High Patient Turnover Research Articles

Incident reporting in one UK accident and emergency department

Greater focus is needed on improving patient safety in modern healthcare systems and the first step to achieving this is to reliably identify the safety issues arising in healthcare. Research has shown the accident and emergency (A&E) department to be a particularly problematic environment where safety is a concern due to various factors, such as the range, nature and urgency of presenting conditions and the high turnover of patients. As in all healthcare environments clinical incident reporting in A&E is an important tool for detecting safety issues which can result in identifying solutions, learning from error and enhancing patient safety. This tool must be responsive and flexible to the local circumstances and work for the department to support the clinical governance agenda. In this paper, we describe the local processes for reporting and reviewing clinical incidents in one A&E department in a London teaching hospital and report recent changes to the system within the department. We used the historical data recorded on the Trust incident database as a representation of the information that would be available to the department in order to identify the high risk areas. In this paper, we evaluate the internal processes, the information available on the database and make recommendations to assist the emergency department in their internal processes. These will strengthen the internal review and staff feedback system so that the department can learn from incidents in a consistent manner. The process was reviewed by detailed examination of the centrally held electronic record (Datix database) of all incidents reported in a one year period. The nature of the incident and the level and accuracy of information provided in the incident reports was evaluated. There were positive aspects to the established system including evidence of positive changes made as a result of the reporting process, new initiatives to feedback to staff, and evolution of the programme for reporting and discussing the incidents internally. There appeared to be a mismatch between the recorded events and the category allocated to the incident in the historical record. In addition the database did not contain complete information for every incident, contributory factors were rarely recorded and relatively large numbers of incidents were recorded as "other" in the type of incident. There was also observed difficulty in updating the system as there is at least a months time lag between reporting or an incident and discussion/resolution of issues at the local departmental clinical risk management committee meetings. We used Leape's model for assessing the reporting system as a whole and found the system in the department to be relatively safe, fairly easy to use and moderately effective. Recommendations as a result of this study include the introduction of an electronic reporting system, limiting the number of staff who categorise the incidents--using clear definitions for classifications including a structured framework for contributory factors, and a process that allows incidents to be updated on the database locally after the discussion. This research may have implications for the incident reporting process in other specialities as well as in other hospitals.

Teaching Techniques in the Clinical Setting: the Emergency Medicine Perspective

AbstractThe emergency department (ED) provides a unique educational experience that is distinct from both inpatient and ambulatory care settings. Because of the high acuity, interesting pathology, and rapid patient turnover, the ED is an ideal location to train medical students. Numerous teaching opportunities exist within the domain of the ED. In the preclinical years, the ED setting provides medical students with an introduction to clinical medicine and may serve as a venue for teaching basic history and physical examination skills. In the clinical years, medical students are exposed to a wide range of undifferentiated patients. Besides common medical and surgical complaints, many medical students will encounter clinical scenarios that they otherwise would have little direct contact with. Encounters such as the acutely poisoned or intoxicated patient, environmental emergencies, interaction with out‐of‐hospital providers, and patients requiring emergency procedures are just a few situations that make emergency medicine a distinct clinical specialty. These and other student–patient encounters can provide the teaching physician an opportunity to focus case‐based teaching on a number of elements including complaint‐directed medical interviewing and physical examination skills, development of case‐specific differential diagnosis, diagnostic evaluation, implementation of patient management plans, and patient disposition. In this review article, the authors discuss various ways to approach and improve clinical teaching of medical students, including: opportunities for teaching in the ED, teaching procedural skills, student case presentations, clinical teaching styles, qualities of an effective clinical teacher, and barriers to effective clinical teaching.

Teaching Techniques in the Clinical Setting: the Emergency Medicine Perspective

AbstractThe emergency department (ED) provides a unique educational experience that is distinct from both inpatient and ambulatory care settings. Because of the high acuity, interesting pathology, and rapid patient turnover, the ED is an ideal location to train medical students. Numerous teaching opportunities exist within the domain of the ED. In the preclinical years, the ED setting provides medical students with an introduction to clinical medicine and may serve as a venue for teaching basic history and physical examination skills. In the clinical years, medical students are exposed to a wide range of undifferentiated patients. Besides common medical and surgical complaints, many medical students will encounter clinical scenarios that they otherwise would have little direct contact with. Encounters such as the acutely poisoned or intoxicated patient, environmental emergencies, interaction with out‐of‐hospital providers, and patients requiring emergency procedures are just a few situations that make emergency medicine a distinct clinical specialty. These and other student–patient encounters can provide the teaching physician an opportunity to focus case‐based teaching on a number of elements including complaint‐directed medical interviewing and physical examination skills, development of case‐specific differential diagnosis, diagnostic evaluation, implementation of patient management plans, and patient disposition. In this review article, the authors discuss various ways to approach and improve clinical teaching of medical students, including: opportunities for teaching in the ED, teaching procedural skills, student case presentations, clinical teaching styles, qualities of an effective clinical teacher, and barriers to effective clinical teaching.

Hospital infection past and present

Why does so much hospital infection still exist despite the attention that it attracts? There were about 9·6 million UK National Health Service (NHS) hospital admissions in 2002–03. 5–10% of inpatients acquire an infection during their stay, and thus about 0·5–1·0 million hospital infections occur each year in the UK alone. Graham Ayliffe and Mary English offer a fascinating account of how the relation between hospitals and infection has altered through the centuries, mainly because of the realisation that many diseases were not a result of bad air (miasma). Although we now understand routes of cross-infection and have preventive strategies for most of these, understanding how beliefs and approaches to hospital infection have changed is instructive for challenges that still exist. In Roman times, hospital orderlies were known as nosocomi, the word deriving from Latin and Greek words for hospital. It is appropriate that in modern times nosocomial (meaning hospital acquired) is so closely linked to an old name for health-care workers. Health-care workers remain inadvertently responsible for most cases of cross-infection, either directly or indirectly via their hands. Airborne transmission of infection is now an uncommon cause of most hospital-acquired infections, but miasmas were widely espoused from the 6th to the 19th centuries as the way in which disease was spread. Ironically, however, there are examples of infections that may be transmitted by aerosols, which continue to confound us. Why have hospitals been over-run by outbreaks of viral gastroenteritis for much of the past 2years? How did severe acute respiratory syndrome spread so dramatically in modern well equipped hospitals? How would we cope with new cases of smallpox? As Ayliffe and English point out, it is still unknown how some of the last cases of hospital-acquired smallpox were contracted. The prevention and control of hospital infection must be underpinned by surveillance, which was pioneered in the USA, notably by the work of Robert Haley in the 1970s. These studies showed that intensive surveillance, feedback to clinicians, and a control prog-ramme could cut rates of hospital infection by about a third. Clinician feedback is fundamental to sharing the responsibility for controlling hospital infection. The US Communicable Disease Center established the National Nosocomial Infections Scheme, which runs to this day and has been copied in many countries. The UK Department of Health has recognised that standardised surveillance methods that are affordable and yet based on Haley's principles are one way forward. These allow comparison of infection rates or proxy measurements between units, but clearly case mix and unit type must be borne in mind; meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia rates are now one of the performance indicators for NHS trusts. This book has many evocative photographs and illustrations. One of these, a Nightingale ward in 1900, reminds me of the picture on my office wall. My grandmother and other nursing staff replete in their starched uniforms are grouped around the ward. Both photographs ooze cleanliness and order, but both are filled with empty beds. The high number and turnover of patients is a major modern day obstacle to ensuring good infection-control practice. Ayliffe and English note that persuading staff to do the basics now seems to be as difficult as it was for Ignaz Semmelweis. Unfortunately, Semmelweis, dismayed by the reluctance of his peers to believe his exhortations about the need to wash their hands to control the spread of puerperal sepsis, was eventually committed to a sanatorium in Vienna, where he died of septicaemia in 1865. Shortly after Semmelweis died, Joseph Lister's first paper on antisepsis was published. In 1999, a UK NHS Executive Health Service Circular instructed health-care providers to strengthen the prevention and control of communicable disease and infection-control processes. Specifically they were asked to “put infection control and basic hygiene where they belong, at the heart of good management and clinical practice with appropriate resources”: fine words, but actions speak louder than words.

Nurse-led discharge from high dependency unit.

High dependency care is a rapidly evolving area of critical care, with high patient turnover, which ultimately leads to high levels of pressure for beds. There is a growing trend emerging, recognizing the importance and value of nurse-led initiatives in delivering effective nursing care in acute care settings. One specific nurse-led initiative this author has developed is that of nurse-led discharge (NLD) from the high dependency unit (HDU), in order to optimize the utilization of critical care beds within the HDU. An audit of the current practice was undertaken, which ultimately led to the implementation of NLD. Early experiences indicate that HDU beds are now being used more effectively.

Operating conditions of psychiatric hospitals and early readmission — effects of high patient turnover

To study the association between hospitals' operating conditions and the risk of early readmission. The hypothesis was that high patient turnover might lead to a rise in the risk of readmission soon after discharge (within 30 days). A multivariate model including hospital and patient variables was tested using Cox's regression analysis, adjusting for clustering effects. The material included data from 20 hospitals, with 5,520 patients in the final model. High patient turnover (annual discharges per bed) was significantly associated with an increased risk of readmission (hazard ratio (HR)= 3.37 (95% CI = 2.39-4.75)). In addition, being discharged from a ward with relatively low access to therapists increased the hazard further. High patient turnover at the discharging ward was found to increase the patients' hazard of early readmission. This observation supports the hypothesis of a link between the operation conditions of the hospitals and patient outcome on a short time-scale.

Challenging the handover ritual: Recommendations for research and practice

Communicating nursing care during the patient's total hospital stay is a difficult task to achieve within the context of high patient turnover, a lack of overlap time between shifts, and time constraints. Clear and accurate communication is pivotal to delivering high quality care and should be the gold standard in any clinical setting. Handover is a commonly used communication medium that requires review and critique. This study was conducted in five acute care settings at a major teaching hospital. Using a grounded theory approach, it explored the use of three types of handover techniques (verbal in the office, tape-recorded, and bedside handovers). Data were obtained from semistructured interviews with nurses and participant field observations. Textual data were managed using NUD*IST. Transcripts were critically reviewed and major themes identified from the three types of handovers that illustrated their strengths and weaknesses. The findings of this study revealed that handover is more than just a forum for communicating patient care. It is also used as a place where nurses can debrief, clarify information and update knowledge. Overall, each type of handover had particular strengths and limitations; however, no one type of handover was appraised as being more effective. Achieving the multiple goals of handover presents researchers and clinicians with a challenging task. It is necessary to explore more creative ways of conducting the handover of patient care, so that an important aspect of nursing practice does not get classified as just another ritual.

The impact of routine chest radiography on ICU management decisions: an observational study

To document the impact of routine daily chest radiographs on treatment decisions in a medical ICU. The study sample consisted of 200 consecutive patients in an 11-bed medical ICU of a university-affiliated teaching hospital. During the study period, each patient's current and previous chest radiographs were reviewed in the ICU during morning rounds. A computerized digital video display system was used. Changes in therapy made as a consequence of this review were recorded. A total of 471 chest radiographs were reviewed. The patients' mean score on the Acute Physiology and Chronic Health Evaluation II (APACHE II) was 14.6 +/- 2.5, and the mean length of stay in the ICU was 3.6 days +/- 2.1 days (range, 11-24 days). A change in therapy was made on the basis of information obtained from review of the chest radiograph in 174 instances (37% of radiographs). The most frequent therapeutic interventions were use of a loop diuretic to treat pulmonary edema (26%), repositioning of an endotracheal tube (24%), and diagnostic studies to determine the cause of a new pulmonary infiltrate (16%). At least one change in therapy was made for 91 (66%) of the 138 intubated patients but for only 14 (23%) of the 62 nonintubated patients; this difference was significant. Differences among diagnostic groups were largely a reflection of the number of patients who were intubated. Routine daily chest radiographs may be justified in critically ill patients in a medical ICU because for a large proportion of these patients management decisions are made on the basis of information obtained from the chest radiograph. This observation may be applicable only to ICUs that have a high turnover of patients who are in the unit for a short time.

The postanesthesia care unit: A high-risk environment for bloodborne and infectious respiratory pathogens

The PACU is a high-risk environment for exposure to infectious diseases. A confluence of risk factors unique to the PACU increases the probability for exposure of personnel to both bloodborne and airborne pathogens. These risk factors include frequent coughing in the PACU, blood-contaminated saliva in the PACU, air mixing maximized in the PACU, high patient census and rapid patient turnover, inadequate patient histories, and the proximity of the postanesthesia nurse to the patient's face. Both the Occupational Safety and Health Administration and the Centers for Disease Control have issued recommended procedures for limiting occupational exposure of personnel to these hazards.

Coding medical concepts: a controlled experiment with a computerised coding tool.

In clinical routine there is a growing need to encode medical concepts with available standard coding systems. The coding process can be time consuming and may significantly add to daily paperwork, particularly regarding patients with multiple diagnoses and in busy clinical environments with a high turnover of patients. We have developed a generic computerised encoding tool--the PADS encoder--to ensure rapid, correct and complete coding of diagnoses in daily routine. The tool is integrated into an electronic patient record system (PADS, Patient Archiving & Documentation System) and takes full advantage of the user friendly Macintosh interface. The tool was tested in a controlled experiment by 18 clinicians who encoded a total of 666 medical concepts in each protocol (study protocol vs. control). The following positive findings were significantly associated with the use of the computerised coding tool: the number of correctly encoded medical concepts was higher (99.55% vs. 86.1%), coding errors were lower (0% vs. 10.81%), more modifier codes were encoded correctly (increase by up to 43%), less coding errors were made (decrease by up to 43%), the overall rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% vs. 66.02%), coding time was reduced by 50%. This paper presents data to suggest that a computerised coding tool can produce more complete data of higher quality and can save time compared with the traditional approach to encode medical concepts.

Patient satisfaction with nursing care, evaluation before and after cutback in expenditure and intervention at a surgical clinic.

After a major cutback in the budget and staffing of a surgical clinic in southern Sweden there was intervention to improve the quality of nursing care and to evaluate the outcome. The intervention consisted of the implementation of: (1) nursing care organized in such a way that it would secure continuity of the nurse-patient relationship, (2) individually planned care by means of diagnostic reasoning, and (3) quality assurance for aspects believed to be connected with quality of care. Patient satisfaction before and after the intervention was assessed by means of a patient questionnaire survey (May 1991; n = 105 and May 1992; n = 137). Patient satisfaction improved significantly in variables related to nursing care viz. overall satisfaction and satisfaction with information and decision making; satisfaction with contact and staff-patient relationship; ward facilities and physical treatment or examinations; and satisfaction with physical nursing care. The results were interpreted to mean that the intervention may have counteracted any negative impact the reduced budget might have had such as the higher patient turn-over and the shorter in-patient periods, and thus seemed to have improved the quality of the nursing care in terms of patient satisfaction.

The Child Consultation Rating Scale.

A consultation psychopathology rating scale is described for use in assessing psychopathology in pediatric patients and their families in a tertiary care general teaching hospital setting with high acuity and rapid patient turnover. The scale is composed of twelve consultation variables, thirty patient variables, and fourteen parent variables. It includes a global rating and a DSM-III-R diagnosis for both parent and child. Pilot findings using the scale are described for sixty pediatric patients and thirty controls. Interrater reliability using Kendall nonparametric correlations between raters was obtained for each variable and achieves significance ranges from p less than .05 to p less than .001. Applications to training pediatric and psychiatry residents in the systemic observation of child psychopathology are discussed.

Why is there a lower prevalence of chronic immobility in geriatric departments with a high turnover of patients?

There is little information available about the characteristics of patients admitted to geriatric units with high and low turnover rates of patients. It is often suggested that high turnover units do not admit the more physically disabled person. This study set out to investigate whether this view is true. Six geriatric units with different patient discharge rates were investigated. Those units with a high turnover of patients tend to admit more severely immobile people per bed, when compared to those units with below average throughput. Although these immobile people admitted to high turnover units suffered a higher mortality rate, a significantly greater proportion regained the ability to transfer themselves independently from bed to chair and to the toilet.

Effect of an expanded physical facility on nosocomial infections in a neonatal intensive care unit

Fifty-two months' data were reviewed to assess the effect of a threefold increase in space per infant in a neonatal intensive care unit on rates of nosocomial infections (NIs) and colonization with Staphylococcus aureus (39 months in a crowded 18-bed unit and 13 months in a spacious 32-bed unit). Mean length of stay, survival rates, mean birth weights, and other parameters indicated that infant populations in the old and new units were similar. NI rates were not significantly different in the old and new units (11.7% and 9.6%, respectively; p = 0.17) nor were rates of colonization of anterior nares with S. aureus (11.7% and 10.7%; p = 0.5). NI rates, but not S. aureus colonization rates, were significantly higher during months of high patient turnover (p < 0.01). Sites of infection were similar in the old and new units. There was, however, a significant change in bacterial species causing NI. Klebsiella pneumoniae and Pseudomonas aeruginosa caused 20.4% of NIs in the old unit, but only 2.1% in the new unit (p < 0.001) and NIs caused by S. epidermidis increased from 4.7% to 14.9% (p = 0.02) in the new unit. There was also a marked decrease in the numbers of clusters of NI occurring in the new unit, indicating that cross-infections between infants were probably minimized.

Day Treatment and Psychotropic Drugs in the Aftercare of Schizophrenic Patients

Schizophrenic patients referred for day treatment at the time of discharge from ten hospitals were randomly assigned to receive day treatment plus drugs or to receive drugs alone. They were tested before assignment and at 6, 12, 18, and 24 months on social functioning, symptoms, and attitudes. Community tenure and costs were also measured. The ten day centers were described on process variables every six months for the four years of the study. Some centers were found to be effective in treating chronic schizophrenic patients and others were not. All centers improved the patients' social functioning. Six of the centers were found to singificantly delay relapse, reduce symptoms, and change some attitudes. Costs for patients in these centers were not significantly different from the group receiving only drugs. More professional staff hours, group therapy, and a high patient turnover treatment philosophy were associated with poor-result centers. More occupational therapy and a sustained nonthreatening environment were more characteristic of successful outcome centers.

Day Treatment and Psychotropic Drugs in the Aftercare of Schizophrenic Patients

Schizophrenic patients referred for day treatment at the time of discharge from ten hospitals were randomly assigned to receive day treatment plus drugs or to receive drugs alone. They were tested before assignment and at 6, 12, 18, and 24 months on social functioning, symptoms, and attitudes. Community tenure and costs were also measured. The ten day centers were described on process variables every six months for the four years of the study. Some centers were found to be effective in treating chronic schizophrenic patients and others were not. All centers improved the patients' social functioning. Six of the centers were found to significantly delay relapse, reduce sumptoms, and change some attitudes. Costs for patients in these centers were not significantly different from the group receiving only drugs. More professional staff hours, group therapy, and a high patient turnover treatment philosophy were associated with poor-result centers. More occupational therapy and a sustained nonthreatening environment were more characteristic of successful outcome centers.

No apology for geriatrics.

A geriatric department is described where turnover has more than kept pace with demand over a period of 17 years. The department provides two basic services-a hospital service to the pensionable population in the community, and support to other hospital departments that care for the elderly.Community emphasis is on a high turnover of patients, enabling early contract and treatment. Over the years a fall in the proportion of "chronic" to "acute" beds has occurred and this has been achieved by having the majority of beds in the general hospital, where it is possible to provide a comprehensive medical service. The hospital role has been to prevent overloading acute resources with potential long-stay cases, and this has been possible without compromising our community obligations.

Making hospital geriatrics work.

The first year's work at a new geriatric department at Northwick Park Hospital shows that active policies revolutionize the geriatric service and result in high turnover of patients and no waiting list. Comparison with low turnover/waiting list departments shows the effects of a waiting list in terms of diminished therapeutic benefit and less favourable outcome for patients admitted. The requirements for elimination of the waiting list appear to be well directed policies and adequate and enthusiastic staff. Active geriatrics results in high morale and could be widely applicable within the present hospital bed resources given the necessary improvements in staffing.