Analysis of a nursing survey: Reasons for compromised quality of care in inpatient mental health wards.

Current evidence suggests understaffing is related to poor quality and missed care in a global context, but this relationship is complex. There is also a research gap for quality in mental health care in the United Kingdom that includes a wider set of patient outcomes. This paper aims to investigate RMN's perception of quality of care on their last shift, their self-reported reasons for compromised care and potential impact on patient outcomes. A mixed methods approach, we used descriptive statistics to create a framework within which to qualitatively analyse data from the 2017 Royal College of Nursing (RCN) employment survey to consider the complex relationship between understaffing and care quality. We established three themes: 'Understaffing', 'Professional Code Expectations and Moral Distress' and 'Management'. In line with the current evidence; lack of resources and understaffing were consistently present throughout. Nurses also felt pressure from the Nursing and Midwifery Council (NMC) code of conduct which in turn instilled shame and fear for their registration when they were unable to achieve the standards expected. This was further exacerbated by poor management and supervision; leading nurses to reflect on poor outcomes for patients which compromised not only legal rights but safety of patients and staff alike. We conclude that focusing on staffing numbers alone is unlikely to improve care quality.

Subclinical brain embolization in left-sided infective endocarditis: results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses (EMBOLISM) pilot study.

BACKGROUND: Acute brain embolization (ABE) in left-sided infective endocarditis has significant implications for clinical decision making. The true incidence of ABE, including subclinical brain embolization, is unknown. METHODS AND RESULTS: We prospectively studied 56 patients with definite left-sided infective endocarditis. Patients were examined by a study neurologist, and those without contraindication had magnetic resonance imaging of the brain. Patients without clinical evidence of acute stroke but with magnetic resonance imaging evidence of ABE were considered to have subclinical brain embolization. Clinical stroke was present in 14 of 56 patients (25%). Among 40 patients undergoing magnetic resonance imaging, the incidence rates of subclinical brain embolization and any ABE were 48% and 80%, respectively. ABE was present in 18 of 19 patients (95%) with Staphylococcus aureus infection. At 3 months, mortality was similar among patients with clinical stroke and subclinical brain embolization (62% versus 53%; P=NS) and was higher among patients with any ABE than among those without ABE (56% versus 12%; P=0.046). Valvular surgery was performed in 25 patients (45%), including 16 with ABE, at a median of 4 days. No patient suffered a postoperative neurological complication. Surgery was independently associated with a lower risk of mortality at 3 months (odds ratio, 0.1; 95% confidence interval, 0.03 to 0.6; P=0.008). CONCLUSIONS: Magnetic resonance imaging detected subclinical brain embolization in a substantial number of patients with left-sided infective endocarditis, suggesting that the incidence of ABE may be significantly higher than reports based on clinical and computed tomography findings have indicated. Brain magnetic resonance imaging may play a role in the complex decision about surgical intervention in infective endocarditis.

The role of heparin anticoagulation during intra-aortic balloon counterpulsation in the coronary care unit.

BACKGROUND: The benefit of heparin anticoagulation in patients undergoing intra-aortic balloon counterpulsation (IABP) is unproven. METHODS: We determined the net clinical benefit (or harm) of heparin therapy during intra-aortic balloon counterpulsation (IABP) in the coronary care unit (CCU) by conducting a prospective "before-and-after" analysis of consecutive patients. We compared a universal heparin (UH) strategy (all patients given heparin) to a selective heparin (SH) strategy (heparin only for a clinical indication). RESULTS: There were 102 patients in the UH group and 150 patients in the SH group. Among the SH group, 70 patients (47%) received no heparin. Major IABP-related complications were uncommon in both groups (2.9% versus 4.6%, P=0.7). Major limb ischemia occurred in one patient in the UH group (overall incidence: 0.4%). Major non-access-site bleeding was more common in the UH group (10.8% versus 3.3%, P=0.02). Inclusion in the UH group was independently associated with the endpoints of: major limb ischemia or any major bleeding (odds ratio (OR) 3.32, P=0.03), any major bleeding (OR 3.35, P=0.03), and major limb ischemia, any major bleeding, or death (OR 2.17, P=0.03). CONCLUSIONS: Among CCU patients undergoing IABP, a selective heparin strategy appears to be superior to a strategy of universal heparin use.