Acute Medical Setting Research Articles

A Cross-Sectional Study of the Perception of Individualized Nursing Care Among Nurses in Acute Medical and Perioperative Settings

Background/Objectives: Individualized nursing care allows for systematic assessment and intervention; considers a patient’s preferences, values, and context; and contributes to a positive care trajectory. However, its operationalization has proven to be challenging. This research aimed to evaluate nurses’ perceptions of individualized care and analyze their relationship with sociodemographic variables. Methods: A cross-sectional study was conducted on 122 eligible and registered nurses at a Hospital Center, in the Ophthalmology (operating room and inpatient ward) service, the Cardiology service, the Internal Medicine service, and the Medical Emergency Unit, for adults/older adults in Portugal. The nursing version of the Individualized Care Scale (ICS-Nurse) was used for the assessment, including three sub-dimensions: clinical situation, personal life situation, and decisional control over care-related decisions. Cronbach’s alpha and principal component analysis were used for the data analysis. The STROBE checklist was used to report this study. Results: No statistically significant differences were found based on the age, gender, level of education, or years of professional experience of the nurses within the sub-dimensions of individualization. The nurses overall had a good perception of the importance of individualized care (4.06 ± 0.46 ICS-A-NURSE) but faced difficulties in its implementation during the last shift they worked (3.97 ± 0.49 ICS-B-NURSE). Conclusions: The items considered to be of greatest importance were the response to the physical and emotional needs arising from illness and assistance in decision-making through educational instructions. Aspects related to the personal lives of patients, such as family inclusion in an individual’s care plan, everyday habits, and previous experiences of hospitalization, received the lowest scores. Recognizing priority areas for improvement in the individualization of nursing care can contribute to developing training programs and policies that promote a holistic approach. Future studies should consider patient outcomes related to their needs for individualization.

A "Whole Child Approach": Parent Experiences with Acute Care Hospitalizations for Children with Autism Spectrum Disorder and Behavioral Health Needs.

Children with Autism Spectrum Disorder (ASD) experience increased hospitalizations as compared to the general population, particularly in the context of mental health crises. Given the unique needs of children with ASD and behavioral health needs that can either lead to or emerge during hospitalization, an understanding of hospital experiences is critical. To date, research on caregiver experiences in acute care medical hospital settings is limited. Therefore, the purpose of this qualitative study was to investigate caregiver experiences with inpatient care for children with ASD and behavioral health needs, including factors and practices that impacted or were desirable for care. Two focus groups were conducted with a total of 12 parents of children with ASD admitted to a large pediatric hospital. Data were analyzed using interpretive description. Emerging themes pointed to the child, family, and staff factors and practices that intersect to influence hospitalization experiences. Child factors included the child's communication, sensory, behavioral, medical, and safety needs. Family factors included the family's relationship with the healthcare team, own needs, and advocacy experiences. Staff factors included staff communication practices, comfort, and knowledge when providing care. Overall, this research demonstrates the complexity of factors and practices that impact the behavioral health hospitalization experience for children with ASD and their caregivers. Experiences varied widely and were guided by the unique needs of each child. Findings point to care practices that can be adopted to best meet the needs of all stakeholders during hospitalization and offer implications for future educational initiatives.

Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians' perspectives (STREAMS-C).

Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEPs) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians' perspectives on SDM in TEP for older patients in the acute medical setting. This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in emergency medicine, general internal medicine, intensive care medicine and palliative care medicine. Reflexive thematic analysis was performed. There were three themes: 'An unequal partnership', 'Options without equipoise' and 'Decisions with shared understanding'. Clinicians' expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important, and clinicians sought control over the high-stakes decision whilst avoiding conflict and achieving shared understanding. Clinicians take responsibility for securing a 'good' TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. SDM is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.

Limitations of Self-Report Tools in Pain Evaluation of Patients With Vertebral Fractures.

Few studies have evaluated the usefulness and limitations of pain assessment using verbal communication tools for acute orthopedic diseases in older patients. The purpose of this study was to assess the rate of usage of the numerical rating scale (NRS), a verbal communication tool, and to identify the characteristics of patients in whom continuous assessment was impossible. We retrospectively examined electronic medical records of patients with acute vertebral fractures who had been admitted to our hospital between April 2018 and March 2020. Continuous pain assessment using the NRS was possible in 43.2% of hospitalized patients with the fractures. The factors preventing continuous pain assessment using the NRS were an advanced age and low Mini-Mental State Examination (MMSE) scores. Based on the receiver-operating characteristic curves, the cutoff age and MMSE score were >85.3 years and <22, respectively. Continuous NRS-based pain assessment is difficult in older adult patients or those with cognitive decline with acute vertebral fractures. In future, a simple observational assessment tool for patients with dementia should be introduced in acute medical care settings.

2142 Shared decision-making on treatment escalation planning in the acute medical setting for older patients: a qualitative study

Abstract Introduction Shared Decision-Making (SDM) is increasingly expected in most aspects of UK medical practice and can be particularly important for older patients to guide goals of care. Treatment Escalation Plans (TEP) summarise medical intervention to be attempted in the event of acute deterioration. Current guidance advocates SDM in TEP but it is unclear whether this is considered practicable by clinicians. This study aims to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting. Methods This was a qualitative study following a relativist constructivist approach. 26 consultant and registrar doctors were recruited from general internal medicine, intensive care, palliative care and emergency medicine. A clinical doctoral student conducted semi-structured interviews including vignettes of older multi-morbid patients with capacity to discuss treatment escalation. Reflexive thematic analysis was performed. Ethics approvals were obtained from the Health Research Authority 22/HRA/4387. Results Three themes were generated: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. SDM incorporating patient preferences with clinical opinion was seldom perceived to be appropriate. Clinical complexity and use of intuition, together with lack of perceived moral equipoise, motivated clinicians to develop medically acceptable TEPs. Shared understanding with the patient and family and avoiding conflict were important. Conclusions Contrary to current guidance, SDM was considered a potential barrier to formulating appropriate TEPs in the acute medical setting. This study suggests potential incompatibility between policies prioritising patient autonomy and the right to make unwise decisions, and those stating clinicians’ prerogative to determine realistic chance of treatment success and not provide intervention considered medically inappropriate.

Identifying Facilitators and Inhibitors of Shared Understanding: An Ethnography of Diagnosis Communication in Acute Medical Settings.

Communication is important in determining how patients understand the diagnostic process. Empirical studies involving direct observation of communication within diagnostic processes are relatively limited. This ethnographic study aimed to identify communicative practices facilitating or inhibiting shared understanding between patients and doctors in UK acute secondary care settings. Data were collected in acute medical sectors of three English hospitals. Researchers observed doctors as they assessed patients; semistructured interviews were undertaken with doctors and patients directly afterwards. Patients were also interviewed 2-4 weeks later. Case studies of individual encounters (consisting of these interviews and observational notes) were created, and were cross-examined by an interdisciplinary team to identify divergence and convergence between doctors' and patients' narratives. These data were analysed thematically. We conducted 228 h of observation, 24 doctor interviews, 32 patient interviews and 15 patient follow-up interviews. Doctors varied in their communication. Patient diagnostic understanding was sometimes misaligned with that of their doctors; interviews revealed that they often made incorrect assumptions to make sense of the fragmented information received. Thematic analysis identified communicative practices that seemed to facilitate, or inhibit, shared diagnostic understanding between patient and doctor, revealing three themes: (1) communicating what has been understood from the medical record, (2) sharing the thought process and diagnostic reasoning and (3) closing the loop and discharge communication. Shared understanding was best fostered by clear communication about the diagnostic process, what had already been done and what was achievable in acute settings. Written information presents an underutilised tool in such communication. In UK acute secondary settings, the provision of more information about the diagnostic process often fostered shared understanding between doctor and patient, helping to minimise the confusion and dissatisfaction that can result from misaligned expectations or conclusions about the diagnosis, and the uncertainty therein. A patient and public involvement group (of a range of ages and backgrounds) was consulted. They contributed to the design of the protocol, including the timing of interviews, the acceptability of a follow-up telephone interview, the development of the interview guides and the participant information sheets.

A Challenging Conundrum; Learning Disability, Schizophrenia and Autism - a Case Report

IntroductionPsychiatric disorders are common in patients with learning disabilities. There are also patients with the triad of autism, schizophrenia and learning disability. Patients with this background can be admitted to general hospitals for psychiatric or non-psychiatric reasons.We are presenting a case who had a very complicated clinical course and her discharge planning was challenging.ObjectivesThe objective of this work was to show the challenges in the investigation, medical management, and discharge planning of the patients with concomitant learning disability, schizophrenia and autism.MethodsWe scrutinized the patient’s casenotes, including blood results and all relevant imaging. We paid a particular attention to all the entries from the psychiatry team, general medical doctors, oncologists, learning disability team and discharge planners.ResultsThe lady had a protracted 4-month inpatient admission throughout which she was physically and verbally aggressive to hospital staff. She was deemed to lack capacity for hospital admission and treated in her best interests under Mental Capacity Act (MCA), frequently requiring sedation with Haloperidol and Lorazepam. Following consultation with the local Psychiatrist her medications were altered to: Risperidone 2 mg BD, Diazepam 5 mg OM, 5 mg afternoon and 10 mg evening, Procyclidine 5 mg BD, Chlorpromazine 25 mg BD, Promethazine 25 mg OD PRN, and Midazolam 10 mg buccal PRN.A change in her clinical condition was noted by the Psychiatry team; increased agitation, confusion and dysarthria. A repeat blood test was advised, due to patient refusal this took weeks to achieve despite the use of buccal Midazolam following Anaesthesiologist advice. Although blood tests were not significantly deranged, she was treated for presumed urinary tract infection with a course of antibiotics. A urine sample was unobtainable.She reported right breast pain and underwent a mammogram. This showed a hypoechoic lesion 8x7x9 mm. Following consultation with a Breast Surgeon and Oncologist, Letrozole was replaced with Tamoxifen. The Psychiatric team concluded that the clinical deterioration with dysarthria was related to anxiety, associated with Autistic patients. The movement disorder was deemed secondary to antipsychotics exacerbated by stress and anxiety.The patient’s discharge planning was complex. She was declined by numerous care homes. At time of writing, she remains an inpatient.ConclusionsThe management of patients with a triad of Learning Disability, Schizophrenia and Autism is extremely difficult, particularly within an acute medical setting. Physical deterioration could be related to medication adverse effects or change in environment. Anxiety and stress are linked to these conditions. The challenging behaviour that these patients often have will make discharge planning very difficult as specialised care homes to accommodate these unique patients are very limiteDisclosure of InterestNone Declared

Switching from VA-ECMO to a Percutaneous right Ventricular assist device as a Bridge to Recovery in a Case of right Ventricular Myocardial Infarction

Acute right heart failure (RHF) is associated with high morbidity and mortality. Temporary mechanical circulatory support (MCS) is now part of the advanced management strategy for refractory cardiogenic shock (CS). Among such support systems, veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) remains the fastest MCS system to set up. The ProtekDuo cannula can be used as a temporary and percutaneous right ventricular assist device (RVAD) in relay with VA-ECMO in the context of prolonged weaning. This case report describes the clinical course of a 69-year-old patient who underwent elective aortic valve replacement surgery complicated by acute RHF due to iatrogenic ligation of the right coronary artery. VA-ECMO was initiated in the context of refractory cardiogenic shock. Faced with prolonged MCS weaning, due to lack of recovery of the right ventricle associated with the absence of any other therapeutic option, a percutaneous RVAD via a ProtekDuo cannula was implanted as a bridge to recovery. The ProtekDuo was gradually weaned while the patient began rehabilitation. The patient was transferred to the medical ward after 5 weeks in the ICU, stayed 5 months in an acute medical setting, went to a rehabilitation center afterward and returned home 6 months after the initial surgery without any neurological sequalae or organ failures. In total, she remained on MCS for 39 days (21 on VA-ECMO and 18 on ProtekDuo). In cases of refractory RHF, after stabilization and organ perfusion restoration under VA-ECMO, it is feasible to switch to a percutaneous RVAD, allowing early mobilization of patients during prolonged MCS weaning until the right ventricle adapts to new loading conditions.

Realist synthesis protocol on the effectiveness of a rapid response system in managing mental state deterioration in acute hospital settings

IntroductionPatient mental state deterioration impacts patient outcomes, staff and increases costs for healthcare organisations. Mental state is broadly defined to include not only mental health but a broad range of...

A conceptual framework for how structural changes in emerging acute substance use service models can reduce stigma of medications for opioid use disorder.

Stigma toward people taking medication for opioid use disorder (MOUD) is prevalent, harmful to the health and well-being of this population, and impedes MOUD treatment resource provision, help-seeking, and engagement in care. In recent years, clinicians have implemented new models of MOUD-based treatment in parts of the United States that integrate buprenorphine initiation into emergency departments and other acute general medical settings, with post-discharge linkage to office-based treatment. These service models increase access to MOUD and they have potential to mitigate stigma toward opioid use and MOUD. However, the empirical literature connecting these emerging service delivery models to stigma outcomes remains underdeveloped. This paper aims to bridge the stigma and health service literatures via a conceptual model delineating how elements of emerging MOUD service models can reduce stigma and increase behavior in pursuit of life goals. Specifically, we outline how new approaches to three key processes can counter structural, public, and self-stigma for this population: (1) community outreach with peer-to-peer influence, (2) clinical evaluation and induction of MOUD in acute care settings, and (3) transition to outpatient maintenance care and early recovery. Emerging service models that target these three processes can, in turn, foster patient empowerment and pursuit of life goals. There is great potential to increase the well-being of people who use opioids by reducing stigma against MOUD via these structural changes.

Reducing Physical Therapy Consults for Patients With High Functional Mobility in the Acute Medical Inpatient Setting: A Difference-in-Difference Analysis

ObjectiveTo evaluate the effectiveness of clinical decision support for reducing misallocation of physical therapy (PT) consults. DesignA prospective quasi-experimental study. Between October 2018 and November 2021, routinely documented data on functional status and physical therapy referrals were collected from electronic medical records. SettingHospital Medicine and General Internal Medicine service lines at a large quaternary academic medical center. Participants20,810 adult patients hospitalized on any of the included treatment (hospital medicine) or control (general internal medicine) service lines. Main Outcome MeasureThe primary outcome was “change in proportion of misallocated PT consults” measured as likelihood of PT consults for patients admitted with high functional mobility scores. Changes in the primary outcome from the pre-intervention to post-intervention period were compared in the control and treatment groups using propensity score–weighted difference-in-differences multivariable logit regression adjusting for clinically relevant covariates. InterventionThe intervention period was measured for 20 months and consisted of a clinical decision support tool embedded in the daily note templates for hospital medicine providers. The tool provided education on patient mobility scores and their relation to need for PT consult. The tool was rolled out without any further announcements or education. ResultsOur cohort included 20,810 unique admissions (mean age 58.9, 55% women, 83% Black). Post-intervention, the likelihood of PT referrals for patients with high baseline mobility (AM-PAC >18) decreased by 7.3% (P<.001) for the treatment group compared with control, adjusted for age, sex, race, ethnicity, length-of-stay, and mobility change. ConclusionMobility score-based clinical decision support can decrease unneeded PT consults in the inpatient setting. This could help allocate therapy time for at-risk patients while also having a positive effect on health care systems.

HIDDEN2: Study protocol for the hospital deep vein thrombosis detection study in patients with cancer receiving palliative care

IntroductionMedical patients, admitted acutely to hospital, are at risk of venous thromboembolism (VTE). Clinical guidelines advise thromboprophylaxis prophylaxis for those at high risk of VTE. VTE is a common sequela...

Recognition and Management of Depression in Adults With a Chronic Physical Health Problem in the Acute Medical Setting

AimsTo compare current trust practice to NICE clinical guideline 91. To identify patients with a history of depression or chronic physical illness on admission to acute medical services. To assess such patients for evidence of new or ongoing depression and establish prevalence of depressive symptoms in high risk patient groups. To establish appropriate pathways for referral to mental health servicesMethodsCycle one: Eligible adult medical patients were screened for self-reported symptoms of low mood and anhedonia over the 2 weeks prior to admission. Inclusion criteria required patients to have either a past history of a chronic physical health condition or a past history of depression.For those who answered “YES” to depressive symptoms, clinicians were prompted to refer to mental health services.Intervention:Screening questions were added to the adult medical clerking proforma for routine screening of admitted patients.Patients self-identifying as depressed were triaged as requiring either inpatient liaison psychiatry team support or were referred to Improving Access to Psychological Therapies (IAPT) team on discharge with GP follow up.Acute Medical departmental teaching session held on CG91 and new referral pathway created with input from liaison psychiatry team.Cycle two:Audit cycle repeated, including audit of outcomes following identification of patients with depressive symptoms.ResultsIn cycle one, of 123 patients, 90 were eligible for inclusion (PPHx depression n=39; PMHx chronic physical condition n=51).Of those with a past history of depression, 85% reported YES to current symptoms.Of patients with a chronic physical condition, without prior history of depression, 48% reported low mood or anhedonia in the past two weeks.Following introduction of electronic screening questions, completion rate by clinicians was 65% (eligible patients n=102; PPHx depression n=43; PMHx chronic physical condition n=59). 44% of patients with a chronic physical health problem self-reported symptoms of depression.After local educational meeting, 84% of identified patients had a planned referral to primary or secondary care for further mental health assessment and support.ConclusionAround half of patients with chronic physical health conditions self-report high levels of depressive symptoms, without a known mental health diagnosis or support in place.Screening of patients on admission provides an opportunity for appropriate intervention.Establishing clear referral pathways and ongoing education is needed to ensure all identified patients are referred for further assessment.

139 Reducing Physical Therapy Consults for Patients with High Functional Mobility in the Acute Medical Inpatient Setting: A Difference-in-Differences Analysis

OBJECTIVES/GOALS: Physical therapy (PT) is key for treating functional decline that inpatients experience but is a constrained resource in hospital settings. The Activity Measure Post-Acute Care (AM-PAC) score is a mobility measurement tool that has been used to define misallocation of PT. We aim to optimize PT referrals using AM-PAC-based clinical decision support . METHODS/STUDY POPULATION: We conducted a prospective study of patients admitted to University of Chicago Medical Center. AM-PAC scores were assessed by nursing staff every 12 hours. Clinical decision support was designed using validated AM-PAC cutoffs (&gt; 18, a predictor of discharge to home). The tool was embedded in hospital medicine note templates, requiring providers to indicate PT referral status based on current AM-PAC scores. The primary outcome, unskilled consult , was defined as PT referral for patients with AM-PAC &gt; 18. Data were collected for one year prior to implementation and one year after implementation for intervention (hospital medicine) and control (general internal medicine) services. Difference in differences analysis was used to assess the association between the intervention and unskilled consults. RESULTS/ANTICIPATED RESULTS: Between October 2018 and March 2021, 18,241 admissions were eligible for the study. Compared to preintervention, there was a lower rate of referral to PT for patients with high AM-PAC mobility scores in the post-intervention period [18.5% vs 16.6%; X2(1) = 7.02; p &lt; 0.01]. In the postintervention time period, the control group experienced a 2.6% increase in unskilled consults while the intervention group experienced a 2.3% decrease, a difference in differences of 4.9% (95% CI -0.07–-0.03 for difference in differences) controlling for age sex, race, LOS, and change in mobility. Compared to preintervention, there was no statistically significant difference in mean change in mobility score post-intervention for either group. DISCUSSION/SIGNIFICANCE: Our results suggest that clinical decision support can decrease unskilled PT consults. Many functionally independent patients can mobilize with nursing or other mobilization staff. Hospitals should consider mobility score-based decision support to prioritize PT for impaired and at-risk patients.

A Pilot Study of Ketamine Infusion after Suicide Attempt: New Frontiers in Treating Acute Suicidality in a Real-World Medical Setting.

Ketamine, in research settings, rapidly reduces suicidal thoughts 2-24 h after a single infusion in patients with high suicidal ideation. In this study, the authors investigate ketamine's effects on suicidality in a real-world sample of recent suicide attempters on a tertiary-care Consultation-Liaison (CL) psychiatry service. Using an open-label design, 16 transdiagnostic CL patients were recruited, 18-65 years old, to receive a single dose of intravenous ketamine (0.5 mg/kg) in the acute medical setting. All were psychiatrically hospitalized post-infusion. Baseline suicidality and depression measures were compared to ratings taken at 24 h, 5 days, 12 days, and 1, 3 and 6 months post-infusion using paired t-tests. Across all measures, rapid, statistically significant decreases (p's < 0.001) were observed with large to very large effect sizes (Cohen's d's: 1.7-8.8) at acute timepoints (24 h; 5 days). These gains were uniformly maintained to 6 months post-infusion. Open-label ketamine appeared to rapidly and robustly reduced suicidal symptoms in an ultra-high-risk, heterogeneous, real-world sample. Ketamine infusion may therefore be a safe, feasible, viable method to rapidly reduce suicidality among medically hospitalized patients after a suicide attempt, with potentially enduring benefits. The current pilot findings suggest ketamine could be readily integrated into the settings where high-risk CL patients already receive healthcare, with the potential to become an important and novel tool in the treatment of suicidality.

What is the evidence that a pharmacy team working in an acute or emergency medicine department improves outcomes for patients: A systematic review.

Pharmacy services within hospitals are changing, with more taking on medication reconciliation activities. This systematic review was conducted to determine the measured impacts of Pharmacy teams working in an acute or emergency medicine department. The protocol followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines and was prospectively registered on PROSPERO, National Institute for Health and Care Research, UK registration number: CRD42020187487. The systematic review had two co‐primary aims: a reduction in the number of incorrect prescriptions on admission by comparing the medication list from primary care to secondary care, and a reduction in the severity of harm caused by these incorrect prescriptions; chosen to determine the impact of pharmacy‐led medication reconciliation services in the emergency and acute medicine setting. Seventeen articles were included. Fifteen were non‐randomized controlled trials and two were randomized controlled trials. The number of patients combined for all studies was 7630. No studies included were based within the UK. All studies showed benefits in terms of a reduction in medicine errors and patient harm, compared to control arms. Nine articles were included in a statistical analysis comparing the pharmacy intervention arm with the non‐pharmacy control arm, with a Chi2 of 101.10 and I 2 value = 92%. However, studies were heterogenous with different outcome measures and many showed evidence of bias. The included studies consistently indicated that pharmacy services based within acute or emergency medicine departments in hospitals were associated with fewer medication errors. Further studies are needed to understand the health and economic impact of deploying a pharmacy service in acute medical settings including out‐of‐hours working.

How Biased and Carceral Responses to Persons With Mental Illness in Acute Medical Care Settings Constitute Iatrogenic Harms.

Recognizing their roles in iatrogenesis requires clinicians and professions to take responsibility for attitudes and policies that harm patients and waste resources. A striking, neglected set of examples of iatrogenic harm involves persons with severe mental illness (SMI) who seek inpatient medical care. This article describes how medicine, despite spending billions each year trying to respond to acute physical medical needs of persons with SMI, participates in carceral policies and practices that fail to prioritize continuity of care. This article also details clinicians' and professions' responsibilities to mitigate their roles in iatrogenic harm incursion by practicing antiracist, evidence-based, collaborative care to motivate equity, reduce waste, and improve outcomes, especially in crisis responses to patients experiencing acute exacerbations of SMI in inpatient medical care settings.

Hospitalized patients dying with SARS-CoV-2 infection-An analysis of patient characteristics and management in ICU and general ward of the LEOSS registry.

COVID-19 is a severe disease with a high need for intensive care treatment and a high mortality rate in hospitalized patients. The objective of this study was to describe and compare the clinical characteristics and the management of patients dying with SARS-CoV-2 infection in the acute medical and intensive care setting. Descriptive analysis of dying patients enrolled in the Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS), a non-interventional cohort study, between March 18 and November 18, 2020. Symptoms, comorbidities and management of patients, including palliative care involvement, were compared between general ward and intensive care unit (ICU) by univariate analysis. 580/4310 (13%) SARS-CoV-2 infected patients died. Among 580 patients 67% were treated on ICU and 33% on a general ward. The spectrum of comorbidities and symptoms was broad with more comorbidities (≥ four comorbidities: 52% versus 25%) and a higher age distribution (>65 years: 98% versus 70%) in patients on the general ward. 69% of patients were in an at least complicated phase at diagnosis of the SARS-CoV-2 infection with a higher proportion of patients in a critical phase or dying the day of diagnosis treated on ICU (36% versus 11%). While most patients admitted to ICU came from home (71%), patients treated on the general ward came likewise from home and nursing home (44% respectively) and were more frequently on palliative care before admission (29% versus 7%). A palliative care team was involved in dying patients in 15%. Personal contacts were limited but more often documented in patients treated on ICU (68% versus 47%). Patients dying with SARS-CoV-2 infection suffer from high symptom burden and often deteriorate early with a demand for ICU treatment. Therefor a demand for palliative care expertise with early involvement seems to exist.

Have You Seen the NEWS Today? - a QI Project

AimsThe main focus of this QIP was to improve the documentation of NEWS (National early warning scores) and subsequent escalation as appropriate in an Old Age Psychiatric Ward setting. This would in turn lead to improved Physical health outcomes, especially in the COVID-19 pandemic.MethodsThe NEWS chart is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, when patients present to, or are being monitored in hospital. This will ensure that patients who are deteriorating, or at risk of deteriorating, will have a timely initial assessment. This should supplement clinical judgement in assessing the patient's condition.Early detection and escalation of deteriorating NEWS leads to improved patient outcomes and referral to the appropriate specialties, for subsequent management.The initial phase of the QIP comprised of retrospective data collection surrounding the recognition and documentation of NEWS on an 18-bedded Old age Psychiatric ward. This period spanned the 2nd wave of the pandemic, from November- December.Potential interventions were implemented in the form of raising NEWS awareness by educating nursing staff via teaching sessions, displaying posters all over the ward and nursing station. Team also reviewed all NEWS charts everyday during ward management rounds which served as a daily reminder for the staff measuring the observations.NEWS of &amp; greater than 3 was defined as the threshold for escalation.Following change implementation, data were collected to capture the progress made over a month.ResultsAnalysis of data pre and post- interventions displayed a significant improvement in escalation of unwell patients from 26% to 60%.ConclusionImproved outcomes and early detection of potentially deteriorating patients, leading to early transfer of patients to an Acute Medical setting and better overall management.Raised awareness and understanding of physical health management in Mental Health nurses.The QIP was presented at the Trust QI Forum meeting and was met by and overwhelmingly positive response. In order to enhance NEWS recording an electronic format is now being adapted. There is also a consideration around providing regular NEWS teaching sessions to all inpatient staff across the trust.

Psychiatry\u2019s role in the prevention of post-intensive care mental health impairment: stakeholder survey

BackgroundMany critical illness survivors experience new or worsening mental health impairments. Psychiatry consultation services can provide a critical role in identifying, addressing, and preventing mental health challenges during and after admission to the acute medical care setting. However, psychiatry involvement in the ICU setting is lower than in other hospital settings and the conventional process in many hospitals requires other care providers to request consultation by psychiatry. Despite these differences, no studies have sought ICU provider perspectives on psychiatry consultation’s current and desired role. We aimed to obtain stakeholder feedback on psychiatry’s current and desired roles in the ICU, and potential benefits and drawbacks of increasing psychiatry’s presence.MethodsA web-based survey obtained perspectives from 373 critical care physicians and advance practice providers, bedside nurses, physical and occupational therapists, pharmacists, and consultation-liaison psychiatry physicians and advance practice providers at a tertiary care center using multiple choice and open-ended questions. Descriptive information and content analysis of qualitative data provided information on stakeholder perspectives.ResultsPsychiatry’s primary current role was seen as assistance with management of mental health issues (38%) and suicide risk assessments (23%). 46% wished for psychiatry’s increased involvement in the ICU. Perceived benefits of increased psychiatry presence in the ICU included early psychological support in parallel with medical care, identification of psychiatric factors impacting treatment, and facilitation of family understanding of the patient’s mental state/delirium. An additional perceived benefit included reduction in provider burnout through processing difficult situations and decreasing family psychological distress. However, one concern included potential conflict among providers regarding treatment.ConclusionsThose who work closely with the critically ill patients think that increased psychological support in the ICU would be beneficial. By contrast, psychiatry’s current involvement is seen to be limited, perhaps driven by varying perceptions of what psychiatry’s role is or should be.