Increased Staff Workload Research Articles

Strategies for adapting under pressure: an interview study in intensive care units

BackgroundHealthcare systems are operating under substantial pressures. Clinicians and managers are constantly having to make adaptations, which are typically improvised, highly variable and not coordinated across teams. This study aimed...

IMPLEMENTING SMART AMBIENT BRIGHT LIGHT (SABL) IN NURSING HOME RESIDENTS WITH DEMENTIA: CHALLENGES AND STRATEGIES

Abstract Effective non-pharmacological interventions are critically needed to reduce agitation for nursing home residents with dementia. Lighting interventions (LIs) improve agitation among persons with dementia. However, LIs have not been widely implemented in “real-world” care settings, and a feasible implementation approach to ambient LIs has not been established. This study describes challenges and strategies in implementing the smart ambient bright light (SABL) to provide auto-controlled, consistent indoor lighting that incorporates natural daylight. This SABL includes tunable LED lights, photosensors, and controllers and has a pre-programmed 24-hour control schedule for illuminance. The SABL will be installed in participants’ bedrooms, dining areas, and activity rooms for four weeks. Key challenges include nursing home leadership team’s concerns about compliance with regulations and increased staff workload. Our implementation strategies include 1) engaging the nursing home stakeholders early on to address their concerns, 2) setting up an advisory board at each facility to involve the administrator, director of maintenance, and frontline healthcare workers to ensure the implementation protocol is congruent with their regulations, policy, and staffing, 3) tailoring lighting schedule based on the care routine and resident schedules, and 4) monitoring the SABL operation on-site and remotely. Moreover, the study incorporates a mixed methods design to interview staff/administrators and evaluate the intervention’s acceptability, feasibility, and appropriateness from their perspectives. This is the first study that addresses the implementation strategies of LIs. Findings will establish evidence-based implementation strategies and the best design for SABL to reduce agitation for nursing home residents with dementia.

Adapting a community pharmacy intervention to improve medication safety

BackgroundCommunity pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation. ObjectivesThis paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization. Practice descriptionThe study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults. Practice innovationSenior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework. Evaluation methodsSenior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group. ResultsA finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites. ConclusionThis multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

Assessing Continuous Epidural Infusion and Programmed Intermittent Epidural Bolus for Their Effectiveness in Providing Labor Analgesia: A Mono-Centric Retrospective Comparative Study.

Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA.

Visualizing Synchronous Virtual Reference Service in Chandigarh Region Innovation and Knowledge Cluster (CRIKC) Institutions in India: Librarians’ Perception

The present study aims to highlight the librarians’ perception pertaining to the implementation of Virtual Reference Service (VRS) in the Chandigarh Region Innovation and Knowledge Cluster Institutions (CRIKC). The study is based on a sample drawn from librarians of the CRIKC libraries. To assess and evaluate the librarians’ perception regarding the feasibility of VRS, a questionnaire was prepared and distributed among 19 library professionals of CRIKC libraries. The reason for choosing the questionnaire was to know the status of virtual reference service as well as librarians’ perception regarding the feasibility of VRS in CRIKC libraries. The findings suggest that the major challenge faced by librarians in providing VRS is the need for an additional budget for staffing, followed by an increased staff workload and a lack of staff training facilities. However, despite these challenges, the librarians perceive VRS to be highly effective in promoting the optimum use of the library’s collection and resources, improving staff efficiency, and promoting information literacy. From the users’ perspective, remote access to online assistance and faster access to information were found to be the most effective features of VRS. Additionally, personalized service, 24/7 availability, and the ability to save chat sessions for later use were also perceived as beneficial by most of the librarians. These results highlight the potential benefits of implementing web 2.0-enabled VRS in academic libraries, despite the challenges involved. It is essential to allocate a sufficient budget for staffing and provide staff training facilities to overcome the challenges faced in implementing VRS successfully. Furthermore, by improving user satisfaction and promoting information literacy, VRS can prove to be an effective tool for enhancing library services and resources.

Associations of flow disruptions with patient, staff, and process outcomes: a prospective observational study of robotic-assisted radical prostatectomies

BackgroundTechnological advancements in the operating room (OR) have sparked new challenges for surgical workflow, OR professionals, and patient safety. Disruptive events are frequent across all surgical specialties, but little is known about their effects on patient outcomes and the influence of systemic factors. The aim was to explore the associations of intraoperative flow disruptions (FDs) with patient outcomes, staff workload, and surgery duration.MethodsProspective, single-center, and multi-source study comprising direct and standardized OR observations of urologic surgical procedures, clinical patient outcomes, and staff- and patient-reported outcome data (PROMs; 3-month follow-up). All data were recorded between 01/2020 and 10/2021. FDs were assessed using standardized procedure observations. Linear and logistic regression analyses including multiple system factors were used to explore the effects of FDs on surgical outcomes.Results61 robotic-assisted radical prostatectomy procedures were captured (with 61 patients and 243 staff reports). High rates of FDs were observed; however, our analyses did not show significant relationships with patient complication rates. Equipment- and patient-related FDs were associated with increased staff workload. No association was found between higher rates of FDs and procedure duration.ConclusionsFDs were not related to inferior patient outcomes. Our findings may inform future OR investigations that scrutinize the complex interplay of human, team, process, and technological components that mitigate the effects of FDs during surgery.Graphical abstract

1357 THE ‘CONSULTATION COMMUNICATION’ PROFORMA: ENHANCING EFFECTIVE COMMUNICATION BETWEEN OUTPATIENTS AND INTERMEDIATE CARE

Abstract Introduction The Norman Power Centre (NPC) is a 32 bedded Intermediate Care Unit, run by an acute hospital trust in Birmingham, UK, for patients who require ongoing 24-hour care, rehabilitation or further assessment, but do not need to be in an acute hospital setting. These frail patients attend numerous outpatient hospital appointments, but rarely do staff receive communication back from these outpatient reviews. This can lead to delays in implementing specialist management plans, with potential for adverse outcomes for patients and increased staff workload in seeking out the required information. A ‘Consultation Communication’ proforma was designed, to be filled in at the appointment and brought back to NPC with the patient. Method Patients and escorts took proformas to outpatient appointments between March and June 2022. The information on the forms was then analysed to assess completeness and usefulness. Results Appointments were in surgical and medical specialities, as well as imaging in three hospitals within one trust. Proformas were taken to 19/20 appointments. 100% of these were at least partially completed, with only two forms being largely incomplete. 17/19 provided information about the assessment carried out. 12/19 included recommendations relevant to admission at NPC. 13/19 had information on medication changes. 14/19 stated whether follow up was required. Eight out of nine required follow-ups had specific details included. 13/19 had the professional’s details, 11 with contact numbers. Of those without details, two were imaging appointments where contact details were not relevant. Conclusions This easy to implement, simple intervention, with an excellent engagement rate from both NPC and outpatient appointment staff, has led to improved continuity of care for patients. The proforma has scope to be improved based on staff feedback, and its use could be expanded across other off-site facilities such as community hospitals or care homes.

Understanding the role and deployment of volunteers within specialist palliative care services and organisations as they have adjusted to the COVID-19 pandemic: A multi-national EAPC volunteer taskforce survey

Background: Early indications were of a major decline in specialist palliative care volunteer numbers during COVID-19. It is important that ongoing deployment and role of volunteers is understood, given the dependence of many palliative care services on volunteers for quality care provision. Aim: To understand the roles and deployment of volunteers in specialist palliative care services as they have adjusted to the impact of COVID-19. Design: Observational multi-national study, using a cross-sectional online survey with closed and free-text option questions. Disseminated via social media, palliative care networks and key collaborators from May to July 2021. Setting/participants: Any specialist palliative care setting in any country, including hospices, day hospices, hospital based or community teams. The person responsible for managing the deployment of volunteers was invited to complete the survey. Results: Valid responses were received from 304 organisations (35 countries, 80.3% Europe). Most cared for adults only (60.9%), provided in-patient care (62.2%) and were non-profit (62.5%). 47.0% had cared for people with COVID-19. 47.7% changed the way they deployed volunteers; the mean number of active volunteers dropped from 203 per organisation to 33, and 70.7% reported a decrease in volunteers in direct patient/family facing roles. There was a shift to younger volunteers. 50.6% said this drop impacted care provision, increasing staff workload and pressure, decreasing patient support, and increasing patient isolation and loneliness. Conclusion: The sustained reduction in volunteer deployment has impacted the provision of specialist palliative care. Urgent consideration must be given to the future of volunteering including virtual modes of delivery, micro-volunteering, and appealing to a younger demographic.

An Assessment of the Practice of Kangaroo Mother Care Among Staff in the Specialised Neonatal Intensive Care Unit at Orotta Paediatric Hospital, Asmara, Eritrea

Preterm delivery remains the major cause of newborn infants’ morbidity and mortality globally and more so in low-income countries like Eritrea. Research has shown that the provision of Kangaroo mother care can contribute to a reduction in morbidity and mortality among newborn infants. However, there is limited research on the practice of KMC in Eritrea. A mixed methods approach was adopted in a phenomenographic study to collect the data. Eleven participants with work experience of at least two years were recruited from the Specialised Neonatal Intensive Care Unit at Orotta Paediatric Hospital, Asmara, Eritrea. Data were collected via individual interviews and observations. The results showed that participants had no prior KMC training and education. In addition, staff had limited knowledge and mixed attitudes about KMC practice. There were also no KMC guidelines and protocols. Furthermore, space was not adequate for full KMC practice except for implementation of the kangaroo position. The researcher’s observation confirmed similar evidence of a lack of availability of a KMC ward and lack of protocols and guidelines. Limited interaction and communication about KMC between participants and parents was also observed. Some of the most common hindrances to KMC practice were the perception that KMC increased staff work load and that it was time consuming. In addition, lack of regular KMC training for staff, lack of a convenient setup and too few staff members were among the hindrances. One staff members also perceived that KMC practice was not culturally accepted. The results of this study concluded that there were no proper KMC guidelines and protocols in the ward. In addition, only the kangaroo position was practiced, not the full KMC protocol. Furthermore, staff had limited knowledge and mixed attitudes. The observation component of the research highlighted the lack of space and KMC protocols and guidelines as key limitations for delivering KMC. Therefore, it is recommended that a programme to improve staff knowledge be implemented, that evidence-based KMC guidelines and polices be made available, that the KMC ward be expanded, and that health education about KMC practice be brought to the population through mass media.

Using Focus Groups to Understand Dialysis Staff Perspectives on Delivering Transplant Education.

Kidney transplant education in dialysis facilities could be optimized with internet resources, like videos, but most qualitative research predates widespread availability of online video education about kidney transplantation. To improve understanding of dialysis staff transplant education practices, as well as the potential value of video, we conducted focus groups of dialysis center staff members in Buffalo, NY. Seventeen focus groups (97 participants: 53 nurses, 10 dialysis technicians, 6 social workers, 6 dieticians, 7 administrative personnel, 2 trainees, and 1 insurance coordinator) from 8 dialysis facilities in Buffalo, NY, were conducted, audio-recorded, transcribed, and analyzed. After thematic data analysis, a diverse patient and caregiver community advisory board was invited to comment, and their voices were integrated. Findings: Five key themes were identified that captured barriers to transplant education delivery and how online video could be a facilitator: (1) delivery of transplant education was reliant on one person, (2) other dialysis staff had time to answer transplant questions but felt uninformed, (3) patient lack of interest in existing supplementary transplant education, (4) patient disinterest in transplantation education was due to education timing, feeling overwhelmed, and transplant fear/ambivalence, and (5) video education could be flexible, low effort, and spark transplant interest. Study limitations are potential selection bias and inclusion of English-speaking participants only. Dialysis staff barriers of time, insufficient knowledge, and limited resources to provide education to patients and their care partners may be mitigated with online educational videos without increasing staff workload.

P007 Service evaluation of the nurse-led telephone advice line in the wake of COVID-19: a report of audit and staff satisfaction

Background/Aims The Rheumatology nurse advice line (NAL) at the Royal National Hospital for Rheumatic Diseases (RNHRD, Bath) provides a vital service for direct patient access to specialist advice via a designated voicemail system. Increasing numbers and difficulty connecting call returns have increased staff workload, reduced efficiency and impacted on staff satisfaction. An audit was therefore undertaken to evaluate service use and efficiency, paired with formal assessment of staff satisfaction in order to identify areas for improvement. Methods The total number of monthly calls through the NAL during 2020 were counted. A subset of consecutive calls were audited in detail, documenting temporal parameters in relation to the call being logged, returned and concluded. The number of clinicians and attempts required to contact the patient was noted. An anonymised staff satisfaction questionnaire was completed by NAL nurses and administrators. Data was analysed using Excel. Results An average 653 calls per month (range 340-894) came through the NAL between January and September 2020. 97 consecutive patient contacts were audited from August 2020. Multiple attempts were required to successfully return the call in 19.6% of cases (n = 19/97). Of those, 68.4% (n = 13/19) of calls needed ≥ 2 nurses to contact the patient. In general, the first attempt to return the call was prompt (average 7.6 hours, range 0.1-27.7). However, the time to conclude the call from the patient’s first call log ranged from 0.1 - 142.6 hours (average 12.7 hours) with increased time associated with difficulties contacting the patient or when further advice was required from a Rheumatology doctor (18.5%, n = 18/97).Staff surveys revealed 67% of staff felt that the NAL is a good service to offer patients. However, 67% of staff did not feel the NAL in its current format was easy to manage. Specific comments included that the lack of rota'd responsibility, unpredictable workload and time inefficiencies were barriers to managing the service. Conclusion From this data, we conclude that patient calls are returned promptly, but utilising a system of voicemail and unscheduled call returns is inefficient and contributes to staff dissatisfaction. This data has driven change for service improvement. To improve efficiency, calls will be answered live by an administrator during working hours and patients given a call-back time. A doctor will be named as a single point of contact for the nurses to seek additional advice and a nurse rota will designate responsibility for NAL calls to reduce work-load uncertainty. Follow up service evaluation will include staff and patient satisfaction questionnaires, and repeat audit, with consideration of ways to support frequent service users. Disclosure J. Day: None. J. Ball: None. J. Down: None. R. Sengupta: None. V. Flower: None.

Challenges of Covid-19 on Adolescent Psychiatric Service Provision in an Independent Inpatient and Outpatient Setting

Background: COVID-19 is one of the most challenging and devastating public health emergencies we have experienced in our lifetimes. There is a growing concern that the pandemic and its imposed public health restrictions may be harming a generation of young people. This article concerns child and adolescent psychiatry as there is already a mismatch between resources and demand. Method: This paper will outline the day to day working challenges encountered by the SPMHS adolescent service, staff, and patients in the initial months of the COVID-19 crisis and some of the strategies implemented to deal with these. Discussion: In St. Patrick’s University Hospital in Ireland, significant challenges in the adolescent service were encountered in the initial months of the COVID-19 crisis. These included the cessation of face-to-face patient interactions, therapeutic leave and visiting restrictions, school closure, social restrictions, difficulties in organizing medical appointments and investigations, family stress and increased workload for staff. Strategies including telepsychiatry have enabled the delivery of an efficient and accessible adolescent service during this crisis. Conclusion: Future research is required to analyse how best we can support children and adolescents during COVID-19, particularly those with existing mental illness is crucial.

Global Current Practices of Ventilatory Support Management in COVID-19 Patients: An International Survey.

BackgroundAs the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors.MethodsAn online survey composed of 32 questions was developed and validated by an international expert panel.ResultsOverall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12–16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management.ConclusionOur results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.

92 Relocation in Care Homes (RICH) Study: The Experience of Different Stakeholders

Abstract Introduction In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes. Methods In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes. Results Seven themes were identified and organised under three stages: pre-move (communication and involvement; preparation for the move; and attitudes towards the move), day-of-the-move (organisation of the move), and post-move (environmental change and impact; staff organisation and management; and settling in). Family and staff members reported that the pre-move information provided was inconsistent and staff did not feel involved in the planning and design process. Pre-move visits and staff and family support were beneficial for residents’ preparation for the move. All participants expressed sadness about the closure, and reported apprehension about moving. The moving day felt disorganised and stressful to staff who had to spread between the two homes. Post-move, the new care home was perceived by many participants as a ‘hotel’ rather than a home. Its larger size and confusing layout impacted negatively on residents and staff. New staff and changes in management structure were perceived by the different stakeholders to cause increased staff workload. Residents adjusted variably to the new home, with family support and staff continuity of care proving to be facilitators. Conclusions Despite extensive planning, relocation and adjustment was challenging. Recommendations for future relocations include: increasing involvement of staff in the planning and design of the home; ensuring consistent communication and organising staff rotas to maintain continuity of care.

Improving the effectiveness and efficiency of a skin dose investigation protocol in interventional radiology

Cardiac catheterisation is an invasive procedure carried out under fluoroscopic guidance, which exposes the patient’s skin to X-ray radiation. In some cases, the skin receives a radiation dose, which is...

Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators.

BackgroundSuicide prevention is a global priority. Psychiatric hospitalization presents an opportunity to intervene positively with, for example, psychological therapies. However, evidenced-based suicide-prevention psychological treatments are rarely available on in-patient wards. Understanding staff engagement with research investigating suicide-prevention psychological treatments is crucial for their effective, efficacious, and pragmatic implementation. A pilot randomised control trial and feasibility study of Cognitive Behavioural Suicide Prevention therapy provided the opportunity for a qualitative investigation of staff experiences and views of a psychological intervention for people with suicidal experiences on psychiatric in-patient wards.AimsTo investigate staff acceptability of Cognitive Behavioural Suicide Prevention therapy for psychiatric inpatients based on their perceptions of their experiences during the conduct of a clinical trial.MethodTranscribed audio-recordings of qualitative interviews and a focus group (n = 19) of purposively sampled staff from eight psychiatric wards were analysed using inductive Thematic Analysis.ResultsFacilitators and barriers were identified for: i) the conduct of the research, and, ii) the suicide-prevention intervention (Cognitive Behavioural Suicide Prevention therapy). Research-related barriers comprised communication difficulties between staff and researchers, and increased staff workload. Research-related facilitators included effective staff/researcher relationships, and alignment of the intervention with organisational goals. Suicide-prevention intervention-related barriers comprised staffs’ negative beliefs about suicide which impacted on their referral of inpatients to the clinical trial, and staff perceptions of insufficient information and unfulfilled expectations for involvement in the therapy. Facilitators included staff beliefs that the therapy was beneficial for inpatients, the service and their own clinical practice.ConclusionsStaff beliefs that ‘suicide-talk’ could precipitate suicidal behaviour resulted in covert gatekeeping and restricted referral of only inpatients judged as stable or likely to engage in therapy, which may not be those who could most benefit. Such threats to sample representativeness have implications for future therapy research design. The findings provide novel information for researchers and practitioners regarding the conduct of psychological treatment and research in psychiatric units.

Emergency Department Workload and Crowding During a Major Electronic Health Record Breakdown.

Background: Emergency Departments (EDs) today rely heavily on Electronic Health Records (EHRs) and associated support systems. EHR updates are known to be associated with adverse events, but reports on the consequences of breakdowns in EDs are lacking.Objectives: To describe the effects on workload, occupancy, patient Length Of Stay (LOS), and admissions at three EDs (a regional trauma center, a community hospital and a rural community hospital) during a 96 h period of EHR downtime, of which 48 h represented an unexpected breakdown.Methods: Assessments of workload, on a scale from 1 (no workload) to 6 (very high workload), were obtained from all staff before, during and after the downtime period. Occupancy, LOS and hospital admissions were extracted from data recorded in the fallback system at each ED during the downtime, and compared with the period before and after (uptime).Results: Workload increased considerably at two EDs during the downtime whereas the third ED lacked resources to assess workload due to the breakdown. The proportion of assessments ≥4 were 28.5% during uptime compared to 38.4% during downtime at the regional trauma center ED (difference 9.9%, p = 0.006, 95% CI 2.7–17%), and 22.9% compared to 41% at the rural community ED (difference 18.1%, p = 0.0002, 95%CI 7.9–28.3%). Median LOS increased by 19 min (3:56 vs. 4:15, p < 0.004) at the regional trauma center ED, by 76 min (3:34 vs. 4:50, p < 0.001) at the community ED and was unaltered at the rural community ED (2:47 vs. 2:51, p = 0.3) during downtime. Occupancy increased significantly at the community ED (1.59 vs. 0.71, p < 0.0001). Admissions rates remained unchanged during the breakdown. Fallback systems and initiatives to manage the effects of the breakdown differed between the EDs.Conclusions: EHR downtime or unexpected breakdowns increased staff workload, and had variable effects on ED crowding as measured by LOS and occupancy. Additional staff and digital fallback systems may reduce the effects on ED crowding, but this descriptive study cannot determine causality.

Drinking vessel preferences in older nursing home residents: optimal design and potential for increasing fluid intake.

residents in nursing and residential care homes are at risk of dehydration due to both resident and institutional factors. Previous studies have focused on improving fluid intakes by concentrating on types of fluids offered and assisting residents to drink. to determine resident opinion of the optimal features of drinking vessels and evaluate the impact of improving vessel design on fluid consumption. residents from two units (25-bed and 21-bed) in one nursing home evaluated a range of drinking vessels. Vessels with preferred features were introduced on a 25-bed unit. The effect was tested by observing residents' fluid consumption during breakfast on three consecutive days and comparing with baseline intakes. vessels that received the highest ratings were lightweight, had large handles and held 200-300 ml of fluid. Following the introduction of the new drinking vessels, mean fluid intakes at breakfast increased from 139 ml (±84 ml) to 205 ml (±12 ml, n=65), p=0.003. some drinking vessels used in nursing homes may be difficult for residents to handle. Making improvements to the design of drinking vessels has the potential to increase fluid intakes without increasing staff workload.

Understanding the process of strengthening multi‐sectoral efforts for anemia reduction: Qualitative findings from Sierra Leone and Uganda

Anemia is a significant global health problem, and progress to reduce it has been slow. A multi-sectoral, context-specific, and country-led approach is recommended to effectively address anemia, but there is limited documentation of how this has worked in practice. We present key findings and lessons learned from Sierra Leone and Uganda's experiences establishing national-level anemia coordination platforms. A longitudinal collective case study methodology was used, with in-depth interviews of National Anemia Working Group members in both countries; data was analyzed to distill the salient lessons learned across countries. Similar factors were identified in the 2 countries. Setting the agenda was an important first step, accomplished by using country-specific anemia-related data and obtaining multi-sectoral commitment. Establishment of a cohesive coordination structure provided an effective platform to prioritize and align anemia activities. Strong, committed leadership and representation of diverse stakeholders was essential to maintain the legitimacy of anemia efforts. The main barriers to the policy-making process included misalignment of sectoral mandates, differences in work cultures, as well as competing priorities and increased staff workload. Sierra Leone and Uganda's experiences contribute to the global evidence base for anemia coordination and planning at the national level, particularly around linking health and non-health sectors and developing multi-sectoral platforms. It remains to be seen how and to what extent resulting policies in Sierra Leone and Uganda will translate to implementation.

Factors affecting patients' knowledge about dispensed medicines: A Qualitative study of healthcare professionals and patients in Pakistan.

BackgroundPatients’ knowledge about their prescribed medicines is one of the most important antecedents of successful therapy. Poor knowledge about medicines can lead to serious consequences such as non-adherence and misunderstanding of the significance of adverse events. The objective of this study is to understand the factors that are responsible for a patients’ lack of knowledge regarding their medicines, by taking the perspective of the patient as well as that of healthcare professionals. Much of the work in this area has been undertaken in the setting of developed or semi-developed countries, and there is a scarcity of information from developing nations such as Pakistan.MethodsThis was a large qualitative study set in the hospital outpatient environment in a teaching hospital in the Punjab province of Pakistan. Data were collected from dialogue with patients (n = 19) and healthcare providers (n = 16) i.e., doctors and dispensers (where a dispenser is a person who merely dispenses medicines; i.e. is not a pharmacist) through in-depth semi-structured interviews. Patients having limited knowledge about their dispensed medicines were assessed using a checklist. The healthcare providers were recruited through a convenience sampling strategy, based on their availability and willingness to participate in the study. Based on the objectives of the study, a pilot tested interview protocol was developed, and used to conduct the interviews. The sample size was controlled by using saturation point criteria. All interviews were audio recorded and transcribed verbatim. The data were analyzed to draw conclusions using inductive thematic content analysis.ResultsThe analysis of data yielded 31 categories (patients = 19, healthcare professionals = 12), 10 subthemes and three themes. The major themes were healthcare professional-related factors, patient-related factors and system-related factors. The health professional related subthemes included: behaviour and attitude and professional liabilities and liaison. The patient related subthemes included: eagerness of the patients and lack of understanding and misconception. The system-related factors included: patients with special needs, perceived role of the pharmacist, prescription and medicines, and staff workload.ConclusionHealthcare professional related, patient related and system related factors have a significant influence on patients’ knowledge about dispensed medicines. The non-professional behaviour of doctors, increased staff workload, inadequate time and attention provided by healthcare professionals to patients, illiteracy of patients, lack of specialized labelling on medicines for illiterate patients and absence of pharmacists at the hospital, were the major concerns identified in this study. The study points to a need for appropriate patient education and counselling with regards medicines, improved coordination between hospital staff, and provision of some basic system-related facilities which are pivotal for enhancing patients’ knowledge and adherence to their treatment regimens.