Outreach Nurses Research Articles

Support provided by outreach team leaders to caregivers of HIV/AIDS orphans in the North-West province of South Africa

BackgroundThe human immunodeficiency virus (HIV) and acquired immunodeficiency deficiency syndrome (AIDS) epidemic have left an overwhelming impact on communities worldwide, particularly in Sub-Saharan Africa, where its effects on family structures are particularly pronounced. Caregivers of HIV/AIDS orphans encounter challenges in fulfilling their caring duties. Consequently, they rely on the outreach team leaders (OTLs) for support to care for HIV/AIDS orphans.AimThis study aimed to explore and describe support provided by OTLs to caregivers of HIV/AIDS orphans in the North West Province of South Africa.MethodsThe exploratory, descriptive, and contextual design meaning the study was conducted was in the contexts where caregivers of HIV/AIDS orphans reside. The study was conducted in five local municipalities in the Ngaka Modiri Molema district of the North West Province of South Africa. Ward-based outreach nurses were participants in the study. Semi-structured focus group interviews were used for data collection. Thematic analysis was used to analyze data. Throughout the study, ethical principles were adhered to. The study also adhered to four trustworthiness principles: credibility, confirmability, transferability, and dependability.ResultsThree main themes emerged from this study: the conduction of home visits to caregivers of HIV/AIDS orphans, the coordination of a multidisciplinary team for support, and the facilitation of support groups.ConclusionsThis study revealed that that caregivers of children orphaned by HIV/AIDS benefitted from the support provided by OTLs in the North West province of South Africa. The support provided by OTLs harnessed positive relationship between caregivers and children orphaned by HIV/AIDS.

Surveillance of Antimicrobial Use in Long-Term Care Facilities: An Antimicrobial Mapping Survey

ObjectivesTo explore antimicrobial management processes in Australian residential aged care facilities (RACFs), including antimicrobial prescribing, supply, administration, and documentation to inform surveillance activities. DesignVoluntary, online cross-sectional survey. Setting and ParticipantsThe survey was disseminated to all South Australian RACFs (n = 237) seeking participation from an infection prevention and control lead (preferred respondent), a nurse or senior RACF staff member, or an aged care pharmacist. MethodsThe survey was open during May-June 2023. Questions aimed to understand clinical and medication management systems, sources of antimicrobial prescription and supply, management by external health care providers and documentation of antimicrobial administration. A process map of antimicrobial management in RACFs was developed. ResultsOf the 54 RACFs included in the analysis (29.5% response rate), most used an electronic clinical documentation system (74.1%) or a hybrid electronic paper-based system (22.2%). Medication charts were either electronic (81.0%), hybrid (5.6%), or paper-based (13.0%). Antimicrobials were prescribed by the resident's usual general practitioner, but also by locums, hospital or specialist physicians, nurse practitioners, virtual care physicians, and dentists. Oral, topical, and inhaled antimicrobial formulations were usually supplied by community pharmacies, and intravenous formulations were predominately supplied by hospitals for administration by outreach nurses. Almost all RACFs (96.2%) had imprest stock of antimicrobials that included both oral and intravenous formulations. Antimicrobials were predominately administered by an enrolled nurse or a registered nurse. Conclusions and ImplicationsAntimicrobial management in RACFs is complex, particularly during care transitions. Multiple prescribers and sources of antimicrobials, use of different systems for clinical documentation, particularly by external health care providers, and clinical governance relating to imprest supplies were identified as key areas where medication management could be improved. Addressing these gaps will facilitate comprehensive, real-time antimicrobial surveillance in Australian RACFs.

Assembling packs: Outreach nurses, disaffiliated persons, and sorcerers.

Nurses working in outreach capacities frequently encounter disaffiliated or 'hard to reach' populations, such as those experiencing homelessness, those who use substances, and those with mental health concerns. Despite best efforts, nurses regularly fail to find meaningful engagement with these populations. Mobilizing the work of Deleuze and Guattari, this paper will critically examine conventional outreach nursing practices as rooted in the royal science of psychiatry, which many 'survivors' of psychiatric interventions reject. The field of Mad Studies offers an understanding of patient resistance to outreach nursing interventions. Delueze and Guattari's concepts of packs and sorcerers provide a framework to envision alternative nursing practices as a form of resistance and creativity, where new alliances may be formed outside the coercive confines of traditional practices. In response to patient resistance, outreach nurses themselves must assemble packs and engage in acts of sorcery.

Advanced clinicians’ experience of participation in an escape room scenario designed to consolidate crisis resource management principles: An exploratory pilot study

BackgroundIntensive care outreach nurses are required to work as part of an ad hoc team to review and manage patients who are deteriorating outside of critical care environments. Nontechnical skills, such as those encompassed by crisis resource management principles, are essential when working in these situations. Used commercially for entertainment, escape rooms have recently been utilised by clinical educators to teach both technical and nontechnical skills. ObjectiveThis exploratory study evaluates how advanced clinicians, intensive care outreach nurses, experience an escape room scenario designed to consolidate crisis resource management (CRM) principles. MethodsThree escape room sessions were conducted in a 1038-bed metropolitan tertiary referral hospital. A purposive sample of 12 intensive care outreach nurses were invited to participate. The participant's experience of the escape room scenario was determined by their responses to a post–escape room survey and focus group discussion. Transcripts of the audio recordings from focus group discussions were analysed using an inductive coding approach. ResultsTwo primary categories emerged from analysis of the focus group discussions: (i) the clinicians’ experiences of the escape room and (ii) CRM principles. The first category included descriptions of emotions, including confusion, frustration, and a dislike for puzzles. The second category included both the participants understanding of the CRM principles, and how the principles influence the work within the escape room. ConclusionsEscape rooms have shown promise as novel educational environments, which challenge participants. Despite initial negative descriptions of the escape room, focus group discussions demonstrated that the participants were able to recognise the impact of CRM principles and acknowledge how these affect their clinical work in an ad hoc team.

Primary care for the urban poor in India during the pandemic: Uninterrupted management of non-communicable diseases and home-based care of patients with COVID-19 infection.

The two waves of COVID-19 severely affected the healthcare system in India. The government responded to the first wave with a strict nationwide lockdown which disrupted primary care, including the management of non-communicable diseases (NCDs). The second wave overwhelmed healthcare facilities leading to inadequate access to hospital services. Collectively, these issues required urgent responses, including the adaptation of primary care. The Low-Cost Effective Care Unit (LCECU) of Christian Medical College, Vellore (CMC) has a network of community volunteers, community health workers, an outreach nurse, social workers and doctors who operate clinics in six poorer areas of Vellore. The network adapted quickly, responding to the lockdown during the first wave and ensuring ongoing primary care for patients with non-communicable diseases. During the second wave, the team developed a system in collaboration with other CMC departments to provide home-based care for patients with COVID-19. The LCECU is a 48-bed unit of the Department of Family Medicine, part of the 3,000-bed CMC. It originated in 1982, aiming to care for the poor populations of Vellore town. It has been actively working among urban communities since 2002, with a focus on delivering Community Oriented Primary Care (COPC), for six poor urban communities since 2016. During the first wave of COVID the LCECU team ensured patients with NCDs had uninterrupted primary care and medications by visiting them in their homes. The team also addressed food insecurity by organizing a daily lunch service for 600 people for over 2 months. In the second wave, the team responded to community needs by organizing and delivering home-based care to monitor patients affected by COVID-19. The COVID-19 pandemic raises many questions about the preparedness of health systems for disasters that disproportionately affect marginalized populations globally. COVID-19 is only one of the many potential disasters, including non-communicable diseases, mental health problems, pollution, climate change, and lifestyle illness. There is an urgent need to study models of care that support vulnerable communities in an accessible, cost-effective, and patient-oriented way, particularly in low- and middle-income countries. This paper outlines lessons on how the LCECU team addressed disaster management:1. The COVID-19 pandemic has highlighted the importance of primary care-based rapid response interventions in disaster management.2. The LCECU model demonstrated the effectiveness of a primary care intervention based on pre-existing networks and familiarity between primary care teams and the community.3. Establishing community-based health care via interdisciplinary teams, including community health workers, community volunteers, outreach nurses, and doctors, is key.4. Addressing other social determinants of health, such as food insecurity, is an important component of care delivery.

Implementation and clinical utility of a Computer-Aided Risk Score for Mortality (CARM): a qualitative study

ObjectivesThe Computer-Aided Risk Score for Mortality (CARM) estimates the risk of in-hospital mortality following acute admission to the hospital by automatically amalgamating physiological measures, blood tests, gender, age and COVID-19...

Outreach nurses critical for delivery of HIV care to women in western Victoria.

Women living with HIV in regional Victoria face barriers accessing care. We evaluated the care cascade and outreach nurse support required for women attending our service between 2005 and 2020. A total of 33 women attended; 97% (32/33) were on antiretroviral therapy; 67% (22/33) retained in care, 27% (9/33) transferred and 6% (2/33) lost to follow up. Of women retained in care, 95% (21/22) were on antiretroviral therapy and 91% (20/22) had virological suppression. A total of 91% (30/33) required outreach nurse care (median care episodes 100/woman; IQR 44-179) - most frequently (87%; 26/30) liaising with pharmacies and prescribers. Outreach nurses are critical in achieving UNAIDS targets for women in western Victoria.

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial.

BackgroundPatients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission.ObjectiveThis study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app–based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission.MethodsIn this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients’ smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients’ usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months.ResultsOverall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually.ConclusionsTCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945

Evaluation of an Intensive Care Outreach Nurse Program in 4 UAE Hospitals.

Intensive care outreach nurses (ICONs) can reduce deterioration and death of patients in hospitals. Evaluate outcomes associated with implementation of the ICON role across 4 UAE hospitals. Trend analyses and χ 2 tests were used to measure changes before ICON program, during ICON year 1, ICON year 2, when the service coverage extended 24/7, and until the end of 2019. From year 1 to year 2, failures to escalate decreased from a rate of 14.8 to 5.6 episodes per 1000 admissions for all sites combined ( P < .001). The cardiac arrest rate went from 4.04 to 1.42 per 1000 admissions in year 2 and continued downward to 0.72 per 1000 ( P < .001). Transfer from ward or readmission to intensive care unit/high dependency unit varied by site, although there was a statistically significant trend for all hospitals combined. The ICON role contributed to fewer failure to escalate incidents and lower cardiac arrest rates.

Why were COVID-19 infections lower than expected amongst people who are homeless in London, UK in 2020? Exploring community perspectives and the multiple pathways of health inequalities in pandemics

High rates of COVID-19 infections and deaths amongst people who are homeless in London, UK were feared. Rates however stayed much lower than expected throughout 2020; an experience that compares to other settings globally. This study sought a community level perspective to explore this rate of infections, and through this explore relationships between COVID-19 and existing health inequalities. Analyses are reported from ongoing qualitative studies on COVID-19 and homeless health service evaluation in London, UK. Repeated in-depth telephone interviews were implemented with people experiencing homelessness in London (n=17; 32 interviews in total) as well as street outreach workers, nurses and hostel staff (n=10) from September 2020 to early 2021. Thematic analysis generated three themes to explore peoples’ experiences of, and perspectives on, low infections: people experiencing homelessness following, creating and breaking social distancing and hygiene measures; social distancing in the form of social exclusion as a long-running feature of life; and a narrative of ‘street immunity’ resulting from harsh living conditions. Further study is needed to understand how these factors combine to prevent COVID-19 and how they relate to different experiences of homelessness. This community perspective can ensure that emerging narratives of COVID-19 prevention success don’t ignore longer running causes of homelessness and reinforce stigmatising notions of people who are homeless as lacking agency. Our findings aid theorisation of how health inequalities shape pandemic progression: severe exclusion may substantially delay epidemics in some communities, although with considerable other non-COVID-19 impacts.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum

BackgroundFor over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required. AimThe aim of this study was to ascertain nurses’ perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system. MethodsAn exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes. ResultsSeventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles. ConclusionsA curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

P108 Service Evaluation - the impact and lessons learnt from the COVID-19 pandemic on a UK burns centre

The COVID-19 pandemic has dramaticallyimpacted healthcare provision in the UK and burns services have had to adapt to ensure the continuityof a safe care. As we return to " normalit y" we reflect on lessons learnt from our response to this pandemic.A service evaluation was performed from patient notes between March 23rd and May8th 2020 and an anonymoussurveygiven to patients attending outpatient appointments.258 patients were referred to our burns service and 148 patients completed the survey. Eleven burns were caused bytreatment or prevention of COVID-19. Patients delayed seeking medical attention due to concern of catching COVID-19 (36% adults, 8% children). There was a delayin referral of 17 patients despite them fulfilling the referral criteria. Infection rates were higher following delayed presentation (21% vs 6%). The majorityof burns were managed conservatively (237/258). Dressing changes were performed at home by32% of patients. The outreach team treated 22 patients.During the pandemic telemedicine has improved the efficiencyof outpatient burn care and outreach nurses have enabled treatment of vulnerable patients. More must be done to raise public awareness of preventable causes of burn injuryand to reassure them to seek help when burns occur.

577 The Collaboration of Burn Outreach and Wound Care Nurses

Abstract Introduction Certified wound care nurses perform a vital role in skin health and management in the hospital setting. During the certification process, minimal time is spent on burn wound education, despite the fact that wound care nurses are consulted for various wound etiologies; one of those being burns. This construct created a need for collaboration between the burn team and wound care nurses. Although all burns are essentially wounds, the reality is that all wounds are not burns. The management of the burn wound is often different from the management of pressure injuries or surgical wounds. In speaking with the wound care nurses at this large urban academic medical center, a knowledge gap was identified in burn wound care education as well as appropriate and timely consultation of the burn team. Methods This knowledge improvement project focused on educating the wound care nurses in assessment and treatment of burns, and the process for burn service consultation. Burn education was provided through in-person didactic presentations. The lecture included burn wound photos with opportunities to classify the potential depth of burn wounds as well as typical complications. Additionally, it discussed when a burn consult is needed. A basic knowledge retrospective pre-posttest method was utilized. Results An educational plan was tailored to meet the learning needs of the wound care nurses to address the knowledge gap. Post test data results were tracked. Post scores were increased, indicating a successful educational intervention. Also, while providing the education, the burn outreach coordinator identified an opportunity to expand the burn center’s presence among colleagues through collaboration with the wound care nurses. The wound nurses made excellent ambassadors for the mission of the burn service. Conclusions Provision of burn education across disciplines may improve recognition of burn wounds and facilitate definitive treatment.

The impact and lessons learnt from the COVID-19 pandemic on a UK Burns Centre

The COVID-19 pandemic has dramatically impacted healthcare provision in the UK and burns services have had to adapt to ensure the continuity of a safe care. As we return to “normality” we reflect on lessons learnt from our response to this pandemic.A service evaluation was performed from patient notes between March 23rd and May 8th 2020 and an anonymous survey given to patients attending outpatient appointments.258 patients were referred to our burns service and 148 patients completed the survey. Eleven burns were caused by treatment or prevention of COVID-19. Patients delayed seeking medical attention due to concern of catching COVID-19 (36% adults, 8% children). There was a delay in referral of 17 patients despite them fulfilling the referral criteria. Infection rates were higher following delayed presentation (21% vs 6%). The majority of burns were managed conservatively (237/258). Dressing changes were performed at home by 32% of patients. The outreach team treated 22 patients.During the pandemic telemedicine has improved the efficiency of outpatient burn care and outreach nurses have enabled treatment of vulnerable patients. More must be done to raise public awareness of preventable causes of burn injury and to reassure them to seek help when burns occur.

Exomphalos major: Conservative management using Manuka honey dressings and an outreach surgical nursing team

IntroductionControversy exists over the best dressing for conservative management of exomphalos major. Here we describe our experience of using Manuka Honey. MethodsOur regimen involved covering the sac with Manuka honey (Advancis Medical™) wrapped with gauze and crepe bandage. Initially, dressings were changed 3 times a week and then twice weekly until full epithelialisation. Babies went home after reaching full feeds, with our outreach nurses continuing dressings in clinic until the parents were trained to do them alone. Only patients needing management of co-morbidities were transferred to our unit. Patients would be reviewed by video consultation. Data was prospectively collected. ResultsFrom 2011–2019, 24 consecutive patients (11:13 M:F; median gestation 37 weeks, birth weight 3.1 kg) with exomphalos major were managed with honey dressings. Fourteen babies had significant associated anomalies of which 10 died of problems unrelated to the exomphalos. Time to full feeds 6 (2-58) days; time to discharge 21(7–66) days if no associated anomalies; time to epithelialisation 73 (27–199) days. Dressings were well tolerated. Definitive closure occurred at 17(11–38) months and was uneventful. No patient required fundoplication and all patients were orally fed. Only one patient developed a clinically significant infection. ConclusionThis is the largest report of using Manuka honey for the management of exomphalos major. Benefits include early feeding, early discharge and a ‘normalisation’ of the neonatal period. Key to our success was the surgical outreach service supporting parents doing the dressings, first at the local hospital and then at home.

Management of minor burns during the COVID-19 pandemic: A patient-centred approach.

Introduction:The UK government introduced lockdown measures on 23 March 2020 due to the first wave of the COVID-19 pandemic. A restructuring of clinical services was necessary to accommodate mandatory changes while also maintaining the best possible standards for patient care. The present study explored the initial management, follow-up and patient-reported outcomes of burn injuries <15% total body surface area (TBSA) during the height of the COVID-19 lockdown at a tertiary burns centre.Methods:A retrospective review of all adult patients with burns <15% TBSA during the national lockdown (23 March 2020 to 10 May 2020) was undertaken at The Queen Elizabeth Hospital Birmingham (QEHB), UK. All referrals from non-QEHB telemedicine (external) or QEHB emergency (internal) departments were reviewed for management, length of hospital stay and pattern of follow-up (ward attender, self-care, community or outreach nurses). A telephone survey based on a structured questionnaire was conducted to establish patients’ satisfaction.Results:A total of 84 burn patients were included in the study. The mean age was 39 years (age range = 19–91 years) and the male:female ratio was 4:1. Patients were managed non-operatively (n = 69, 82%) or operatively (n = 15, 18%). Patients attended the ward attender acute burns clinic only once (n = 36, 61%). The telephone survey captured 70% (n = 59) of the study population and 57 patients (97% of respondents) were pleased with the ongoing care and burn healing.Conclusion:The integration of patient led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for small burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with the burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.Lay SummaryThe lockdown measures due to the first wave of COVID-19 pandemic affected the way we manage all medical emergencies including burns. The initial management, follow-up and patient satisfaction for small burn injuries during lockdown has not been reported previously. The aim of this study is to examine the outcome in terms of small burn management, hospital stay, number of clinic reviews, healing and patient satisfaction during the lockdown period in a burn centre in the UK. This would look at the need for operations and whether patients stayed longer if they required an intervention. We reviewed adult patients with small burns during the national lockdown (23 March 2020 to 10 May 2020) at The Queen Elizabeth Hospital Birmingham (QEHB). All referrals from telemedicine, referral system (external) or QEHB (internal) were reviewed for management, length of hospital stay and pattern of follow-up. Patients were reviewed in the acute burns clinic and given advice for burn management and dressing for self-care. Follow-up was mostly via email (telemedicine) A telephone survey based on a structured questionnaire was conducted to find out patients’ satisfaction. Four times more men than women had small burns during the lockdown period. The average age was 39 years. The majority were managed conservatively with dressings (82%) and a small proportion required an operation (18%). Most patients attended the acute burns clinic only once (61%) for initial assessment and management. The telephone survey captured 70% of patient and 97% of respondents were pleased with the care and burn healing. The integration of patient-led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.

Critical ethnography of outreach nurses- perceptions of the clinical issues associated with social disaffiliation and stigma.

The aim of this study was to gain a better understanding of how nurses experience their practice with homeless people. More specifically, we wanted to consider the role as it is practised and certain clinical characteristics associated with social disaffiliation and stigma. Previous research has shown the need to implement adapted nursing interventions to address the problems homeless people encounter in obtaining health services. According to the literature, such interventions have positive health outcomes for homeless people, who exhibit complex health needs. We chose critical ethnography as our research method. Semi-structured interviews were conducted with 12 nurses who work with people experiencing homelessness in Eastern Canada. They were selected using the convenience sampling method. Recruitment was conducted between June-October 2019. Four categories emerged from the qualitative analysis of the data: (1) the professional role and identity of nurses; (2) the social function of outreach nursing; (3) clinical realities; and (4) disaffiliation and stigmatization. In this article, we will present the findings associated with the fourth category. Nursing practice with this population is conducted in non-traditional settings such as shelters, community groups, camps, and the street. Nurses must be able to gain acceptance in these environments in order to forge trusting relationships with disaffiliated and stigmatized patients. Our analysis of the data also indicates that nurses who care for homeless people may be subject to stigma by association or "courtesy stigma." The results of this critical ethnography are useful in that they highlight the clinical interventions and health policies best suited to a highly marginalized clientele that is poorly served by traditional health services.

Routine critical care step-down programmes: Systematic review and meta-analysis.

Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills. This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care? Systematic review of quantitative studies and meta-analysis. Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool. Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge. This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge. While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.

A Critical Ethnography of Outreach Nursing for People Experiencing Homelessness

ABSTRACT People experiencing homelessness have a high prevalence of substance abuse and mental and physical problems. Although they have very complex health needs, they face many barriers that reduce their access to health care and social services. Several research studies have shown the need to implement adapted nursing interventions to address these crucial access issues. In this article, we present the results of a critical ethnography of outreach nurses who work with homeless people (n = 12). Robert Castel’s theoretical model, which focuses on the process of social disaffiliation, provided the conceptual underpinnings for this research. Our qualitative data analysis revealed four categories, namely 1) the professional role and identity of nurses; 2) the social function of outreach nursing; 3) clinical realities and 4) disaffiliation and stigmatization. Our findings highlight the need to raise awareness among health care providers about the ethical, clinical and organizational issues of homelessness, particularly the mechanisms of exclusion and stigmatization in health care settings that affect people experiencing homelessness.

From Hospital to the Community: Redesigning the Human Immunodeficiency Virus (HIV) Clinical Service Model to Respond to an Outbreak of HIV Among People Who Inject Drugs.

An outbreak of human immunodeficiency virus (HIV) among people who inject drugs in Glasgow, Scotland started in 2014. We describe 156 cases over 5 years and evaluate the impact of clinical interventions using virological and phylogenetic analysis. We established (1) HIV services within homeless health facilities, including outreach nurses, and (2) antiretroviral therapy (ART) via community pharmacies. Implementation of the new model reduced time to ART initiation from 264 to 23 days and increased community viral load suppression rates to 86%. Phylogenetic analysis demonstrated that 2019 diagnoses were concentrated within a single network. Traditional HIV care models require adaptation for this highly complex population.