Valid consent in the acute hospital setting: perspectives of patients and members of the public.

BACKGROUND: People who interact with healthcare services have an ethical and legal right to control their own lives, to make informed decisions, and to consent to what happens to them. For consent to be considered ethically and legally valid, three key criteria must be met: consent must be given voluntarily; people must be sufficiently informed of all options; and people should have capacity to make the decision to give or withhold their consent. AIM: This study set out to explore, through the use of surveys, the perspectives of patients and public in relation to consent. METHOD: Surveys were developed for patients and the public and administered paper based (patients) and through social media (public). RESULTS: One hundred and forty surveys were posted to patients, with a 38% response rate; 104 responses were received from the public. Ninety-six percent of patients were satisfied that the decision they made was informed; 100% felt they had made a voluntary decision; 98% felt the clinician seemed knowledgeable about the procedure. What matters most to the public were being informed about the risks associated with the proposed procedure and being assured that whatever choice they make they will receive the best care possible. CONCLUSIONS: The results highlight interesting similarities and differences in relation to consent between members of the public thinking about a possible treatment, surgery, or procedure and those patients who have actually been through the process in the past 12 months. Recommendations have been developed on the basis of these findings to co-design improvements in consent practices.

Mind the implementation gap: a systems analysis of the NHS Long Term Workforce Plan to increase the number of doctors trained in the UK raises many questions.

BACKGROUND: The National Health Service (NHS) in England is facing a workforce crisis. A new Long Term Workforce Plan (LTWP) seeks to address this, setting out ambitious proposals to expand and reform domestic medical education and training in England. However, there are concerns about their feasibility. SOURCES OF DATA: In September 2023, over 60 individuals representing medical education and training in the UK participated in an exercise run by UK Medical Schools Council by using systems theory to identify risks. AREAS OF AGREEMENT: The UK does need more 'home grown' doctors, but the LTWP has important gaps, including lack of attention to postgraduate training, absence of reference to the need for more educators and capital investment and risk of inadequate clinical placement capacity, particularly in primary care settings. AREAS OF CONTROVERSY: There are unresolved differences in the understanding of a proposed medical apprenticeship model and no scheme has, as yet, been approved by the General Medical Council. Participants were unable to determine who the beneficiaries of this scheme will be (apart from the apprentices themselves). GROWING POINTS: While the LTWP represents a welcome, although overdue, commitment to address the NHS workforce crisis, we identified significant gaps that must be resolved. AREAS TIMELY FOR DEVELOPING RESEARCH: First, the development of the LTWP provides a case study that adds to literature on policymaking in the UK. Second, while we only examined the expansion of medical training, the method could be applied to other parts of the LTWP. Third, a prospective evaluation of its implementation is necessary.

The impact of the COVID-19 pandemic on patient complaints within one Irish teaching hospital.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic dramatically impacted the delivery of hospital care in terms of quality and safety. OBJECTIVES: To examine complaints from two time points, quarter 4 (Q4) 2019 (pre-pandemic) and Q4 2020 (second wave), and explore whether there was a difference in the frequency and/or content of complaints. METHODS: A retrospective analysis of complaints from one Irish hospital was conducted using the Healthcare Complaints Analysis Tool (HCAT). Within each complaint, the content, severity, harm reported by the patient, and stage of care were categorised. The complaints were analysed using descriptive statistics and chi-square tests of independence. RESULTS: There were 146 complaints received in Q4 2019 and 114 in Q4 2020. Complaint severity was significantly higher in Q4 2019 as compared to Q4 2020. However, there were no other significant differences. Institutional processes (e.g. staffing, resources) were the most common reason for complaints (30% in Q4 2019 and 36% in Q4 2020). The majority of complaints were concerned with care on the ward (23% in Q4 2019 and 31% in Q4 2020). CONCLUSIONS: The severity of complaints was significantly higher in Q4 2019 than in Q4 2020, which requires further exploration as the reasons for this are unclear. The lack of a difference in the frequency and content of complaints during the two time periods was unexpected. However, this may be linked to a number of factors, including public support for the healthcare system, existing system-level issues in the hospital, or indeed increased staff collaboration in the context of the COVID-19 crisis.

A socio-technical systems analysis of the application of RFID-enabled technology to the transport of precious laboratory samples in a large acute teaching hospital.

The scale and pace of improvement in patient safety in healthcare has been unacceptably slow. A paucity of research into the application of systems-thinking concepts and a failure to appreciate health systems complexity are cited as barriers to sustainable health systems improvement. This study reports on a socio-technical systems analysis, called the CUBE, of the characteristics of a large acute teaching hospital's system for the transport of precious specimens, a system enabled by radio-frequency identification tracking technology. The CUBE proved itself to be an effective analytic tool. The analysis provided a constructive framework to link diverse data and documentation; explicitly inviting consideration of the roles and understandings of different stakeholders; as well as broader cultural factors that could influence current or future activity. The analysis also supported recommendations to improve and extend operations. This study supports the argument for systems understanding and systems thinking being at the core of new approaches to patient safety.

Evaluation of an Access-Risk-Knowledge (ARK) Platform for Governance of Risk and Change in Complex Socio-Technical Systems.

Three key challenges to a whole-system approach to process improvement in health systems are the complexity of socio-technical activity, the capacity to change purposefully, and the consequent capacity to proactively manage and govern the system. The literature on healthcare improvement demonstrates the persistence of these problems. In this project, the Access-Risk-Knowledge (ARK) Platform, which supports the implementation of improvement projects, was deployed across three healthcare organisations to address risk management for the prevention and control of healthcare-associated infections (HCAIs). In each organisation, quality and safety experts initiated an ARK project and participated in a follow-up survey and focus group. The platform was then evaluated against a set of fifteen needs related to complex system transformation. While the results highlighted concerns about the platform's usability, feedback was generally positive regarding its effectiveness and potential value in supporting HCAI risk management. The ARK Platform addresses the majority of identified needs for system transformation; other needs were validated in the trial or are undergoing development. This trial provided a starting point for a knowledge-based solution to enhance organisational governance and develop shared knowledge through a Community of Practice that will contribute to sustaining and generalising that change.

Acceptability of and symptom findings from an online symptom check-in tool for COVID-19 outpatient follow-up among a predominantly healthcare worker population.

INTRODUCTION: Health systems worldwide have had to prepare for a surge in volume in both the outpatient and inpatient settings since the emergence of COVID-19. Early international healthcare experiences showed approximately 80% of patients with COVID-19 had mild disease and therfore could be managed as outpatients. However, SARS-CoV-2 can cause a biphasic illness with those affected experiencing a clinical deterioration usually seen after day 4 of illness. OBJECTIVE: We created an online tool with the primary objective of allowing for virtual disease triage among the increasing number of outpatients diagnosed with COVID-19 at our hospital. Secondary aims included COVID-19 education and the promotion of official COVID-19 information among these outpatients, and analysis of reported symptomatology. METHODS: Outpatients with acute COVID-19 disease received text messages from the hospital containing a link to an online symptom check-in tool which they were invited to complete. RESULTS: 296 unique participants (72%) from 413 contacted by text completed the online check-in tool at least once, generating 831 responses from 1324 texts sent. 83% of text recipients and 91% of unique participants were healthcare workers. 7% of responses to the tool were from participants who admitted to a slight worsening of their symptoms during follow-up. Fatigue was the most commonly reported symptom overall (79%), followed by headache (72%). Fatigue, headache and myalgia were the most frequently reported symptoms in the first 3 days of illness. 8% of responses generated in the first 7 days of illness did not report any of the cardinal symptoms (fever, cough, dyspnoea, taste/smell disturbance) of COVID-19. Participants found the tool to be useful and easy to use, describing it as 'helpful' and 'reassuring' in a follow-up feedback survey (n=140). 93% said they would use such a tool in the future. 39% reported ongoing fatigue, 16% reported ongoing smell disturbance and 14% reported ongoing dyspnoea after 6 months. CONCLUSION: The online symptom check-in tool was found to be acceptable to participants and saw high levels of engagement and satisfaction. Symptomatology findings highlight the variety and persistence of symptoms experienced by those with confirmed COVID-19 disease.

Online videos promote brain health literacy.

Misinformation and lack of understanding of memory loss, dementia and brain health are barriers to dementia risk reduction and timely health seeking behaviour. Online video technology for health promotion has been popularised with the increase in online networks, improved access to technology, and the rise of online health seeking behaviour. However, an understanding of the efficacy of this technology in the context of brain health awareness in older adults is lacking. This research explored whether three short brain health animations could reduce worry, impart new knowledge, and promote behavioural change in older adults. METHODS: Participants (8,179) completed an online survey pre- and post-engagement with three animated films. RESULTS: Level of worry significantly decreased, and over half of the participants indicated that they intended to change their behaviour after watching the videos. The majority of participants indicated they had learned something new from the videos, and found the videos enjoyable. Regression analysis described how participants who reported learning from the videos were more likely to report behavioural change. In addition, enjoyment significantly predicated outcomes of learning and behaviour change. CONCLUSIONS: our research suggests that short animated brain health films are effective in educating the public about memory, attention and brain health, may motivate people to make changes in lifestyle, and possibly reduce stigma towards dementia.

Survey of isolation room equipment and resources in an academic hospital.

PURPOSE: The purpose of this paper, a point prevalence study, is to quantify the incidence of isolation and identify the type of communicable diseases in isolation. The paper evaluates isolation precaution communication, availability of personal protective equipment (PPE) as well as other equipment necessary for maintaining isolation precautions. DESIGN/METHODOLOGY/APPROACH: A standardised audit tool was developed in accordance with the National Standards for the Prevention and Control of Healthcare Associated Infections (May 2009). Data were collected from 14 March 2017 to 16 March 2017, through observation of occupied isolation rooms in an academic hospital in Dublin, Ireland. The data were subsequently used for additional analysis and discussion. FINDINGS: In total, 14 per cent (125/869) of the total inpatient population was isolated at the time of the study. The most common isolation precaution was contact precautions (96.0 per cent). In all, 88 per cent of known contact precautions were due to multi-drug resistant organisms. Furthermore, 96 per cent of patients requiring isolation were isolated, 92.0 per cent of rooms had signage, 90.8 per cent had appropriate signs and 93.0 per cent of rooms had PPE available. Finally, 31 per cent of rooms had patient-dedicated and single-use equipment and 2.4 per cent had alcohol wipes available. PRACTICAL IMPLICATIONS: The audit tool can be used to identify key areas of noncompliance associated with isolation and inform continuous improvement and education. ORIGINALITY/VALUE: Currently, the rate of isolation is unknown in Ireland and standard guidelines are not established for the evaluation of isolation rooms. This audit tool can be used as an assessment for isolation room compliance.

The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns.

BACKGROUND: We believe junior doctors are in a unique position in relation to reporting of incidents and safety culture. They are still in training and are also 'fresh eyes' on the system providing valuable insights into what they perceive as safe and unsafe behaviour. The aim of this study was to co-design and implement an embedded learning intervention - a serious board game - to educate junior doctors about patient safety and the importance of reporting safety concerns, while at the same time shaping a culture of responsiveness from senior medical staff. METHODS: A serious game based on the PlayDecide framework was co-designed and implemented in two large urban acute teaching hospitals. To evaluate the educational value of the game voting on the position statements was recorded at the end of each game by a facilitator who also took notes after the game of key themes that emerged from the discussion. A sample of players were invited on a voluntary basis to take part in semi-structured interviews after playing the game using Flanagan's Critical Incident Technique. A paper-based questionnaire on 'Safety Concerns' was developed and administered to assess pre-and post-playing the game reporting behaviour. Dissemination workshops were held with senior clinicians to promote more inclusive leadership behaviours and responsiveness to junior doctors raising of safety concerns from senior clinicians. RESULTS: The game proved to be a valuable patient safety educational tool and proved effective in encouraging deep discussion on patient safety. There was a significant change in the reporting behaviour of junior doctors in one of the hospitals following the intervention. CONCLUSION: In healthcare, limited exposure to patient safety training and narrow understanding of safety compromise patients lives. The existing healthcare system needs to value the role that junior doctors and others could play in shaping a positive safety culture where reporting of all safety concerns is encouraged. Greater efforts need to be made at hospital level to develop a more pro-active safe and just culture that supports and encourages junior doctors and ultimately all doctors to understand and speak up about safety concerns.

Developing outcome, process and balancing measures for an emergency department longitudinal patient monitoring system using a modified Delphi.

BACKGROUND: Early warning score systems have been widely recommended for use to detect clinical deterioration in patients. The Irish National Emergency Medicine Programme has developed and piloted an emergency department specific early warning score system. The objective of this study was to develop a consensus among frontline healthcare staff, quality and safety staff and health systems researchers regarding evaluation measures for an early warning score system in the Emergency Department. METHODS: Participatory action research including a modified Delphi consensus building technique with frontline hospital staff, quality and safety staff, health systems researchers, local and national emergency medicine stakeholders was the method employed in this study. In Stage One, a workshop was held with the participatory action research team including frontline hospital staff, quality and safety staff and health systems researchers to gather suggestions regarding the evaluation measures. In Stage Two, an electronic modified-Delphi study was undertaken with a panel consisting of the workshop participants, key local and national emergency medicine stakeholders. Descriptive statistics were used to summarise the characteristics of the panellists who completed the questionnaires in each round. The mean Likert rating, standard deviation and 95% bias-corrected bootstrapped confidence interval for each variable was calculated. Bonferroni corrections were applied to take account of multiple testing. Data were analysed using Stata 14.0 SE. RESULTS: Using the Institute for Healthcare Improvement framework, 12 process, outcome and balancing metrics for measuring the effectiveness of an ED-specific early warning score system were developed. CONCLUSION: There are currently no published measures for evaluating the effectiveness of an ED early warning score system. It was possible in this study to develop a suite of evaluation measures using a modified Delphi consensus approach. Using the collective expertise of frontline hospital staff, quality and safety staff and health systems researchers to develop and categorise the initial set of potential measures was an innovative and unique element of this study.

An introduction to the Emergency Department Adult Clinical Escalation protocol: ED-ACE.

PURPOSE OF THE STUDY: This study demonstrates how a participatory action research approach was used to address the challenge of the early and effective detection of the deteriorating patient in the ED setting. The approach enabled a systematic approach to patient monitoring and escalation of care to be developed to address the wide-ranging spectrum of undifferentiated presentations and the phases of ED care from triage to patient admission. This paper presents a longitudinal patient monitoring system, which aims to provide monitoring and escalation of care, where necessary, of adult patients from triage to admission to hospital in a manner that is feasible in the unique ED environment. METHODS: An action research approach was taken to designing a longitudinal patient monitoring system appropriate for the ED. While the first draft protocol for post-triage monitoring and escalation was designed by a core research group, six clinical sites were included in iterative cycles of planning, action, reviewing and further planning. Reasons for refining the system at each site were collated and the protocol was adjusted accordingly before commencing the process at the next site. RESULTS: The ED Adult Clinical Escalation longitudinal patient monitoring system (ED-ACE) evolved through iterative cycles of design and testing to include: (1) a monitoring chart for adult patients; (2) a standardised approach to the monitoring and reassessment of patients after triage until they are assessed by a clinician; (3) the ISBAR (I=Identify, S=Situation, B=Background, A=Assessment, R=Recommendation) tool for interprofessional communication relating to clinical escalation; (4) a template for prescribing a patient-specific monitoring plan to be used by treating clinicians to guide patient monitoring from the time the patient is assessed until when they leave the ED and (5) a protocol for clinical escalation prompted by single physiological triggers and clinical concern. CONCLUSIONS: This tool offers a link in the 'Chain of Prevention' between the Manchester Triage System and ward-based early warning scores taking account of the importance of standardisation, while being sufficiently adaptable for the unique working environment and patient population in the ED.

Imbuing medical professionalism in relation to safety: a study protocol for a mixed-methods intervention focused on trialling an embedded learning approach that centres on the use of a custom designed board game.

INTRODUCTION: Healthcare organisations have a responsibility for ensuring that the governance of workplace settings creates a culture that supports good professional practice. Encouraging such a culture needs to start from an understanding of the factors that make it difficult for health professionals to raise issues of concern in relation to patient safety. The focus of this study is to determine whether a customised education intervention, developed as part of the study, with interns and senior house officers (SHOs) can imbue a culture of medical professionalism in relation to patient safety and support junior doctors to raise issues of concern, while shaping a culture of responsiveness and learning. METHODS AND ANALYSIS: We will use quantitative and qualitative methods to collect data. The sample size will be approximately 200 interns and SHOs across the two hospital sites. Two surveys will be included with one measuring leadership inclusiveness and psychological safety and a second capturing information on safety concerns that participants may have witnessed in their places of work. The PlayDecide embedded learning intervention will be developed with key stakeholders. This will be trialled in the middle stage of data collection for both interns and SHOs. A detailed content analysis will be conducted on the surveys to assess any changes in reporting following the PlayDecide intervention. This will be compared with the incident reporting levels and the results of the preintervention and postintervention leadership inclusiveness and psychological safety survey. Statistical analysis will be conducted using SPSS. Differences will be considered statistically significant at p<0.05. Semistructured interviews using a critical incident technique will be used for the ongoing analysis and evaluation of the project. These will be transcribed, de-identified and coded into themes. ETHICS AND DISSEMINATION: The study has been granted ethics approval from University College Dublin (Ref. LS-15-19-Ward-McAuliffe: Imbuing Medical Professionalism in Relation to Safety). The study results will be disseminated through peer-reviewed publications.

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach.

BACKGROUND: Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED). METHODS: A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of 'Plan Do Study Act' (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed. DISCUSSION: Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

Implementing Major Trauma Audit in Ireland.

BACKGROUND: There are 27 receiving trauma hospitals in the Republic of Ireland. There has not been an audit system in place to monitor and measure processes and outcomes of care. The National Office of Clinical Audit (NOCA) is now working to implement Major Trauma Audit (MTA) in Ireland using the well-established National Health Service (NHS) UK Trauma Audit and Research Network (TARN). AIMS: The aim of this report is to highlight the implementation process of MTA in Ireland to raise awareness of MTA nationally and share lessons that may be of value to other health systems undertaking the development of MTA. METHODS: The National Trauma Audit Committee of the Royal College of Surgeons in Ireland, consisting of champions and stakeholders in trauma care, in 2010 advised on the adaptation of TARN for Ireland. In 2012, the Emergency Medicine Program endorsed TARN and in setting up the National Emergency Medicine Audit chose MTA as the first audit project. A major trauma governance group was established representing stakeholders in trauma care, a national project co-ordinator was recruited and a clinical lead nominated. Using Survey Monkey, the chief executives of all trauma receiving hospitals were asked to identify their hospital's trauma governance committee, trauma clinical lead and their local trauma data co-ordinator. Hospital Inpatient Enquiry systems were used to identify to hospitals an estimate of their anticipated trauma audit workload. RESULTS: There are 25 of 27 hospitals now collecting data using the TARN trauma audit platform. These hospitals have provided MTA Clinical Leads, allocated data co-ordinators and incorporated MTA reports formally into their clinical governance, quality and safety committee meetings. There has been broad acceptance of the NOCA escalation policy by hospitals in appreciation of the necessity for unexpected audit findings to stimulate action. CONCLUSION: Major trauma audit measures trauma patient care processes and outcomes of care to drive quality improvement at hospital and national level. MTA will facilitate the strategic development of trauma care in Ireland by monitoring processes and outcomes and the effects of changes in trauma service provision.

Estimating the impact of somatic cell count on the value of milk utilising parameters obtained from the published literature.

The impact of mastitis on milk value per litre independent of the effect of mastitis on milk volume, was quantified for Ireland using a meta-analysis and a processing sector model. Changes in raw milk composition, cheese processing and composition associated with increased bulk milk somatic cell count (BMSCC) were incorporated into the model. Processing costs and market values were representative of current industry values. It was assumed that as BMSCC increased (i) milk fat and milk protein increased and milk lactose decreased, (ii) fat and protein recoveries decreased, (iii) cheese protein decreased and cheese moisture increased. Five BMSCC categories were examined from ⩽100 000 to >400 000 cells/ml. The analysis showed that as BMSCC increased the production quantities reduced. An increase in BMSCC from 100 000 to >400 000 cells/ml saw a reduction in net revenue of 3·2% per annum (€51·3 million) which corresponded to a reduction in the value of raw milk of €0·0096 cents/l.

A new era for emergency care services in Ireland.

The National Emergency Medicine Programme Strategy is a comprehensive plan to improve and develop emergency care in Ireland. It recommends significant changes in how emergency care is organised and delivered so that patients can be confident that they will receive high quality, safe and timely care. Emergency nurses were involved in developing aspects of the strategy document and will play a crucial role in its implementation to ensure that patient outcomes and satisfaction with emergency care services in Ireland are improved.

Evaluation of a new needle catching instrument for suturing simple wounds in the Emergency Department.

OBJECTIVES: The Needlecatcher comprises a tissue forceps at one end, with a 'piston and barrel' system, which acts as a needle grasper, at the other end of the instrument. It minimizes exposure of the needle during suturing, potentially reducing risk of injury. We evaluate its effect on operator safety during simple wound closure. METHODS: Video analysis of 10 clinicians (six junior doctors and four advanced nurse practitioners) closing a standard simulated wound using their normal technique was performed. They were trained in the use of the Needlecatcher, and used it for 10 weeks closing simple wounds in the Emergency Department. Video analysis of wound closure was repeated, using the new instrument. Clinicians filled out a questionnaire for each episode of wound closure, which assessed how they perceived their safety was affected by the device. RESULTS: Video analysis of clinicians showed that the needle was secured in an instrument and thus unexposed for an average of 60% of the duration of the procedure by standard technique, compared with 95% using the Needlecatcher, with a change of 35% [95% confidence interval (CI): 14-58%, P = 0.005]. Episodes where the needle was grasped by an operator's finger were reduced by 50% (95% CI: 15-85%, P = 0.028). In the questionnaire study of 53 episodes of wound closure, operators perceived their safety to be increased in 38 (71.7%, 95% CI: 66.2-77.2%) episodes, were neutral in 10, and felt their safety was reduced in five. CONCLUSION: The Needlecatcher showed the potential to reduce the risk of needlestick injury while suturing.