Patient Care Plans Research Articles

Restraint Practices in Incapable Wandering Patients During COVID-19: Ethics and Best Practice Recommendations.

Patients who wander as one of their psychological and behavioural symptoms of dementia are often unable to follow or recall Infection Prevention and Control precautions, putting them at risk of contracting or spreading COVID-19. Physical and chemical restraints have been used to limit the risk of transmission to wandering patients and their care providers, but restraints are not the standard of care for wandering behaviour in non-pandemic scenarios. Although provincial policies on restraint use are available, their guidance may not provide the context-dependent information necessary for individual patient decisions. To address this knowledge gap, we reviewed the medical, ethical, and legal considerations through an interdisciplinary approach including nurses, physicians, ethicists, hospital leadership, risk management, and legal counsel. We present an ethical framework that front-line health-care workers can use to create a balanced patient-centred care plan for incapable wandering patients who are at risk of contracting or spreading COVID-19.

Reducing 48-h emergency department revisits and subsequent admissions: a retrospective study of increased emergency medicine resident floor coverage

BackgroundEarly unexpected hospital admission after emergency department (ED) discharge is an important topic regarding effective preventive measures. Reducing avoidable return visits can improve ED effectiveness and emergency care. This study evaluated the effects of an increase in the number of physicians and the 24-h coverage of emergency physicians on 48-h ED revisits with subsequent hospital admission. The characteristics and risk factors of the patients were also investigated.ResultsThis was a retrospective analysis performed 2 years before and 2 years after the implementation of an intervention in a tertiary care hospital in Thailand. The medical records of adult patients who revisited the ED within 48 h for related complaints were reviewed. The effect of the intervention was analyzed, and a prediction model was developed based on logistic regression.After implementing the intervention, the hospital admission rate at the second ED visit decreased from 44.5 to 41.1%; no significant difference was found (95% confidence interval (CI) − 5.05 to 11.78). Patients who required hospital admission had a significantly higher comorbidity score, more ED visits, and more hospitalizations within the past 12 months. A significantly higher hospital admission rate was also observed among patients older than 60 years, those who had an initial infectious diagnosis, and those who had a higher triage severity level (ESI II) at their first visit. The odds ratio (OR) showed lower odds of hospital admission at the second visit in the postintervention period; this difference was not significant (OR 0.87; 95% CI 0.61 to 1.23).ConclusionOur intervention did not significantly decrease the incidence of admission at an ED revisit. However, some factors identified in this study seem to have some benefits and might be helpful for preventing errors and constructing a standard discharge care plan for patients with these risk factors.

Advanced Care Planning for Patients with End Stage Renal Disease: An Integrative Review

Introduction: Patients with end stage renal disease have a high rate burden of disease and mortality. Advance care planning is important for improving the end-of life care for these patients but it is complex and challenging. This review aims to find out the interventions, context and experiences of advance care planning for end stage renal disease.Methods: Databases ProQuest Nursing and Allied Health, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, PubMed were searched for 15 years’ period from 2006-2020 yielded 10 articles. We included the studies with adult patients, diagnosed with end stage renal disease, have hemodialysis, peritoneal dialysis or without dialysis, any setting and any design quantitative and qualitative, any interventions and outcomes, qualitative studies, and family members and significant caregivers.Results : We included ten studies that involved 1526 participants (one study not mentioned theparticipants) which investigated advance care planning to patients with end-stage renal disease and their families/friends/surrogates. The interventions used were Patient‐centered Advance Care Planning, Peer-mentoring, Printed material, Booklets and patient expert, Sharing Patient’s Illness Representations to Increase Trust, Model test. Patients and caregivers felt the more need of advance care planning.Conclusion: Advance care planning needs to include as important component of renal care formanagement of patients with end stage renal disease though it is inadequately used. More interventional studies are needed to be carried out to find the most effective intervention and context to manage this trajectory illness.

Virtual interprofessional team care planning and communication for chronic pain management: An educational model

Ideal patient care involves interprofessional collaboration and therefore emphasizes the importance of communicating how roles and responsibilities differ to create a team environment critical for providing optimal patient care. In light of the ongoing opioid epidemic associated with chronic pain, this interprofessional simulation focused on utilizing an interprofessional team approach to recognize the biopsychosocial and pharmacologic aspects of chronic pain management through creation of a patient-centered care plan using a virtual platform. Virtual IPE events can be performed by institutions with limited access to other healthcare disciplines for remote learning opportunities and can be adapted to develop comprehensive strategies to evaluate effectiveness of learning interventions among varied disciplines. Participants from the Schools of Medicine, Nursing, Pharmacy, and Health Related Professions, including occupational and physical therapy, participated in the virtual simulation event. The format was chosen to adhere to current COVID-19 safety guidelines and facilitate easier scheduling between disciplines. The event included individual pre-work through an online learning management system leading to a 2-h virtual simulation event. Interprofessional Education Collaborative, or IPEC developed competencies focused on communication and teamwork to establish activity objectives. International Association for the Study of Pain, or IASP, pain curriculum outlines provided additional objectives and guided presented information on best practice approaches for interprofessional pain management. Objectives were evaluated through peer team feedback, peer discipline feedback, and assessment of the comprehensive team care plan that consisted of pharmacologic and nonpharmacologic pain management strategies. Programmatic review demonstrated students were able to have effective communication that led to a holistic patient care plan at the end of this activity.

“Am I Going to Die?”: Delivering Serious News to Patients With Liver Disease

“Am I Going to Die?”: Delivering Serious News to Patients With Liver Disease

Mishel's uncertainty in illness theory: Informing nursing diagnoses and care planning.

Patients with glioblastoma multiforme (GBM) face uncertainty during the illness trajectory that decreases their quality of life. Uncertainty manifests as an altered state of mind in patients with GBM and increases the burden of managing their diagnosis. The uncertainty in illness theory (UIT) can be used to guide nursing practice and create care plans to decrease this uncertainty. The UIT and conceptual model were used to pair diagnoses from NANDA-I Nursing Diagnoses to form care plans for patients with GBM. In a stepwise approach, concepts from the UIT were organized and cross-walked into an integrated theory-driven practice framework to enhance care planning. The UIT helps define and identify circumstances of uncertainty in patients experiencing illness, and Nursing Diagnoses provide engagement and outcomes for those uncertainty-based diagnoses. Some examples of the UIT guiding Nursing Diagnoses includes a patient's cognitive level guiding a Nursing Diagnosis care plan of Risk for Acute Confusion. Social Support can guide the care plan of Risk for Loneliness, and appraisal of uncertainty can guide a care plan for Ineffective Individual Coping. Using the UIT to guide theory-driven practice links interventions and outcomes in patients with GBM. The UIT can guide NANDA-I Nursing Diagnoses to assist nurses in creating a nursing care plan for nursing engagement to decrease uncertainty and increase the quality of life in patients with GBM. Theory-driven research defines the application of the UIT in GBM and provides foundational knowledge for theory-driven practice to occur.

Abstract 14507: Perceptions and Attitudes About Advance Care Planning Among Healthcare Professionals of Cardiac Care: A Q Methodology Study

Background: Provision of advance care planning (ACP) in patients with cardiovascular diseases is suboptimal in South Korea, which leads to an increase in the burden of care. Healthcare professionals’ perspectives of ACP are particularly important to facilitate its utilization. However, Korean healthcare professionals’ perspectives on ACP remain unknown. Aim: We explored perspectives and attitudes regarding ACP among healthcare professionals (physicians and nurses) who provide care to patients with cardiovascular diseases, using a Q methodology. Methodology: The Q sample consisted of 40 statements representing perspectives for and attitudes toward ACP derived from a literature review, mass media reports, and an in-depth qualitative interview. P samples consisted of 10 physicians and 14 nurses. The P sample filled each grid with a statement in the Q sorting table. Data were analyzed using the PQ Method program. Results: Seventy-one percent of the variance was explained with four factors represented by 18 Q – sorters, with each variance explained by each factor ranging from 16% to 20%: Factor A (n=5), healthcare professional-led decision about ACP; Factor B (n=5), patient value-based persuasive decision about ACP; Factor C (n=5), prognosis-based passive support for ACP; Factor D (n=3), comprehensive consideration -induced decision for ACP. Six Q-sorters fell into either confounded or non-significant. Shared perspectives for ACP among Korean healthcare professionals emerged in areas including conceptual definition, educational support and training, and ethical and legal concerns, while each factor also presented unique and primary perspectives for ACP. Conclusions: Our research revealed shared and unique perspectives for ACP in Korean healthcare professionals who treat cardiac patients. The findings of this study provide basic data for the provision of ACP in which, as a major stakeholder, healthcare providers’ perspectives should be considered in educational support and training. Keywords: advance care planning; cardiac disease; nurse; physician; perspectives; Q methodology

The decisional balance, attitudes, and practice behaviors, its predicting factors, and related experiences of advance care planning in Taiwanese patients with advanced cancer

BackgroundPatients with advanced cancer are prone to experience burdensome physical, psychological, and financial consequences. Healthcare providers may not fully appreciate advanced cancer patients’ medical care autonomy, such as at that emboded by Advance Care Planning (ACP), and by doing so may compromise their quality of end-of-life (EOL). Hence, it is essential for healthcare providers to effectively assess and communicate with patients’ regarding their medical decisions before their patients are incapacitated by their disease progression. The purpose of this investigation was to describe the decisional balance, attitudes, and practice behaviors of ACP and its predictors of ACP-related experiences in Taiwanese patients with advanced cancer.MethodsThis cross-sectional, descriptive study employed a mixed-methodsquantitative and qualitative design with a sample of 166 patients that were purposely recruited from in-patient oncology units at a regional teaching hospital in southern Taiwan. Study data consisted of patient replies to a 34-item self-report tool, Decisional Balance, Attitudes, Practice Behaviors of ACP (DAP-ACP) and 4 semi-structured questions.ResultFindings indicated that, in general, study participants exhibited favorable ACP-decisional balance and positive ACP-attitudes & practice behaviors. The results also indicated that gender, educational level, and cancer diagnosis were associated with significant differences on the “ACP-decisional balance” and “ACP-attitudes” scales. In addition, our findings documented that the participants’ gender and educational level were significant predictors of both ACP-decisional balance and ACP-attitudes. Furthermore the participants’ ACP-practice behaviors were predicted by ACP-decisional balance, but not with their ACP-attitudes. The qualitative analysis of the semi-structured questions identified six themes in responses to current medical decision making (e.g., compliance with physician instructions, family engagement in treatment decision-making); and eight themes pertaining to future ACP-related concerns were identified (e.g., family conflict, effectiveness of time-limited trials).ConclusionTo promote patients’ engagement in ACP, the healthcare professional need to assess and advocate patients’ concerns or attitudes regarding ACP in a timely manner. In addition, factors or concerns that might influence patients’ responses to ACP derived from both the quantitative and qualitative findings of this current study need to be considered especially in initiating the dialogue regarding ACP with patients with advanced cancer.Trial registrationNo. CYCH 2,019,072, Date of registration 5 Dec 2019.

The Needs of Orthopaedic Patients in Discharge Planning.

Patients' transition from hospital to home could be challenging for patients and caregivers. This is of utmost importance for patients requiring special or long-term care such as post-orthopaedic surgery. Effective discharge planning is required to ensure that patients are prepared to and get continuous care after returning home to prevent complications. Patients' need assessment is essential to develop effective discharge planning to meet the patient's needs. This mixed-method study aimed to determine the patient's needs to develop a discharge planning for total knee replacement surgery. The needs for 96 total knee replacement patients were assessed using the Needs Evaluation Questionnaire (NEQ). The in-depth interview primary focus was to explore the lived experience of the post-total knee replacement patients receiving care in the hospital. A total of 96 participants (100%) completed the NEQ questionnaire. Most of the needs concerned by the participants were expressed by at least 70% of them except the financial need (59.4%). The semi-structured interview found two elements which were a support group and patients' needs in terms of emotional, physical and spiritual preparation in developing effective discharge planning. This study clarified that the patient needs assessment in the patient care plan.

Emergency medical care of patients with psychiatric disorders - challenges and opportunities: Results of a multicenter survey

BackgroundPre-clinical psychiatric emergencies are generally treated by emergency medical staff. The subsequent clinical treatment is often conditioned by interaction problems between emergency medical staff and psychiatric clinical staff.ObjectivesTo identify problems affecting interaction between emergency medical and psychiatric care of mentally ill patients and pinpoint aspects of optimized emergency care.MethodsTo shed light on the interaction problems an anonymous, questionnaire-based, nonrepresentative survey of 98 emergency physicians (EM) and 104 psychiatrists (PS) practicing in acute psychiatry was conducted between March 1, 2021 and October 1, 2021.ResultsThe chi-square test for multiple response sets revealed consistently significant differences (p < 0.001) between EM and PS with respect to the questions analyzed. Approximately 36% of EM reported not to be adequately qualified to handle psychiatric emergencies (p = 0.0001), while around 50% of respondents were neutral in their assessment in how to deal with psychiatric emergencies. 80% of EM reported a negative interaction (rejection of patients) with PS when referring a psychiatric emergency patient to the acute psychiatric unit. The most common reasons for refusal were intoxication (EM: 78.8%, PS: 88.2%), emergency physician therapy (EM: 53.8%, PS: 63.5%), and not resident in the catchment area of the hospital (EM 68.8%, PS: 48.2%). In the casuistry presented, most respondents would choose “talk down” for de-escalation (EM: 92.1%, PS: 91.3%). With respect to drug therapy, benzodiazepine is the drug of choice (EM: 70.4%, PS: 78.8%). More EM would choose an intravenously (i.v.) or a Mucosal Atomization Device (MAD) administration as an alternative to oral medication (i.v.: EM: 38.8%, PS: 3.8%, p = 0.001, MAD: EM: 36.7%, PS: 10.6%, p = 0.006). Significantly more EM would seek phone contact with the acute psychiatric hospital (EM: 84.7%, PS: 52.9%, p = 0.0107). A psychiatric emergency plan was considered useful in this context by more than 90% of respondents. The need for further training for EM with regard to treating psychiatric clinical syndromes was considered important by all respondents. In particular, the topics of “psychogenic seizure,“ “intoxication,“ and “legal aspects of psychiatric emergencies” were considered important (Mann-Whitney U test, p < 0.001).ConclusionThe interaction-related problems identified in the emergency medical care of pre-clinical psychiatric patients relate to non-modifiable, structural problems, such as insufficient admission capacity and non-existent or inadequate monitoring capabilities in acute psychiatric hospitals. However, factors such as the education and training of EM and communication between EM and PS can be improved. Developing personalized emergency care plans for psychiatric patients could help to optimize their care.

Difficulties faced by patients following orthopedic day surgery

Background: An increasing share of orthopedic surgery is delivered as day surgery. Care during home rehabilitation becomes particularly important. To better provide continuity of care, understanding difficulties faced by patients is getting increasing attention by researchers and professionals around the world. Methods：The authors systematically searched the PubMed, Embase and Web of Science databases for relevant articles on orthopedic day surgery patients’ recovery experience after discharge from 2017 till present. Screening was performed strictly according to the inclusion and exclusion criteria, and finally, the relevant literature was read and summarized. Results: A total of 5 articles met the criteria published between 2017 and 2022. A diversity of difficulties faced by patients was identified, including flaws related to follow-up, education, emotional support, unclear functional rehabilitation exercise guidance and other challenges identified by recent evidence. Conclusion: Published studies indicate the importance and necessity of effective postoperative care for day surgery patients. This review also suggests that nurses should pay more attention to the recovery experience, and difficulties faced by orthopedic day surgery patients to provide high-quality continuity of care. The issue may not be receiving the best required attention in what should be a priority of healthcare management and concern with impacts on the patients’ recovery. Contribution to Evidence-Based Practice: The article contributes to an update on difficulties faced by orthopedic day surgery patients during their recovery and rehabilitation period. Professionals around the world can find a diversity of practical challenges summarized by recent international literature. This can support better patient care and rehabilitation planning following orthopedic day-surgery. Additionally, the article sustains that evidence-based nursing care can ensure better quality of care and contribute to the improvement of impacts on patients' rehabilitation.

Developing a care pathway for hospital-based advance care planning for cancer patients: A modified Delphi study.

The objective of this study is to develop a care pathway for a hospital-based advance care planning service for cancer patients. A web-based modified Delphi study consulted an expert panel consisting of a convenience sample of stakeholders including professionals with a special interest in advance care planning as well as a 'public and patient involvement group'. After generating ideas for core elements of a care pathway in the first round, numerical ratings and rankings informed the multi-professional research steering group's decision process eventually resulting in a final pathway. The 41 participants in the Delphi study identified 177 potential core elements of the pathway in the first round. In two further rounds, consensus was reached on a final version of the pathway with 148 elements covering the 10 domains: prerequisites, organisation and coordination, identification and referral, provision of information, information sources, family involvement, advance care planning discussion, documentation, update and quality assurance. We propose a care pathway for advance care planning for hospital patients with cancer based on the results of a Delphi study that reached consensus on an implementation strategy. Our study pioneers the standardisation of the process and provides input for further policy and research with the aim of aligning cancer patients' care with their preferences and values.

Transplant Open Registry Initiative

Health data science aims to extract knowledge from data allowing better decision-making, using multidisciplinary approaches from fields such as computation, statistics, epidemiology, and several medical knowledge domains. We live in the ‘big data’ era, with a growing availability of health data, in volume, variety, and velocity, also for tasks such as kidney transplantation. Hereby, secondary use of this health data must be encouraged to improve patient care planning, disease research, and policymaking around transplantation. This article presents the Transplant Open Registry (TxOR) website where some health data science applications on kidney transplantation are available. With it, we try to answer, some of the remaining questions on kidney transplantation in Portugal, with a new approach.

Assessment of differences in stress markers of edentulous patients rehabilitated with complete dentures

BackgroundBiomarkers can aid in determining the success of complete denture. Fewer studies evaluated the biomarkers in edentulous patients. This can aid in planning of better qualitative care for edentulous patients. The study compared the quantities of nitric oxide (NO), salivary alpha amylase (SAA) and thiobarbituric acid reactive substances (TBARS) before and after denture insertion in complete denture patients. MethodsThe study involved 25 edentulous patients. The saliva samples were obtained from patients prior, 1 h, and 1 week after denture insertion. Standardized procedure was followed in sample management, transportation and storing. The investigations varied with the biomarkers. SAA was estimated by enzymatic assay. TBARS by lipid peroxidation and NO was assessed by Griess reaction. The obtained data were tabled and statistically analyzed. ResultsThe results displayed variation in the level of markers between before and after denture insertion. The mean levels of SAA decreased from 8.26 ± 1.32 nm/ml to 3.44 ± 1.25 nm/ml in following denture insertion. The mean of TBARS and NO increased after denture insertion to 14.33 ± 4.72 nm/ml and NO 22.92 ± 5.79 ng/ml. The results were statistically significant with p < 0.05. ConclusionThe study concluded that denture insertion decreased the levels of psychological stress marker (SAA) and increased the Oxidative stress marker (TBARS, NO).

How to use the Malnutrition Universal Screening Tool

A five-step resource to identify issues and develop care plans for patients with malnutrition

Reprint of: Development and Evaluation of a Global Malnutrition Composite Score.

Reprint of: Development and Evaluation of a Global Malnutrition Composite Score.

Virtual coaching system for continuity of care and rehabilitation in patients with stroke. Results of the pilot study in the home scenario

With the purpose of supporting self-care at home and health management as secondary prevention, the lack of continuity of care for patients with stroke requires innovative approaches that embed the home-rehabilitation into the clinical-care-chain. vCare, a European multicenter project (EU’s Horizon2020 - https://vcare-project.eu), proposes a new ICT-based concept offering personalized home rehabilitation solutions and care pathways through a Virtual Coach (VC) that integrates machine learning technologies with coaching and clinical pathway services. Coaching at home can help these patients to proceed with a personalized form of rehabilitation and the VC can be a key technology to ensure continuity of care, reinforce self-management, enhance adherence to the care plan and risk prevention and ultimately empower patients. From the technical point of view, vCare integrates a set of technologies in a single platform. The VC provides the patient with a number of services clustered into: 1) coaching services such as physical training based on motion tracking and cognitive training; 2) supporting services such as reminders; 3) clinical pathways services allowing the seamless configuration of the VC [1,2]. The aim of this study was to evaluate the health status (EQ-5D), the reduction of risk factors and the adherence to the prescribed care plan in patients with stroke, who experienced home rehabilitation, either mediated by the virtual coach (experimental group – EG) or conventional (control group – CG). Patients with stroke were enrolled among those who were hospitalized at the Casa di Cura del Policlinico (Milan, Italy). For a period of 30-60 days in their own home, patients experienced rehabilitation treatments and activities based on the neurologist, physiotherapist and neuropsychologist’s clinical indications, provided at the discharge after the hospital care. All participants signed an informed consent. All research procedures were approved by the Local Ethics Committee. The patients in the CG performed motor and cognitive exercises suggested by therapists during the first visit. For the EG, personalized treatments and activities were suggested by the VC through a tablet, following the therapists’ predefined schedule. The rehabilitation plan consisted mainly in motor and cognitive serious games executed in a virtual reality environment realized in the patient’s home through a 3D depth camera and a monitor for the motor games, and the tablet for the cognitive ones. Additional risk factor–related activities (e.g.: e-learning session) were also foreseen and suggested. Every day the VC proposed videos with different contents; the patient could evaluate them, allowing the VC to refine the choice of videos and increase the patient’s satisfaction. Moreover, based on the monitoring of patient’s physical activity by means of an activity tracker wristband, the VC counseled additional exercise or leisure activities. The EQ-5D descriptive system and the EQ-5D visual analogue scale (EQ- VAS) were used as measure of health status for both patients belonging to the EG and CG. All the enrolled participants (N=20; 71.9±10.2 years old; 13 males; 16 ischemic) completed the experimental protocol and no adverse events were encountered during the treatment period. Subjects showed mild impairment as documented by median NIHSS of 2.5 (IQR 2.0–4.8), and median FIM score of 115 (IQR 101.3–121.8). Preliminary results on the experimental group showed, for each week of treatment, an average of: 3.07±1.76 accesses to the VC’s platform, 3.60±2.07 e-learning videos viewed, 12.69±10.75 active interactions of patients with the VC (i.e., feedback, reminders, questionnaires). In addition, results showed that patients worn the activity tracker 28.6 ± 7.7% of days of monitoring. Data-analysis and interpretations on potential benefits (quality of life, reduction of risk factors, adherence to the care plan) related to both groups (i.e., experimental and control) will be presented during SIAMOC 2022. Considering: the preliminary results related to the activities performed by the experimental group, the state of the art regarding the adherence to conventional cares and the data already obtained in a clinical home-like scenario during the previous testing phase [3], we expect to demonstrate that the vCare solution is promising in educating and empowering patients to adhere and to pursue personalized physical and cognitive rehabilitation programmes, with the final aim of regaining independence and a better quality of life through a consistent healthier lifestyle.

Increasing advance directive completion within the 4R oncology model in patients with breast cancer prior to surgery in a racially diverse patient population.

54 Background: Advance directives (ADs) are an important part of life care planning in patients with cancer. There is a lack of effective interventions to increase AD rates in breast cancer patients prior to surgery. In this quality improvement project, we implemented an intervention for breast cancer patients receiving care in an integrated healthcare delivery system. 4R (Right Info / Right Care / Right Patient / Right Time) is a novel care planning and delivery model that enables the patient and oncology care team to manage complex time-sensitive care using a multi-modality 4R Care Sequence plan, coupled with follow-up workflows. Methods: We studied two groups of patients with newly diagnosed non-metastatic breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at one facility. The Usual Care (UC) cohort received care from 10/1/19 to 9/30/20. The 4R Intervention (4R) cohort received care from 10/1/20 to 9/30/21 using a 4R Care Sequence plan that included AD completion prior to surgery; those without an AD were referred for follow-up to a health educator to discuss AD completion. Bivariate analyses were used to compare the UC and 4R cohorts on demographics, NCCN thermometer distress scores, and AD completion rates. Results: Characteristics of age, gender, race/ethnicity, needing interpreter, Elixhauser Comorbidity Index, NCCN distress scores &gt; 4, surgery type, grade, ER/PR/HER-2 status were similar in the UC (N = 140) and 4R cohorts (N = 141). AD completion prior to surgery was significantly higher for the 4R vs. UC cohort, both overall (15% vs 74%, p &lt;.01), and for White, Black, and Asian/PI subgroups (Table). The Hispanic subgroups were too small to compare AD completion. AD completion did not significantly differ by higher vs. lower distress scores. Conclusions: Implementation of a 4R Care Sequence plan coupled with health educator follow-up can significantly increase rates of time-sensitive AD completion, regardless of patient distress score and patient race/ethnicity. Use of an effective standardized care delivery model like 4R can promote equitable care.[Table: see text]

Improving plan-of-care visit completion.

288 Background: Plan of Care Visits (POCV) facilitate communicating daily plan of care among providers, nursing, and patients and their families together at the bedside. This discussion standardizes how patients and caregivers collaboratively develop treatment plans that provide the highest quality of care. Daily Plan of Care Visit Completion is expected to improve patient experience with regards to provider effectiveness and interaction. Improved opportunities for understanding, communication, and patient care planning amongst patients, patient family members, and caregivers are a function of Plan of Care Visits. The documented completion of daily POCV in 2020 on the inpatient solid oncology unit was 42% compared to an expected target of 80%. Methods: Team utilized A3 thinking and tools including process mapping, trips to gemba, brainstorming, 5 Whys and fishbone to determine which Potential Root Causes drove failure to complete POCV. Results: Team identified multiple root causes including: Lack of awareness amongst providers that POCV needs to be completed Lack of provider understanding of how to complete a POCV Inconsistent notification of the nurse and staff of when POCV are occurring. Providers unaware of the results of their POCV documentation completion rate Physician attestation templates do not include an option for proper POCV documentation. By implementing retraining and standard procedures for handoff and setting expectations at the start of each change of provider, the team was able increase POCV completion. The subsequent development of a routine to notify staff of their performance daily (and later weekly), and the integration of the POCV completion documentation option into their attestation enhanced completion from 42% in 2020 to 74% in 2021 to 85% in 2022. Conclusions: Following our QI project, POCV completion exceeded the original enterprise target of 55% and revised target of 80%. Improvement in POCV has been sustained for over a year. POCV completion led to improved communication between physicians and nurses on the inpatient unit. The standardization of the process led to consistent completion and improved interaction with the patient. The interdisciplinary care and team were a large contributor to the success of this process.

Improving the perioperative pathway of patients with diabetes undergoing surgery – a quality improvement project

Background: More than 323 000 operations take place in the UK each year in diabetic patients, accounting for 15% of all operative procedures.1 This group continues to have a longer length of stay and higher rates of adverse postoperative outcome.2 As per the 2019 National Diabetes Inpatient Audit (NaDIA), our institution currently operates below the benchmark (staff knowledge and patients’ ability to take control of their diabetes).3 Our length of stay for elective diabetes patients was 0.36 days above the national average.4 Methods: Data were collected prospectively in diabetic patients undergoing elective surgery between 1 and 30 September 2021. Pregnant, paediatric, and non-elective patients were excluded. Patient characteristics and information relevant to perioperative management was collected and analysed against The Centre for Perioperative Care (CPOC) recommendations.4 Results: Our data are shown in Table 1.Table 1Data collected perioperatively in diabetic patients.Characteristics of study subjects. Values are given as mean or n (%). DM, type of diabetes mellitus; CBG, capillary blood glucose.n27Age (yr)69 (49–89)BMI30.4 (18–38.8)ASA 10 214 (51.8%) 312 (44.4%) 41 (0.037%)DM 11 (0.037%) 226 (96.2%)Preop HbA1C <69 mmol L–122 (81.5 %) >69 mmol L–15 (18.5%)Fasting >10 h15 (55.5%)Not first on list20 (74%)WHO Checklist completed27 (100%)Anaesthetic technique GA15 (55.5%) Other12 (44.4%)CBG not measured Intraoperatively12 (44.4%) Postoperatively4 (14.8%)Duration in recovery <1 h20 (74%) >24 h1 (0.037%)Postoperative diabetes management plan As per protocol21 (77.7%) No plan identifiable6 (22.2%)Discharged Day care18 (16.6%) Ward8 (29.6%) HDU1 (0.037%) Open table in a new tab Conclusions: Compliance with CPOC guidelines was variable with some evidence of good practice and some requiring further improvement and education. To improve delivery of care in this group of patients, perioperative interventions were recommended including introduction of individualised perioperative care plans for diabetic patients, flash cards designed for glycaemic management, and development of institutional guidelines for perioperative diabetes management. We emphasise the need for teaching and training of nursing staff and educating patients about their perioperative journey and diabetes management. 1.Rotruck S, Suszan L, Vigersky R, et al. AANA J 2018; 86: 194–2002.Sampson MJ et al. Diabetes Res Clin Pract 2007; 77: 92–83.National Diabetes Inpatient Audit. NHS Digital, 2019. Available from: https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-inpatient-audit4.Guidelines for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Centre for Perioperative Care, 2021. Available from: https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes