Ward Level Research Articles

Overcoming barriers and improving adherence to nutritional protocols in enhanced recovery after surgery (ERAS) for colorectal surgery

Objectives: Nutrition is an essential component of Enhanced Recovery After Surgery (ERAS) programs. ERAS programs advocate resumption of diet within a few hours post surgery with supplementation of high-calorie drinks. In March 2016, Tan Tock Seng Hospital started to adopt ERAS protocols for elective colorectal surgery. However, internal audits and retrospective review of our data indicated poor compliance with ERAS nutritional protocols. Our aim was to identify barriers and develop strategies to improve adherence to ERAS nutritional protocols, so as to facilitate the integration of nutritional protocols within ERAS. Methods: In July 2016, a multidisciplinary project team was formed. Root cause analysis was carried out with different stakeholders. Four actionable barriers were identified in the implementation of nutritional aspect of ERAS: 1) unfamiliarity with new ERAS protocols; 2) confusion caused by an outdated existing Colorectal Clinical Pathway; 3) reluctance to adopt new practice; and 4) resource limitation and logistic issues. Strategies implemented included: educational talks to staff and patients on ERAS nutritional protocols to disseminate the practice changes; revising the existing Colorectal Clinical Pathway to align with new ERAS nutritional protocols; sharing favourable results to convince staff and overcome resistance; conducting frequent meetings to reflect on practice, build teamwork and align different ward cultures; identifying and training ERAS champions in different wards as ERAS advocates; collaborating with pharmacy to store nutritional supplements at the ward level to promote early oral nutrition. A comparison of pre and post-implementation of strategies on ERAS nutritional compliance and clinical outcomes were carried out during the period of March to October 2016 (n=135) and Nov 2016 to July 2017(n=157). Results: Overall, adherence to ERAS nutritional measures improved by 25% with an overall increasing trend. Patients recovered faster with decreased median length of stay from 7 to 6 days, complication rate dropped from 47.4% to 39.5% and 30 days readmission rate from 7.2% to 5.2%. Conclusion: Implementation of strategies addressing actionable barriers successfully improved adherence to nutritional standardisation of ERAS protocols and clinical outcomes following colorectal surgery. Disclosure of Interest: None declared.

Formula Milk Supplementation on the Postnatal Ward: A Cross-Sectional Analytical Study.

Breastfeeding rates are low in the UK, where approximately one quarter of infants receive a breastmilk substitute (BMS) in the first week of life. We investigated the reasons for early BMS use in two large maternity units in the UK, in order to understand the reasons for the high rate of early BMS use in this setting. Data were collected through infant feeding records, as well as maternal and midwife surveys in 2016. During 2016, 28% of infants received a BMS supplement prior to discharge from the hospital maternity units with only 10% supplementation being clinically indicated. There was wide variation in BMS initiation rates between different midwives, which was associated with ward environment and midwife educational level. Specific management factors associated with non-clinically indicated initiation of BMS were the absence of skin-to-skin contact within an hour of delivery (p = 0.01), and no attendance at an antenatal breastfeeding discussion (p = 0.01). These findings suggest that risk of initiating a BMS during postnatal hospital stay is largely modifiable. Concordance with UNICEF Baby Friendly 10 steps, attention to specific features of the postnatal ward working environment, and the targeting of midwives and mothers with poor educational status may all lead to improved exclusive breastfeeding rates at hospital discharge.

The effect of quality of overtime work on nurses' mental health and work engagement.

Recent research has suggested that the reasons why nurses work overtime hours exert differential effects on the overall impact of the work. This study aimed to clarify why nurses work overtime, and whether well-being effects differed by reason, at both the ward and individual level. Participants were 1,075 permanent nurses from 54 wards. Overtime reasons' distribution and impact on nurses were examined by a multilevel structural equation modelling approach. Nurses typically worked overtime due to a pressure to conform, high workload and to enhance self-development. Involuntary overtime work demonstrated a detrimental effect on mental health and work engagement at both the ward and individual level, whereas voluntary overtime work exerted a beneficial effect on well-being. The distribution and impact of overtime work differed by the reasons for working the overtime. These results suggest the importance of assessing the reasons for overtime, aside from the length of overtime hours. When trying to reduce overtime work, hospital managers and nurse managers need to advance the plan by ward as a whole, and also carefully assess the reasons for overtime.

14.3 CAUSES AND PREVENTION OF AGGRESSION FROM PSYCHOTIC INPATIENTS

BackgroundPatients with schizophrenia and other psychotic disorders have an increased likelihood of engaging in violent behavior. These increased risks of dangerous and aggressive behavior, in combination with a lack of insight in their own illness, relatively often make involuntary admission of acutely disturbed psychotic patients on locked psychiatric admissions wards often inevitable. On these locked psychiatric admissions wards, aggression from psychotic patients against staff and fellow patients is a prevalent phenomenon, with the mean in the Netherlands being about 18 aggressive incidents per bed per year on locked psychiatric admissions wards.MethodsIn the lecture, a model of what causes or triggers aggressive behavior on (locked) psychiatric wards is presented. In this model, patient, ward and staff variables are integrated to explain why, and in what specific situations, psychotic patients particularly run a high risk of engaging in aggressive behavior.ResultsBased on the presented model, a number of preventive measures can be formulated.On the patient level, the administration of anti-psychotic medication is used to reduce the negative cognitive schemes and delusional thoughts that are depicted in the center of the model. A more novel intervention at the patient level may be the additional administration of nutritional supplements with (among others) high levels of omega 3 fatty acids. The results of two Dutch studies on this topic will be briefly presented in the lecture, among which a RCT on the effects of the use of nutritional supplements on aggressiveness.On the staff level, the use of short-term (daily) risks assessments by the ward nursing staff, among others by means of the six item BrØset Violence Checklist (BVC), has been found to reduce aggressiveness and the use of coercive measures on psychiatric wards in two cluster randomized RCTs.On the ward level, studies indicate that aggression on psychiatric wards can be reduced by preventing overcrowding on psychiatric wards, and by providing more space and privacy to the patients.DiscussionThe proposed model elucidates how certain patient, staff and ward characteristics may interact in causing aggression. The model also emphasizes that repeated inpatient aggression may be the result of a vicious circle, i.e. inpatient violence is often followed by an increase in environmental and/or communication stress on the patient, thereby heightening the risk of a repeated outburst of violence.

14. VIOLENCE IN SCHIZOPHRENIA: PREVALENCE, MEASUREMENT, PREDICTION AND PREVENTION

Overall : Most patients with schizophrenia and bipolar disorders (severe mental illness, SMI) are not violent in their lifetimes, however, a minority of patients are violent at some points in the course of their illness. As the illness appears relatively early in life, and typically runs a chronic course, the number of violent incidents caused by patients can be considerable in some cases. Due to the stigma toward SMI, the media often emphasize reporting of these incidents, which fuel the stigma even more. Although violent behavior is a common cause of concern for patients, their families and clinicians, it is not often discussed in scientific meetings. The purpose of this symposium is to bring this relatively neglected, but very important topic into the spotlight in SIRS, in order to summarize the latest evidence for clinicians and researchers, and to foster new work on reducing these risks of violence.Dr. Weiser will present an overview of the prevalence of violent behavior in patients with SMI, and will present a population-based, case-control study from Israel, showing increased rates of violent crime in patients with SMI, particularly in female patients and patients who abuse drugs. Secondary analyses will show increased rates of violent behaviour in siblings of patients as well.Dr. Fazel will present a systematic review on the prognostic (or predictive) accuracy of structured ways to assess violence risk in patients with severe mental illness, and present new work on a scalable and potentially useful predictive model of violent behaviour based on 75,000 patients in Sweden.Dr. Nijman will present a model based on patient, ward and staff variables focused on the causes and triggers of aggressive behavior on (locked) psychiatric wards. Based on this model, a number of preventive measures can be formulated. At the patient level, the administration of anti-psychotic medication is used to reduce the negative cognitive schemes and delusional thoughts that are depicted in the center of the model. A more novel intervention at the patient level may be the additional administration of nutritional supplements with (among others) high levels of omega 3 fatty acids. The results of two Dutch studies on this topic will be briefly presented in the lecture, among which a RCT on the effects of the use of nutritional supplements on aggressiveness. On the staff level, the use of short-term (daily) risks assessments by the ward nursing staff, among others by means of the six item BrØset Violence Checklist (BVC), has been found to reduce aggressiveness as well as the use of coercive measures on psychiatric wards in two cluster randomized RCTs. On the ward level, studies indicate that aggression on psychiatric wards can be reduced by preventing overcrowding on psychiatric wards, and by providing more space and privacy to the patients.Dr. Torrey will present data on rates of re-arrest in patients with SMI, showing that the average five-year re-arrest rate is approximately 40% for those released from psychiatric hospitals and 60% for those released from jails or prisons, and will present comparison data from other countries. He will then present data on the effect of extended conditional release, Forensic Assertive Community Treatment (FACT) teams, and Psychiatric Security Review Boards on re-arrest rates.

Relationship of nurses' intrapersonal characteristics with work performance and caring behaviors: A cross-sectional study.

This study aimed to describe intrapersonal characteristics (professional values, personality, empathy, and job involvement), work performance as perceived by nurses, and caring behaviors as perceived by patients, and to examine the relationships among these variables. A cross-sectional design was employed. A sample was recruited of 218 nurses and 116 patients in four private hospitals and four public hospitals. Data were collected using self-report measures. Data analysis included descriptive statistics, exploratory and confirmatory factor analyses, hierarchical linear modelling, correlations, and structural equation modeling. Nurses perceived their work performance to be of high quality. Among the intrapersonal characteristics, nurses had high scores for professional values, and moderately high scores for personality, empathy and job involvement. Patients perceived nurses' caring behaviors as moderately high. Professional values of nurses were the only selected intrapersonal characteristic with a statistically significant positive relationship, of practical importance, with work performance as perceived by nurses and with caring behaviors as perceived by patients at ward level. Managers can enhance nurses' work performance and caring behaviors through provision of in-service training that focuses on development of professional values.

Compassion in practice-Evaluating the awareness, involvement and perceived impact of a national nursing and midwifery strategy amongst healthcare professionals in NHS Trusts in England.

To report the findings from an evaluation of the impact of the Compassion in Practice Vision and Strategy (National Health Service England (NHSE), 2012) on nursing, midwifery and care staff. The Compassion in Practice Vision and Strategy was a programme of work to highlight the importance of compassionate care following the Francis Report in 2013 into the deficits in care in an NHS Hospital Trust. It was launched by NHS England in 2012 at a time when fiscal cuts were introduced by the Department of Health in England. Mixed methods. Inferential statistics were used to test whether there were significant differences between staff at different levels of seniority with regard to awareness and involvement in Compassion in Practice Vision and Strategy and their attitudes to it. Awareness and involvement of staff in Compassion in Practice Vision and Strategy were high amongst middle and senior management but limited at ward level. Staff involvement in Compassion in Practice Vision and Strategy was limited due to a lack of awareness. Ward level staff who were aware and involved, perceived a lack of support and communication from senior leadership to deliver the Compassion in Practice Vision and Strategy. Results reveal professional anger, distress and resistance to the Compassion in Practice Vision and Strategy and a view of the programme as a top-down initiative which did not sufficiently recognise structural constraints on nurses' ability to deliver compassionate care. We discuss the implications of our findings for global nursing. Participants emphasised that compassion for patients is only sustainable where there is compassion for staff and many participants felt that they were not being treated with compassion. National Health Service England should strongly affirm that nurses and midwives in general provide compassionate care. Trust leadership should provide support for ward level staff who deliver compassionate care in difficult circumstances.

Identifying positively deviant elderly medical wards using routinely collected NHS Safety Thermometer data: an observational study

ObjectiveThe positive deviance approach seeks to identify and learn from exceptional performers. Although a framework exists to apply positive deviance within healthcare organisations, there is limited guidance to support its...

AB130. 147. An initiative, to improve ward level efficiency using a modified treatment room layout in Cork University Hospital and University Hospital Waterford

Background: An observation was made of doctors performing routine tasks on the ward. Much time was wasted in the treatment rooms gathering equipment required to perform routine tasks such as intravenous cannulation due to poor equipment room layout. The aim was to improve efficiency and decrease frustration

Patient satisfaction, patients leaving hospital against medical advice and mortality in Italian university hospitals: a cross-sectional analysis

BackgroundHealthcare systems are increasingly focusing on outcomes that are the endpoints of care: patient health status and patient satisfaction. The availability of patient satisfaction (PS) data has encouraged research on its relationship with other outcomes, such as mortality. In Italy, an inter-regional performance evaluation system (IRPES) provides 13 regional healthcare systems with a multidimensional assessment of appropriateness, efficiency, financial sustainability, effectiveness, and equity. For university hospitals, IRPES includes the percentage of patients leaving hospital against medical advice (PLHAMA) and mortality rates at the ward level. This paper investigates the relationship between PS and PLHAMA across and within regional healthcare systems in Italy. Secondly, PLHAMA is used as a PS proxy to investigate its relationship with mortality at the ward level in the IRPES university hospitals.MethodsPLHAMA and mortality rates were gathered from administrative data, and PS scores from patient surveys. We explored the association between PS and PLHAMA through a correlation analysis, using data for the 13 IRPES regions. We tested this relationship also at the clinical directorate level in 28 hospitals in Tuscany (5482 interviewed patients in 100 clinical directorates). Secondly, we explored the association between PLHAMA and mortality at the ward level through correlation and regression analyses, using data of 405 wards of eight clinical specialties within 24 IRPES university hospitals.ResultsLower PLHAMA rates were associated with a higher PS in both regional and clinical directorate levels. A positive association between PLHAMA and mortality was shown at the ward level for IRPES university hospitals, with different results for medical and surgical clinical specialties.ConclusionsPS is an important performance dimension that provides healthcare managers and professionals with useful insights for improving care quality and effectiveness. Based on the study results, the PLHAMA rate could be regularly measured to highlight patient dissatisfaction. Due to the association between PLHAMA and mortality, this study also provides evidence of the importance of the patient perspective in assessing the quality of healthcare services. This relationship proved to be significant for surgical clinical units, suggesting the need for further analysing outcomes considering their different determinants in medical and surgical care.

IDENTIFYING CONSTRAINTS FOR HOSPITAL INFECTION CONTROL MANAGEMENT VIA MCKINSEY 7S FRAMEWORK IN PAKISTAN

Background: In Pakistan, structured guidelines for hospital infection control and prevention are deficient in most public sector facilities. There is dearth of literature available on management of hospital-care acquired infections and related issues. This study aims to understand infection control management as a proxy measure for quality of health care provided at a public sector tertiary care hospital in Karachi, Pakistan. In this study, we identify barriers to implementation of infection control measures and highlight key areas for quality improvement. Methods: A cross sectional study was carried out in 2008 using qualitative research methods. In-depth interviews were conducted with hospital staff belonging to three different management tiers. Results: There was lack of a centralized documented infection control policy, structure or management hierarchy in the hospital. The infection control mechanisms were managed at the individual ward level depending upon the interest of the individual Head of the Department. Lack of well-defined systems for human resource and financial management, resource allocation, documentation, communication, monitoring and evaluation for infection control further augmented the problem. Conclusion: Based on the results of this study, it is evident that quality infection control mechanisms must be organized and controlled at the hospital level not at the individual ward level. Human resource recruitment and training, budgetary allocation and designing of communication channels specific to infection control are needed at this tertiary care hospital. This is the first study to understand the management perspective for hospital infection control using 7S McKinsey framework of management in the largest tertiary care public sector hospital in Sindh.

Dismissing De-Escalation Techniques as an Intervention to Manage Verbal Aggression Within Mental Health Care Settings: Attitudes of Psychiatric Hospital-Based Nigerian Mental Health Nurses

The risk of violence within mental health care settings is high. Although literature does indicate certain mental illness symptoms, and or labels, as associated with increased risk for violence there is no definitive causative factor. Interrelated environmental factors directly influence verbal aggression and risk of violence. Specifically, lack of, or inadequate, mental health care legislation and policy, and practitioner attitudes, knowledge and skills are noted as core influential factors. The purpose of this study was to present de-escalation techniques, as an intervention, and describe the response of psychiatric hospital-based Nigerian mental health nurses. A qualitative approach using content analysis of audio recorded pre- and post-intervention focus group discussions was adopted. The intervention – one oral and visual presentation of de-escalation techniques – bisected focus group discussions. The objective for the pre-intervention focus group was to facilitate participants’ descriptions of current experiences and practices towards verbal aggression and violence management in order to inform and contextualise the intervention, specifically the relevant application of information within the intervention. The objective of the post-intervention focus group discussion was to describe participants’ responses to the intervention. Purposive sampling of nurses at unit or ward manager level yielded eight participants who attended both focus groups and the intervention. Results indicate that participants felt betrayed by all role players within the mental health care service system, were disappointed that de-escalation techniques were considered evidence-based practice, and hopeless about their introduction. Participants’ fears for their safety are suggested to have informed a more militant approach to the management of aggression, an approach perceived by participants to strengthen nurses’ control over their own and patients’ physical and emotional welfare. A review of Nigerian mental health legislation to set the context for human rights of both nurses and mental health care patients is recommended. In addition, a need exists for further research utilising a participatory action research approach. Such an approach will allow the participants to reflect, develop self-awareness, understand and respond to a specific context.

Spatial inequality in water access and water use in South Africa

Abstract The importance of measuring inequalities in sustainable development is reflected in the requirement to disaggregate national data for the Sustainable Development Goals (SDGs). In this paper, piped water access, water use and water stress are mapped and reported at national, provincial, district, municipal, town and ward levels, and urban and rural areas. The results show that although 45% of the population has water access in their dwelling this ranges from 0.07% to 100% at ward level, with a high level of inequality (Gini index of 0.36). National per capita water use is 208 litres per person per day (l/c/d) but ranges from 8 l/c/d to 2,414 l/c/d at town level, with a Gini index of 0.27. The analysis shows that social factors, such as water access and income, and not natural factors, such as rainfall or runoff, have the greatest influence on per capita water use. The paper provides the first in-depth analysis of per capita water use at the local level across South Africa and suggests new water indicators that could support equitable allocation of water resources and SDG reporting.

Comprehensive approach for community-based integrated care reduces risk of falls after fracture.

Objectives:The aim of this study was to examine whether the risk of falls could be reduced among patients in our ward using the standing test for imbalance and disequilibrium (SIDE).Methods:The study participants were 97 inpatients (24 men, 73 women; mean age, 81.9±9.0 years) who had been diagnosed with spinal compression or hip or other fractures in a ward for community-based integrated care in Japan. The participants took part in six daily 40-min rehabilitation training sessions per week. We investigated patient data obtained from medical records, including duration of stay in the ward, discharge destination, and SIDE level at admission and discharge. We compared indices at admission and discharge using Fisher’s exact test (P<0.05).Results:The mean duration of stay was 38.5±15.9 days, and 83.5% of the patients were discharged home. Significant increases in SIDE levels were observed at discharge compared with admission (P<0.001).Conclusions:The results of the present study suggest that exercises in the ward reduce the risk of falls.

Human Development in Gujarat: Evidence from 2011 Population Census

This article uses the data available from the 2011 population census to construct the human development index (HDI) right up to the village and municipal ward level in Gujarat. The analysis reveals that the human progress in the state and in its constituent districts, sub-districts, towns and villages has largely been average to low, and strong residence and social class inequalities in human development continue to persist. The human development scenario is contrastingly different in rural and urban areas of the state. There is, however, a substantial proportion of municipal wards within towns where human development appears to be low or very low. The analysis also suggests very strong residence and social class effects on human development in the state. It also appears that human progress in the state has stagnated at average levels during the last decade. Despite the fact that there is still substantial scope for human progress. There is a need to reinvigorate human development efforts in the state.

Micro-spatial distribution of malaria cases and control strategies at ward level in Gwanda district, Matabeleland South, Zimbabwe

BackgroundAlthough there has been a decline in the number of malaria cases in Zimbabwe since 2010, the disease remains the biggest public health threat in the country. Gwanda district, located in Matabeleland South Province of Zimbabwe has progressed to the malaria pre-elimination phase. The aim of this study was to determine the spatial distribution of malaria incidence at ward level for improving the planning and implementation of malaria elimination in the district.MethodsThe Poisson purely spatial model was used to detect malaria clusters and their properties, including relative risk and significance levels at ward level. The geographically weighted Poisson regression (GWPR) model was used to explore the potential role and significance of environmental variables [rainfall, minimum and maximum temperature, altitude, Enhanced Vegetation Index (EVI), Normalized Difference Vegetation Index (NDVI), Normalized Difference Water Index (NDWI), rural/urban] and malaria control strategies [indoor residual spraying (IRS) and long-lasting insecticide-treated nets (LLINs)] on the spatial patterns of malaria incidence at ward level.ResultsTwo significant clusters (p < 0.05) of malaria cases were identified: (1) ward 24 south of Gwanda district and (2) ward 9 in the urban municipality, with relative risks of 5.583 and 4.316, respectively. The semiparametric-GWPR model with both local and global variables had higher performance based on AICc (70.882) compared to global regression (74.390) and GWPR which assumed that all variables varied locally (73.364). The semiparametric-GWPR captured the spatially non-stationary relationship between malaria cases and minimum temperature, NDVI, NDWI, and altitude at the ward level. The influence of LLINs, IRS and rural or urban did not vary and remained in the model as global terms. NDWI (positive coefficients) and NDVI (range from negative to positive coefficients) showed significant association with malaria cases in some of the wards. The IRS had a protection effect on malaria incidence as expected.ConclusionsMalaria incidence is heterogeneous even in low-transmission zones including those in pre-elimination phase. The relationship between malaria cases and NDWI, NDVI, altitude, and minimum temperature may vary at local level. The results of this study can be used in planning and implementation of malaria control strategies at district and ward levels.

Assessment Monitoring of an Expanded Program on Immunisation's Activities in Northern Nigeria States

Over two million deaths are delayed through immunization each year worldwide. Despite this, vaccine preventable diseases remain the most common cause of childhood mortality. With an estimated three million deaths each year, this field work summarises the main activities and findings of polio eradication activities in Nigeria, from 1 th Feb to 30 th April 2012. 33 health facilities and 3 hospitals were visited in order to assess the immunisation activates and surveillance system. The keys activities included technical support in Feb and March IPDs, community sensitization by visiting community leader to solve Non-Compliances (NC), training personnel, validating and reviewing micro plan in ward and Local Government Authorities (LGAs)level, reviewing high risk operational plan in high risk LGA. The main key finding includes Poor quality of training in ward level, there was no training material for Oral Polio Vaccine (OPV), absenteeism and non-comfortable place for training, missed children and missed settlements reported in Immunisation Plus Days (IPDs)in some ward due to inadequate number of teams, dishonest teams and poor close supervision. The main recommendations include State team should continue advocate for political engagement to support the successes polio eradication activities, Intensified monitoring and supervision at field level during the IPDs by all level of supervisors is great solution for improving team performance and reach the missed children, Generalize the pilot team to the rest of LGAs in the state especially in improving the program, team performance, coverage and reducing non-compliance and missed children, Intensify supportive supervision to the surveillance site by the State, WHO officers and the LGA Facilitator. Keywords: Activities; Assessment; Immunisation; Program

The role of participatory music making in supporting people with dementia in hospital environments.

Background Improving the quality of care for people with dementia in general hospitals is a key priority. Creative activities including music have been examined for their potential role in enhancing quality of life for people with dementia, although relatively few studies have evaluated their use in acute hospital settings. Methods A mixed methods study examined the effects of a ten week period of weekly music sessions on the wellbeing of patients with dementia and on the ward environment in an acute elderly care service in a UK hospital. Potential effects of the music project on the ward environment were examined by comparing descriptive quantitative ward level data for two equivalent time periods, one with music and one with no music. The impact of the activity on participants' wellbeing was assessed using observational data as well as semi-structured interviews and focus groups with patients, visitors, the musician and staff. Results Ward level data were available for 85 patients with a dementia diagnosis who had stayed on the wards during the study periods. Comparison between the two periods showed a number of differences between the music and the non-music time periods, including a reduction in prescription of antipsychotic drugs. However, many factors could have contributed to the differences in the ward environment. Observational data revealed nuanced responses to music and suggested that participants generally enjoyed the activity. The impacts of music making were mediated strongly by staff responses and hospital organisation. Conclusion Data from this limited pilot study suggest that music is a useful intervention for enhancing patient and staff experiences and improving care in acute dementia care environments. The suggestion that use of anti-psychotic drugs may be reduced when music is present warrants further research.

Learning from the development of Integrated Care Projects in Dementia

Introduction: Due to demographical shifts and potential high demand for care, increased attention and leadership around dementia care within acute hospital services is anticipated. This is of particular concern due to potential barriers to timely patient flow associated with this cohort of vulnerable service users. This paper aims to report on scope and nature of service delivery reform needed to achieve integration in dementia care within the acute hospital sector. Methods: Three acute hospital sites are included in the analysis, with data collected pre-implementation of the ICP. An audit of hospital organisation/environment and case notes was conducted. Ethical approval was secured from the Faculty of Health Sciences Research Ethics Committees in Trinity College Dublin and relevant hospital Ethics Committees. Results: There was a high level of commitment and enthusiasm amongst service providers for dementia care and the development of an ICP. Data revealed the high demand for dementia-sensitive care and a number of gaps in service provision including absence of formalised dementia care pathways, inconsistent inreach/outreach arrangements between hospital and community, lack of standardisation in documentation and assessment and absence of formal system to alert personnel of dementia diagnosis. Gaps at an environmental and ward level such as reduced staffing levels were noted. The physical limitation of hospital as a suitable care environment for PwD was also highlighted. Areas for improvement to be addressed included colour schemes to allow PwD to find their way around the ward and clear marking of key areas. Pressure on resources and the need for active management of patients were highlighted as potential barriers to dementia care. A number of obstacles to optimal and timely patient flow were detected. The need for a central record was one of the most important aspects of early learning. Difficulties within the journey of care were highlighted including, for example, difficulties in assessment, delays in resolving capacity issues, high level of movement of patients within the hospital, and insufficiency in suitable community care provision. Discussion: Findings highlight the significant and wide reaching reforms needed in all aspects of service delivery so the hospital care environment may be optimised to meet the needs of PwD. Such reform necessitates a coherent dementia strategy within hospitals so the environment, care processes and staff are appropriately responsive to the needs of PwD. Considerable investment of time and resources is needed to fully understand the systems and processes that underpin the quality of integration in dementia care. The implementation of the proposed ICP is a lengthy and onerous process and there is significant change yet to be implemented within the three sites. These findings will inform the respective development and implementation process. Conclusion: The findings outlined here provide an important comparison for assessment post-implementation of the ICP across all sites. There is significant early learning from the data, both on a national and international level, in relation to the development and implementation of ICPs in an acute hospital setting, with critical barriers to same highlighted.

Death by suicide at the Ward level in Northern Ireland.

Deaths from suicide, as recorded within the Northern Ireland Coroner's Office for the years 2005-2011 inclusive, were analysed in terms of standardised mortality ratios (SMRs), within Wards and Local Government Districts (LGDs). The aim of the study is to examine factors relating to the ecological context of the area within which the person resided at time of death. Area deprivation, religious composition and age structure are examined in terms of SMRs, while controlling for the number of individuals living within a designated area. Random-intercept Poisson regression models were used in conjunction with empirical Bayes prediction to examine area effects. Considerable variation occurs between the numbers of recorded deaths within each area. A strong association is shown between deprivation and the number of deaths by suicide within an area. There was considerable variation at the LGD level in terms of the number of deaths, but once the nested nature of Wards was taken into account and adjusted for level of deprivation, the variation between LGD was no longer statistically significant. When adjusted for the number of individuals within each age group, the number of deaths in the younger and middle-aged groups did not show a statistical difference (0.05 level), nor did the religious composition of the area in terms of the number of recorded deaths. Based on SMRs, using empirical Bayes prediction, area effects were shown to be substantial, especially in urban locations where there are high rates of deprivation.