Referral Order Placement Decreases Time to Transfer to Adult Congenital Heart Disease Care.

Pediatric patients with moderate and great complexity congenital heart disease (CHD) may benefit from coordinated transfer to adult congenital heart disease (ACHD) centers to reduce the risk of complications; however, there are a variety of transfer practices. We examined the impact of referral order placement at the last pediatric cardiology visit on time to transfer to an ACHD center. We analyzed data collected from pediatric patients with moderate and great complexity CHD who were eligible to transfer to our tertiary center's accredited ACHD center. We examined transfer outcomes and time-to-transfer between those with a referral order placed at the last pediatric cardiology visit and those without using Cox proportional hazards modeling. The sample (n = 65) was 44.6% female and mean age at study start was 19.5 years (± 2.2). Referral orders were placed for 32.3% of patients at the last pediatric cardiology visit. Those who had a referral order placed at the last visit had significantly higher number of successful transfers to the ACHD center compared to those who did not (95% vs 25%, p < 0.001). In a Cox regression model, placement of a referral order at the last pediatric cardiology visit was associated significantly with a sooner time to transfer (HR 6.0; 95% CI 2.2-16.2, p > 0.001), adjusting for age, sex, complexity, living location, and pediatric cardiology visit location. Placement of a referral order at the last pediatric cardiology visit may improve transfer occurrence and time to transfer to accredited ACHD centers.

Survival analysis 101: an easy start guide to analysing time-to-event data.

Survival analysis, also called time-to-event analysis, is a common approach to handling event data in cardiovascular nursing and health-related research. Survival analysis is used to describe, explain, and/or predict the occurrence and timing of events. There is a specific language used and methods designed to handle the unique nature of event data. In this methods paper, we provide an 'easy start guide' to using survival analysis by (i) providing a step-by-step guide and (ii) applying the steps with example data. Specifically, we analyse cardiovascular event data over 6 months in a sample of patients with heart failure.

Testing effectiveness of the revised Cape Town modified early warning and SBAR systems: a pilot pragmatic parallel group randomised controlled trial.

BACKGROUND: Nurses' recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries. METHODS: We tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed. RESULTS: We recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06-1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and "looks unwell". SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38-6.86)). CONCLUSIONS: The revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses' ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses' reporting behaviour. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org.

Treatment of individuals who cannot receive blood products for religious or other reasons.

By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.

Validation of a modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool: A mixed methods study.

AIMS AND OBJECTIVES: To develop and validate a modified Situation-Background-Assessment-Recommendation communication tool incorporating components of the Cape Town modified early warning score vital signs chart for reporting early signs of clinical deterioration. BACKGROUND: Reporting early signs of physiological and clinical deterioration could prevent "failure to rescue" or unexpected intensive care admission, cardiac arrest or death. A structured communication tool incorporating physiological and clinical parameters allows nurses to provide pertinent information about a deteriorating patient in a logical order. DESIGN: Mixed methods instrument development and validation. METHODS: We used a sequential three-phase method: cognitive interviews, content validation and inter-rater reliability testing to validate a self-designed communication tool. Participants were purposively selected expert nurses and doctors in government sector hospitals in Cape Town. RESULTS: Cognitive interviews with five experts prompted most changes to the communication tool: 15/42 (35.71%) items were modified. Content validation of a revised tool was high by a predetermined ≥70% of 18 experts: 4/49 (8.2%) items were modified. Inter-rater reliability testing by two nurses indicated substantial to full agreement (Cohen's kappa .61-1) on 37/45 (82%) items. The one item achieving slight agreement (Cohen's kappa .20) indicated a difference in clinical judgement. The high overall percentage agreement (82%) suggests that the modified items are sound. Overall, 45 items remained on the validated tool. CONCLUSION: The first modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool developed in South Africa was found to be valid and reliable in a local context. RELEVANCE TO CLINICAL PRACTICE: Nurses in South Africa can use the validated tool to provide doctors with pertinent information about a deteriorating patient in a logical order to prevent a serious adverse event. Our findings provide a reference for other African countries to develop and validate communication tools for reporting early signs of clinical deterioration.