Key Aspects Of Care Research Articles

Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists

The incidence of pyogenic spondylodiscitis is increasing, and the disease is associated with considerable morbidity, mortality, long-term healthcare utilization and societal costs. Disease-specific treatment guidelines are lacking and there is little consensus regarding optimal conservative and surgical management. This cross-sectional survey of German specialist spinal surgeons sought to determine practice patterns and degree of consensus regarding the management of lumbar pyogenic spondylodiscitis (LPS). An electronic survey covering provider information, diagnostic approaches, treatment algorithms, and follow-up care of patients with LPS was distributed to members of the German Spine Society. Seventy-nine survey responses were included in the analysis. Magnetic resonance imaging is the diagnostic imaging modality of choice for 87% of respondents; 100% routinely measure C-reactive protein in suspected LPS and 70% routinely take blood cultures before therapy initiation; 41% believe that surgical biopsy to obtain microbiological diagnosis should be carried out in all cases of suspected LPS, whereas 23% believe that surgical biopsy should only be carried out when empirical antibiotic therapy proves ineffective; 38% believe an intraspinal empyema should always be surgically evacuated, regardless of spinal cord compression. The median intravenous antibiotic duration is 2weeks. The median total duration of the antibiotic therapy (intravenous and oral) is 8weeks. Magnetic resonance imaging is the preferred imaging modality for follow-up of both conservatively and operatively treated LPS. There exists considerable variation of care in the diagnosis, management, and follow-up of LPS among German spine specialists with little agreement on key aspects of care. Further research is required to understand this variation in clinical practice and to enhance the evidence base in LPS.

Management of the Patient with Chronic Critical Illness - Part 2.

Patients with chronic critical illness (CCI) represent a growing segment of the hospitalized population. Key aspects of care in CCI patients including tracheostomy, prolonged mechanical ventilation, nutritional support, wound care, and others require a comprehensive, goal-directed approach. Infectious complications of CCI including pneumonia, tracheobronchitis and urinary tract infection may be caused by nosocomial organisms requiring awareness and adjustment of treatment regimen. Finally, psychiatric, palliative, rehabilitative components of care impact heavily upon outcomes in CCI patients. As care that is typically associated with the intensive care unit is extended to the hospital ward, we aim to increase awareness among providers and outline a systematic approach to deliver high quality, patient centered care to CCI patients.

Management of the Patient with Chronic Critical Illness - Part 1: This is part one of a two part series. Part two will be published in September.

Patients with chronic critical illness (CCI) represent a growing segment of the hospitalized population. Key aspects of care in CCI patients including tracheostomy, prolonged mechanical ventilation, nutritional support, wound care, and others require a comprehensive, goal-directed approach. Infectious complications of CCI including pneumonia, tracheobronchitis and urinary tract infection may be caused by nosocomial organisms requiring awareness and adjustment of treatment regimen. Finally, psychiatric, palliative, rehabilitative components of care impact heavily upon outcomes in CCI patients. As care that is typically associated with the intensive care unit is extended to the hospital ward, we aim to increase awareness among providers and outline a systematic approach to deliver high quality, patient centered care to CCI patients.

Predicting and Communicating Geriatric Trauma Outcomes

To provide an overview of the most recent research in geriatric trauma outcomes, specifically highlighting advances in risk prediction for the elderly injured patient. Geriatric-specific evidence and best practices continue to evolve for older adult trauma patients. There are a number of risk stratification systems that offer insights into prognosis for elderly patients, and newer models using machine learning methods show promise in this population as well. These non-linear models can provide useful prognostic information to guide communication with patients and families, including the incorporation of palliative care interventions and geriatric-specific pathways that have been shown to be of benefit to this patient population. Key aspects of care for geriatric trauma patients include knowing the best clinical practices for this population, along with up-to-date research on risk prediction in this group. While there has been some success with the use of risk stratification systems to guide implementation of palliative care interventions, further implementation-based research is needed on specific programs in order to make this more widespread.

Management of low back pain in Australian emergency departments

BackgroundTo describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by...

Nursing Training Requirements for Implementation of a Commercial T Cell Product

Topic Significance & Study Purpose/Background/Rationale In 2016, a Comprehensive Cancer Center (CCC) created an Immunotherapy outpatient clinic dedicated to treating patients with T cell-based therapies. In 2017-18, this CCC obtained site certification for commercially approved Chimeric Antigen Receptor (CAR) T cell products and implemented an operationalization plan for best practices for CAR-T cell patient care. One essential aspect of this care practice implementation was comprehensive nursing education process incorporating the FDA mandatory patient education requirements, product administration, side effect recognition and treatment. Methods, Intervention, & Analysis In accordance with the site certification process, our nurses underwent REMS (Risk Evaluation and Mitigation Strategy) training which provided a product specific overview and treatment recommendations. Additional trainings were then conducted for product administration, product specific patient education requirements, T cell specific side effects, and documentation requirements. One of our final steps prior to implementation was a multidisciplinary review of the programmatic implementation plan which outlined the process for financial clearance, online product ordering and management, timing considerations for apheresis and cell formulation, and coordinating inpatient/outpatient cell infusions. Findings & Interpretation The comprehensive education provided nurses with foundational, product specific and logistical considerations to help support a successful implementation plan for each commercial product. In addition to didactic training, reference tools, including a product infusion policy, standard work documents, and a workflow to facilitate hospital admission were developed. These tools have demonstrated effectiveness in providing nurses with product specific implementation details and continue to be adapted as new improvements and processes are made. Discussion & Implications Nurses are on the forefront of caring for these novel CAR T cell patients. Specific clinical education and establishment of standard protocols are essential to creating best clinical practices. Implementation of these state of the science care modalities is a multidisciplinary effort, and nurses play a primary role in many key aspects of care, including patient education, product collection and infusion, side effect recognition and symptom management. With future increases in the utilization of novel T cell-based therapies, comprehensive nursing education and training is imperative for the realization of best patient outcomes.

Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association.

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, withcomplex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionalsproviding foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.

A Multifaceted Quality Improvement Programme to Improve Acute Kidney Injury Care and Outcomes in a Large Teaching Hospital

Acute kidney injury (AKI) is now widely recognised as a serious health care issue, occurring in up to 25% of hospital in-patients, often with worsening of outcomes. There have been...

Use of Lean and CAHPS Surgical Care Survey to Improve Patients' Experiences with Surgical Care.

(1) Measure patients' experiences with surgical care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey. (2) Use lean thinking to analyze and improve quality of patient care. A prospective quality improvement study. Hospital-based otolaryngology clinic. The CAHPS Surgical Care Survey was distributed to 17 surgical patients to determine their perception of the current state of care. Survey results were analyzed with lean thinking, and changes were made to improve critical areas. A second set of surveys was distributed to 10 patients to assess the success of the interventions immediately and 2 months later. The data were analyzed with the Mann-Whitney U test. Seventeen patients completed the CAHPS Surgical Care Survey to determine the initial state. A3 Thinking was used to analyze the results and design an improvement. Overall positive patient experience was 57% at the postoperative visit with 3 key aspects of care: time spent during visit, encouragement to ask questions, show of respect to the patient. Two causes were postulated; then, solution approaches were developed and tested in a series of rapid experiments. Two groups of 10 patients completed the CAHPS Surgical Care Survey to determine the postintervention state. Overall positive patient experience significantly improved to 93% (U = 474, P < .001) and 83% (U = 546, P = .009) immediately and 2 months later, respectively. Lean thinking helps to eliminate defects by breaking down complex problem solving into a scientific process. When combined with the CAHPS Surgical Care Survey, it can be successfully used to improve patients' surgical experiences.

PWE-030 The Inflammatory Bowel Disease (IBD) Audit Programme at The Royal College of Physcians Reports on 10 Years of Achievements and Demonstrates Improvements in Care Of People with IBD

Introduction The IBD audit programme, first established in 2004 has conducted several rounds of audit. The programme’s aim is to improve the care of people with IBD by; facilitating the collection of key aspects of data on patient care and organisational services, analysing and disseminating the results, providing recommendations for improvements based on the key findings in the analyses. Methods Since 2006 the programme has facilitated up to 4 rounds of data collection on adults and children for inpatient care, organisation of IBD services and administration of biological therapies. We also collected data on patients experiences of care and the provision of care in primary care services. In 2015 the programme team hosted 8 regional workshops and proactively helped hospital IBD teams to develop action plans on key aspects of care that required improvements in their local areas. Results Over the 10 years of the programme’s work - a high level of participation in the audit has been achieved, >90% participation rate from IBD hospital teams across the UK. There have been many improvements in patient care, the most notable since 2006 to date, are a reduction in mortality during admissions, reduction in unplanned surgery, increased patient contact with an IBD nurse, improved rates of prescribing heparin and bone protection. From the biological therapies audit, results clearly demonstrate biological therapies for IBD are effective and safe treatments. Patterns of prescribing are changing with earlier use in patients with less severe disease suggesting doctors have become more familiar with the treatment. Despite the positive improvements, the most recent audit, reported in 2014, identified that there were still aspects of care requiring improvements including treatment of anaemia, access to dietetic support and management of people attending out patient care. Also, the two audits on patient experience between 2010 and 2012 showed no improvements in patient’s experiences of care. The 8 regional workshops hosted in 2015 across the UK proved to be a successful initiative. They were attended by 84 trusts and healthcare boards. 74% of delegates surveyed at 6 months agreed that these had helped them to improve their service. Conclusion 10 years of intensive working and engagement with the IBD community, the programme could not boast of its achievements without acknowledging the support of the community. However further and continued improvements in patient care for people with IBD are necessary. In 2016 the IBD audit programme will be transitioning to the UK IBD Registry. There will be a continued emphasis to help hospital teams to make continued improvements in the quality of care of people with IBD through a number of initiatives. Disclosure of Interest None Declared

Management of adults with diabetes on the haemodialysis unit: summary of new guidance from the Joint British Diabetes Societies (JBDS) and the Renal Association

Diabetic nephropathy remains the principal cause of end-stage renal failure (ESRF) in the UK, as elsewhere in the developed world, and its prevalence is set to increase. People with diabetes and ESRF on maintenance haemodialysis are a highly vulnerable group, often with complex comorbidities, who are at high risk of adverse cardiovascular outcomes, which is the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and ESRF require improved delivery of care to overcome organisational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of the diabetes patient on maintenance haemodialysis. The guideline is based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and patients to promote patient empowerment and self-management.

An international collaborative design of clinical nursing practice guidelines for patients with cholangiocarcinoma.

65 Background: Cholangiocarcinoma (CC) accounts for approximately 3% of all gastrointestinal cancers and have a poor incident to mortality rate. The incidence in the United States (US) is 2,000-3,000 cases annually, with this rate steadily increasing during the last twenty years; this trend is not solely observed in US but also seen in Europe, Australia and Japan. The highest incidence is seen in Southeast Asia due to parasitic infection. CC presents many challenges to healthcare professionals due to the anatomic nature of CC (Lowe et al, 2015). The worldwide increase in incidence of CC is indication for the essential development of nursing practice guidelines underpinned by expert evidence and knowledge and regarding the key aspects of care. Methods: A collaboration of nursing professionals representing major cancer research institutions from around the country and the United Kingdom worked together to identify key aspects of care, the aim being to develop Clinical Nursing Practice Guidelines. The process included an exhaustive literature review using Pubmed, Uptodate, Medline, and CINAHL databases; submission of respective institutional practices; group consensus on guideline content, evidence-based scoring assignment and approval by the Cholangiocarcinoma Medical Advisory Board. Results: The guidelines developed include the care of the patient: (1) with external biliary drains and internal bile duct stents, (2) with intractable nausea and vomiting resulting from disease process, (3) with fatigue resulting from disease process, (4) undergoing chemotherapy, (5) undergoing photon radiation, (6) undergoing radiation on a clinical trial, and (7) preparing for liver transplantation. The purpose of the guidelines are to advance the scientific knowledge of the symptoms experienced, quality of life of patients with CCA, establish standards in patient care, and improve quality of care and satisfaction for patients diagnosed with CC. Conclusions: Creation of evidence-based guidelines will provide a springboard for expanded competent knowledge and a model to test for improvement in the care and quality of life of the patient with CC.

Managing paediatric death in the emergency department.

Death of a child in an emergency department is a rare occurrence, but one with significant impact on the family and staff involved. The rarity means few emergency department clinicians feel 'expert' in the overall management process. However, most have some knowledge and experience which can be augmented by collaborating with other health professionals. By exploring some of the main management issues and challenges for the emergency department, key aspects of care are identified for emergency department clinicians to consider in reviewing local procedures and guidelines.

Implementation and evaluation of a checklist to improve patient care on surgical ward rounds.

Key aspects of care may be overlooked on a busy surgical ward round. This study assessed the use of a checklist to correct these omissions. Its use as the basis of structured ward round documentation was then measured. Using a structured checklist, key aspects of surgical care were observed and recorded during ward rounds. Initially, members of the surgical team were unaware of the checklist. Subsequently, rounds were performed with a designated member of the team acting as 'prompter' if aspects of care were not considered per the checklist. A structured ward round progress form was developed and its completion assessed before and after specific education in its use. Changes in the use of checklist and documentation using the structured form were analysed for statistical significance. Following the use of a checklist and prompting during ward rounds, significant improvement occurred in the consideration of the majority of criteria included in the checklist, all of which reached statistical significance (P < 0.05). Provision of a structured progress form did not initially improve documentation but this was substantially improved with specific education (P < 0.05). The use of a checklist during surgical ward rounds makes significant improvement in the consideration of most key aspects of care and education in the completion of a structured progress form substantially improved documentation.

Commentary: Mexico: Moving from universal health coverage towards health care for all

Commentary: Mexico: Moving from universal health coverage towards health care for all

Assessing the quality of record keeping for cesarean deliveries: results from a multicenter retrospective record review in five low-income countries

BackgroundReliable, timely information is the foundation of decision making for functioning health systems; the quality of decision making rests on quality data. Routine monitoring, reporting, and review of cesarean section (CS) indications, decision-to-delivery intervals, and partograph use are important elements of quality improvement for maternity services.MethodsIn 2009 and 2010, a sample of CS records from calendar year 2008 was reviewed at nine facilities in Bangladesh, Guinea, Mali, Niger, and Uganda. Data from patient records and hospital registers were collected on key aspects of care such as timing of key events, indications, partograph use, maternal and fetal outcomes. Qualitative interviews were conducted with key informants at all study sites to provide contextual background about CS services and record keeping practices.ResultsA total of 2,941 records were reviewed and 57 key informant interviews were conducted. Patient record-keeping systems were of varying quality across study sites: at five sites, more than 20% of records could not be located. Across all sites, patient files were missing key aspects of CS care: timing of key events (e.g., examination, decision to perform CS), administration of prophylactic antibiotics, maternal complications, and maternal and fetal outcomes. Rates of partograph use were low at six sites: 0 to 23.9% of patient files at these sites had a completed partograph on file, and among those found, 2.1% to 65.1% were completed correctly. Information on fetal outcomes was missing in up to 40% of patient files.ConclusionsDeficits in the quality of CS patient records across a broad range of health facilities in low-resource settings in four sub-Saharan Africa countries and Bangladesh indicate an urgent need to improve record keeping.

G262(P) Small Wonders Change Programme. Supporting parents to be at the heart of their baby’s care

AimThe Small Wonders Change Programme was developed to address the current gap between policy and practice by supporting practitioners in helping parents of a premature or sick baby to be...

G318 Experiences of transition from paediatric to adult services for young people with Sturge-Weber syndrome (SWS)

Background: Sturge-Weber syndrome (SWS) is a rare, sporadic genetic condition associated with learning disability, hemiplegia, epilepsy and headache for which children require multidisciplinary management. Guidelines for transition recommend: planning from age 14 years, identification of a key coordinator and a written transition plan for the young person. Objective: To assess experiences of the transition process from paediatric to adult services for young people with SWS and their families. Methods: An audit of all children and young adults aged 12–22 years known to the Sturge Weber Foundation (UK) database. Questionnaires were developed from existing healthcare transition questionnaires, and adapted to specifically evaluate key aspects of care and provision for young people with SWS and their parents. Results: Twenty families completed a parent-rated questionnaire; in 14 cases the young person with SWS completed a patient-rated questionnaire (mean age17.5 years; range 12–22 years, 50% male). 55% had experienced both adult and paediatric services. Fewer appointments had been offered in adult health services compared to paediatric services across all disciplines identified, with the exception of psychiatry. These discrepancies were most marked for general practice, neurology, physiotherapy and occupational therapy. Parents/carers more often rated adult services as ‘poor’ in response to questions about professionals’ understanding of their child’s condition (56%), multidisciplinary communication (67%), and the ability to meet their child’s needs (56%). Mean age at which transition planning started was 16.77 years. Seven out of 13 respondents could not identify a key professional involved in their transition process; 80% felt there was no clear handover of information to adult services; one respondent had received a written transition plan. The areas most frequently rated by young people with SWS as causing difficulties included: learning, anxiety, socialising, vocational/independence skills, and headaches. Whilst most had received support with respect to their learning needs and headaches, the majority had received no help in the other areas. Conclusions: Currently, the needs of young people with SWS, in common with young people with other causes of disability are not being adequately met by adult services. Planning for transition requires improvement, with access to services that are responsive to complex childhood disorders.

Quality of Care for Patients With Acute Coronary Syndromes as a Function of Hospital Revascularization Capability: Insights From Get With The Guidelines‐CAD

Revascularization availability at US hospitals varies and may impact care quality for acute coronary syndrome patients. The hypothesis of this study was that there would be differences in care quality at Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) hospitals based on revascularization capability. For acute coronary syndrome patients admitted to GWTG-CAD hospitals between 2000 and 2010, care quality at hospitals with or without revascularization capability was examined by assessing conformity with performance and quality measures. This study included 95 999 acute coronary syndrome patients admitted to 310 GWTG-CAD hospitals. There were 89 000 patients admitted to 226 revascularization-capable hospitals and 6999 patients admitted to 84 hospitals without revascularization capability included. Adjusted multivariate analysis demonstrated that 8 of the 19 measures were more frequently performed in the revascularization cohort: aspirin (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.04-1.92), clopidogrel (OR: 2.31, 95% CI: 1.78-3.00), lipid-lowering therapies at discharge (OR: 1.39, 95% CI: 1.04-1.87), lipid-lowering therapies for low-density lipoprotein >100 mg/dL (OR: 1.85, 95% CI: 1.23-2.77), achievement of blood pressure <140/90 mm Hg (OR: 1.20, 95% CI: 1.03-1.40), LDL recorded (OR: 1.47, 95% CI: 1.05-2.06), and recommendations offered for physical activity (OR: 3.82, 95% CI: 2.23-6.55) or weight management (OR: 1.74, 95% CI: 1.12-2.69). The GWTG-CAD revascularization hospitals were associated with better performance in some, but not all, measures assessed. Although the difference in conformity between hospital types was modest for performance measures but more variable for quality measures, room for improvement exists in key aspects of care.

Identifying knowledge-translation opportunities in the treatment of locally advanced breast cancer.

47 Background: Guidelines are usually developed using systematic literature reviews. Expert opinion plays a key role but can be difficult to incorporate. The objective of this study was to develop a national consensus of expert opinion on the management of Locally Advanced Breast Cancer (LABC) and subsequently identify gaps in knowledge translation in current practice. Methods: 361 Canadian oncologists were subdivided into LABC experts (n = 83) and non-experts (n = 278). Experts were surveyed with a modified Delphi protocol to establish consensus. A systematic literature review was performed and compared to expert opinion. Non-experts were then surveyed with a 29-item questionnaire to determine current practice patterns. Z test was used to assess discordance. Results: Response rate for the expert survey was 61% (51/83). Consensus was achieved in all key aspects of care and was concordant to published literature in areas of: clinical assessment with caliper at each cycle, option of lumpectomy if good clinical response, radiotherapy to loco-regional lymph nodes, and no further adjuvant chemotherapy outside of clinical trial if residual disease found at time of surgery. Response rate for the non-expert survey was 50% (140/278). Areas of discordance are highlighted below. Conclusions: A national practice consensus guideline reflective of current evidence and expert opinion has been developed on the management of LABC. Differences in expert opinion and current practice have been identified as targets for knowledge translation interventions (KTIs) that may improve quality of care and resource utilization. Further exploration of KTIs to address identified gaps is warranted. [Table: see text]