'Doing the best we can': Registered Nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

AIMS: To explore registered nurses' experiences of patient safety in intensive care during COVID-19. DESIGN: A qualitative interview study informed by constructivism. METHOD: Semi-structured interviews were conducted and audio-recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. RESULTS: Two key themes were identified. 'On a war footing'-an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. 'Doing the best we can'-Safe Delivery of Care which describes the ramifications of the actions taken on short- and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer Support. CONCLUSION: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an understanding of the holistic and long-term impacts on patient safety and recovery from critical illness. IMPACT: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing workforce modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

An audit of independent nurse prescribing in a critical care outreach team.

BACKGROUND: In 2006, legislative changes enabled independent prescribers to prescribe any licensed medication within their field of expertise. This has transformed nurse prescribing and opened up more opportunities for nurses to develop their practice in acute care settings. The need for further evaluation in this developing area of advanced practice was highlighted in the British Association of Critical Care Nurses (BACCN) position statement published in 2009. AIMS: The aims of this audit were to describe the prescribing practices of nurses working in a critical care outreach (CCO) team by exploring: which medications were prescribed; the number of prescribing decisions being made and if prescribing practice changed during the out of hours period. The findings can be used to inform practice, develop CCO services, provide a basis for further research, and contribute to the debate in this developing area of CCO practice. METHODS: The prescribing practices of two independent non-medical prescribers in a CCO team were audited from January to April 2011. RESULTS: The findings showed that; there were a wide range of medications prescribed, that prescribing decisions increased over time and that the majority of prescriptions were written out of hours. CONCLUSIONS: This preliminary audit has shown that prescribing in a CCO setting which covers a wide patient population is manageable. By evaluating drug prescribing patterns, a 'critical care outreach formulary' can be developed to guide individuals and the team in their continuing professional and service development. The CCO teams ability to prescribe could have the potential to improve the patients' experience and outcome, and positively affect the efficiency of service delivery; however, an increase in CCO referrals can have an impact on the CCO service resource. Further evaluation and study are needed to explore this developing area of critical care delivery.

Call 4 Concern: patient and relative activated critical care outreach.

Patients can experience unexpected deterioration in their physiological condition that can lead to critical illness, cardiac arrest, admission to the intensive care unit and death. While ward staff can identify deterioration through monitoring physiological signs, these signs can be missed, interpreted incorrectly or mismanaged. Rapid response systems using early warning scores can fail if staff do not follow protocols or do not notice or manage deterioration adequately. Nurses often notice deterioration intuitively because of their knowledge of individual patients. Patients and their relatives have the greatest knowledge of patients, and can often pick up subtle signs physiological deterioration before this is identified by staff or monitoring systems. However, this ability has been largely overlooked. Call 4 Concern (C4C) is a scheme where patients and relatives can call critical care teams directly if they are concerned about a patient's condition- it is believed to be the first of its kind in the UK. A C4C feasibility project ran for six months, covering patients being transferred from the intensive care unit to general wards. C4C has the potential to prevent clinical deterioration and is valued by patients and relatives. Concerns of ward staff could be managed through project management. As it is relatively new, this field offers further opportunities for research.

Surviving sepsis: a trust-wide approach. A multi-disciplinary team approach to implementing evidence-based guidelines.

AIM: To share an experience of examining the true extent of the number of patients with severe sepsis being admitted, and the overall compliance with existing treatment guidelines in a district general hospital (DGH). BACKGROUND: Because of its aggressive, multi-factorial nature, sepsis is a rapid killer. Mortality associated with severe sepsis remains unacceptably high: 30-50%. When shock is present, mortality is reported to be even higher: 50-60%. The rapid diagnosis and management of sepsis is vital to successful treatment. The International Surviving Sepsis Campaign (SSC) was developed to help meet the challenges of sepsis and to improve its management, diagnosis and treatment. The overall aim is to reduce mortality from sepsis by 25% by 2009. DATA SOURCES AND METHODS: Data on the number of patients admitted with severe sepsis to the DGH were previously unknown. The aim of the baseline audits was to determine the true extent of the problem and baseline mortality rates, resulting in an action plan to provide evidence-based care to patients with sepsis regardless of where in the hospital they were located. RESULTS: It was found that 11% of the patients audited presented with signs of severe sepsis and demonstrated elements of poor compliance with some elements of existing treatment guidelines as set out by the resuscitation component of the Surviving Sepsis Care Bundle. CONCLUSION: As an international campaign introduced predominantly within critical care, within this DGH the SSC teams' innovative approach has resulted in: * Better educated staff; * Objectives agreed within multi-disciplinary teams; * The appropriate assessment of resources; * Standardization of practice in terms of patients presenting with severe sepsis.