Acute Care Context Research Articles

Patients with Non-Specific Complaints in Emergency Departments: A Growing Patient Safety Concern in an Aging Population with Multimorbidity.

In this opinion, we offer a new perspective on the important and persistent problem of diagnostic errors for patients with non-specific complaints (NSCs). As an increasing number of complex patients present clinicians with challenging diagnostic work in the time-pressured and high-volume contexts of EDs, we need to improve how clinicians and healthcare organizations can understand and perform safe diagnostics for patients with NSCs. The combination of a growing number of patients with NSCs and the ways in which clinicians use the categories 'non-specific complaints' and 'non-specific diagnosis' in diagnostic work in emergency departments presents a growing patient safety concern especially for older patients with multimorbidity that require the integration of clinical and organizational research. We argue why the growing numbers of patients with NSCs and clinicians' use of these categories have implications for patient safety both within and beyond the acute care context. We end by pointing to the importance of an interdisciplinary patient safety research agenda, ideally followed by the development of targeted usable protocols for older multimorbid patients with non-specific complaints.

Key stakeholders’ perspectives of illicit drug use and associated harms in the Northern Territory of Australia

BackgroundIn the Northern Territory (NT) of Australia, there are significant evidence gaps about illicit drug use and harms, despite having established monitoring and reporting systems. This paper reports on illicit drug use, associated harms, contributing factors, service needs and priorities in the NT from the perspective and experiences of key stakeholders engaged in providing services for, or advocating on behalf of, people who use illicit drugs in the NT.MethodsFace-to-face and online qualitative interviews were conducted with stakeholders across urban and remote locations in the NT. Key stakeholders were service providers, including acute and primary care clinicians, representatives of Aboriginal community controlled health organisations, lived experience advocates, peak body representatives and public health executives. Qualitative data were analysed thematically.ResultsFour researchers interviewed 21 participants across urban (62%), and remote areas (38%) of the NT. Themes identified were: (1) Illicit drug use and harms are diverse and distinct; (2) Client support needs are complex and influenced by co-morbidities, socio-demographic and cultural factors; (3) Priority population sub-groups need targeted strategies; (4) Local service strengths can be further developed and enhanced; (5) Local services need better resourcing; (6) Invest in progressive legislative and policy reforms; and (7) Improve routine monitoring and evaluation.ConclusionsKey stakeholders described illicit drug use, harms and contributing factors, which provided insights into the local challenges. Participants emphasised that clients have complex care needs, and further investment into targeted strategies are required to improve service engagement with priority groups. Service needs included greater understanding the role of dual diagnosis and its implementation and enhancing integrated and collaborative care in both primary health and acute care contexts. The voices of people with lived experience captured in this paper must inform local strategy and policy development relating to illicit drug use, in alignment with national strategy.

Minimizing the Risk of Diagnostic Errors in Acute Care for Older Adults: An Interdisciplinary Patient Safety Challenge.

Modern healthcare systems are increasingly organized according to diagnosis-specific clinical pathways and treatment protocols. At the same time, the number of patients with complex problems and needs that do not fit the single-diagnosis approach is rising, contributing to a high prevalence of diagnostic errors. In this article, we focus on the risk of diagnostic errors arising from missed or incomplete diagnosis and assessment of older adult patients' care needs in the first hours of acute hospitalizations in EDs. This focus is important for improving patient safety, as clinical decisions made in EDs impact patient safety in the subsequent steps of the process, thereby potentially causing new risks to arise. Based on our discussion of clinical decision-making and diagnostic errors in the acute care context, we propose a more comprehensive interdisciplinary approach to improvements in patient safety that integrates organizational and clinical research and examines where, when, how, and why risks to patient safety arise in and across different clinical-organizational contexts.

Patient-related factors impact the implementation of inpatient antibiotic allergy delabeling

BackgroundThe clinical consequences of an antibiotic allergy label (AAL) are detrimental impacting health care delivery and patient outcomes. We assessed hospital inpatients with intent to offer free AAL assessment within a randomised controlled trial (RCT). ObjectiveTo determine the feasibility of establishing an adult antibiotic allergy delabeling service in a Western Australian tertiary public hospital. MethodsInpatients (N=1503) with AAL were identified through medical records and screened for eligibility to participate in an RCT. Those recruited were randomised to undergo assessment by skin testing +/- oral challenge, or direct oral challenge. A control group received usual care. ResultsOf the 1503 inpatients with an AAL, 429 (28.5%) were eligible for AAL assessment. The primary excluding factor (1,074, 71.5%) was contraindicated medication use (387, 36.0%), followed by cognitive impairment (298, 27.9%). Thirty-nine patients were randomised, 20 received allergy testing and 19 usual care; all patients were followed up for 5 years. Older patients were less likely to be eligible (10- year increase: OR = 0.82, 95% CI = 0.77-0.88, p<0.0001); whilst surgical patients were more likely to be eligible than medical patients (OR = 2.49, 95% CI = 1.97-3.16, p<0.0001). ConclusionsAntibiotic allergy delabeling in the acute care context is not straightforward. Competing clinical concerns and patient acceptance are some barriers to an inpatient service. Nor is it apparent that inpatient vs outpatient testing is cost saving although select patient groups may benefit. Testing younger people and those with predicted high antibiotic usage will derive maximal individual and health system benefits.

A national education program for rapid genomics in pediatric acute care: Building workforce confidence, competence, and capability

PurposeTo develop and evaluate a scalable national program to build confidence, competence and capability in the use of rapid genomic testing (rGT) in the acute pediatric setting. MethodsWe used theory-informed approaches to design a modular, adaptive program of blended learning aimed at diverse professional groups involved in acute pediatric care. The program comprised 4 online learning modules and an online workshop and was centered on case-based learning. We evaluated the program using the Kirkpatrick 4-level model of training evaluation and report our findings using the Reporting Item Standards for Education and its Evaluation (RISE2) guidelines for genomics education and evaluation. ResultsTwo hundred and two participants engaged with at least 1 component of the program. Participants self-reported increased confidence in using rGT, (P < .001), and quiz responses objectively demonstrated increased competence (eg, correct responses to a question on pretest counseling increased from 30% to 64%; P < .001). Additionally, their capability in applying genomic principles to simulated clinical cases increased (P < .001), as did their desire to take on more responsibility for performing rGT. The clinical interpretation of more complex test results (such as negative results or variants of uncertain significance) appeared to be more challenging, indicating a need for targeted education in this area. ConclusionThe program format was effective in delivering multidisciplinary and wide-scale genomics education in the acute care context. The modular approach we have developed now lends itself to application in other medical specialties or areas of health care.

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings.

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

Use of wearable devices to monitor post-operative activity following cardiac surgery: a systematic scoping review.

There is an emerging trend of using wearable digital technology to monitor patient activity levels in acute care contexts. However, the overall extent and quality of evidence for their use in acute cardiac surgery care are unclear. The purpose of this systematic scoping review was to evaluate current literature regarding the use of wearable activity trackers/accelerometers to monitor patient activity levels in the first 30 days following cardiac surgery. A systematic scoping review was conducted. A search of CINAHL and MEDLINE Complete databases identified all peer reviewed research evidence published in English between 2010 and 2023. Studies evaluating the use of wearable technology in adults who had undergone coronary artery bypass graft surgery and valve replacement were included. Study data were summarized thematically. A total of 853 citations were identified. Once duplicates were removed, 816 studies were screened by title and abstract, 54 full-text studies were assessed for eligibility, and 11 studies were included. Accelerometers were able to capture changing exercise and physical activity levels over an acute care admission. Device use was acceptable to clinicians and patients. Low activity levels in the early post-operative period were associated with longer length of stay and higher 30-day readmissions. Wearable devices are acceptable and feasible to use in acute care. The use of wearable activity trackers by acute cardiac patients may increase patient participation in exercise and identify more sedentary patients who are a greater risk of increased length of stay and hospital readmission.

Head Protection Device for Individuals at Risk for Head Injury due to Ground-Level Falls: Single Trauma Center User Experience Investigation.

Falls represent a large percentage of hospitalized patients with trauma as they may result in head injuries. Brain injury from ground-level falls (GLFs) in patients is common and has substantial mortality. As fall prevention initiatives have been inconclusive, we changed our strategy to injury prevention. We identified a head protection device (HPD) with impact-resistant technology, which meets head impact criteria sustained in a GLF. HPDs such as helmets are ubiquitous in preventing head injuries in sports and industrial activities; yet, they have not been studied for daily activities. We investigated the usability of a novel HPD on patients with head injury in acute care and home contexts to predict future compliance. A total of 26 individuals who sustained head injuries, wore an HPD in the hospital, while ambulatory and were evaluated at baseline and 2 months post discharge. Clinical and demographic data were collected; a usability survey captured HPD domains. This user experience design revealed patient perceptions, satisfaction, and compliance. Nonparametric tests were used for intragroup comparisons (Wilcoxon signed rank test). Differences between categorical variables including sex, race, and age (age group 1: 55-77 years; age group 2: 78+ years) and compliance were tested using the chi-square test. Of the 26 patients enrolled, 12 (46%) were female, 18 (69%) were on anticoagulants, and 25 (96%) were admitted with a head injury due to a GLF. The median age was 77 (IQR 55-92) years. After 2 months, 22 (85%) wore the device with 0 falls and no GLF hospital readmissions. Usability assessment with 26 patients revealed positive scores for the HPD post discharge regarding satisfaction (mean 4.8, SD 0.89), usability (mean 4.23, SD 0.86), effectiveness (mean 4.69, SD 0.54), and relevance (mean 4.12, SD 1.10). Nonparametric tests showed positive results with no significant differences between 2 observations. One issue emerged in the domain of aesthetics; post discharge, 8 (30%) patients had a concern about device weight. Analysis showed differences in patient compliance regarding age (χ12=4.27; P=.04) but not sex (χ12=1.58; P=.23) or race (χ12=0.75; P=.60). Age group 1 was more likely to wear the device for normal daily activities. Patients most often wore the device ambulating, and protection was identified as the primary benefit. The HPD intervention is likely to have reasonably high compliance in a population at risk for GLFs as it was considered usable, protective, and relevant. The feasibility and wearability of the device in patients who are at risk for GLFs will inform future directions, which includes a multicenter study to evaluate device compliance and effectiveness. Our work will guide other institutions in pursuing technologies and interventions that are effective in mitigating injury in the event of a fall in this high-risk population.

Exploring perceptions of frailty, resilience, and self-efficacy in older adults and caregivers in acute care context.

This study aimed to explore the experience and perceptions of frailty in hospitalized older adults and caregivers caring for older adults, in relation to resilience and self-efficacy. A qualitative explorative descriptive study design was utilized. Face to face interviews were conducted from September 2020 to July 2021 with 24 older adults who were 65 years and above and hospitalized in the acute care hospital. Ten informal family caregivers were also recruited. Data were analysed using an inductive content analysis approach. Frailty encompassed physical elements as well as manifestations of psychological traits, fear of the unknown, and being in control. Resilience was determined by individual psychological traits and mindset, and the possession of a coping mechanism. Self-efficacy could influence both frailty and resilience through inner motivation and assistance received. Older adults and family caregivers reported that considerable decline in physical health with age and level of perseverance can determine the level of frailty. Resilience and self-efficacy play a pivotal role in the context of frailty. Understanding resilience in this context will assist nurses to facilitate the use of individual and sociocultural resources to improve the way resilience is experienced by older adults. Various coping strategies can enhance self-efficacy and build greater resilience in older adults, including maintaining their active involvement in health management and social life.

Improving communicative access and patient experience in acute stroke care: An implementation journey

IntroductionPatient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts. MethodsThe project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) – an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years. OutcomesExamples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products – a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process. ConclusionsThis implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.

260 Using participatory action research to examine attitudes and awareness of adult safeguarding practices in the acute hospital context

Abstract Background The investigation of, and interventions on, the alleged abuse of vulnerable adults has become an important feature of social work and other professional practices in Ireland. This implies important organisational challenges in ensuring that adult safeguarding responsibilities are delivered in ways that ensure positive outcomes for all stakeholders. Many factors can influence staff responses to concerns in acute care contexts. This can relate to awareness of the many forms of abuse and reporting obligations, attitudes to adult safeguarding and understanding the impact of abuse. Acute hospitals offer unique opportunities to intervene in abusive situations and to offer support to those at risk. This study set out to explore the awareness, understanding and attitudes towards safeguarding practices of staff in a large Dublin teaching hospital using a Participatory Action Research Approach (PAR). Methods A PAR methodology was utilised involving a social work academic and six members of the Medical Social Work team as co-researchers in the study design, data collection and data analysis. A quantitative, descriptive study design was adopted, which utilised a cross-sectional online survey of hospital staff which generated 100 responses from a variety of hospital staff including nurses, doctors and health and social care professionals. Results Findings indicate that acute care staff have varying levels of awareness of different categories of abuse. 59% of respondents reported being ‘somewhat confident’ in recognising and reporting suspected harm, neglect or abuse of a patient they were treating. 66% of respondents reported being aware of their mandated reporting requirements under the Criminal Justice (Withholding of Information on Offences against Children and Vulnerable Persons) Act 2012. Conclusion Many staff in acute care contexts lack confidence and knowledge in detecting and reporting the abuse of adults at risk, including their mandated reporting obligations with 90% of respondents stating that they need further training in this area.

Undertaking risk and relational work to manage vulnerability: Acute medical patients’ involvement in patient safety in the NHS

Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient's health status and vulnerability on their ability to participate in their safety.Drawing on qualitative interviews with 28 acute medical patients, this article aims to show how patients’ contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff.Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of how vulnerability shapes patients’ involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. Patients are made responsible for speaking up about their care but simultaneously, by virtue of the expectations of the sick role and their relational vulnerability, encouraged to remain passive, compliant or silent. We show how risk frames the extent to which patients can activate their role in creating patient safety at the point of care. Foregrounding the theory of vulnerability, the concept of the sick role and the relationship of both to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context.

The Influence of Busyness on the Therapeutic Relationship, Nursing Activities and Teamwork: An Ethnography

ABSTRACT To explore a notion of busyness within the context of pediatric acute care and how this influences the therapeutic relationship, nursing activities and teamwork between pediatric nurses and families. Ethnography was the research design. Semi-structured interviews and non-participant observation were used for data collection, which was undertaken in a level four pediatric inpatient unit in Sydney, New South Wales Australia. Brewer’s (2000) ethnographic framework for analysis and interpretation was utilized and findings are presented as a realist tale. Interviews with 10 pediatric nurses and 10 parents, and 40 h of non-participant observations were conducted. Three themes are presented, which detail the cultural dimensions of busyness: i) the meaning of busyness; ii) relationships within the pediatric nursing team; and iii) shaping the therapeutic relationship. This ethnography identified how pediatric nurse and parental expectations and collaborative partnerships were re-shaped by busyness. Importantly, the ethnography has presented how busyness is perceived by pediatric nurses and parents, which require new negotiations and a rebalance of workload. Findings have implications for the healthcare workforce and organizational structure. Future research is required to explore how different ways of working better support the pediatric nurse and families during busyness.

Pregnancy, Opioid Use Disorder and COVID-19: An Evaluation of Acute Care Presentations During a Pandemic.

The opioid epidemic has been exacerbated by the COVID-19 pandemic, resulting in increased acute care opioid-related and overdose visits. We sought to assess how the pandemic may have impacted an obstetric cohort impacted by opioid misuse in the acute care context. A retrospective review of acute care presentations of patients with concomitant pregnancy (Z33.1) and opioid-related diagnostic codes (T10 codes and/or F11) was conducted over a 24-month period (pre-COVID = March 2019 through February 2020, post-COVID = March 2020 through February 2021). Descriptive statistics and χ2 analysis of pre- versus post-COVID presentations were performed. A total of 193 individuals, 104 (53.9%) pre- and 89 (46.1%) post-COVID, accounting for 292 total encounters, 160 (54.8%) pre- and 132 (45.2%) post-COVID, were seen for acute care visits ( P = 0.84). Age ( P = 0.15), race ( P = 0.59), and insurance status ( P = 0.17) were similar pre- versus post-COVID. The majority of presentations, pre- (40.4%) and post-COVID (44.9%), were for opioid withdrawal ( P = 0.74). Although post-COVID individuals were more likely to lack prenatal care (48.3% versus 39.4% pre-COVID), this trend was not significant ( P = 0.19). Similar proportions of individuals were affected by pregnancy complications (51.9% pre-, 44.9% post-COVID; P = 0.30). Similar proportions of individuals were affected by adverse pregnancy outcomes (44.2% pre-, 48.3% post-COVID; P = 0.64). The COVID-19 pandemic did not have a statistically significant effect on opioid-related acute care presentations or outcomes for obstetric patients. In this acute care cohort, however, opioid misuse had significant general impact on pregnancy complications and outcomes, suggesting unmet needs in this population.

Educational Needs of People Living with Atrial Fibrillation: A Qualitative Study.

BackgroundThis study explored the educational and self‐management needs of adults living with atrial fibrillation (AF).Methods and ResultsThis is a qualitative study of adults living with AF, clinicians, and expert key stakeholders. Interviews were conducted via a one‐to‐one semistructured videoconference or phone and transcribed verbatim for thematic analysis. A total of 34 participants were recruited and included in analyses (clinicians n=13; experts n=13, patients n=8). Interviews were on average 40 (range 20–70) minutes in duration. Three key themes were identified: (1) “Patient‐centered AF education”; (2) “Prioritizing AF education”; and (3) “Timing AF education.” The availability of credible information was perceived as highly variable. Information primarily focused on anticoagulation, or procedural information, as opposed to other aspects of management, such as risk factor reduction. Factors to optimize learning, such as multimedia, apps, case studies, or the use of visuals were perceived as important. Continuity of care, including engagement of caregivers, was important to help develop relationships, and facilitate understanding, while concurrently creating opportunities for timely targeted education. Clinicians described acute care as a suboptimal setting to deliver education. Competing interests aligned with the time‐pressured context of acute care were prioritized over patient education. In contrast, patients valued continuity of care. AF education strategies need to pivot from a “one size fits all” approach and modernize to implement a range of approaches.ConclusionsThere remain many unmet needs in the provision of quality AF education to support self‐management. Multimodal offerings and the ability to tailor to individual patient needs are important design considerations for new education programs.

Older Adults and Family Perspective on Interaction with Nurses in Hospital: the Role of Mutual Understanding

Optimal nurse-patient-family interaction is required to provide effective family-centered care for hospitalized older adults and their families. This qualitative descriptive study explored nurses’ interactions with older adult patients and their family members during acute hospitalization. We used semi-structured interviews to collect data from a convenience sample of nine dyads of older adults (aged 62-85) and family members (7 children and 2 spouses) who accompanied them during an acute hospitalization in medical or surgical units. Interviews were performed via Zoom beginning in December 2020 until August 2021, 1-12 months after the hospitalization. Thematic analysis was used to inductively capture key patterns in data. Both patients and family members revealed three factors contributing to the way nurses interact with patients and families: (1) nurses’ recognition and understanding of patients’ needs for family members’ presence and participation in care; (2) nurses recognition that family members expect dedication of attention, beyond nurses’ focus on patient’s care (3) patient and family members’ recognition of the extreme workload of nursing staff. Participants described a range of informal approaches used by both nurses and families to address each other’s needs. Both patients and families emphasize the benefits and costs of nurses engaging in “exceptional” interactions with patients and families considering structural characteristics such as establishing a personal relationship or accepting family visits beyond the rules. The findings provide direction for further exploration of hospitalization structures and processes needed to support optimal nurses’ interactions with families accompanying older adults and family-centered approach training in acute care context.

Examining emergency department inequities in Aotearoa New Zealand: Findings from a national retrospective observational study examining Indigenous emergency care outcomes.

There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions. This retrospective observational study used a Kaupapa Māori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Māori:non-Māori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity. Despite some ED process measures favouring Māori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Māori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Māori. To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

Developing ClinFIT COVID-19

Introduction: Health systems worldwide are challenged to address the health-care needs of persons with COVID-19. After the immediate need to mitigate the spread of COVID-19 and scale up relevant health-care capacities, one major challenge has emerged – scaling up rehabilitation to address the functioning limitations experienced by COVID-19 patients/survivors. To meet this challenge, the International Society of Physical and Rehabilitation Medicine (ISPRM) endeavors to develop a tool for the assessment and reporting of functioning of COVID-19 patients/survivors – “ClinFIT COVID- 19” to assist health professionals to optimally address patients' health-care needs. The first step in the development process is identifying the International Classification of Functioning, Disability, and Health (ICF) categories that ClinFIT COVID-19 should cover for acute, postacute, and long-term settings. Methods: The multistep process to develop the ClinFIT COVID-19 category list involved the development of a proposed list of ICF categories, a survey of ISPRM members worldwide about the proposed category list, and a postsurvey consultation with the ISPRM ClinFIT Task Force. Results: The final category list for the acute care context contains the seven categories provided to the survey participants (energy/drive functions, sleep, emotional functions, pain, exercise tolerance functions, carrying out daily routine, and walking) plus six categories related to respiration, mobility, and cognition. The postacute and long-term care versions also contain the seven categories plus additional categories relevant for the specific context. The postacute version contains 15 categories and the long-term 16 categories. Conclusions: To advance the next steps, the leaders of ISPRM and the Task Force call national and international societies of rehabilitation professionals to join this coordinated effort.

Moral distress experienced by community service providers of home health and social care in Ontario, Canada.

Moral distress occurs when one knows a morally correct action to take but feels powerless to act the way one believes is right. Moral distress has been studied in many contexts but there remains a gap in our understanding of the phenomenon as it manifests outside of hospital-based settings. The aim of this study was to explore the nature of the moral distress experience among community-based health and social care professionals working with older adults and their caregivers. Using a qualitative constructionist design, we interviewed 24 participants from a single health authority in southwestern Ontario, Canada. Participants were both urban and rurally based. Data were collected in the winter and summer of 2020 and analysed using Braun and Clarke's thematic analysis strategy. Three factors: reluctant clients, human resource shortages and system challenges, contributed to the creation of perceived morally precarious care plans, resulting in symptoms of moral distress. Study participants described frustration, guilt, anger, and grief at not being able to act consistently with their core values and provide the amount and/or quality of care their clients and unpaid caregivers deserved. We consider possible reasons for our finding that community service providers did not always respond to the consequences of moral distress symptoms in a manner similar to those in acute care contexts. Our findings suggest that study participants may have been able to cultivate moral resilience in the face of moral distress through the positive reframing of adversity and therefore maintain their overall sense of moral integrity.

Documenting plans for care: advance care directives and the 7-step pathway in the acute care context

BackgroundAdvance care planning involves the discussion and documentation of an individual’s values and preferences to guide their future healthcare should they lose capacity to make or communicate treatment decisions. Advance care planning can involve the individual’s completion of an Advance Care Directive (ACD), a legislated and common-law instrument which may include appointment of a substitute decision-maker and binding refusals of treatment. In South Australia, ACDs intersect in the acute-care context with the Resuscitation Plan 7-Step Pathway (7-SP), an integrated care plan written for and by clinicians, designed to organise and improve patients’ end-of-life care through the use of structured documentation. Here, we examine the perspectives of healthcare professionals (HCPs) within a hospital setting on the practical integration of ACDs and the 7-SP, exploring the perceived role, function, and value of each as they intersect to guide end-of-life care in an Australian hospital setting.MethodsQualitative data were collected via eight focus groups with a total of 74 HCPs (acute care, and oncology specialists; medical intern; general and emergency nurses; social workers) across two hospitals. Audio recordings were transcribed and thematically analysed.ResultsHCPs viewed ACDs as a potentially valuable means of promoting patient autonomy, but as rarely completed and poorly integrated into hospital systems. Conversely, the process and documentation of the 7-SP was perceived as providing clarity about clinicians’ responsibilities, and as a well-understood, integrated resource. Participants sometimes exhibited uncertainty around which document takes precedence if both were present. Sometimes, the routinisation of the 7-SP meant it was understood as the ‘only way’ to determine patient wishes and provide optimal end-of-life care. When this occurs, the perceived authority of ACDs, or of patients’ choice not to participate in end-of-life discussions, may be undermined.ConclusionsThe intersection of ACDs and the 7-SP appears problematic within acute care. Clinicians’ uncertainty as to whether an ACD or 7-SP takes precedence, and when it should do so, suggests a need for further clarity and training on the roles of these documents in guiding clinical practice, the legislative context within which specific documentation is embedded, and the dynamics associated with collaborative decision-making in end-of-life care.