General Surgical Wards Research Articles

Comparative study of proportions of post-operative sepsis _ maternity versus general surgical ward

Abstract: Post-operative sepsis tends to complicate the recovery course of many patients. Across the globe, the proportion of post-operative sepsis varied from 2.9% to 30% in various studies. To de...

Antibiotics in Prevention and Treatment of Multi-Drug Resistant (MDR) Organisms causing Surgical Site Infection (SSI)

Antibiotics play a vital role in prevention and treatment of various infections. But inappropriate antibiotic choice could lead to emergence of multi-drug resistance (MDR) among microorganisms. Since, the antibiotic susceptibility pattern of organisms could vary from place to place; forming a local prophylaxis and treatment protocol could hugely reduce this global burden. The primary objectives of the study were to observe the frequency of multi-drug resistant organisms causing Surgical Site Infections (SSIs) and to study the pattern of antibiotic usage for the prophylaxis and treatment of SSIs. A descriptive study was carried out in general surgical wards of KR hospital, Mysore for a period of 18 months (2015-2016). The relevant data was collected from the case sheets of patients who were diagnosed with SSI. Pus samples were collected, and culture-sensitivity was done. Collected data were analyzed using relevant statistical tests. A total of 263 study subjects including both males and females were enrolled in the study. Cefotaxime was the most common antibiotic used for pre-surgical prophylaxis (n=221). Out of 263 pus samples 92% were culture positive. The most common organisms causing SSI were E-coli-ESBL (n=73) and MRSA (n=44). About 95% of organisms showed multi-drug resistance. Imipenem, Gentamicin, Piperacillin-Tazobactum and Linezolid were the most common antibiotics used in the treatment of SSIs. The result of the study is alarming. Overall, there is great rise in the prevalence of MDR organisms causing SSIs. The hospital antibiotic policy should be revised in such a way to decrease the emergence of MDR microbes.

Evaluation of Postoperative Pyrexia within 48 Hours of Elective Surgery in General Surgical Ward of Rajah Muthiah Medical College and Hospital

Evaluation of Postoperative Pyrexia within 48 Hours of Elective Surgery in General Surgical Ward of Rajah Muthiah Medical College and Hospital

Factors affecting In-patient stay in patients operated for peptic ulcer perforation.

Objectives: Recognizing the risk factors affecting the in-hospital stay of the patients operated for peptic ulcer perforation. Study Design: Cross Sectional study. Setting: General Surgical Wards, Nishtar Hospital Multan. Period: From 15th November 2018 to 5th of March 2019. Material & Methods: A total of 100 patients of all ages who had a peptic ulcer perforation were included. Patients with a perforation that wasn't attributable to a peptic ulcer e.g. malignancy or gastrinoma were excluded. Patients were asked about their smoking and drinking habits. Data was collected about various risk factors of peptic ulcer, their co-morbidities and the medications. Results: Gender, smoking, alcohol intake, H-pylori infection, size & site of perforation did not have a significant effect on hospital stay days. In patient stay days differed in groups based on comorbidities and medication. A weak correlation was found among age and stay days. Conclusion: Patients with complain of COPD and other pulmonary complications have a longer hospital stay in the hospital. The association of arthritis and hypertension could not be demonstrated comprehensively.

Outbreaks of Healthcare-Associated Infections in Sao Paulo State, Brazil: Results From a Statewide Monitoring System

Background: Outbreaks of healthcare-associated infections (HAI) are relevant causes of morbidity and mortality. Healthcare-authorities should monitor them to allow prompt interventions, identify tendencies along the time, and develop large scale strategies to avoid new cases and clusters. According to the Brazilian legislation, any outbreak should be reported to health authorities. Sao Paulo State Health Department (Brazil) has a system in place since 2011 to monitor HAI outbreaks. This study aims at describing the 3.5 last year’s results of surveillance system for monitoring HAI outbreaks. Methods:Study design: Quantitative descriptive study. Source of information: Database from HAI outbreak reports, Division of Hospital Infection at Sao Paulo State Health Department. Reports were filled out online by professionals from healthcare settings or regional health authorities according to predefined criteria. Interventions were put in place by the health authorities based on the analysis of each situation in a timely manner. Variables analyzed: Number of reports, local, infection site, type of care unit, causative microorganisms, number of cases, and number of deaths. Results: The number of reports have been stable for 3 years: 2016 (n = 34, 34.7%), 2017 (n = 28, 28.6%), 2018 (n = 25, 25.5%) and the first semester of 2019 (n = 11, 11.2%). These reports encompassed 712 confirmed cases and 123 deaths. The reports were mainly about infection outbreaks; 6 reports were about colonization of multidrug-resistant microorganisms. The bloodstream was the most frequent infection site in the HAI outbreak reports (n = 37, 37.7%), followed by respiratory tract (n = 25, 25.5%), urinary tract (n = 10, 10.2%), and surgical wound (n = 9, 9.2%). HAI outbreaks happened more frequently in intensive care units, including neonatal, pediatric, and adult ICUs (n = 38, 38.8%), followed by clinical and general wards (n = 20, 20.4%), hemodialysis (n = 6, 6.1%), and surgical wards (n = 5, 5.1%). Among reported outbreaks, 62.2% occurred in the capital and the metropolitan region of São Paulo. Microorganisms causing the HAI outbreaks reports were mainly carbapenem resistant, both Klebsiella pneumoniae (n = 28, 28.5%) and Acinetobacter baumannii (n = 12, 12.2%), but carbapenem-susceptible Pseudomonas aeruginosa (n = 7, 7.1%) was also reported. Conclusions: HAI outbreaks reported to health authorities in Sao Paulo may represent only a minute percentage of the total outbreaks, most of which are still not being reported, despite the normative. However, the available data emphasize the importance of developing strategies for intensive care units and hemodialysis units that focus on reducing bloodstream infections caused by multidrug-resistant gram-negative organisms.Funding: NoneDisclosures: None

Pathogens Associated With Repeat Versus Single Central-Line–Associated Bloodstream Infections, Acute-Care Hospitals, NHSN

Background: The NHSN is the nation’s largest surveillance system for healthcare-associated infections. Since 2011, acute-care hospitals (ACHs) have been required to report intensive care unit (ICU) central-line–associated bloodstream infections (CLABSIs) to the NHSN pursuant to CMS requirements. In 2015, this requirement included general medical, surgical, and medical-surgical wards. Also in 2015, the NHSN implemented a repeat infection timeframe (RIT) that required repeat CLABSIs, in the same patient and admission, to be excluded if onset was within 14 days. This analysis is the first at the national level to describe repeat CLABSIs. Methods: Index CLABSIs reported in ACH ICUs and select wards during 2015–2108 were included, in addition to repeat CLABSIs occurring at any location during the same period. CLABSIs were stratified into 2 groups: single and repeat CLABSIs. The repeat CLABSI group included the index CLABSI and subsequent CLABSI(s) reported for the same patient. Up to 5 CLABSIs were included for a single patient. Pathogen analyses were limited to the first pathogen reported for each CLABSI, which is considered to be the most important cause of the event. Likelihood ratio χ2 tests were used to determine differences in proportions. Results: Of the 70,214 CLABSIs reported, 5,983 (8.5%) were repeat CLABSIs. Of 3,264 nonindex CLABSIs, 425 (13%) were identified in non-ICU or non-select ward locations. Staphylococcus aureus was the most common pathogen in both the single and repeat CLABSI groups (14.2% and 12%, respectively) (Fig. 1). Compared to all other pathogens, CLABSIs reported with Candida spp were less likely in a repeat CLABSI event than in a single CLABSI event (P < .0001). Insertion-related organisms were more likely to be associated with single CLABSIs than repeat CLABSIs (P < .0001) (Fig. 2). Alternatively, Enterococcus spp or Klebsiella pneumoniae and K. oxytoca were more likely to be associated with repeat CLABSIs than single CLABSIs (P < .0001). Conclusions: This analysis highlights differences in the aggregate pathogen distributions comparing single versus repeat CLABSIs. Assessing the pathogens associated with repeat CLABSIs may offer another way to assess the success of CLABSI prevention efforts (eg, clean insertion practices). Pathogens such as Enterococcus spp and Klebsiella spp demonstrate a greater association with repeat CLABSIs. Thus, instituting prevention efforts focused on these organisms may warrant greater attention and could impact the likelihood of repeat CLABSIs. Additional analysis of patient-specific pathogens identified in the repeat CLABSI group may yield further clarification.Funding: NoneDisclosures: None

Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial.

BackgroundPeripheral intravenous catheters (PIVCs) are ubiquitous medical devices, crucial to providing essential fluids and drugs. However, post-insertion PIVC failure occurs frequently, likely due to inconsistent maintenance practice such as flushing. The aim of this implementation study was to evaluate the impact a multifaceted intervention centred on short PIVC maintenance had on patient outcomes.MethodsThis single-centre, incomplete, stepped wedge, cluster randomised trial with an implementation period was undertaken at a quaternary hospital in Queensland, Australia. Eligible patients were from general medical and surgical wards, aged ≥ 18 years, and requiring a PIVC for > 24 h. Wards were the unit of randomisation and allocation was concealed until the time of crossover to the implementation phase. Patients, clinicians, and researchers were not masked but infections were adjudicated by a physician masked to allocation. Practice during the control period was standard care (variable practice with manually prepared flushes of 0.9% sodium chloride). The intervention group received education reinforcing practice guidelines (including administration with manufacturer-prepared pre-filled flush syringes). The primary outcome was all-cause PIVC failure (as a composite of occlusion, infiltration, dislodgement, phlebitis, and primary bloodstream or local infection). Analysis was by intention-to-treat.ResultsBetween July 2016 and February 2017, 619 patients from 9 clusters (wards) were enrolled (control n = 306, intervention n = 313), with 617 patients comprising the intention-to-treat population. PIVC failure was 91 (30%) in the control and 69 (22%) in the intervention group (risk difference − 8%, 95% CI − 14 to − 1, p = 0.032). Total costs were lower in the intervention group. No serious adverse events related to study intervention occurred.ConclusionsThis study demonstrated the effectiveness of post-insertion PIVC flushing according to recommended guidelines. Evidence-based education, surveillance and products for post-insertion PIVC management are vital to improve patient outcomes.Trial registrationTrial submitted for registration on 25 January 2016. Approved and retrospectively registered on 4 August 2016. Ref: ACTRN12616001035415.

Sepsis in surgical inpatients: under-recognised but with significant consequences.

The true incidence of sepsis in surgical cohorts in Ireland remains unclear. According to inpatient audits, patients in surgical diagnostic groups (DRG) who developed sepsis had a longer length of stay and higher mortality rate compared with medical DRG patients who developed sepsis. We investigated sepsis incidence on a general surgical ward to identify risk factors and strategies to improve management. Demographics, admission and discharge details, infection risk factors, infection, and sepsis were studied prospectively on a surgical ward in July 2018. The mean age of 164 patients was 60.5 years (range 18-93 years), 107 (65.2%) were admitted electively, 16 (9.8%) were colonised with a multidrug-resistant organism (MDRO), and 30 (18.3%) were classified as frail on admission. Twelve (7.3%) developed sepsis (ward sepsis rate 118.2/10,000 bed days used). 'Sepsis' was documented in six cases and the national sepsis screening form used in four patients. Patients with sepsis were three times as likely to be MDRO-colonised (OR 3.56; 95% CI = 0.86-14.82; p = 0.065) or frail (OR 3.63; 95% CI = 1.07-12.35; p = 0.03), four times as likely to be an inpatient at the end of the study (OR 4.22, 96% CI 1.23-14.49; p = 0.01), and three times as likely to be readmitted (OR 3.46, 95% CI 1.02-11.76; p = 0.03). Sepsis was under-documented, and barriers exist with use of the national sepsis screening form. Frailty, which is a sepsis risk factor, should be assessed pre-operatively to maximise prevention.

Surgical Site Infection in a 1000-Bed Tertiary-Care Teaching Hospital in New Delhi, India

Background: Surgical site infection (SSI) includes infections occurring after 48 hours of any surgery and accounts for most of the healthcare-associated infections (HAIs) in surgical centers. Surgical site infections can result in pain, discomfort, prolonged hospital stay, increased exposure to antimicrobials, and consequentially, increased healthcare costs. Objectives: The study intended to characterize the incidence, etiology, and emerging resistance of SSI in a 1000-bed tertiary-care teaching hospital in New Delhi. Methods: The ambispective study was conducted in a 1000-bed tertiary-care teaching hospital in New Delhi. Clinical, laboratory, and environmental surveillance and screening of health care providers (HCPs) were conducted using the National Healthcare Safety Network (NHSN) definitions and methods given by the US Centers for Disease Control and Prevention (CDC). Results: With 3,541 patients admitted to the Gynecology and Obstetrics Ward and General Surgical Ward of the hospital, the total episodes of SSI were 80 (2.26%). The mean rates of superficial, deep, and organ space SSI were 46.25%, 47.5%, and 6.25%, respectively. The most common organisms isolated were Acinetobacter baumannii (23.75%), Pseudomonas aeruginosa (17.5%), Escherichia coli (15%), and Staphylococcus aureus (12.5%). Conclusions: The rate of SSI in our study was comparable to the unadjusted rates in India, lower-middle, upper-middle, and high-income countries worldwide. Patients with pre-existing medical illness, prolonged operation time, and wound contamination are strongly predisposed to surgical site infection.

Antibiotic susceptibility pattern of organisms causing surgical site infection

Background: Approximately 30-50% of antibiotic use in hospitals is now for pre-surgical prophylaxis. Selection of antibiotics for prophylaxis should be based on its activity against expected bacteria at the desired surgical site. Appropriate antibiotic prophylaxis can reduce the risk of postoperative morbidity and mortality. Abuse of antimicrobials increases the cost of treatment and supports the emergence of resistant bacteria. This study was undertaken with the primary objective of to test the antibiotic susceptibility pattern of organisms causing SSIs.Methods: A descriptive study was carried out in general surgical wards of KR hospital, Mysore for a period of 18 months (2015-2016). The relevant data was collected from the case sheets of patients who were diagnosed with SSI. Pus samples were collected, and culture-sensitivity was done. Collected data were analysed using appropriate statistical tests.Results: A total of 263 study subjects including both males and females were enrolled in the study. Out of 263 pus samples 92% were culture positive. The most common organisms causing SSI were E. Coli-ESBL (n=73) and MRSA (n=44). Gram-negative organisms were highly resistant to β-lactam antibiotics and Gram-positive organisms were resistant to cotrimoxazole, erythromycin, clindamycin, cefoxitin and ciprofloxacin.Conclusions: Good hygienic measures should be followed by the patients and health-workers. A revision of hospital antibiotic policy according to the local antibiotic susceptibility pattern is recommended.

Rapid tranquillisation: an issue for all nurses in acute care settings.

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

Effectiveness of a daytime rapid response system in hospitalized surgical ward patients.

BackgroundClinical deteriorations during hospitalization are often preventable with a rapid response system (RRS). We aimed to investigate the effectiveness of a daytime RRS for surgical hospitalized patients.MethodsA retrospective cohort study was conducted in 20 general surgical wards at a 1,779-bed University hospital from August 2013 to July 2017 (August 2013 to July 2015, pre-RRS-period; August 2015 to July 2017, post-RRS-period). The primary outcome was incidence of cardiopulmonary arrest (CPA) when the RRS was operating. The secondary outcomes were the incidence of total and preventable cardiopulmonary arrest, in-hospital mortality, the percentage of “do not resuscitate” orders, and the survival of discharged CPA patients.ResultsThe relative risk (RR) of CPA per 1,000 admissions during RRS operational hours (weekdays from 7 AM to 7 PM) in the post-RRS-period compared to the pre-RRS-period was 0.53 (95% confidence interval [CI], 0.25 to 1.13; P=0.099) and the RR of total CPA regardless of RRS operating hours was 0.76 (95% CI, 0.46 to 1.28; P=0.301). The preventable CPA after RRS implementation was significantly lower than that before RRS implementation (RR, 0.31; 95% CI, 0.11 to 0.88; P=0.028). There were no statistical differences in in-hospital mortality and the survival rate of patients with in-hospital cardiac arrest. Do-not-resuscitate decisions significantly increased during after RRS implementation periods compared to pre-RRS periods (RR, 1.91; 95% CI, 1.40 to 2.59; P<0.001).ConclusionsThe day-time implementation of the RRS did not significantly reduce the rate of CPA whereas the system effectively reduced the rate of preventable CPA during periods when the system was operating.

Nurses' role in delivering discharge education to general surgical patients: A qualitative study.

To explore nurses' perceived role and experience in providing discharge education to general surgical patients. Qualitative, using focus groups and face-to-face individual interviews. Purposive sampling with maximum variation was used to recruit nurses from the general surgical wards in a tertiary hospital in Queensland, Australia. Semi-structured interviews (three focus groups and four individual interviews) were conducted with 21 nurses involved in delivering postoperative discharge education from August 2018 - July 2019. Interview data were analysed using inductive content analysis. Four themes emerged: assuming responsibility for patient education in the absence of discharge communication; supporting patients to participate in self-management after hospitalization; variability in the resources, content and delivery of discharge education; and meeting operational demands compromises the quality of patients' discharge education. This study highlights the importance of nurses' role and the challenges encountered in delivering effective discharge education. These findings can be used to identify strategies to enhance discharge communication among health professionals and standardize the delivery of education to improve surgical patients' postoperative outcomes. Ineffective discharge education contributes to patients' poor management of their postdischarge recovery. Developing an understanding of nurses' role in discharge education can inform policies and nursing practice to improve patients' well-being and reduce the potential for unplanned and emergency care.

Adolescents: a paediatrician’s or an adult physician’s domain? clinical profile of Indian adolescents admitted in pediatric ward and those admitted in other than pediatric ward

Background: Study of the clinical profile and no. of admissions of adolescents admitted in pediatric ward and other than Pediatric ward.Methods: A Prospective Study, conducted during August 2018 to March 2019, at a tertiary care teaching hospital, including age group 10-19 years.Results: Out of 1645, highest adolescents’ admissions 749 (46.37%) were to medical ward, 2nd highest in the Pediatric ward which was 317 (19.6%), followed by general surgical ward which was 312(19.3%). Highest among late adolescents, infectious diseases were still the leading cause of hospitalization of adolescents as it constituted 68.4% (902) of admissions to other than pediatric ward followed by surgical cause[135(10.2%)] followed by accidents [5%(66)].Conclusions: Infectious diseases are more common in adolescents compared to developed countries. The shift in hospitalisation of adolescents from pediatrics to general medicine at about 14 years is illustrated in present study and reflects the need of better implementation of clinical policy on the age divide.

Sepsis Six implementation on a general surgical ward. More work to be done

Background: Sepsis can lead to significant morbidity and mortality if not recognised and managed early. On the basis of national mortality reports, Irish guidelines recommend that patients at risk of neutropenia, patients with sepsis or those with a systemic inflammatory response (SIRS) with one plus co-morbidity should receive Sepsis Six. We assessed the implementation of the Sepsis Six on a surgical ward in our institution. Methods: All inpatients on a surgical ward in July 2018 were prospectively assessed for the presence of infection and sepsis. If the Sepsis Six was required, implementation of each of the Sepsis Six elements was recorded. Results: Of 164 patients, 40.2% (66/164) developed an infection of whom 47% (31/66), met the criteria for requiring Sepsis Six. Of these, 7.3% (12/164) patients had sepsis, with 3% (5/164) developing septic shock. Patients required Sepsis Six for the following reasons: ³1 co-morbidity and ³2 SIRS criteria(n=19); new onset organ failure (n=12) and neutropenic risk(n=0).Only 12.9% (4/31) patients received all of the Sepsis Six elements within one hour; 77.4% (24/31) received some and 9.67% (3/31) did not receive any elements. Blood cultures were taken in 54.8% (17/31) of cases but only 32.3% (10/31) patients had their lactate level checked. Conclusion: Further research action is required to better understand and improve Sepsis Six implementation. This should facilitate improved sepsis recognition and enhance patient care.

Antimicrobial prophylaxis for adult surgical patients in a Pakistani teaching hospital

Summary Objective To evaluate the compliance rate of Surgical antimicrobial prophylaxis (SAP) practices with guidelines among adult surgical patients. Method A cross-sectionalobservational study was conducted in a teaching hospital in Pakistan. A total of 235 surgical procedures were investigated during two-month study period through convenient sampling technique. Important data was collected from patients’ prescription records through specialized data collection form. The observed practices were compared with international evidence-based guidelines. Results Most of the surgical procedures belonged to general surgical wards (60%; n = 141). Clean surgical procedures were more important (51%; n = 120) when compared to clean-contaminated surgeries (49%; n = 115). The selection of antimicrobial was correct in 32% (n = 76), timing in 39.5% (n = 93), route and dose in 100% (n = 235) of the surgical cases. The selection and timing of SAP administration were more adhered with the guidelines in the urological ward as compared to orthopaedic and general surgical wards (P

Testing effectiveness of the revised Cape Town modified early warning and SBAR systems: a pilot pragmatic parallel group randomised controlled trial

BackgroundNurses’ recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries.MethodsWe tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed.ResultsWe recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06–1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and “looks unwell”. SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38–6.86)).ConclusionsThe revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses’ ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses’ reporting behaviour.Trial registrationPan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org.

Postoperative quality and safety using Efficacy Safety Score (ESS) and a wireless patient monitoring system at the ward: A randomised controlled study.

Postoperative pain, side-effects and time to mobilisation are indicators for the quality of postoperative recovery. The aim of this randomised controlled study was to investigate if efficacy safety score (ESS) combined with a wireless patient monitoring system would improve these clinical outcomes for patients at a general surgical ward. The trial included 195 patients randomised to a standard care group (SC-Group) or intervention group (INT-Group) receiving continuous wireless monitoring of vital signs combined with ESS during the first 24 postoperative hours. The primary outcome was time to mobilisation. Secondary outcomes were average pain, doses of postoperative opioids, unscheduled interventions, side-effects, patient satisfaction and length of hospital stay (LOS). Mean time to postoperative mobilisation was 10.1hours for patients in the INT-Group compared to 14.2hours in the SC-Group; this corresponds to an adjusted hazard ratio of 1.54 (95% confidence interval 1.04-2.28). INT-Group patients received a higher dose of oral morphine equivalents; 26mg vs 15mg, P<.001; reported lower intensity of pain on a 0-10 scale; 2.1 vs 3.3, P<.001; and had higher patient satisfaction on a 5-point scale; 4.9 vs 4.3, P<.001. The LOS was similar between the groups; 71hours in INT-Group vs 77hours in SC-Group, P=.58. No serious side-effects were registered in INT-Group, whereas two were registered in SC-Group. Introducing ESS as a decision tool combined with a wireless monitoring system resulted in less pain, increased satisfaction and more rapid mobilisation for patients in this study. clinicaltrials.gov Identifier: NCT03438578.

Nurses' just-in-time training for clinical deterioration: Development, implementation and evaluation

Background‘Just-in-time training’ is an innovative approach to nursing education. It has demonstrated positive outcomes in other industries, such as manufacturing and aviation, but it has limited published application in the acute-care setting. ObjectivesWe aimed to implement and evaluate a nursing ‘just-in-time training’ program for the recognition and response to patient deterioration. DesignTo promote consistency, one Clinical Deterioration Educator provided education to nursing staff in both recognising the need for escalation and providing subsequent care for the deteriorating ward patient. Nurses' perception of the ‘just-in-time training’ program was determined using electronic questionnaire responses. Medical Emergency Team call prevalence and outcome data was compared before and after the program implementation for further evaluation. SettingThe ‘just-in-time training’ program was implemented in a 508-bed acute metropolitan private hospital over a 12-month period. Education was provided in general medical and surgical wards, not specialty areas. ParticipantsNurses received the just-in-time training based on their patients' perceived risk of deterioration, therefore, participants are not randomised. MethodsA quantitative research study investigated nurses' self-perceived confidence after receiving just-in-time training. Medical Emergency Team call frequency data was also examined to identify trends. ResultsThe ‘just-in-time training’ program consisted of 534 bedside nursing encounters over 12 months. During the study, the need for the educator to recommend that nurses escalate care reduced in prevalence from 20% to 5.5%. Questionnaire responses demonstrated a self-perceived confidence following intervention of 4.32/5.0. Medical Emergency Team call prevalence, per 1000 patient bed days, increased from 13.6 pre-intervention to 15.4 post-intervention. ConclusionsJust-in-time training’ can be effectively implemented to educate ward nursing staff in recognising and responding to the deteriorating patient. The program is well received by nursing staff and leads to high self-perceived confidence to recognise and appropriately care for a deteriorating patient.

A Ward-Round Non-Technical Skills for Surgery (WANTSS) Taxonomy

Around half of surgical adverse events occur outside the operating room. However the majority of nontechnical skills (NTS) training programs have been developed for the intraoperative environment. Ward rounds are a crucial part of extraoperative care and to date no specific NTS training manual has been developed targeting emergency general surgical ward rounds. To develop a NTS taxonomy for emergency general surgical ward rounds that can be used to improve surgical team members' NTS and improve outcomes. A literature review of existing NTS taxonomies was conducted, followed by semistructured interviews and observational data collection, to determine good and poor surgical ward-round behaviors. These behaviors were reviewed by a panel of subject matter experts and categorized into a taxonomy, using the Non-Technical Skills for Surgeons taxonomy framework as a guide. The Ward-round Non-Technical Skills for Surgery taxonomy includes examples of good and poor ward-round-specific behaviors, grouped into elements and categories. The taxonomy can be used as both a training and teaching manual for the surgical team. Ward rounds are a crucial part of extraoperative surgical care. The Ward-round Non-Technical Skills for Surgery taxonomy provides surgical teams with a manual to help them improve their ward-round NTS.