption of EWS relies on effective and meaningful interactions among multidisciplinary staff.

Ethical considerations for paediatrics during the COVID-19 pandemic: A discussion paper from the Australian Paediatric Clinical Ethics Collaboration.

Children have not been severely affected by SARS-CoV-2-related illness but are vulnerable to the economic and social deprivation arising from the pandemic. This document describes unique risks and burdens for children and their care givers during the COVID-19 pandemic.

Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

BackgroundThe COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside.MethodsA multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic.ResultsAlthough transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination.ConclusionsIn the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.

Emergency presentations in patients treated with immune checkpoint inhibitors

IntroductionImmune-mediated toxicities are potentially fatal and can affect virtually any organ system. The prevalence of immune-mediated toxicity in patients being treated with immune checkpoint inhibitors (ICIs) is well described. However, the reasons for presentation and the prevalence of immune-mediated toxicity in acutely unwell patients being treated with ICIs is less well described. Materials and methodsA prospective analysis of all emergency presentations in patients being treated with ICIs was performed at a specialist oncology hospital in England from 20th May 2018 to 19th May 2019. The primary outcome measure was whether the emergency presentation related to an immune-mediated toxicity. Secondary outcome measures were length of stay associated with immune-mediated toxicities and 7- and 30-day mortalities related to these presentations. ResultsDuring the study period, 300 patients on ICIs presented. The most common primary presenting complaints were dyspnoea 59 (19.7%), diarrhoea 47 (15.7%) and fever 37 (12.3%). Ninety-eight (32.7%) patients were diagnosed with an immune-mediated toxicity of which colitis 38 (38.8%), hepatitis 19 (19.4%) and pneumonitis 14 (14.3%) were the most common. The mean length of inpatient stay for those diagnosed with an immune-mediated presentation was 7.1 (0–45) days compared with 6.2 (0–44) days in those without. Seven patients died within 7 days of the emergency presentation, of whom 2 died from immune-mediated toxicity. ConclusionsOne-third of cancer patients treated with ICIs admitted as an emergence had an immune-mediated toxicity and 2% died because of this. Acute care clinicians managing these patients need to be aware that immune-mediated toxicity is common in this patient population, but it can be challenging to differentiate these from other causes for emergency presentation.

Angiotensin II for the emergency physician

Refractory hypotension is one of the most common and difficult clinical problems faced by acute care clinicians, and it poses a particularly large problem to the emergency physician when a...

The Use of Lung Ultrasound in Acute Medicine

POCUS (Point of Care Ultrasound) refers to ultrasound performed by clinicians as part of their initial patient evaluation, often with the aim of answering a specific question as opposed to being a comprehensive assessment. Such ultrasound is noninvasive, involves no radiation and can be rapidly performed at the bedside. It is also widely practiced in emergency and intensive care medicine leading to earlier and more accurate diagnoses for a wide range of presentations such as shock, renal failure and dyspnoea. POCUS has evolved from cardiological or radiological studies, reduced in complexity and scoped for clinician use. Lung ultrasound (LUS) has been largely developed by acute care clinicians and is a more recent addition to POCUS. Procedural LUS is widely recommended to improve the safety profile of pleural catheter placement (referring to BTS guidelines) but in the UK diagnostic LUS is not widely practiced despite good evidence and guideline support for its use. In this article we briefly review and describe the role of diagnostic LUS as applied to acute medicine. Potential advantages of LUS include a decreased time to diagnosis, improved diagnostic accuracy, a reduction in radiation exposure and unnecessary expensive tests. Studies have shown that at least one diagnosis was missed in around a fifth of patients with acute respiratory symptoms, resulting in increased length of stay and mortality in a third of patients.

Respecting Patient’s Wishes—How an Electronic POLST Tool Can Drive Goal-aligned Care (FR435)

•Describe the key principles to work effectively with your system’s Information Technology specialists to design an electronic POLST tool.•Discuss applying lessons from the experience of deploying an electronic POLST tool across multiple states.•Discuss how clinical decision support can help avoid administering unwanted treatments and aid delivery of goal-aligned care. Honoring a patient’s treatment preferences and priorities are key features of providing goal-aligned care. Having a clear record of a person’s choices related to life-sustaining treatments is particularly valuable. Forty-seven states have developed or are developing a Physician Orders for Life-Sustaining Treatments (POLST) form to unambiguously convey treatment plans that reflect a patient’s wishes to either receive or decline critical interventions. While conceptually straightforward, access to POLST forms and their utility are challenged by the information being static, a “snapshot” of a patient’s preferences, and the lack of interface to the rest of the EHR. In 2012, we created ePOLST, an integrated EHR-based tool for the electronic completion of POLST forms. In 2016, we improved upon the ePOLST tool leveraging EHR clinical decision support to alert acute care clinicians of potential discrepancies between orders on a patient’s POLST form and inpatient orders. Specifically, we developed a real-time clinical alert for providers of patients with POLST-prescribed ‘Do not attempt CPR’ (DNAR) status. In a Providence-affiliated ED or hospital, if a provider attempts to write a ‘Full Code’ order for a patient with an ePOLST order of DNAR, the provider is alerted to the discrepancy prior to signing the order. In the first 18 months, 16,570 ePOLST forms were generated across five states; 52% (8,548) included DNAR status, and 14% (2,311) also opted for comfort measures only. In patients with an ePOLST indicating DNAR, the alert was triggered approximately 200 times per month. Fifteen percent of the time, the ordering provider removed the apparently conflicting ‘Full Code’ status order and wrote an alternative code status order instead. This session will explore the principles and resources necessary to design and implement an ePOLST system. Updated data and detailed outcome analyses of the ePOLST clinical alert will be presented.

Connecting With Clinicians: Developing the 5-Min Digital Download to Advance Interpretive Description in Health-Care Research

The recruitment of health-care practitioners and their subsequent engagement in data collection is often a difficult and time-consuming task for research teams, especially in acute care settings. Yet clinical challenges require the experience and expertise of these clinical practitioners for the derivation of successful solutions. Innovative qualitative research techniques are emerging in an effort to involve diverse populations in research. To promote the participation of acute care clinicians in the design of a digital pediatric patient and family portal, a 5-Minute Digital Download ( 5MDD) tool was used. This article details the development of the 5MDD application, the results of the tool deployment in recruiting pediatric health-care practitioners, and the effectiveness of the method in supporting interpretive description research. With the encouraging results and an increasing need for acute care practitioner voices to be present in clinical digital health research, future direction and use of the 5MDD should be considered.

Pulmonary embolism critical care update: prognosis, treatment, and research gaps

We provide a timely update on treatment care issues facing clinicians and patients with acute pulmonary embolism accompanied by either right ventricular strain (sub-massive pulmonary embolism) or shock (massive pulmonary embolism). Care and research changes over the last several years have resulted in four important trends: more consensus and accuracy in the way acute pulmonary embolism severity is described and communicated among acute care clinicians and researchers, increased availability and use of risk prediction scoring systems, increased use of advanced invasive therapy in the setting of severe right ventricular dysfunction, and emergence of multidisciplinary pulmonary embolism response teams to guide standard care decision-making. Pulmonary embolism with shock should be treated with either systemic or catheter-based thrombolytic therapy in the absence of contraindications. Patients with sub-massive pulmonary embolism accompanied by right heart dysfunction who are treated with thrombolytic therapy likely will experience more rapid improvement in RV function and are less likely to progress to hemodynamic decompensation. This comes, however, with an increased risk of major bleeding. Our recommendation is to consider catheter-based or systemic fibrinolytic therapy in sub-massive pulmonary embolism cases where patients demonstrate high-risk features such as: severe RV strain on echo or CT, and importantly worsening over time trends in pulse, SBP, and oxygenation despite anticoagulation. Understanding the impact of advanced therapy beyond standard anticoagulation on patient-centered outcomes, such as functional status and quality of life represent a research knowledge gap.

Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke.

Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.

Sustainable implementation of innovative, technology-based health care practices: A qualitative case study from stroke telemedicine

Introduction Technology-based innovation requires long-term changes to workforce routines, otherwise practices will not be sustained. The aim of this study was to identify influential factors in the ongoing use of an acute stroke telemedicine programme. Methods A new acute stroke telemedicine programme in a regional hospital receiving 375 patients with stroke or transient ischaemic attack per year was used as an exploratory case study. Semi-structured interviews with acute care and emergency department clinicians (n = 25) were conducted at two time-points: after a six-month pilot and then after a further 12-month implementation phase. Interviews (between 12–60 min) were recorded, transcribed and analysed inductively using descriptive thematic analysis. Reported barriers and facilitators were compared with those previously reported pre-implementation (deductive analysis) to identify changes over time. Using an implementation framework and a behaviour change taxonomy, strategies were developed to address influential factors on sustainability. Results New facilitators were identified including hospital system changes, benefits to clinicians and telemedicine becoming standard practice. New and ongoing barriers included infrequent use, competing demands and the continued resistance to a specific treatment. Discussion Understanding the factors supporting a health service in successfully implementing change can accelerate population benefits. The innovation itself may include barriers to be addressed, and barriers and facilitators can change over time. Individual attitudes remain critical to initial and ongoing success. Strategies proposed included promoting benefits across the organisation and allaying uncertainties with site-specific evidence. The effectiveness of these strategies, however, needs to be evaluated. Strategies sustaining change post-implementation should be considered.

Prehospital Management of Pediatric Hanging.

Hanging may inflict laryngotracheal injuries and increase the potential for difficult airway management. We describe the management of pediatric hangings attended by an urban physician-led prehospital trauma service to provide information on a clinical situation encountered infrequently by most acute care clinicians. Retrospective trauma registry-based observational study of all children younger than 16 years attended with hanging as mechanism of injury in the period between 2000 and 2014. Twenty-three thousand one hundred thirty patients were attended; 2415 (10%) of which were children. Of these, 32 cases (<1%) were pediatric hanging (1 case excluded due to missing data). There were 22 (71%) boys and 9 (29%) girls. Median age was 13 years. There was suicidal intent in 23 (74%) cases, and in 8 (26%) cases, hanging was accidental. There were 17 (55%) deaths, of which 14 (82%) were suicides.The doctor-paramedic team intubated 25 (80%) patients, with a 100% success rate. One (3%) patient was managed with a supraglottic airway device, and 5 (16%) patients did not require any advanced airway management. Pediatric hanging is rare, but has a high mortality rate. Attempted suicide is the leading cause of hangings in children and preventive measures should target psychiatric morbidity. Despite concerns about airway edema or laryngeal injury, experienced doctor-paramedic teams had no failed airway attempts.

Ulcerative colitis: management in adults, children and young people – concise guidance

Ulcerative colitis is a chronic, relapsing and remitting -inflammatory disease of the colon and rectum. Effective -management requires prompt recognition and treatment of those with acute relapses as well as appropriate choice and monitoring of drugs for maintenance of remission. This therefore involves specialist gastroenterology teams as well as acute and general physicians and primary care clinicians. Treatment options need to be discussed with those with -ulcerative colitis and their families and appropriate information provided. This concise guideline focuses (with the generalist particularly in mind) on recommendations from the National Institute for Health and Care Excellence clinical guideline 166 considered of key importance for implementation.

Building better systems on strong relationships: A co-design case study of a local initiative

In 2012, a small team made up of experienced acute care clinicians was established, and based in the local Primary Health Care Organisation. The challenge was to address specified health targets focused on nurturing excellence in acute care delivery within the General Practice Team environment. Our primary focus was to build energy and enthusiasm for acute care, increase capability and capacity in practice by working with multiple teams in a co-design, integrative fashion. Foundational work involved identifying the willing who understood the aim and the shared vision, and who had the passion to engage in this new way of working. Building relationships with the primary health care providers was pivotal - the point of difference involved working in partnership to identify the challenges and opportunities. Being responsive, transparent and honest in a timely fashion was critical. This approach was underpinned by co-design and quality improvement principles. This enabled ongoing trust and confidence in the processes being tested. Over time as relationships built and confidence grew, the focus changed from targeted initiatives to a whole of systems approach. The building blocks had been laid in the form of individual acute care packages such as standing orders, acute knowledge and skills education programme and intravenous training. Other packages were developed as the need was identified in partnership with the teams involved. As acute care delivery in the community became more embedded, and the strategic focus shifted to move acute care closer to the health home, another key programme aimed at avoiding unnecessary admissions to hospital evolved. The key aims were: • To reduce the escalation of care from community to hospital • To implement specific acute clinical pathways • To support innovation and responsiveness • To support a quality improvement approach to acute care which was systematic, focused and reflexive Our small team acted as a conduit between primary and secondary providers, linking the services together and enabling new connections. The team’s methodology was simple but effective - having the right people at the table, working within their environments to develop effective systems with an overarching focus on integration across the health care continuum. The presentation will highlight the journey with our key partners, our successes and our challenges. It will depict the evolution of our programme of work from targeted acute care packages, to the development of the Primary Options for Acute Care programme and the introduction of a primary Early Warning Score. It will demonstrate the challenges and highlights of our approach as we continue to move acute care forward for our people in the Manawatu, Tararua, and Horowhenua districts.

Stop that Train! I Want to Get Off: Emergency Care for Patients with Advanced Dementia

Stop that Train! I Want to Get Off: Emergency Care for Patients with Advanced Dementia

Women May Benefit From Cardiac Rehabilitation Programs Tailored to Their Specific Needs.

Women are much less likely than men to complete cardiac rehabilitation with only ≈15% to 20% of eligible women participating in comparison with 22% to 30% of eligible men. There are many reasons for this divide. Women are less likely to receive a referral for cardiac rehabilitation than men (39.6% versus 49.4%) even though the American Heart Association’s guidelines for treating women with cardiovascular disease recommend rehabilitation. “Women are less likely to get referred,” said Sherry L. Grace, a professor in the School of Kinesiology and Health Science at York University and the University Health Network in Toronto. “We also know that if they are referred they are less likely to go. There are structural and system barriers that we still need to address and overcome.” The onset of heart disease is often later in women than in men, and many women may be widowed, not able to drive, or otherwise lack the support they need to get to rehabilitation sessions, Grace explained. They may find exercising tiring or painful. They also may have caregiver responsibilities that hold them back from participating. “They put their family responsibilities in front of their health,” she said. To help boost women’s participation, some studies have found that tailoring cardiac rehabilitation programs …

Clinician Perspectives of Barriers to Effective Implementation of a Rapid Response System in an Academic Health Centre: A Focus Group Study.

Background: Systemic and structural issues of rapid response system (RRS) models can hinder implementation. This study sought to understand the ways in which acute care clinicians (physicians and nurses) experience and negotiate care for deteriorating patients within the RRS. Methods: Physicians and nurses working within an Australian academic health centre within a jurisdictional-based model of clinical governance participated in focus group interviews. Verbatim transcripts were analysed using thematic content analysis. Results: Thirty-four participants (21 physicians and 13 registered nurses [RNs]) participated in six focus groups over five weeks in 2014. Implementing the RRS in daily practice was a process of informal communication and negotiation in spite of standardised protocols. Themes highlighted several systems or organisational-level barriers to an effective RRS, including (1) responsibility is inversely proportional to clinical experience; (2) actions around system flexibility contribute to deviation from protocol; (3) misdistribution of resources leads to perceptions of inadequate staffing levels inhibiting full optimisation of the RRS; and (4) poor communication and documentation of RRS increases clinician workloads. Conclusion: Implementing a RRS is complex and multifactorial, influenced by various inter- and intra-professional factors, staffing models and organisational culture. The RRS is not a static model; it is both reflexive and iterative, perpetually transforming to meet healthcare consumer and provider demands and local unit contexts and needs. Requiring more than just a strong initial implementation phase, new models of care such as a RRS demand good governance processes, ongoing support and regular evaluation and refinement. Cultural, organizational and professional factors, as well as systems-based processes, require consideration if RRSs are to achieve their intended outcomes in dynamic healthcare settings

Defining Entry-Level Practice in Acute Care Physical Therapist Practice

Background and Purpose: The requirements of an entry-level physical therapist to practice in acute care are not well defined. The Academy of Acute Care Physical Therapy convened the Minimum Skills Task Force to define entry-level practice in acute care. The purpose of this report is to discuss the process and outcome of the development of the Core Competencies for Entry-level Practice in Acute Care Physical Therapy. Methods: A task force of acute care clinicians and educators was assembled to develop this document. This document was created through a multistep process consisting of a review of limited existing literature and educational documents, reviews from 4 physical therapists with extensive specialized expertise in acute care physical therapy, and solicitation of Academy of Acute Care Physical Therapy member feedback through 2 webinar forums. Results: The final document was adopted by the Academy of Acute Care Physical Therapy in December 2015. The Core Competencies for Entry-Level Practice in Acute Care Physical Therapy identifies the necessary knowledge, actions, and behaviors that are required of an entry-level clinician in the acute care environment. Conclusion: The task force charged with the process and creation of the Core Competencies for Entry-Level Practice in Acute Care Physical Therapy met the challenge of integrating best available research, clinical experience, member feedback of all levels of experience, and expert feedback to develop this document. Further research on the benefits of this document to guide preparation for the entry-level clinician is needed.

Post-acute care referral and inpatient rehabilitation admission criteria for persons with brain injury across two Canadian provinces

Purpose: Investigate health care providers’ perceptions of referral and admission criteria to brain injury inpatient rehabilitation in two Canadian provinces.Methods: Health care providers (n = 345) from brain injury programs (13 acute care and 16 rehabilitation facilities) participated in a cross-sectional web-based survey. The participants rated the likelihood of patients (traumatic brain injury and cerebral hypoxia) to be referred/admitted to rehabilitation and the influence of 19 additional factors (e.g., tracheostomy). The participants reported the perceived usefulness of referral/admission policies and assessment tools used.Results: Ninety-one percent acute care and 98% rehabilitation participants reported the person with traumatic brain injury would likely or very likely be referred/admitted to rehabilitation compared to respectively 43% and 53% for the patient with hypoxia. Two additional factors significantly decreased the likelihood of referral/admission: older age and the combined presence of minimal learning ability, memory impairment and physical aggression. Some significant inter-provincial variations in the perceived referral/admission procedure were observed. Most participants reported policies were helpful. Similar assessment tools were used in acute care and rehabilitation.Conclusions: Health care providers appear to consider various factors when making decisions regarding referral and admission to rehabilitation. Variations in the perceived likelihood of referral/admission suggest a need for standardized referral/admission practices.Implications for RehabilitationVarious patient characteristics influence clinicians’ decisions when selecting appropriate candidates for inpatient rehabilitation.In this study, acute care clinicians were less likely to refer patients that their rehabilitation counter parts would likely have admitted and a patient with hypoxic brain injury was less likely to be referred or admitted in rehabilitation than a patient with a traumatic brain injury.Such discrepancies suggest that policy-makers, managers and clinicians should work together to develop and implement more standardized referral practices and more specific admission criteria in order to ensure equitable access to brain injury rehabilitation services.

A survey of acute care clinicians' views on factors influencing hand hygiene practice and actions to improve hand hygiene compliance

Abstract Introduction Hand hygiene best practice compliance rates are low in acute care settings despite investment in strategies in the acute care setting to improve hand hygiene practice. Knowledge of local influences such as health professionals' views on current strategies and influential factors is required to develop effective and sustainable interventions. Methods A single-centre cross-sectional survey was conducted to identify the views of 300 randomly sampled acute care health professionals from a tertiary referral teaching hospital, on the factors that they believe influence hand hygiene practice, and their views on strategies to improve compliance. Data were collected using a 19-question self-administered questionnaire and were analysed using descriptive statistics and chi-square tests to analyse differences between the clinical disciplines. Results The sample response rate was 39% (n = 118). Doctors were significantly less likely to report receiving hand hygiene education (p Conclusion Hand hygiene education may require targeting of particular groups of health professionals to ensure that all clinical disciplines receive hand hygiene education. Hand hygiene strategies should be based on local needs and take into account contextual factors.