Areas Of Care Research Articles

Catchment area rates of involuntary care and subsequent patient morbidity and mortality in Norway

IntroductionMental health legislation allows for involuntary care of patients with severe mental disorders, assuming it improves health and reduces risk. Professionals have warned against potentially adverse effects of recent initiatives to heighten involuntary care threshold, such as CRPD and national coercion-reduction strategies. We have not found that the impact of high thresholds for involuntary care have been studied.ObjectivesOur aim was to use national data from Norway to test implications of the hypothesis that areas with lower levels of involuntary care show higher levels of morbidity and mortality in their severe mental disorder populations compared to areas with higher levels. We pre-specified five models of how such adverse effects could manifest in national register data.MethodsUsing national register data, we calculated standardized (by age, sex, and urbanicity) involuntary care ratios across Community Mental Health Center areas in Norway. For patients diagnosed with severe mental disorders (ICD10 F20-31), we tested whether lower area ratios in 2015 interacted with 1) case fatality over four years, 2) an increase in inpatient days, and 3) time to first episode of involuntary care over the following two years. We also assessed 4) whether area ratios in 2015 predicted an increase in the number of patients diagnosed with F20-31 in the subsequent two years and whether 5) standardized involuntary care area ratios in 2014–2017 predicted an increase in the standardized suicide ratios in 2014–2018.ResultsWe included 21481 patients with either an F20-31 diagnosis, an episode of involuntary care in 2015, or both. The standardization variables age, sex, and urbanicity explained 70.5% of the variance in raw rates of involuntary care, and the remaining extremal quotient was 2.5. Age and sex predicted case-fatality, but involuntary care-rate was insignificant. Patients with F20-31 and no involuntary care episode in 2015 showed a steady reduction in inpatient days the following years, but not significantly related to the area’s involuntary care rates. For the same sample, these rates did not predict the time to an episode of involuntary care. The area’s involuntary care rate in 2015 did not predict changes in the number of patients in treatment for a diagnosis of F20-31 from 2015-2017. Finally, the area’s involuntary care rate from 2014-2018 explained 1.2% of the variance in suicides in 2014-2019 in the area.ConclusionsIn the models, we found no significant associations between low standardized catchment area rates of involuntary care and the pre-specified outcomes. This raises questions about some assumptions in mental health legislation and merits further research.Disclosure of InterestNone Declared

Acceptability of a pilot motivational interviewing intervention at public health facilities to improve the HIV treatment cascade among people who inject drugs in Indonesia.

HIV-positive people who inject drugs (PWID) experience challenges in initiating and adhering to antiretroviral treatment (ART). Counselling using motivational interviewing (MI) techniques may help them formulate individualised strategies, and execute actions to address these challenges collaboratively with their providers. We evaluated the acceptability of MI from a pilot implementation at three public health facilities in Indonesia. Adapting the acceptability constructs developed by Sekhon (2017) we assessed the acceptability to HIV-positive PWID clients (n = 12) and providers (n = 10) in four synthesised constructs: motivation (attributes that inspire engagement); cost consideration (sacrifices made to engage in MI); learned understanding (mechanism of action); and outcomes (ability to effect change with engagement). We included all providers and clients who completed ≥ 2 MI encounters. Qualitative analysis with an interpretive paradigm was used to extract and categorise themes by these constructs. In motivation, clients valued the open communication style of MI, while providers appreciated its novelty in offering coherent structure with clear boundaries. In cost consideration, both groups faced a challenge in meeting MI encounters due to access or engagement in other health care areas. In learned understanding, clients understood that MI worked to identify problematic areas of life amenable to change to support long-term ART, with reconciliation in family life being the most targeted change. By contrast, providers preferred targeting tangible health outcomes to such behavioural proxies. In outcomes, clients were confident in their ability to develop behaviours to sustain ART uptakes, whereas providers doubted the outcome of MI on younger PWID or those with severe dependence. There is broad acceptability of MI in motivating engagement for both actors. Relative to providers, clients were more acceptable in its mechanism and had greater confidence to perform behaviours conducive to ART engagement. Design innovations to improve the acceptability of MI for both actors are needed.

Ophthalmic Nursing in Specialized Healthcare

In health care settings, due to advancement in technologies, the expectations from every individual have increased over the last few years. Advance nursing educational programs & trainings are developing competency of nurses in every specialized area. Consequently the nurses need to enhance practical skills to meet the expectations of the patient. Nurses have upgraded standard of nursing care both in community health & hospital based health care settings. Specialized ophthalmic nurse plays significant role regarding promotion of eye health, preventive & curative treatment of eye disease as well as for low vision services & rehabilitation. In challenging situation to meet the growing needs of ophthalmic profession, modern ophthalmic nurse is frequently encountered with expectations to deal more patients, more swiftly by using specialized ophthalmic skills & new technology to meet the goals regarding eye health and wellbeing of the patients. This advanced specialized skill enables ophthalmic nurses to expand their practices in different areas of ophthalmic care. Nurses are more vigilant to deal emergencies especially in areas where the resources are minimum and burden of patients. In tertiary eye hospitals nurses perform administrative duties very efficiently as well as clinical duties. An ophthalmic nurse can assess visually impaired patient. They also helps to meet the psychological or spiritual needs of the patient. They can educate and counsel patient which plays a significant role in increasing the awareness of visually impaired.

A Re-audit of the Management of Diabetic Ketoacidosis (DKA): The Importance of the Seven-Day Working Inpatient Diabetes Specialist Nurse Service.

Background Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency due to insulin deficiency in patients with diabetes mellitus. The United Kingdom national survey and local audits of the management of DKA have revealed several areas of suboptimal care, and room for improvement, necessitating the need for intensified education, updating local guidelines, and increased recruitment of seven-day working inpatient diabetes specialist nurses. Therefore, this project aimed to re-audit our adherence to the DKA treatment guidelines. Methodology A retrospective re-audit examining patient admissions with DKA between October 2022 and September 2023. A list of 18 standards/criteria, adopted from the Joint British Diabetes Society (JBDS) DKA treatment guidelines was used for this re-audit. Results were compared with that of the previous audit. Results We had 126 patients admitted with DKA between October 2022 and September 2023. There were 62 males and 64 females with an average (range) age of 46.5 (19-92) years. Eighty percent had type 1 diabetes, and common precipitating factors for admission included infection and poor adherence to insulin treatment. The median (IQR) length of hospital stay was 2.1 (1.0-5.1) days. Compared to the previous audit, improvements occurred in 11 of 18 standards/criteria. This included timely commencement of intravenous fluids and fixed-rate insulin, commencing glucose infusion to prevent hypoglycemia,potassium replacement, continuation of long-acting insulin during treatment, timely conversion to variable-rate insulin infusion, and conversion to the usual subcutaneous insulin regimen. Additionally, 124 patients (98.4%) were reviewed at least once by the inpatient diabetes specialist nurses (DSN) during their admission. Complications of treatment, namely, iatrogenic hypoglycemia and transient hypokalemia occurred in 13 (10.3%) and 40 (31.7%) patient admissions, respectively. Conclusions This re-audit demonstrated improved adherence to the guidelines during several steps in the management of DKA. It also demonstrated room for improvement regarding other aspects of care. The importance of continued education, accurate documentation, and the presence of seven-day working inpatient DSN cover cannot be overemphasized.

Heart failure care in the Central and Eastern Europe and Baltic region: status, barriers, and routes to improvement.

Despite improvements over recent years, morbidity and mortality associated with heart failure (HF) are higher in countries in the Central and Eastern Europe and Baltic region than in Western Europe. With the goal of improving the standard of HF care and patient outcomes in the Central and Eastern Europe and Baltic region, this review aimed to identify the main barriers to optimal HF care and potential areas for improvement. This information was used to suggest methods to improve HF management and decrease the burden of HF in the region that can be implemented at the national and regional levels. We performed a literature search to collect information about HF epidemiology in 11 countries in the region (Bulgaria, Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Serbia, and Slovenia). The prevalence of HF in the region was 1.6-4.7%, and incidence was 3.1-6.0 per 1000person-years. Owing to the scarcity of published data on HF management in these countries, we also collected insights on local HF care and management practices via two surveys of 11 HF experts representing the 11 countries. Based on the combined results of the literature review and surveys, we created national HF care and management profiles for each country and developed a common patient pathway for HF for the region. We identified five main barriers to optimal HF care: (i) lack of epidemiological data, (ii) low awareness of HF, (iii) lack of national HF strategies, (iv) infrastructure and system gaps, and (v) poor access to novel HF treatments. To overcome these barriers, we propose the following routes to improvement: (i) establish regional and national prospective HF registries for the systematic collection of epidemiological data; (ii) establish education campaigns for the public, patients, caregivers, and healthcare professionals; (iii) establish formal HF strategies to set clear and measurable policy goals and support budget planning; (iv) improve access to quality-of-care centres, multidisciplinary care teams, diagnostic tests, and telemedicine/telemonitoring; and (v) establish national treatment monitoring programmes to develop policies that ensure that adequate proportions of healthcare budgets are reserved for novel therapies. These routes to improvement represent a first step towards improving outcomes in patients with HF in the Central and Eastern Europe and Baltic region by decreasing disparities in HF care within the region and between the region and Western Europe.

Abstract 998: Pursuing leadership in literacy to ameliorate head and neck cancer disparities

Abstract Overview of Proposed Research. Head and neck cancers are a deadly cancer that ranks among the six most common cancers worldwide. (American Cancer Society, 2021). Studies have shown greater disease burden among minority populations for head and neck cancer, higher mortality rates and lower oral cancer knowledge, but limited evidence has defined the underlying causes of late stage diagnoses and access to the healthcare system (Suzuki et al, 2019). More specifically, in comparison to the national rates, South Carolina is among the top ten for head and neck cancers (Community Outreach, Hollings Cancer Center, MUSC, 2019). Dental and primary care play a critical role delivering quality patient education, prevention, risk reduction and treatment regimes. However, there is a paucity of information published on the value of designing and implementing a health literacy program to prioritize head and neck cancer screening and prevention. Rural communities face unique challenges to achieving optimal oral health, impacted mainly by geographic location and socioeconomic status (IOM&NRC, 2011). More specifically, rural southern states such as SC continues to have a tremendous shortage of primary care providers. SC currently has 44 of 46 counties designated as geographic Primary Care and Dental Health Professional Shortage Areas and approximately 25% of SC citizenry are living in rural areas (HRSA, 2018). Because the vast majority of the state has challenges with availability of primary care and dental providers, this potentially exacerbates access to care inequities for rural and underserved minority populations. To enhance the quality and equity of oral cancer prevention in rural SC, it is critical that we prioritize strategies to elevate the significance of head and neck cancer risks. Therefore, the need to design and deliver innovative strategies to increase opportunities that intersect the healthcare system and community is inevitable. In this regard, we propose PULL A-HEAD, Pursuing Leadership in Literacy to Ameliorate HEAd and neck cancer Disparities. PULL A-HEAD is aimed to develop and implement a community-centered approach design for increasing the health literacy and efficacy of navigating the healthcare system for early detection of head and neck cancers. In this presentation we will share outcome and impact results of a community-centered, health literacy program in collaboration with our Regional Medical Library - Region 2 (RML2), National Library of Medicine partners at the Medical University of South Carolina. The program (i.e. PULL A-HEAD) will emphasize the delivery of health literacy education and health systems navigation tools to improve the early detection of head and neck cancers. Citation Format: Joni D. Nelson, Irene M. Lubker. Pursuing leadership in literacy to ameliorate head and neck cancer disparities [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 998.

Abstract P153: Disruptions to Diabetes and Hypertension Care During the COVID-19 Pandemic and Recovery Approaches in the Latin America and Caribbean Region

Background: The COVID-19 pandemic disrupted healthcare services in Latin America and the Caribbean (LAC). However, few studies provided comprehensive and quantitative data on the magnitude of this disruption. Objectives: To synthesize evidence on the extent of disruptions to diabetes and hypertension care in LAC during the COVID-19 pandemic and interventions to recover. Methods: We conducted a scoping review of published papers in English, Spanish, and Portuguese. We adopted the Primary Health Care Performance Initiative (PHCPI) Framework to identify healthcare services susceptible to disruptions during the COVID-19 pandemic, specific to diabetes and hypertension, including recovery approaches. We synthesized study findings narratively to represent the diversity of findings geographically and health system. Results: Our search yielded 33,510 abstracts after de-duplication; following title/abstract screening and full-text review, 330 articles (218 on disruptions; 112 on interventions) were included in the synthesis. Although there was high heterogeneity, similarities in landscape of disruptions to primary care services across LAC exist. Of the PHCPI Framework domains, disruptions to workforce, medications and supplies, and patient-related outcomes were most recurrent. Intervention studies focused telehealth using digital strategies for diverse care areas and counseling support for health behaviors and mental health. There were data gaps within LAC regarding health system readiness and digital health effectiveness, adoption, efficiency, reach, and sustainability ( Figure ). Conclusions: This scoping review identified priorities for action within LAC: 1) establish and fund high-quality research and surveillance systems for hypertension and diabetes; 2) Optimally integrate digital health into hypertension and diabetes care; 3) implement mental health promotion strategies among healthcare workers; 4) establish optimal governance, leadership, and financing of healthcare systems.

Elderly Migrants and their Socially Isolated Living

Elderly population has a rapid rise in Nepal. The 2021 census reports 2.97 million elderly people, which equals 10.21 percentage of Nepal's total population, and 38.2 percentage more from the 2011 census. Realizing the problems faced by elderly population in areas of social-cultural, economic, demographic, labor, health, and care, the Elderly Citizens Act, 2006 was ratified by Nepal to address senior citizens' social security needs and issues. The study analyzes how elderly residents of Kirtipur have managed to survive in a family and community setting. Data is gathered from participant observation and in-depth interviews. I have made efforts to analyze whether financial reliance, parental assistance, social interaction, social isolation, and health issues have co-worked for giving stresses to the elderly people. Senior citizens experience many problems like loneliness and helplessness, which are sufficient for creating troubles and anxieties. They also struggle with having a low social position relative to where they were born and missing out on social and cultural events. They also have gone through social and cultural disengagement, family rejection, loss of social contact, and social isolation from their place of origin.

Key Indicators for Monitoring the Efficiency of Iranian Health System: A Synthesized Design Study.

A significant share of medical care, primary health care, and health-related education and research in Iran is provided by the Ministry of Health and its affiliated universities of medical sciences. We aimed to identify a set of key metrics for monitoring their efficiency in the four areas of medical care, primary health care, education and research. A combination of scoping review, expert panel and Delphi method was used. First, the relevant keywords were searched in the appropriate databases between 2000 and 2020. The final extracted indicators then reviewed, reduced and refined through the expert panel meetings. The last metrics were established following a three-stage Delphi study. Out of 2327 studies, 155 were selected following the different screening stages of scoping review. After summarizing and refining the indicators via several expert panel meetings and the Delphi method, a total of 36 key indicators were considered appropriate for measuring efficiency of the health system, 23 of which were for the sub-systems of public health (4 indicators), medical services (10 indicators), education (4 indicators) and research (5 indicators) and 13 indicators for the whole system efficiency. The set of indicators presented representing both the technical and allocative efficiency, might be a reliable basis for designing information systems and management dashboards for periodic monitoring of health system efficiency at national, regional and local levels.

Advancing pediatric perioperative care in India: Acontemporary overview.

In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care. With this background, we aim to provide an overview of the present and future of healthcare in India. With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable. With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships. India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

Telephone follow-up after outpatient nail surgery - a retrospective analysis.

One of the areas of care in dermatosurgery is the surgical treatment of diseases of the nail organ. Side effects and complications after nail surgery were investigated by telephone follow-up (TFU), and its suitability for postoperative monitoring and consultation was assessed. All patients who underwent nail surgery at the Department of Dermatology at the Ludwigshafen City Hospital from October 2019 to December 2021 in outpatient setting were contacted by telephone on the second to third postoperative day and questioned in a standardized manner about postoperative complaints and counselled if necessary. A total of 100 cases were followed up. The most common procedures performed were phenol matricectomy (41%), nail avulsion (16%), and nail matrix biopsies (9%). 50% and 21% of patients reported pain on the day of the procedure and the day after surgery, respectively. After nail avulsion, pain was statistically significantly more frequently reported on the day following the procedure and pain medication was statistically significantly more frequently required (p = 0.002). Serious adverse events did not occur after nail surgery. 10% of the respondents raised specific questions and needed counseling by TFU. All nail surgeries were well tolerated in the outpatient setting. Pain was the most common side effect, although only half of all patients reported pain on the day of surgery and only 21% on the day after the procedure. The TFU proved to be an effective and practical as well as easy to establish method for postoperative follow-up and consultation after outpatient nail surgery.

Choosing a nursing specialty: connection to nursing students’ personality traits, clinical self-efficacy, adoption of technology changes, and specialty prestige; a cross-sectional study

BackgroundChoosing a field of specialization within the nursing profession is affected by nurses’ personality traits, self-confidence in performing clinical skills, and the field’s prestige. A successful choice of area of expertise may improve nurses’ job satisfaction and reduce job mobility. This study aims to examine the relationship between personality traits, clinical self-efficacy, perceived prestige, adoption of technological changes, and choice of specialty field among nursing students.MethodsA cross-sectional study was conducted. One-hundred-twenty-seven undergraduate nursing students in their fourth year of studies at a large university in Israel participated in the study. The questionnaire administered was comprised of six parts: demographic data, personality traits, adoption of technological changes, clinical self-efficacy, perceived prestige, and intention to select a field of specialization.ResultsAcute disciplines were rated more prestigious than chronic disciplines, with intensive care and emergency medicine considered the most prestigious, while mental health and geriatrics were the least prestigious. Students’ mean perceived confidence in performing nursing clinical skills was high and more than half considered themselves open to technology changes. Positive correlations were found between prestige and intention to choose a field of expertise (r = 0.41, p < 0.001) and the personality trait of openness and the intention to choose an acute care area (r = 0.26, p < 0.01).ConclusionsDespite the gradual aging of the population and the increase in chronic morbidity, which demand a greater nursing focus on older adults, and notwithstanding the mental health reforms, nursing students perceive geriatrics and mental health as less prestigious fields. A career development path can be applied by developing a tool for occupational guidance designed to rank students’ suitability for specialty fields and thus help them choose the area that best suits them.

Neuropalliative care in deep brain stimulation for Parkinson’s disease: Potential impactful areas of care

Neuropalliative care (NPC) is a relatively new subspeciality of neurology. Recent studies have demonstrated efficacy of NPC in Parkinson’s disease (PD). However, the implementation of NPC in deep brain stimulation (DBS) has yet to be addressed. Patients with PD being evaluated for and having undergone DBS potentially have unmet needs that may be best assessed and managed by neuropalliative neurologist. Specific areas include an in-depth psychosocial evaluation, exploration of patient and caregiver expectations, addressing caregiver needs, providing spiritual and marital support, and discussing advance directives.

Effect of Dzikir (Religious Chanting) Therapy on The Anxiety Level of Third-Trimester Pregnant Women Facing Labor

ABSTRACT Anxiety in the third trimester of pregnancy is often related to impending labor and childbirth. In Indonesia, 28.7% of pregnant women in the third trimester experienced anxiety. The negative impact of anxiety during pregnancy includes the risk of miscarriage and fetal abnormalities. Non-pharmacological therapies based on Islam, such as dzikir (religious chanting) therapy, have been developed. To determine the effect of dzikir (religious chanting) therapy on the anxiety level of third-trimester pregnant women facing labor in the working area of Bandar Negeri Suoh Primary Health Care in the year 2023. This research was quantitative in design and employed a pre-experimental design with a one-group pretest and posttest design. The population of this study consisted of third-trimester pregnant women in the working area of Bandar Negeri Suoh Primary Health Care in July. The total was 35 people, with 30 people as the sample. The sampling technique used is purposive sampling. Moreover, the data analysis involved univariate and bivariate analyses with the Wilcoxon test.The results of this r esearch showed that the average anxiety level of third-trimester pregnant women facing labor before undergoing dzikir (religious chanting) therapy was 21.4, and after undergoing dzikir (religious chanting) therapy, it decreased to 10.7. Bivariate analysis revealed that there was an effect of dzikir (religious chanting) therapy on the anxiety level of third-trimester pregnant women facing labor, with a p-value of 0.000. An effect of dzikir (religious chanting) therapy on the anxiety level of third-trimester pregnant women facing labor in the working area of Bandar Negeri Suoh Primary Health Care in the year 2023. Keywords: Anxiety, The Dzikir (Religious Chanting) Therapy, Pregnant Women

Midwifery support and intervention in the framework of care for women with mental disorders during the postpartum period

Abstract Aim. The postpartum period is very demanding due to hormonal changes, changing social roles and financial concerns, i.e., factors affecting a woman´s mental health and quality of life. Midwifery care also includes interventions in this area of holistic care. This study aims to identify and describe midwifery interventions focussing on moderating mental disorders by women in the postpartum period. Methods. A scoping review designed following PRISMA – ScR guidelines in databases Science Direct, Web of Science and PubMed was conducted in 2022. Results. The analyses of articles identified ten interventions, which were further merged into five categories: Use of measuring scale in women´s care; Support of the mother–child relationship; Education of women, counselling for women; Midwife – support for women; Visit of a midwife in women´s home environment. All interventions, except for the use of measuring scales, use communication skills. Conclusions. The analysed studies outlined a wide variety of non-pharmacological interventions midwives use to care for women with mental disorders during the postpartum period. Midwives use communication skills, education, support, and encouragement to make women feel safe and secure and thus improve their mental postpartum experience.

Definition, Management, and Training in Impacted Fetal Head at Cesarean Birth: A National Survey of Maternity Professionals

ABSTRACT Impacted fetal head (IFH) is a complication that occurs in 10% of cesarean deliveries (CDs). Disimpacting the fetal head can have significant maternal risks, including trauma to the uterus, vagina, cervix, and bladder, postpartum hemorrhage, as well as neonatal risks, including skull fracture, intracranial hemorrhage, head and face trauma, low oxygen levels, admission to the neonatal intensive care unit, and death. Perinatal head injury due to IFH has resulted in increased litigation, with IFH identified as a contributing factor in nearly 10% of the most expensive maternity claims in the United Kingdom in 2018. International consensus on the most effective and safe management of IFH is lacking. Moreover, recent surveys of maternity professionals in the United Kingdom have reported a scarcity of training, lack of confidence, and underused techniques for IFH. Understanding how maternity professionals view the management of IFH during CD is helpful to improve care, training, and research. The aim of this study was to assess the views, understanding and practices to manage IFH during CD. This was a survey of health care professionals who provide maternity care or work in policy, research, or other areas of maternity care, using a secure online collaborative platform called Thiscovery. Participants included Thiscovery subscribers and members of clinical practice societies, such as the Royal College of Midwives, Royal College of Obstetricians and Gynecologists, and Royal College of Anesthetists. The survey analyzed responses for open-ended questions, with free-text entries, and closed-ended questions. A total of 419 participants were included in the analysis, including 144 midwives, 216 obstetricians, and 59 other maternity professionals. A high level of agreement was found among 79% of obstetricians who preferred a definition of IFH at CD that included “additional maneuvers and/or tocolysis to disimpact and deliver the fetal head.” About a third of free-text responses from 17 respondents noted a need to incorporate the difficulty or inability to get a hand below the fetal head for delivery. Approximately 95% of participants agreed or strongly agreed that management of IFH at CD requires a multiprofessional approach. When asked about communicating an IFH emergency, 55% preferred using the declaration, “This is an impacted fetal head.” Free-text responses from 57 participants emphasized the importance of clear communication and awareness of the emergency across all team members before and during the management of IFH as well as with the woman and birth partner. More than 70% found that a change of operator, manual cephalic extraction, tocolysis, operating changing hand, reserve breech extraction, Fetal Pillow, head-down tilt, and vaginal disimpaction were safe and effective techniques and adjunctive measures for managing IFH at CD. However, free-text responses from 56 participants found mixed views on the use of tocolysis, noting the risk of complications such as postpartum hemorrhage. The use of Fetal Pillow was positively accepted by 71 participants. Comparing obstetricians with midwives, approximately three quarters of obstetricians considered vaginal disimpaction before CD acceptable (72% preincision and 76% postincision). Fewer midwives favored this technique (25% preincision and 52% postincision), with 88% reporting that knowing the position of the fetal head would be helpful to know before undertaking vaginal disimpaction. Training in vaginal disimpaction was considered essential by 85% of midwives and obstetricians. Yet only 81% of midwives and 57% of obstetricians had received such training. The preferred method of training was hands-on training in simulation (91%), followed by animated video illustrating disimpaction techniques (73%) and small-group teaching (55%). Free text responses form 159 participants demonstrated a need and appetite for more training. The most frequent suggestions to improve care for IFH at CD included holding briefings and debriefings before and after the emergency and having robust plans for escalation and calling for help. This study identified high agreement among United Kingdom maternity professionals to define IFH at CD. The study authors suggested a standard definition as “a cesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional maneuvers and/or tocolysis are required to disimpact and deliver the fetal head.” In addition, using unambiguous language in the emergency, such as declaring “This is an impacted fetal head,” facilitates teamwork and collaboration and improves care.

Sprint-inspired One-on-One Post-Go-Live Training Session (Mini-Sprint) Improves Provider Electronic Health Record Efficiency and Satisfaction.

Inefficient electronic health record (EHR) usage increases the documentation burden on physicians and other providers, which increases cognitive load and contributes to provider burnout. Studies show that EHR efficiency sessions, optimization sprints, reduce burnout using a resource-intense five-person team. We implemented sprint-inspired one-on-one post-go-live efficiency training sessions (mini-sprints) as a more economical training option directed at providers. We evaluated a post-go-live mini-sprint intervention to assess provider satisfaction and efficiency. NorthShore University HealthSystem implemented one-on-one provider-to-provider mini-sprint sessions to optimize provider workflow within the EHR platform. The physician informaticist completed a 9-point checklist of efficiency tips with physician trainees covering schedule organization, chart review, speed buttons, billing, note personalization/optimization, preference lists, quick actions, and quick tips. We collected postsession survey data assessing for net promoter score (NPS) and open-ended feedback. We conducted financial analysis of pre- and post-mini-sprint efficiency levels and financial data. Seventy-six sessions were conducted with 32 primary care physicians, 28 specialty physicians, and 16 nonphysician providers within primary care and other areas. Thirty-seven physicians completed the postsession survey. The average NPS for the completed mini-sprint sessions was 97. The proficiency score had a median of 6.12 (Interquartile range (IQR): 4.71-7.64) before training, and a median of 7.10 (IQR: 6.25-8.49) after training. Financial data analysis indicates that higher level billing codes were used at a greater frequency post-mini-sprint. The revenue increase 12 months post-mini-sprint was $213,234, leading to a return of $75,559.50 for 40 providers, or $1,888.98 per provider in a 12-month period. Our data show that mini-sprint sessions were effective in optimizing efficiency within the EHR platform. Financial analysis demonstrates that this type of training program is sustainable and pays for itself. There was high satisfaction with the mini-sprint training modality, and feedback indicated an interest in further mini-sprint training sessions for physicians and nonphysician staff.

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life

BackgroundNon-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.MethodsQualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.ResultsOverall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.ConclusionsAn intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.Trial registrationAustralia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Clinical mentorship of midwifery students: The perceptions of registered midwives.

Clinical mentors are experienced practitioners who play an important role in encouraging the professional development of students in clinical areas. The responsibility of clinical mentorship in nursing is often difficult to maintain. However, there is a dire need for clinical mentorship in maternity units, especially in South African hospitals were high maternal mortality rates remain alarmingly high. This study aimed to describe the perceptions of registered midwives regarding the clinical mentorship of midwifery students. The study occurred in a semi-rural state regional hospital in the eThekwini district, KwaZulu-Natal. A qualitative exploratory and descriptive design was conducted using in-depth individual interviews with midwives in maternity units. A purposive and convenient sampling method recruited 17 registered midwives from 3 maternity care areas within a single setting. Interviews were audio-recorded and all data were analysed using qualitative content analysis. Five categories emanated from this study namely, sharing knowledge and skills; encouraging role model behaviour; promoting self-worth; Is a challenging task; and requiring additional support. Clinical mentorship has a reciprocal effect on teaching and learning in maternity care areas and encouraged registered midwives to lead as role-models. The process demands competence, professionalism, and leading by example. Despite the confidence, satisfaction and interest in clinical mentorship, registered midwives often find the process challenged by patient care priorities. Therefore, registered midwives require additional support to mentor students in clinical practice. This article shows that clinical mentorship places various challenges on registered midwives and formal mentorship training could be beneficial.

"I think we did the best that we could in the space:" A qualitative study exploring individuals' experiences with three unconventional environments for patients with a delayed hospital discharge.

Given growing hospital capacity pressures, persistent delayed discharges, and ongoing efforts to improve patient flow, the use of unconventional environments (newly created or repurposed areas for patient care) is becoming increasingly common. Despite this, little is known about individuals' experiences in providing or receiving care in these environments. The objectives of this study were to: (1) describe the characteristics of three unconventional environments used to care for patients experiencing a delayed discharge, and (2) explore individuals' experiences with the three unconventional environments. This was a multi-method qualitative study of three unconventional environments in Ontario, Canada. Data were collected through semi-structured interviews and observations. Participants included patients, caregivers, healthcare providers, and clinical managers who had experience with delayed discharges. In-person observations of two environments were conducted. Interviews were transcribed and notes from the observations were recorded. Data were coded and analyzed thematically. Twenty-nine individuals participated. Three themes were identified for unconventional environments: (1) implications on the physical safety of patients; (2) implications on staffing models and continuity of care; and, (3) implications on team interactions and patient care. Participants discussed how the physical set-up of some unconventional spaces was not conducive to patient needs, especially those with cognitive impairment. Limited space made it difficult to maintain privacy and develop social relationships. However, the close proximity of team members allowed for more focused collaborations regarding patient care and contributed to staff fulfilment. A smaller, consistent care team and access to onsite physicians seemed to foster improved continuity of care. There is potential to learn from multi-stakeholder perspectives in unconventional environments to improve experiences and optimize patient care. Key considerations include keeping hallways and patient rooms clear, having communal spaces for activities and socialization, co-locating team members to improve interactions and access to resources, and ensuring a consistent care team.