A theoretical framework for identifying sociocultural factors that influence nurses' compliance with early warning systems for acute clinical deterioration: A cross-sectional survey.

BACKGROUND: Systematic adoption of early warning systems in healthcare settings is dependent on the optimal and reliable application by the user. Psychosocial issues and hospital culture influence clinicians' patient safety behaviours. OBJECTIVE: (i) To examine the sociocultural factors that influence nurses' EWS compliance behaviours, using a theory driven behavioural model and (ii) to propose a conceptual model of sociocultural factors for EWS compliance behaviour. DESIGN: A cross-sectional survey. SETTING: Nurses employed in public hospitals across Queensland, Australia. PARTICIPANTS: Using convenience and snowball sampling techniques eligible nurses accessed a dedicated web site and survey containing closed and open-ended questions. 291 nurses from 60 hospitals completed the survey. METHODS: Quantitative data were analysed using ANOVA or t-tests to test differences in means. A series of path models based on the theory were conducted to develop a new model. Directed or theory driven content analysis informed qualitative data analysis. RESULTS: Nurses report high levels of previous compliance behaviour and strong intentions to continue complying in the future (M=4.7; SD 0.48). Individual compliance attitudes (ß 0.29, p<.05), perceived value of escalation (ß 0.24, p<.05) and perceived ease or difficulty complying with documentation (ß -0.31, p<.05) were statistically significant, predicting 24% of variation in compliance behaviour. Positive personal charting beliefs (ß 0.14, p<.05) and subjective norms both explain higher behavioural intent indirectly through personal attitudes. High ratings of peer charting beliefs indirectly explain attitudes through subjective norms (ß 0.20, p<.05). Perceptions of control over one's clinical actions (ß -0.24, p<.05) and early warning system training (ß -0.17, p<.05) directly contributed to fewer difficulties complying with documentation requirements. Prior difficulties when escalating care (ß -0.31, p<.05) directly influenced the perceived value of escalating. CONCLUSIONS: The developed theory-based conceptual model identified sociocultural variables that inform compliance behaviour (documenting and escalation protocols). The model highlights areas of clinical judgement, education, interprofessional trust, workplace norms and cultural factors that directly or indirectly influence nurses' intention to comply with EWS protocols. Extending our understanding of the sociocultural and system wide factors that hamper nurses' use of EWSs and professional accountability has the potential to improve the compliance behaviour of staff and subsequently enhance the safety climate attitudes of hospitals. TWEETABLE ABSTRACT: A newly developed model reports nurse's personal attitudes, peer influence, perceived difficulties encountered documenting and escalation beliefs all predict early warning system compliance behaviour.

An integrative literature review of factors contributing to hypothermia in adults during the emergent (ebb) phase of a severe burn injury.

BACKGROUND: During the emergent (ebb) phase (first 72 h), the adult person with a severe burn experiences loss of body heat, decreased metabolism, and poor tissue perfusion putting them at risk of hypothermia, increased morbidity, and mortality. Therefore, timely and targeted care is imperative. AIM: The aim of this integrative literature review was to develop a framework of the factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase. METHODS: An integrative review of research literature was undertaken as it provides an orderly process in the sourcing and evaluation of the literature. Only peer reviewed research articles, published in scholarly journals were selected for inclusion (n = 26). Research rigor and quality for each research article was determined using JBI Global appraisal tools relevant to the methodology of the selected study. FINDINGS: Contributing factors were classified under three key themes: Individual, Pre-hospital, and In-hospital factors. CONCLUSION: The structured approach enabled the development of an evidence-based framework identifying factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase and adds knowledge to improve standardized care of the adult person with a severe burn injury.

Classic grounded theory: identifying the main concern.

Grounded theory comprises a family of research approaches designed to support the generation of a theory explaining a phenomenon experienced by a group of participants. One style of grounded theory, Classic grounded theory, is used less often than other types of grounded theory. The less frequent use of Classic grounded theory may be attributed to the limited availability of clearly articulated processes for conducting this method. Particularly important within Classic grounded theory, and not used in other forms of grounded theory, is identifying the participants' main concern. Identifying the participants' main concern is a signature feature of Classic grounded theory and is a prerequisite for ascertaining the core category and subsequent discovery of theory. In this article we provide a detailed explanation of how to identify the participants' main concern, and in so doing, we offer an exemplar to illustrate the process involved.

Indicators of patient deterioration in poorly resourced private hospitals: Which vital sign to watch? A retrospective case-control study.

BACKGROUND: Patient vital signs are a measure of wellness if monitored regularly and accurately. Staff shortages in poorly resourced regional hospitals often result in inadequate patient monitoring, putting patients at risk of undetected deterioration. OBJECTIVE: This study aims to explore the pattern and completeness of vital sign monitoring and the contribution of each vital sign in predicting clinical deterioration events in resource-poor regional/rural hospitals. METHOD: Using a retrospective case-control study design, we compared 24 h of vital sign data from deteriorating and nondeteriorating patients from two poorly-resourced regional hospitals. Descriptive statistics, t-tests, and analysis of variance are used to compare patient-monitoring frequency and completeness. The contribution of each vital sign in predicting patient deterioration was determined using the Area Under the Receiver Operator Characteristic curve and binary logistical regression analysis. RESULTS: Deteriorating patients were monitored more frequently (9.58 [7.02] times) in the 24-h period than nondeteriorating patients (4.93 [2.66] times). However, the completeness of vital sign documentation was higher in nondeteriorating (85.2%) than in deteriorating patients (57.7%). Body temperature was the most frequently omitted vital sign. Patient deterioration was positively linked to the frequency of abnormal vital signs and the number of abnormal vital signs per set (Area Under the Receiver Operator Characteristic curve: 0.872 and 0.867, respectively). No single vital sign strongly predicts patient outcomes. However, a supplementary oxygen value of >3 L/min and a heart rate of >139 beats/min were the best predictors of patient deterioration. CONCLUSION: Given the poor resourcing and often geographical remoteness of small regional hospitals, it is prudent that the nursing staff are made aware of the vital signs that best indicate deterioration for the cohort of patients in their care. Tachycardic patients on supplementary oxygen are at high risk of deterioration.

From pilot to a multi-site trial: refining the Early Detection of Deterioration in Elderly Residents (EDDIE +) intervention.

BACKGROUND: Early Detection of Deterioration in Elderly Residents (EDDIE +) is a multi-modal intervention focused on empowering nursing and personal care workers to identify and proactively manage deterioration of residents living in residential aged care (RAC) homes. Building on successful pilot trials conducted between 2014 and 2017, the intervention was refined for implementation in a stepped-wedge cluster randomised trial in 12 RAC homes from March 2021 to May 2022. We report the process used to transition from a small-scale pilot intervention to a multi-site intervention, detailing the intervention to enable future replication. METHODS: The EDDIE + intervention used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide the intervention development and refinement process. We conducted an environmental scan; multi-level context assessments; convened an intervention working group (IWG) to develop the program logic, conducted a sustainability assessment and deconstructed the intervention components into fixed and adaptable elements; and subsequently refined the intervention for trial. RESULTS: The original EDDIE pilot intervention included four components: nurse and personal care worker education; decision support tools; diagnostic equipment; and facilitation and clinical support. Deconstructing the intervention into core components and what could be flexibly tailored to context was essential for refining the intervention and informing future implementation across multiple sites. Intervention elements considered unsustainable were updated and refined to enable their scalability. Refinements included: an enhanced educational component with a greater focus on personal care workers and interactive learning; decision support tools that were based on updated evidence; equipment that aligned with recipient needs and available organisational support; and updated facilitation model with local and external facilitation. CONCLUSION: By using the i-PARIHS framework in the scale-up process, the EDDIE + intervention was tailored to fit the needs of intended recipients and contexts, enabling flexibility for local adaptation. The process of transitioning from a pilot to larger scale implementation in practice is vastly underreported yet vital for better development and implementation of multi-component interventions across multiple sites. We provide an example using an implementation framework and show it can be advantageous to researchers and health practitioners from pilot stage to refinement, through to larger scale implementation. TRIAL REGISTRATION: The trial was prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

Application of classic grounded theory in nursing studies: a qualitative systematic review protocol.

INTRODUCTION: Classic grounded theory (CGT) is a valuable method for nursing research, but the application of CGT methodology in nursing studies has not been specifically investigated. With the increasing use of CGT in nursing research, attention is now focusing on the quality of studies using this methodology. In this systematic review, we aim to develop an understanding of the application of CGT methodology, specifically appraising the quality of the methodology's application in the field of nursing research. METHODS AND ANALYSIS: The reporting of this review will be guided by the Preferred Reporting Items for Systematic and Meta-Analysis guidelines statement and data synthesis guided by the Synthesis Without Meta-analysis guideline. Publications will be uploaded to Rayyan. The quality of each article will be assessed using the Critical Appraisals Skills Programme qualitative research appraisal tool. Analysis of the selected studies will be performed using the Guideline for Reporting and Evaluating Grounded Theory Research Studies, explicitly the CGT guiding principles. ETHICS AND DISSEMINATION: Ethical approval is not required because only secondary data will be used in this review. The results of the final study will be published in a peer-reviewed open-access journal. PROSPERO REGISTRATION NUMBER: CRD42021281103.

Protocol for a process evaluation of a stepped wedge randomised controlled trial to reduce unnecessary hospitalisations of older people from residential aged care: the EDDIE+ study.

INTRODUCTION: The Early Detection of Deterioration in Elderly residents (EDDIE+) programme is a theory-informed, multi-component intervention aimed at upskilling and empowering nursing and personal care staff to identify and manage early signs of deterioration in residents of aged care facilities. The intervention aims to reduce unnecessary hospital admissions from residential aged care (RAC) homes. Alongside a stepped wedge randomised controlled trial, an embedded process evaluation will be conducted to assess the fidelity, acceptability, mechanisms of action and contextual barriers and enablers of the EDDIE+ intervention. METHODS AND ANALYSIS: Twelve RAC homes in Queensland, Australia are participating in the study. A comprehensive mixed-methods process evaluation, informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, will assess intervention fidelity, contextual barriers and enablers, mechanisms of action, and the acceptability of the programme from various stakeholder perspectives. Quantitative data will be collected prospectively from project documentation, including baseline context mapping of participating sites, activity tracking and regular check-in communication sheets. Qualitative data will be collected postintervention via semi-structured interviews with a range of stakeholder groups. The i-PARIHS constructs of innovation, recipients, context and facilitation will be applied to frame the analysis of quantitative and qualitative data. ETHICS AND DISSEMINATION: Ethical approval for this study has been granted by the Bolton Clarke Human Research Ethics Committee (approval number: 170031) with administrative ethical approval granted by the Queensland University of Technology University Human Research Ethics Committee (2000000618). Full ethical approval includes a waiver of consent for access to residents' demographic, clinical and health services de-identified data. A separate health services data linkage based on RAC home addresses will be sought through a Public Health Act application. Study findings will be disseminated through multiple channels, including journal publications, conference presentations and interactive webinars with a stakeholder network. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trial Registry (ACTRN12620000507987).

Identifying the core components of a nursing home hospital avoidance programme.

BACKGROUND: Nursing home hospital avoidance programmes have contributed to a reduction in unnecessary emergency transfers but a description of the core components of the programmes has not been forthcoming. A well-operationalised health-care programme requires clarity around core components to evaluate and replicate the programme. Core components are the essential functions and principles that must be implemented to produce expected outcomes. OBJECTIVES: To identify the core components of a nursing home hospital avoidance programme by assessing how the core components identified at one nursing home (Site One) translated to a second nursing home (Site Two). METHODS: Data collected during the programme's implementation at Site Two were reviewed for evidence of how the core components named at Site One were implemented at Site Two and to determine if any additional core components were evident. The preliminary updated core components were then shared with seven evaluators familiar with the hospital avoidance programme for consensus. RESULTS: The updated core components were agreed to include the following: Decision Support Tools, Advanced Clinical Skills Training, Specialist Clinical Support and Collaboration, Facility Policy and Procedures, Family and Care Recipient Education and Engagement, Culture of Staff Readiness, Supportive Executive and Facility Management. CONCLUSION: This study launches a discussion on the need to identify hospital avoidance programme core components, while providing valuable insight into how Site One core programme components, such as resources, education and training, clinical and facility support, translated to Site Two, and why modifications and additions, such as incorporating the programme into facility policy, family education and executive support were necessary, and the ramifications of those changes. The next step is to take the eight core component categories and undertake a rigorous fidelity assessment as part of formal process evaluation where the components can be critiqued and measured across multiple nursing home sites. The core components can then be used as evidence-based building blocks for developing, implementing and evaluating nursing home hospital avoidance programmes.

Midwives' recognition and response to maternal deterioration: A national cross-sectional study.

BACKGROUND: Early warning systems (EWS) are used across health care settings as a tool for the early identification of clinical deterioration and to determine the need to escalate care. Early detection of clinical deterioration and appropriate escalation of care in maternity settings is critical to the safety of pregnant women and infants; however, underutilization of EWS tools and reluctance to escalate care have been consistently reported. Little is known about midwives' use of EWS in the Australian context. METHODS: Using a cross-sectional approach, we elicited the attitudes, beliefs, and behaviors of a purposive sample of Australian midwives (n = 87) with respect to the Maternal Early Warning Trigger Tool (MEWT). Participants answered a 25-question Likert scale survey and one open-ended question. Qualitative answers were analyzed using consensus coding. RESULTS: Midwives reported positive attitudes toward the MEWT, describing it as a valuable tool for identifying clinical deterioration, especially when used as an adjunct to clinical judgment. However, midwives also identified training gaps; 25% had received no training, and only half of those who had received training felt it was effective. In addition, professional tension can create a significant barrier to the effective use of the MEWT. Midwives also reported feeling influenced by their peers in their decision-making with respect to use of the MEWT and being afraid they would be chastised for escalating care unnecessarily. CONCLUSIONS: Although the MEWT is valued by Australian midwives as a useful tool, barriers exist to its effective use. These include a lack of adequate, ongoing training and professional tension. Improving interdisciplinary collaboration could enhance the use of this tool for the safety of birthing women and their infants.

Clinical judgement in nursing - An evolutionary concept analysis.

AIMS: The aim of this concept analysis was to develop a contemporary operational definition of Clinical Judgement in nursing. DESIGN: Concept analysis. METHODS: Rodgers' evolutionary method of concept analysis. Throughout the study, the authors followed the SRQR checklist. RESULTS: This concept analysis guided the development of an operational definition of clinical judgement, within the context of nursing, articulated as Clinical judgement is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base and results in the formation of a clinical conclusion. CONCLUSION: The purpose of this concept analysis was to propose a detailed definition of clinical judgement in nursing, that reflected its theoretical base within today's contemporary healthcare system. Using Rodgers' evolutionary method of concept analysis, surrogate terms, attributes, antecedents and consequences were identified, and a contemporary definition was developed. No patient or public contribution was required to design or undertake this research.

Research Ready Grant Program (RRGP) protocol: a model for collaborative multidisciplinary practice-research partnerships.

BACKGROUND: Little attention has been given to the process of implementing or evaluating a structured academic-clinician (university-health service) research capacity-building (RCB) model within healthcare settings. We have developed a model for collaborative multidisciplinary practice-research partnerships called the Research Ready Grant Program (RRGP). The RRGP is informed by Cooke's (BMC Fam Pract 6:44, 2005) RCB framework and principles. The aim of the study outlined in this protocol is to conduct a process and outcome evaluation of the programme. We will explore how the RRGP's structured mentor model contributes to RCB of clinician-led multidisciplinary research teams. We will identify key factors at the organization, team and individual levels that affect research capacity of health professionals working in one regional health service district. This protocol describes the RRGP design and outlines the methods we will employ to evaluate an RCB programme, the RRGP, delivered in a regional health service in Australia. METHODS: The study will adopt an exploratory concurrent mixed-methods approach designed to evaluate the process of implementing an RCB model across one regional hospital and health service. Both quantitative and qualitative data collection methods over a 12-month period will be implemented. Data triangulation will be applied to capture the complex issues associated with implementing collaborative multidisciplinary practice-research partnerships. DISCUSSION: The RRGP is an innovative RCB model for clinicians in their workplace. It is expected that the programme will facilitate a culture of collaborative multidisciplinary research and strengthen hospital-university partnerships.

Research capacity-building for clinicians: understanding how the research facilitator role fosters clinicians' engagement in the research process.

BACKGROUND: There is evidence reporting more positive outcomes from research capacity-building (RCB) programmes that include a research facilitator role. Further, it has been suggested that research facilitator roles can be a useful strategy in building the research capacity of healthcare clinicians. However, until now, little attention has been applied to identifying the characteristics of the research facilitator role and how this role contributes to clinicians' engagement with the research process. The aim of this present study is to explore the characteristics required of the research facilitator role in the educational workshop phase of an RCB programme. METHODS: This qualitative study employed an inductive approach and utilized face-to-face interviews to gather data from a purposely selected cohort. Professionally transcribed responses were thematically analysed. RESULTS: The role of the research facilitator emerged as comprising two main themes: (1) facilitating the research process and (2) engaging expert clinicians as novice researchers. Pragmatically, analysis of data led to the development of a table outlining the responsibilities, skills and attributes related to each theme. Conceptually, theme 1 encapsulates the research facilitators' skills and experience and their role as knowledge brokers and cocreators of knowledge. Theme 2 provides insight into the clinician-centric approach the research facilitators utilized to build and foster relationships and support the clinicians through their research journey. CONCLUSION: This study reports on the characteristics of the research facilitator role in one phase of an RCB programme in one regional health service district in Australia and explains how the role fosters clinicians' engagement with the research process. Findings from this study will inform the development of future RCB programmes, which is important considering that clinicians' increased engagement with the research process is vital for developing a sound evidence base to support decision-making in practice and leads to higher levels of skills and greater ability to perform useful research.

Factors contributing to the restoration of normothermia after hypothermia in people with a major burn injury in the first 24 h of hospital admission.

BACKGROUND: People with burn injury experiencing hypothermia are at risk of serious complications such as shock, multisystem organ failure, and death. There is limited information available for health professionals with regard to factors that contribute to restoration of normothermia after hypothermia in people with a major burn injury. OBJECTIVE: The aim of the study was to identify factors that contribute to normothermia restoration after hypothermia in people with 10% or more total body surface area (TBSA) burn in the first 24 h of admission to a burn care hospital. METHODS: The study was guided by the Gearing Framework for retrospective chart audit. The sample comprised medical charts of all adult people (n = 113) with a burn injury more than 10% of their TBSA admitted to a single-site burn care hospital intensive care unit in Victoria, Australia, between May 31, 2013, and June 1, 2015. Descriptive statistics were used to describe the sample, and logistic regression was conducted to predict variables contributing to return to normothermia in people with burn injury. Charts with incomplete data were excluded. FINDINGS: The sample (n = 50) recorded a median initial temperature on admission to the emergency department (ED) of 35.4°C (range = 31.9-37.2°C) and took on an average of 6.2 (standard deviation [SD] = 4.96) hours to return to normothermia (36.5°C). Women took around 6 h longer than men to return to normothermia (mean = 11.14 h, SD = 5.58; mean = 5.38 h, SD = 4.41). Positive correlations were noted between TBSA%, the length of time between admission to the ED and the intensive care unit, and the hours taken to reach normothermia. Regression analysis suggests the initial recorded temperature on admission to the ED was the main predictor of the time body temperature takes to return to normothermia (ß = .513, p < .001). CONCLUSION: This study provides information for practice changes by highlighting the need for guidelines and education programs for health professionals to ensure the delivery of optimum care to people with burn injury.

A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol.

BACKGROUND: Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia. METHODS: A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers. DISCUSSION: The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives. TRIAL REGISTRATION: The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry ( ACTRN12620000507987 , registered 23/04/2020).

Associations between health behaviors and mental health in Australian nursing students.

AIM: Nursing students experience high levels of stress, anxiety and depression. This study examined associations between health behaviors and stress, anxiety and depression in Australian nursing students. DESIGN: this was a cross-sectional study. METHODS: Participants completed an online survey providing demographic information and responses to the 21-item Depression Anxiety Stress Scale, Fagerström Test for Nicotine Dependence, short Food Frequency Questionnaire, Alcohol Use Disorders Identification Test, International Physical Activity Questionnaire and Workforce Sitting Questionnaire. Associations were evaluated using multivariate linear regression. RESULTS: Mild to extremely severe stress (46.6%), anxiety (52.8%) and depression (42.2%) were prevalent. Intake of snack-foods was associated with higher depression (ß = 8.66, p < 0.05) and stress (ß = 3.92, p = 0.055) scores. More time spent sitting was associated with higher depression (ß = 0.48, p < 0.001) and stress (ß = 0.28, p < 0.05) scores. Skipping meals correlated with higher stress, anxiety and depression scores. CONCLUSION: More support must be provided to nursing students to manage psychological distress and mental health during university study.

Predictive factors of the general public's willingness to be seen and seek treatment from a nurse practitioner in Australia: a cross-sectional national survey.

BACKGROUND: Health care delivery in Australia is experiencing challenges with services struggling to keep up with the increasing demands of an aging population, rising levels of chronic disease and limited funding for care. Where adjunct models of health care such as the Nurse Practitioner (NP) have the potential to address this gap, in Australia, they remain an underutilised service. Clarifying the nature of the consumers 'willingness' to be seen by NPs warrants further investigation. METHODS: Australia-wide, cross-sectional population-based survey was undertaken using computer-assisted telephone interviewing technique. RESULTS: While just over 53% of the general public participants (n = 1318) had heard of an NP, once they became aware of their scope of practice, the majority agreed or strongly agreed they were willing to be seen by an NP in the community (91.6%), the emergency department 88.2%), to manage chronic conditions (86%), to have scrips written and referrals made (85.3%), and if they did not have to wait so long to see a medical doctor (81%). Factors significantly predicting willingness were being: female, less than 65 years of age, native English speakers, or residents from town/regional and rural settings. CONCLUSION: Despite limited awareness of the NP role, a large proportion of the Australian population, across different demographic groups, are willing to be seen and treated by an NP. Expansion of this role to support medical services in areas of need could improve healthcare delivery.

Patient Deterioration in Australian Regional and Rural Hospitals: Is the Queensland Adult Deterioration Detection System the Criterion Standard?

OBJECTIVE: This study compares the efficiency of six early warning systems (EWSs) to determine whether the EWS used in most public hospitals in Queensland, Australia, The Queensland Adult Deterioration Detection System (Q-ADDS), is best suited for use in small regional and rural hospitals. METHOD: In this retrospective case-control study, patients who experienced an in-hospital severe adverse event (index patients) for a 3.5-year period were demographically and diagnostically matched with patients who had uneventful hospital stays (control patients). The EWS efficiency was based on the area under the receiver operator characteristic curve (AUROC) and the number of false and true alerts generated by each EWS. RESULT: The incidence of severe adverse events was 1.2% of in-hospital patients, and 2500 sets of vital signs were collected from 159 index and 172 control patients. The EWSs were only able to identify approximately half of the index patients. The AUROC was 0.666 to 0.801 and the EWS generated 2.4 to 7.6 false alerts to every true alert per 1000 admissions. The National Early Warning Score had the best ratio of false to true alerts (2.4:1) but was only able to identify 40.8% of deteriorating patients. The Q-ADDS identified 46.5% of the deteriorating patients and had a false to true alert ratio of 3.2:1. When compared with the National Early Warning Score, systems with higher AUROCs (0.744 and 0.801) also had higher proportion of false alerts. None of the alternative EWSs seem to provide marked benefits over Q-ADDS. CONCLUSIONS: At present, there is insufficient evidence to replace Q-ADDS with an alternative EWS. Because the EWSs were only able to identify half of the deteriorating patients, EWSs should be used in conjunction with good clinical judgment.

The effectiveness and cost effectiveness of a hospital avoidance program in a residential aged care facility: a prospective cohort study and modelled decision analysis.

BACKGROUND: Residential aged care facility residents experience high rates of hospital admissions which are stressful, costly and often preventable. The EDDIE program is a hospital avoidance initiative designed to enable nursing and care staff to detect, refer and quickly respond to early signals of a deteriorating resident. The program was implemented in a 96-bed residential aged care facility in regional Australia. METHODS: A prospective pre-post cohort study design was used to collect data on costs of program delivery, hospital admission rates and length of stay for the 12 months prior to, and following, the intervention. A Markov decision model was developed to synthesize study data with published literature in order to estimate the cost-effectiveness of the program. Quality adjusted life years (QALYs) were adopted as the measure of effectiveness. RESULTS: The EDDIE program was associated with a 19% reduction in annual hospital admissions and a 31% reduction in the average length of stay. The cost-effectiveness analysis found the program to be both more effective and less costly than usual care, with 0.06 QALYs gained and $249,000 health system costs saved in a modelled cohort of 96 residents. A probabilistic sensitivity analysis estimated that there was an 86% probability that the program was cost-effective after taking the uncertainty of the model inputs into account. CONCLUSIONS: This study provides promising evidence for the effectiveness and cost-effectiveness of a nurse led, early intervention program in preventing unnecessary hospital admissions within a residential aged care facility. Further research in multi-site randomised studies is needed to confirm the generalisability of these results.

Understanding nurses perspectives of acuity in the process of emergency mental health triage: a qualitative study.

Background: Post deinstitutionalisation, mental health mainstreaming has led to substantial increases in presentations to Emergency Departments (EDs). The assessment process requires the ED triage nurse to undertake a rapid client assessment, assign a clinically appropriate triage score, and then refer the client to a mental health clinician. The initial assessment is important, and a number of factors influence the process of triage, referral and response including an understanding of mental health presentation acuity. Aim: To understand the factors that influence the ED triage assessment, referral and clinical response of clients with a mental illness. Methods: An ethnographic methodology underpinned the research design. ED triage nurses and mental health triage nurses who worked in a regional hospital provided insights through interviews and observations. The study was also informed by institutional policies and procedures regarding triage. Transcribed in-depth interviews, field notes and memos were analysed using an inductive thematic process. Findings: Mental health triage nurses and ED triage nurses concur that triage is an important part of the assessing process for a person who presents to the ED with a mental health problem. Timely and clinically accurate assessment, followed by referral and response is strongly influenced by the user knowledge of the mental health triage scale, and comprehension of mental health acuity. The conflicting understandings between the two professional nursing groups, called professionally cultured orientations, further impact this process. Conclusion: Professionally cultured orientation to mental health triage and acuity comprehension influence the process of emergency mental health triage and therefore may affect optimal client outcomes. Further research into ED triage design, ED triage education, and a shared understanding of acuity is called for.

Developing a sociocultural framework of compliance: an exploration of factors related to the use of early warning systems among acute care clinicians.

BACKGROUND: Early warning systems (EWS) are most effective when clinicians monitor patients' vital signs and comply with the recommended escalation of care protocols once deterioration is recognised. OBJECTIVES: To explore sociocultural factors influencing acute care clinicians' compliance with an early warning system commonly used in Queensland public hospitals in Australia. METHODS: This interpretative qualitative study utilised inductive thematic analysis to analyse data collected from semi-structured interviews conducted with 30 acute care clinicians from Queensland, Australia. RESULTS: This study identified that individuals and teams approached compliance with EWS in the context of 1) the use of EWS for patient monitoring; and 2) the use of EWS for the escalation of patient care. Individual and team compliance with monitoring and escalation processes is facilitated by intra and inter-professional factors such as acceptance and support, clear instruction, inter-disciplinary collaboration and good communication. Noncompliance with EWS can be attributed to intra and inter-professional hierarchy and poor communication. CONCLUSIONS: The overarching organisational context including the hospital's embedded quality improvement and administrative protocols (training, resources and staffing) impact hospital-wide culture and influence clinicians' and teams' compliance or non-compliance with early warning system's monitoring and escalation processes. Successful adoption of EWS relies on effective and meaningful interactions among multidisciplinary staff.