Acute Care Organizations Research Articles

Mapping breastfeeding services: a method to inform effective implementation and evaluation of evidence‐based policy in practice

This paper aims to introduce a method for mapping local service provision to local demographic and health outcome data, to inform evidence-based policy and practice in public health. A mapping exercise was conducted in London, England with the aims of: (1) describing services provided for breastfeeding women in primary and tertiary health care sectors and government, voluntary and private sectors; and (2) linking this information with routine data on deprivation, breastfeeding rates and health outcomes. Quantitative data on local breastfeeding services were collected via an online questionnaire by a designated 'mapping lead' in each locality. Data were collected at the level of individual health care organisations on the provision, nature and management of breastfeeding services, and related organisational inputs such as leadership, staffing, accreditation and policy. Demographic and health outcome data were identified from existing routine national data collections. Ninety-one per cent of eligible acute and primary care organisations participated in the mapping exercise. A range of mapping tools and profile were developed and launched in 2009 (http://atlas.chimat.org.uk/IAS/dataviews/view?viewId=66). These tools can be used for descriptive analyses of service provision on the basis of local need. Comparative analyses on the impact of service provision on breastfeeding or health outcomes will be feasible from 18 months of data collection onwards. This case study has demonstrated the potential utility of this mapping method to inform effective implementation and evaluation of public health policy in practice consistent with the World Health Organisation framework. Formal evaluation of the utility of the tools is recommended.

Meeting patient needs with a risk-stratified colorectal cancer follow-up

Managing the increasing numbers of colorectal cancer survivors with complex needs while minimizing recurrence or secondary cancer is bringing fresh challenges to healthcare providers. A baseline study completed in five counties in England with eight acute care organizations highlighted the importance of developing a risk-stratified follow-up pathway that goes beyond the traditional follow-up. In the absence of guidelines, this follow-up pathway was developed in consultation with the Network Site Specific Group consisting of specialist care clinicians from all the acute care providers. This comprehensive follow-up pathway encourages healthcare providers and clinicians to address complex patient needs by a process of shared decision making and holistic needs assessment (HNA), providing optimum surveillance testing combined with various coping and self-management strategies

Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. study protocol

BackgroundWe know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK's National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers' perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations.MethodsThe study will involve nine comparative case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems.DiscussionUnlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready.

Technology adoption and implementation in organisations: comparative case studies of 12 English NHS Trusts

ObjectivesTo understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process.DesignQualitative, multisite, comparative case study design.SettingOne primary care and...

Caring for Nurses

This article describes a hospital-based initiative that provides support for nurses who wish to become certified in a nursing specialty. Because certification becomes increasingly important to individual nurses and acute care organizations, opportunities to support nurses in this endeavor need to be developed. Through the efforts of the director of education and the support of nursing administration, study groups aimed toward assisting nurses to become certified have grown in number throughout this hospital.

Defining and Integrating Informatics Competencies Into a Hospital Nursing Department

Expanding use of complex patient information management systems and communication technology in healthcare organizations requires nurses to possess core competencies that until recently were not considered as integral to practice as those of a strictly clinical nature. Organizational changes necessary to formally integrate informatics competencies into nursing practice require strong partnerships among facility nursing leaders, educators, and informaticists. The authors describe a strategic initiative one acute care organization used to develop nursing practice that ensures use of system tools to manage patient information, support clinical decision making, optimize workflow, and communicate with members of the care team. The initiative involved defining nursing computer and informatics management skills for the clinical system applications and technologies utilized in the organization and integrating the introduction, evaluation, and on going professional development of the defined informatics competencies into organizational processes and tools to support the bedside nurse.

Evaluation of the organisation and delivery of patient-centred acute nursing care

The key driver for this study arose from two serious untoward incidents that occurred in a large district general hospital in the United Kingdom. Following investigation of both these events the Director of Nursing in post at that time believed that poor organisation and delivery of care may have been a contributory factor. This paper reports the findings on one phase of a multi-phase study and focuses upon the perceptions and experiences of the hospital staff around the organisation and delivery of patient-centred acute nursing care. Although we saw little evidence of multi-disciplinary approaches to care, it was evident that the issue which had the biggest impact upon both the organisation and delivery of care was staffing levels.

The UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project – a feasibility study of large‐scale clinical service peer review

Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale. All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals. A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4-week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions. It is possible to deliver successful large-scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation.

Decisional involvement of senior nurse leaders in Canadian acute care hospitals

The aim of the present study was to describe the scope and degree of involvement of senior nurse leaders (SNLs) in executive level decisions in acute care organizations across Canada. Significant changes in SNL roles including expansion of decision-making responsibilities have occurred but little is known about the patterns of SNL decision-making. Data were collected by mailed survey from 63 SNLs and 49 chief executive officers (CEOs) in 66 healthcare organizations in 10 Canadian provinces. Regression analyses were used to examine whether timing, breadth of content expertise and the number of decision activities predicted SNL decision-making influence and quality of decisions. Breadth of content expertise and number of decision activities with which the SNL was involved were significant predictors of decision influence explaining 22% of the variance in influence. Overall, CEOs rated SNL involvement in decision-making higher than the SNL. Senior nurse leaders contribute to organizational processes in healthcare organizations that are important for nurses and patients, through their participation in decision-making at the senior team level. Findings may be useful to current and future SNLs learning to shape the nature and content of information shared with CEOs particularly in the area of professional practice issues.

Supporting Evidence-Based Practice for Nurses through Information Technologies

To evaluate the usability of mobile information terminals, such as personal digital assistants (PDAs) or Tablet personal computers, to improve access to information resources for nurses and to explore the relationship between PDA or Tablet-supported information resources and outcomes. The authors evaluated an initiative of the Nursing Secretariat, Ontario Ministry of Health and Long-Term Care, which provided nurses with PDAs and Tablet PCs, to enable Internet access to information resources. Nurses had access to drug and medical reference information, best practice guidelines (BPGs), and to abstracts of recent research studies. The authors took place over a 12-month period. Diffusion of Innovation theory and the Promoting Action on Research Implementation in Health Services (PARIHS) model guided the selection of variables for study. A longitudinal design involving questionnaires was used to evaluate the impact of the mobile technologies on barriers to research utilization, perceived quality of care, and on nurses' job satisfaction. The setting was 29 acute care, long-term care, home care, and correctional organizations in Ontario, Canada. The sample consisted of 488 frontline-nurses. Nurses most frequently consulted drug and medical reference information, Google, and Nursing PLUS. Overall, nurses were most satisfied with the Registered Nurses Association of Ontario (RNAO) BPGs and rated the RNAO BPGs as the easiest resource to use. Among the PDA and Tablet users, there was a significant improvement in research awareness/values, and in communication of research. There was also, for the PDA users only, a significant improvement over time in perceived quality of care and job satisfaction, but primarily in long-term care settings. It is feasible to provide nurses with access to evidence-based practice resources via mobile information technologies to reduce the barriers to research utilization.

A Case Study in Evaluating Infrastructure for EBP and Selecting a Model

In this department, Dr Newhouse highlights hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal was to discuss the practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the authors describe a case using a systematic approach to evaluating infrastructure for evidence-based practice and selecting an evidence-based practice model for application in an acute care organization, the University of Maryland Medical Center.

Introducing the national COPD resources and outcomes project.

BackgroundWe report baseline data on the organisation of COPD care in UK NHS hospitals participating in the National COPD Resources and Outcomes Project (NCROP).MethodsWe undertook an initial survey of participating hospitals in 2007, looking at organisation and performance indicators in relation to general aspects of care, provision of non-invasive ventilation (NIV), pulmonary rehabilitation, early discharge schemes, and oxygen. We compare, where possible, against the national 2003 audit.Results100 hospitals participated. These were typically larger sized Units. Many aspects of COPD care had improved since 2003. Areas for further improvement include organisation of acute care, staff training, end-of-life care, organisation of oxygen services and continuation of pulmonary rehabilitation.ConclusionKey Points: positive change occurs over time and repeated audit seems to deliver some improvement in services. It is necessary to assess interventions such as the Peer Review used in the NCROP to achieve more comprehensive and rapid change.

Looking Upstream: Factors Shaping the Demand for Postacute Joint Replacement Rehabilitation

Tian W, DeJong G, Brown M, Hsieh C-H, Zamfirov ZP, Horn SD. Looking upstream: factors shaping the demand for postacute joint replacement rehabilitation. Since 1993, the numbers of hip and knee replacements in the United States have increased 2-fold to 3-fold while lengths of stay in acute care have decreased by about half, leading to a significant growth in the use of postacute rehabilitative care for patients with a joint replacement. To document these trends, this article uses secondary analysis of acute hospital discharge survey data and evaluates projections to 2030. This article uses a market approach to identify 3 sets of factors that influence the use of joint replacements: (1) increasing patient demand, (2) increasing supply of practitioners, and (3) the role of fiscal intermediaries. The article reviews underlying epidemiologic trends, growing numbers of orthopedic surgeons performing the procedure, technologic innovations, changing indications for the procedure, changing payer mix, and the effects of payer attempts to contain joint replacement costs. An unintended effect of Medicare payment policy has been to shift costs from acute care to downstream postacute care. Medicare and private health plan reimbursement policies need to take into account this broader perspective and not examine joint replacement care and payment in isolated care settings. Future research and health policy needs to consider the interdependent features of the health care system by linking changes in postacute care with upstream changes both in society at large and in the organization, delivery, and financing of acute care associated with joint replacement.

Management of severely injured children in road accidents in France: Impact of the acute care organization on the outcome*

To examine the impact of acute care management on outcome in children severely injured in road accidents. Prospective follow-up study conducted in 12 French pediatric intensive care units over a 24-month period. Excluding those in refractory shock or in brain death at admission, a total of 125 children aged <17 years admitted to the pediatric intensive care unit with severe trauma (Injury Severity Score > or =16) were included. Intracranial pressure (ICP) monitoring and admission into a trauma resuscitation room (TRR) were used as proxy markers for the center management aggressiveness. Centers which admitted to TRR and monitored ICP when indicated in >75% of cases were called aggressive centers. Children with an ICP monitoring indication admitted to a TRR and monitored, as well as those without an indication treated in a TRR, were judged appropriately managed. A poor outcome at pediatric intensive care unit discharge was defined as a difference between the baseline and discharge pediatric overall performance category above 3, or a hospital death. Children with traumatic brain injury appropriately managed in a less-aggressive center were more likely to have a poor outcome than those appropriately managed in an aggressive center (odds ratio 7.56, 95% confidence interval 1.5-38.4), after adjustment for severity, age, and type of road user. The management in a more aggressive center for children admitted to TRR and monitored for ICP, when indicated, is associated with a better outcome. This could be explained by a more extensive experience in trauma management.

Using the Quality-Caring Model to Organize Patient Care Delivery

The organization of patient care in many acute care institutions lacks a foundation in nursing theory, yet preliminary evidence of the value of professional nursing care is increasing. The process and preliminary benefits of organizing patient care according to a professional practice model are presented using a collaborative partnership between an acute care organization and a school of nursing. A pilot implementation plan with formative and summative evaluation provided preliminary evidence used in project expansion.

Benchmarking the UK Military Deployed Trauma System

Benchmarking the UK Military Deployed Trauma System

Developing Leaders at Every Level

The shortage of frontline nursing staff and their managers in acute care organizations necessitates strategies to both use and recognize the unique knowledge and skills of these individuals. The authors describe one organization's successful implementation of a shared decision-making structure that promotes an empowering work environment in which professional fulfillment and personal satisfaction can flourish. With support and opportunity, leaders are developed across all levels of nursing.

Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare

The flow of technical work in acute healthcare varies unpredictably, in patterns that occur regularly enough that they can be managed. Acute care organizations develop ways to hedge resources so that they are available if they are needed. This pragmatic approach to the distribution of work among and across groups shows how rules can be used to manage a response to irregular demands for care. However, no rule set can be complete enough to cover this setting’s variety of care demands. Expertise is also needed to tie together the loose ends of conflicts that remain where rules no longer suffice. Many informal solutions to systemic problems go unnoticed unless they are the subjects of study. Naturalistic decision making (NDM) methods such as observational study, interviews, and process tracing reveal the activities of workers in their natural settings. Results of findings from such explorations of technical work can improve understanding of large scale work processes and, ultimately, patient safety. We have explored how practitioners cope with the demands that the system presents to them. While not all succeed, successful initiatives workers have developed demonstrate how their solutions create resilience at large scale.

Finnish Trauma Audit 2004: Current state of trauma management in Finnish hospitals

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.

WEST: new data on the integration of early thrombolysis and mechanical intervention in the early management of STEMI

The choice between reperfusion strategies to manage ST-segment elevation acute myocardial infarction is a topic of immense interest, given the frequency of STEMI, its short-term mortality, and the potential impact on organization of acute cardiac care. There is general agreement that primary PCI, performed in timely fashion in an experienced centre, is an excellent and probably the best strategy.1 However, in many regions of the world, this cannot be implemented. Therefore, intravenous thrombolysis remains the default strategy. Several studies have therefore explored two avenues to improve the results of intravenous thrombolysis: the first is to attempt to provide earlier treatment by using pre-hospital thrombolysis (PHT). In general, PHT is associated with a reduction in 45–60 min in the delay to treatment and this is associated with a reduction in mortality.2 The second avenue is to combine PHT with subsequent mechanical intervention. In the CAPTIM randomized trial, pre-hospital lysis and systematic transfer to an interventional centre was associated with excellent results,3 very similar to those obtained by primary PCI. In addition, there is data to support the concept that for patients seen very early (within the first 2–3 h after symptom onset), pre-hospital lysis may even be superior to primary PCI, with a lower mortality and incidence of cardiogenic shock.4 In that time window, the advantages of primary PCI (high efficacy for recanalization of the infarct vessel, … *Corresponding author. Tel: +33 1 40 25 86 69; fax: +33 1 40 25 88 65. E-mail address : gabriel.steg{at}bch.aphp.fr