Medical Rounds Research Articles

A gap between the philosophy and the practice of palliative healthcare: sociological perspectives on the practice of nurses in specialised palliative homecare

Palliative care philosophy is based on a holistic approach to patients, but research shows that possibilities for living up to this philosophy seem limited by historical and administrative structures. From the nurse perspective, this article aims to explore nursing practice in specialised palliative homecare, and how it is influenced by organisational and cultural structures. Qualitative, semi-structured interviews with nine nurses were conducted, inspired by Bourdieu. The findings showed that nurses consolidate the doxa of medicine, including medical-professional values that configure a control-oriented, positivistic approach, supported by the organising policy for clinical practice. Hierarchically, nurses were positioned under doctors: medical rounds functioned as a structuring structure for their working day. They acted as medical assistants, and the prevailing medical logic seemed to make it difficult for nurses to meet their own humanistic ideals. Only short time slots allowed nurses to prioritise psychosocial needs of patients and relatives. Point-of-actions had high priority, added financial resources and ensured that budgets were allocated. Weekly visits made it possible for nurses to measure, control and govern patients’ drugs and symptoms which was a necessity for their function as medical assistants. The findings challenge nurses to take on an ethical point of view, partly to ensure that patients and their families receive good palliative care focusing on more than medical issues and logic, and partly to strengthen the nurses’ profession in the palliative field and help them implement palliative care philosophy in practice.

63. THE NEXT MORNING: MODIFICATIONS MADE ON ROUNDS TO ORDERS PLACED BY OVERNIGHT ADMITTING RESIDENTS

Background An increased focus on quality and safety has resulted in increased resident supervision by attending physicians. At our large pediatric academic medical center, the overnight shift is when residents admit general pediatrics patients without immediate attending supervision. As such, admission orders are not evaluated by an attending until morning rounds. To the authors’ knowledge these orders have not been previously evaluated in the academic literature. Objectives To categorize orders placed by residents overnight that were subsequently discontinued on medical rounds the next morning and to examine the reasons for those changes. Methods We utilized our hospital's Enterprise Data Warehouse to generate a report of all orders placed on newly admitted patients by residents on the general pediatrics night shift over a 12-month period that were subsequently discontinued the following morning on rounds. All charts were reviewed by two independent reviewers. Orders were categorized by type of order and perceived reason for discontinuation. Disagreements on categorization were discussed with the research team until consensus was achieved. Results 290 discontinued patient orders were included in the analysis. Inter-rater agreement was very good with a kappa of 0.91. 66% of orders were medicines, 11% were diets, 4% were diagnostic testing, and 19% were for patient care. Within medication orders, 29% were antibiotics, 17% were antiasthmatics, and 10% were non-narcotic analgesics. The reason for order discontinuation was due to a change in clinical trajectory in 44% of cases (98% of which was patient improvement), primary attending decision in 11% of cases, and due to medical errors in 8% of cases. The most common medical error was a duplicate order (37.5%). Conclusions This study suggests that admission orders placed by pediatrics residents overnight are clinically appropriate. Medical errors were most commonly duplicate orders. This pilot identifies the need for further study to better understand the overnight care delivered by residents and to identify areas for increased resident autonomy.

Exploring the Gap Between Needs and Practice in Facilitating Breastfeeding Within the Neonatal Intensive Care Setting: An Italian Survey on Organizational Factors.

Introduction: The system-level factors of the neonatal intensive care unit work environment contribute to breastfeeding promotion in the preterm population. The aim of this study was to investigate the operative policies related to breastfeeding support in a sample of Italian Neonatal Intensive Care Units.Materials and Methods: A multicenter cross-sectional survey was conducted, including a sample of 17 head nurses. The items of the questionnaire investigated the following areas: breastfeeding policies, staff education, family centered care, and breastfeeding promotion and support both in the neonatal intensive care units and after discharge.Results: Written breastfeeding policies were available for staff in all the neonatal intensive care units, most commonly addressing procedures related to skin-to-skin contact, human milk expression, and preterm infant breastfeeding. Most of the neonatal intensive care units correctly advised the mothers to initiate milk expression within 6 h from delivery and to pump milk at least 6 times/days. Breastfeeding training for the nursing staff was planned in the majority of the neonatal intensive care units although according to different schedules. With regard to the family centered care implementation, time restrictions were present in seven neonatal intensive care units, mostly occurring during the night shift, and the morning hours concomitantly with medical rounds. Moreover, in the majority of the investigated neonatal intensive care units, the parents were asked to leave the ward when their infant underwent a major invasive procedure or during the nurse/physician shift change report. With regard to breastfeeding promotion and support, eight neonatal care units had a multidisciplinary team with several health care professionals and 10 provided information about community-based support services. Most of the units assessed breastfeeding after discharge.Conclusion: Based on the present findings, enrolled Neonatal Intensive Care Units appear to provide breastfeeding-supportive environments with special regard to breastfeeding policies, milk expression practices, interprofessional collaboration, and continuity of care. Health care professionals should exert efforts to ensure continuous and updated breastfeeding staff education and promote parent-infant closeness and family centered care.

Ward round accreditation: an innovative quality improvement project to develop and improve the existing medical ward round at Warrington Hospital

Ward round accreditation: an innovative quality improvement project to develop and improve the existing medical ward round at Warrington Hospital

Ward round accreditation: an innovative quality improvement project to develop and improve the existing medical ward round at Warrington Hospital

Medical ward rounds have long been considered the centrepiece of inpatient care. They provide an opportunity for high quality, safe, multidisciplinary patient review while facilitating shared decision making, patient flow and important educational input. Variation in ward round structure is

Communicating with patients, families and health professionals about managing medications in intensive care: A qualitative observational study

ObjectivesTo explore communication between patients, families, and health professionals about managing medications in intensive care. DesignA qualitative exploratory study was undertaken using participant observations. A thematic analysis of the data was performed. SettingThe setting comprised an intensive care unit at a public, teaching hospital in Melbourne, Australia. FindingsThree themes were identified: provision of information, therapeutic relationships, and patient and family centred care. Nurses and pharmacists communicated regularly about medications with patients and family members. Doctors were occasionally present at the bedside during medical ward rounds or in undertaking medical procedures and subsequently their patient and family interactions about managing medications tended to be minimal. Pharmacists spent time in clarifying patients’ medication history prior to their admission to the intensive care unit. Nurses were at the forefront of communication with patients and their family members. However, nurses sometimes missed cues and valuable opportunities to respond to families’ concerns during their interactions. Communication was commonly hampered by time constraints and competing responsibilities of health professionals. ConclusionCommunication tended to involve clarification of patients’ medication history and the ways in which medications affected patients’ clinical status or medical condition. Attention is needed in attending to cues from families in communicating about medications.

The Clinical Outcomes of Pharmacist Interventions at Critical Care Services of Private Hospital in Riyadh City, Saudi Arabia

Pharmacology, Toxicology and Biomedical Reports,2019,5,1,16-19.DOI:10.5530/PTB.2019.5.4Published:January 2019Type:Research ArticleAuthors:Yousef Ahmed Alomi, Manal El-Bahnasawi, Mohammed Kamran, Tasneen Shaweesh, and Soha Alhaj Author(s) affiliations:Yousef Ahmed Alomi*, The Former General Manager of General Administration of Pharmaceutical Care Former Head, National Clinical Pharmacy and Pharmacy Practice Former Head, Pharmacy R and D Administration Ministry of Health, Riyadh, SAUDI ARABIA. Manal El-Bahnasawi, Head, Pharmacy Services Sulaiman Al-Habib Medical Group, Riyadh, SAUDI ARABIA. Mohammed Kamran, Clinical Pharmacy Staff, Pharmacy Services Sulaiman Al-Habib Medical Group, Riyadh, SAUDI ARABIA. Tasneen Shaweesh, Clinical Pharmacy Staff, Pharmacy Services Sulaiman Al- Habib Medical Group, Riyadh, SAUDI ARABIA. Soha Alhaj, Clinical Pharmacy Staff, Pharmacy Services Sulaiman Al-Habib Medical Group, Riyadh, SAUDI ARABIA. Reem Ahmed Radwan, Staff Pharmacist, Pharmacy Services Armed Forces Center for Health Rehabitition Taif, SAUDI ARABIA. Abstract:Objective: Dr. Sulaiman Al-Habib Medical Group (HMG) of Hospitals is one of the largest private chains of hospitals in the Kingdom of Saudi Arabia. At HMG, the clinical pharmacy services were started in 2015 which provides services to the acute and chronic cases of neonates, pediatrics and adults. In this study, we aimed to explore the clinical and economic outcomes of providing clinical pharmacy services at critical care units at a private hospital in Riyadh City, Saudi Arabia. Methods: This was a 6-month cross-sectional study conducted from January to June 2016 at the critical care unit of HMG involving adult patients. The critical care unit has 30 beds dedicated to the treatment of trauma, medical, surgical and maternity patients. The clinical pharmacist monitors all patients through daily medical rounds and documents any intervention that needs to be provided to the patient. The pharmacist intervention system utilized an international study model, a measure of the level of activity, rational of clinical intervention, recommendation and patient outcome. Results: A total number of 1222 pharmacist interventions were provided to 1124 adult patients. The highest number of critical care interventions were found to be potentially significant (610 (49.9%)) followed by potentially serious (360 (29.5%)) and neutral (249 (20.4%)) cases. Anti-infective medications (185 (25.9%)) were the most category of intervention provided followed by cardiovascular medications (96 (13.5%)) and gastro-intestinal medications (73 (10.2%)). The documented rationale of clinical intervention activities was others (203 (28.7%)), inappropriate dose (122 (17.3%)) and therapeutic duplication ((99 (14%)). Most of the patient outcomes were unknown (539 (44.1%)) followed by patient condition improved (408 (33.4%)) and therapeutic endpoint reached (133 (10.9%)). Conclusion: The clinical pharmacy services at critical care units of a private hospital is a significant and essential component for patients care. The clinical pharmacist prevents the occurrence of drug-related problems in addition to saving additional economic burden on the healthcare system at HMG in the Kingdom of Saudi Arabia. Keywords:Clinical outcomes, Critical care services, Interventions, Pharmacist, Private hopsital, Riyadh, Saudi ArabiaView:PDF (178.1 KB) PDF PDF Images Table 2: Prescriber qualification.

Patients under 4 years old treated with overhead extension for isolated femoral fractures - lessons learned concerning parents' satisfaction.

Conservative options are the standard for treatment of femoral fractures for patients under the age of 4 years. We investigated possible factors influencing the satisfaction of the parents in order to improve their experience. We analyzed 42 cases of children under the age of 4 years treated with overhead extension therapy (OHE) for femoral fracture. Our protocol requires transition to spica cast treatment (SCT) and discharge from the hospital after the initial 10-day OHE. X-rays were analyzed for fracture healing. A pseudonymized questionnaire was sent to the parents in order to evaluate their experiences during the treatment. The nature of the fracture was explained to 73.3% of the parents in a way that was "understandable and in detail". However, 23.3% stated that "many questions were not answered". Seventy percent of parents noticed behavioral abnormalities during treatment, and 63.3% reported treatment-specific problems. Additionally, 86.7% of parents were satisfied with the therapy outcome, 80% were content with the type of therapy, and 73.3% would choose OHE again. We found a high Spearman correlation between general satisfaction and parents who felt well informed. There was also a strong correlation between high general satisfaction and the opportunity for any problems to be discussed and addressed during the medical rounds. The reasons for nonsatisfaction were primarily due to communication problems. Thorough evaluation during medical rounds, communication with healthcare professionals and care provided by the nurses affects the contentment of the families significantly.

Research on Patient Satisfaction of Robotic Telerounding: A Pilot Study in a Korean Population

ObjectivesTo evaluate the efficacy and functionality of robotic telerounding among Korean patients using the RP-7 robot system and a questionnaire survey comparing the results of robotic telerounding and standard rounding in Korean patients. MethodsA total of 40 patients who underwent urologic minimally invasive video-assisted minilaparotomy surgery, laparoscopic and robotic surgery, and endoscopic surgery were recruited. The patients were divided into 2 groups – telerounding (20) and standard rounding (20) – and underwent robotic telerounding and standard rounding. We assessed the patients using a 24-item questionnaire to evaluate the efficacy and functionality of their hospital care. ResultsThe hospital factors such as self-rated health, assistance, and pain control scores showed no statistically significant differences between groups. Patient satisfaction showed a statistically significant difference in MD confidence, medical communication, explanation understanding, explanation satisfaction, mutual communication, and mutual response. In the telerounding group, participants were satisfied with the audio and video qualities and believed that the robotic telerounding provided better care, and 85% of patients preferred telerounding in the absence of the attending physician. ConclusionRobotic telerounding can provide efficient and cost-effective medical rounding by reducing inconvenience and labor cost with greater patient satisfaction with postoperative care. However, there is no statistically significant difference in the hospital factors and postoperative morbidity. In addition, the patients doubted that the robotic telerounding could replace standard rounding due to the Eastern culture.

A study to assess drug related problems in patients with Cardiovascular Diseases in a tertiary care teaching hospital

Back ground: Drug related problems are common in hospitalized patients and may lead to increase hospital stay, health care cost and augment the risk of morbidity and mortality. Objective: The aim of the study is to examine the nature and frequency of drug related problems, to minimize drug related problems and to improve therapeutic outcome by pharmaceutical care provided by clinical pharmacist. Methodology: A prospective study was conducted in the cardiology department of a tertiary care hospital over a period of six months. Necessary demographic and clinical data was collected from the case records including drug history, other relevant details of the admitted patients and reviewed by the clinical pharmacist for drug related problems. Results: A total of 280 patient case sheets were reviewed during the study period, out of which 244 drug related problems were identified. The most common drug related problem was found to be drug interactions (58.6%) followed by untreated indication (19.26%) and drug use without indication (15.57%). The most frequent suggestions provided by the intervening pharmacist were drug discontinuation (5.32%), addition of a new drug (5.32%) and change of dosage form (4.5%). Conclusion: Drug related problems are common among medical ward patients. Routine participation of clinical pharmacist in clinical medical rounds facilitates the identification of drug related problems and the current study highlights the importance of pharmacist in a multidisciplinary team of reviewing drug therapy for identification and resolution of DRPs which helps in achieving better therapeutic outcomes and improved patient care. Keywords: cardiovascular diseases, clinical pharmacist, dyslipidemia, drug related problem.

Participation of Parents of Hospitalized Children in Medical Rounds: A Qualitative Study on Contributory Factors

PurposeFactors that promote parents' participation during medical rounds on their hospitalized child have not been fully addressed. The aim of this study was to identify factors that promote the participation of family members during medical rounds. Design and methodsThis was a descriptive qualitative study using elements of analysis from the grounded theory method. Semi-structured interviews and non-participant observations were performed from December 2015 until June 2016 and took place on a general academic pediatric ward where the age of children did not exceed 12 months. ResultsIn total 20 participants were interviewed: 10 pediatric nurses, 4 pediatricians and 6 parents. In addition, five medical rounds were videotaped. Five themes emerged from the analyses of the interviews and videotapes: “conditions”, “structure of medical rounds”, “cast”, “adaptive professionals” and “parents' participation as a process”. ConclusionContextual factors, such as the room and seating arrangement, as well as the willingness of healthcare professionals to work together with the parents are important in enabling parents' participation. To promote active participation, professionals have to communicate in layman's terms and information given by parents has to be taken seriously. Support and coaching of parents during the medical rounds and evaluating the rounds are meaningful factors. Practice implicationsThese findings help healthcare professionals to restructure the traditional medical rounds to enable parents' participation. The identified communication skills and attitudes can enhance the competencies of nurses and doctors as communicators and collaborators. This urge the need for more specific education for professionals to promote parents' participation.

The medical unit round: engaging trainees in curriculum-relevant teaching

To provide weekly curriculum-relevant teaching for medical juniors as per Joint Royal Colleges of Physicians Training Board (JRCPTB) quality criteria for core medical trainees. Previous attempts at establishing sustainable weekly medical teaching at our hospital had failed secondary to poor attendance from both trainees and consultants. At the beginning of the year, the Royal College of Physicians college tutors, associate college tutors and chief registrar agreed that re-establishing high quality weekly teaching was a high priority …

Workforce: Newly graduated doctors’ experiences of conducting medical ward rounds alone: A regional cross-sectional study

Newly graduated doctors may be expected to conduct ward rounds alone, yet studies exploring this are limited. A regional cross-sectional study was undertaken to explore foundation year 1 doctors' (FY1s) experiences of conducting ward rounds alone; all 289 FY1s on medical rotations in Yorkshire and the Humber Foundation School were invited to participate in an online survey in November 2016. Thirty-four percent (n=98) responded. The majority (62%, n=61) of respondents reported conducting the daily ward round alone (without a more senior doctor present) two or more times a week. However, 56% (n=55) reported that they had never received teaching on ward round conduct and only 7% (n=7) reported feeling prepared for conducting ward rounds alone at the start of their medical rotation. FY1-led ward rounds are a regular occurrence yet training is not commonplace; widespread, early training should be considered to prepare future doctors for their role.

Parents' presence and participation in medical rounds in 11 European neonatal units.

Parents' involvement during hospital care is beneficial for preterm infants and their parents. Although parents are encouraged to be present in many neonatal intensive care units (NICUs), little is known about their role during medical rounds. To study parents' presence in the NICU, the degree of parents' participation during medical rounds, and to identify underlying factors for participation. A prospective study was performed in 11 neonatal units in six European countries including parents of preterm infants born before 35 gestational weeks. Parents' presence and the degree of participation (7-point Likert scale) during medical rounds were asked using a text-message question sent to the mobile phone of each parent separately. A total of 241 families were included in the study; mothers responded to 630 and fathers to 474 text-message questions, respectively. In studied units, mothers were present during medical rounds on 62.5% to 91% and fathers 30.8% to 77.8% of the days. The degree of mothers' and fathers' participation also varied between units (p < 0.001 and p = 0.022, respectively). In multivariate analysis, parents' presence increased by increasing gestational age (p = 0.010), fathers' education (p = 0.009), and by the policy in the unit to invite parents to medical rounds (p = 0.036). The background characteristics did not explain the degree of participation. There is significant variation between neonatal units in how they include parents in medical rounds. Only few background characteristics explained the differences suggesting that unit culture plays a major role in welcoming parents to participate.

Parental perceptions of neonatal therapeutic hypothermia; emotional and healing experiences

Introduction: Parents of infants who undergo therapeutic hypothermia experience emotional challenges that have not been fully characterized. Comprehensive understanding of the parental experience of hypothermia is needed to provide better care to the family of the infant. This study aimed to improve the understanding of the parental emotional experience of therapeutic hypothermia in the Neonatal Intensive Care Unit (NICU).Methods: Semistructured interviews were conducted in a group setting with parents matched into groups according to the severity of the infant’s presenting encephalopathy. The interviews were transcribed and coded into principal and additional subthemes.Results: Families of 15 infants, who were between 2 months and 2 years at the time of the interview, participated. Infants had a mean gestational age of 40.0 weeks and 11 (73%) were male. Eleven (73%) were transferred from other hospitals following birth and eight (53%) had seizures. Emotional Experiences was a principal theme and included subthemes of traumatic experiences, Loss of normalcy, and Separation of parent and infant. The birth was frequently described as traumatic with descriptions of chest compressions, excessive blood loss and infants not crying. Trauma was also described in the parental observations of the shivering hypothermic infant. Parents highlighted the loss of normalcy in terms of their expected birth narrative and the loss of the early opportunity to breastfeed and hold their infant. Parents reported that the physical separation imposed by hypothermia adversely impacted their ability to bond with their infant. Healing Experiences was the other principal theme with subthemes identified as Incorporation of parents into NICU care, Reclaiming parenthood and Support from other hypothermia families. Parents reported feeling a connection to their infant when they were involved in medical rounds and when asked to participate in routine care of their infant. Occasionally, parents strongly advocated for their own participation in a particular aspect of their infant’s care such as a diaper change and this was perceived as reinforcing their role as parent. Lastly, parents requested greater access to peer support from parents who had experienced therapeutic hypothermia.Conclusion: Parents of infants treated with hypothermia reported the experience of their unexpected adverse delivery and their baby subsequently being treated with therapeutic hypothermia as traumatic. This trauma can be compounded by the pale, still and shivering appearance of their newborn and the delay in bonding as a result of physical separation during hypothermia treatment. Parents described feeling connected to their infant in the context of performing routine care activities and desired greater access to peer support. The themes reported in this study could be used to inform high level NICU care and raise provider awareness of the parent experience.

Starobinski's Resistance to Theory—Le regard de l'absent

Starobinski's Resistance to Theory—Le regard de l'absent Evelyne Ender In memory of Jean Starobinski The work becomes person only if I cause itto live as one. My reading must breathe lifeinto the work so as to endow it with presenceand appearances of personality. I must bringthe work back to life in order to love it; Imust make it speak in order to respond to it… One might say the work always begins as'our dearly departed' awaiting resurrectionthrough us, or if not resurrection then atleast the most vivid evocation. --Starobinski, "The Critical Relation" This essay, devoted to a master of close reading and of the interpretation of signs and symptoms—textual and medical—was born in a classroom at Johns Hopkins University.1 It was born, furthermore, in the very place that shaped the vocation and the intellectual trajectory of a young, highly gifted literary scholar and medical student from [End Page 878] Geneva. In the mid-1950s, accompanying his wife Jaqueline who was in training at Hopkins Hospital, Jean Starobinski followed medical rounds while polishing his doctoral thesis on Jean-Jacques Rousseau and taking part in the intellectual creative spirit that marked those Hopkins years. This was a time when many ideas about the creative potential of cross-disciplinary exchanges were first seeded, a time that found its echo when visitors (many from Paris) convened with the local intelligentsia a decade later at Hopkins at an international symposium. In the chronicle of American intellectual life, this 1966 conference, "The Languages of Criticism and the Sciences of Man," marked the birth of "theory." In this initial gathering, local faculty, scholars representing highly diversified fields, and guest speakers from Europe had convened for presentations and conversations that prompted a radical rethinking of longstanding enlightenment ideals and values. Embedded in the cultural and intellectual crisis of a Europe torn apart by two wars, the conference also prompted a radical rethinking of values attached to learning and culture in academia; "human sciences" and the humanities were at the forefront. The proceedings for the 1966 conference were later collected under the heading of Richard Macksey and Eugenio Donato's The Structuralist Controversy: The Languages of Criticism; the Sciences of Man (1972), thus inviting a connection between the original event and the twentieth-century epistemic and philosophic revolution brought about by structuralism. However, Jean Starobinski was not present and his name is barely mentioned in the proceedings; his absence seems all the more remarkable when one considers the wide-ranging influence of his book, Jean-Jacques Rousseau: La transparence et l'obstacle. On his return to Europe, after finishing his internship in psychiatry, Starobinski did not open a cabinet médical, but began instead a life of reading and teaching. The first step into his life journey as a critic had steeped him in the "fusion and confusion of existence and the idea" in the oeuvre of an author, Rousseau, which he helped build (Transparency and Obstruction 9).2 The practice of close, symptomatic reading and the philosophical questions defined in this book had a major influence, meanwhile, on critical thought and the linguistic turn that marked late twentieth-century hermeneutics, especially with Jacques Derrida and Paul de Man. [End Page 879] In his critical dialogue with Rousseau's texts, Starobinski offers an utterly transformative approach to author criticism. Though indissociable from literature, it deciphers in its subject an epoch-making history of ideas, of sensibility, and of consciousness. Thus, the patient examination of Rousseau's every word and work offers new keys to the "interiority" and sensibility of an eighteenth-century luminary. Seen through the eyes (le regard) of a trained psychiatrist, Rousseau's existence provides the richest of case studies for the exploration of the modern psyche and, to use Freud's coinage for "Dora," of das Seelenben, namely what constitutes modern subjectivity.3 Studying a work of such scope sets up a challenge under any circumstances and yet, as the originating point of Starobinski's critical imprint, Transparency and Obstruction, could not be overlooked. In our seminar at Hopkins, we read most of it, adding ancillary materials as well as other crucial...

Clinical effect of checklist for early recognition and treatment of acute illness in department of intensive care unit: a prospective observational study

To evaluate the clinical performance of checklist for early recognition and treatment of acute illness (CERTAIN) on patients in the intensive care unit (ICU). A prospective observational study was performed. 100 patients (age > 18 years old, the length of ICU stay > 72 hours) admitted to ICU of the Second People's Hospital of Lu'an from January to July in 2018 were enrolled. By convenience sampling methods, 50 patients admitted to the hospital from January to April in 2018 were selected as the control group. Standard ward inspection was given to the control group by three senior-level and intermediate-level doctors blinded from the research plan; at the end of March 2018, these three doctors were trained with the CERTAIN checklist and certified by the Mayo Clinic distance learning training. Fifty patients enrolled from March to July 2018 received medical rounds using CERTAIN (observation group). The CERTAIN checklist contained 20 items that cover the range of daily critical ward rounds, which need clinicians to quantify each item. The data included the length of ICU stay, central venous catheter (CVC) indwelling time, catheter indwelling time, duration of mechanical ventilation, drug use rate, ICU mortality, and incidence of adverse events were collected and compared between the two groups. The independent factors affecting ICU death were analyzed by log-rank univariate analysis and Cox regression multivariate analysis. Compared with control group, the length of ICU stay (days: 8.68±4.84 vs. 13.64±9.37), catheter indwelling time (days: 8.16±5.29 vs. 13.32±9.31), duration of mechanical ventilation (days: 3.46±4.14 vs. 6.62±9.57) in observation group were significantly decreased, insulin use rate (34.0% vs. 56.0%) and ICU mortality (2.0% vs. 14.0%) were significantly decreased, with statistically significant differences (all P < 0.05). Besides, the use of CERTAIN can significantly improve the efficiency of the ward inspection. The ward inspection time was shortened from (8.00±0.45) minutes to (5.00±0.33) minutes by using the CERTAIN checklist (t = 9.312, P < 0.01). Survival analysis showed that CERTAIN application could reduce ICU mortality (χ2 = 3.898, P = 0.048), but the use of CERTAIN was not an independent factor for reducing ICU mortality [odds ratios (OR) = 1.001, P = 0.922]. CERTAIN application has a significant effect on critical patients. It is suggested to spread in ICU of China.

203. Impact of an Infectious Diseases Fellow-Led Antimicrobial Stewardship Initiative in a Medical/Surgical ICU

BackgroundIntensive care units carry the heaviest antibiotic burden within hospitals. Providing active and ongoing stewardship oversight in these areas is challenging for institutions with limited stewardship resources. The purpose of this study was to assess the impact of leveraging trainees, namely an infectious disease fellow, in implementing a stewardship initiative in an intensive care unit.MethodsA single-center retrospective, quasi-experimental study assessed the impact of an infectious diseases fellow participating in daily medical rounds in a mixed medical and surgical ICU over a consecutive 4-month period. The ID fellow conducted physical examinations, reviewed antimicrobial therapy, and de-escalated or discontinued antimicrobials when appropriate. Monthly days of therapy (DOT) per 1,000 days at risk (DAR) for individual agents and total antimicrobial use were measured and compared for 4 months in the pre-, during-, and postintervention phases.ResultsMedian overall antimicrobial use was similar between the pre-, during-, and postintervention periods at 1,089, 1,100, and 1,146 DOT/1,000 DAR, respectively. For the five most commonly used drugs, reductions in DOT/1,000 DAR were observed between the pre- and during-intervention groups for ampicillin/sulbactam (26%) and metronidazole (12%), while ceftriaxone, cefepime, and vancomycin use was unchanged. ConclusionWhile no change in median total antibiotic use was observed, a reduction in anti-anaerobic agent use noted, consistent with local efforts to reduce inappropriate antibiotic prescribing for aspiration pneumonitis. Actively involving medical residents and fellows in establishing evidenced-based approaches to antimicrobial stewardship is key to improving antibiotic utilization and minimizing the development of antimicrobial resistance.Disclosures All authors: No reported disclosures.

Overcoming barriers to diabetes care in the hospital: The power of qualitative observations to promote positive change.

AimsDespite advocacy by diabetes societies and evidence about how to prevent the deleterious consequences of dysglycemia among hospitalized patients, deficits in clinical practice continue to present barriers to care. The purpose of this study was to examine inpatient rounding practices using a qualitative research lens to assess challenges on the care of hospitalized patients with diabetes and to develop ideas for positive changes in hospital management of diabetes and hyperglycemia.MethodsWe conducted an interpretive analysis of qualitative observations during medical and surgical inpatient rounds at an academic institution. We coded, analysed, and reported data as thematic findings.ResultsEmerging themes include omissions in discussions during rounds; unpreparedness to address diabetes or dysglycemia during rounds; identifying practice improvement opportunities to address diabetes issues: and recognizing accountability within the routine of practice.ConclusionsThis work guides clinicians and informs systems of practice about improvement strategies that can emerge from within hospital teams. These recommendations emphasize the interconnectedness of practice elements including thoughtful review of glucose status during rounds among patients with and without diabetes; fostering doctors and nurses to work in unison; promoting awareness and integration within and across disciplines; and advocating for better use of existing resources.

A new infrastructure for patient empowerment through Family Integrated Obstetric and Neonatal Healthcare in Single Family Rooms. A case study

Introduction : Patient empowerment in mother and newborn care requires participation and a family centered approach, but is prevented by insufficient integration of Obstetrics and Neonatology in hospitals. Based on logistic grounds healthcare for sick newborns and sick mothers is still organized separately. The changes as described in this study are fed by the many stress-related disadvantages for empowerment due to separation of parents and newborns. Parents reported higher levels of perceived incapability in caring for their child, caused by a reduced level of bonding and breastfeeding success. This study describes and analyzes the changes for an unique infrastructure for integrated obstetric and neonatal healthcare from the concepts of patient empowerment. Methods : A qualitative descriptive methods design was used. All filed documentation regarding the preparation of the transition was collected. In-depth interviews with 5 stakeholders were conducted. Thematic analysis was performed using a conceptual map of patient empowerment, describing interventions and moderators at three levels; the Healthcare System, the Healthcare Providers and the Patient. Results : A positive culture for change of the two units and one vision of integrated care based on proven concepts for better outcomes for mother and newborns was the breeding ground for the transition process. The vision is: Families always stay together. From here all further changes were initiated. 1. Building one ward with only Single Family Rooms SFR with rooming in facilities for partners. 2. Reorganisation of high obstetric and neonatal level 2 care around the patients in the SFR. 3. The integration of the separate staff into one multidisciplinary staff and the two units into one unit for day to day management. 4. Training of the nurse staff to extend professional goals. 5. Create a new all-round nurse position and training for providing medium care for both, mother and newborn in order to limit the number of healthcare providers around the patients. 6. Implementing medical rounds in the SFR for shared decision making and healthcare planning with parents. 7. Intensify counseling and coaching of the parents. Discussion : Integration of high Obstetric Care and Neonatal level 2 care in the SFR may add to the discussion around patient empowerment. Conclusions : A positive change culture at the healthcare system level with one vision of integrated care for mother and newborn seems to be an important moderator for the design of the integrated infrastructure. All changes facilitating the new infrastructure are interventions and moderators for patient empowerment and should contribute to a higher level of patient empowerment. Lessons learned : Some interventions and moderators for patient empowerment were discussed less. Especially personal values of the staff related to patient empowerment and group-focused interventions such as patient education need more attention. Limitations : This case is about level 2 neonatal care with post-IC facilities. Additional requirements will be necessary for level 3 NICU’s. Suggestions for future research : As the levels of the model of Bravo seem to be interrelated, all levels should be explored in depth. Especially the patient level to establish whether the new infrastructure is sufficient for patient empowerment.