Acute hospital preoperative assessment redesign: streamlining the patient pathway and reducing on-the-day surgery cancellations

IntroductionAvoidable surgery cancellations in an acute trust were often attributed to inadequate preoperative assessment. These assessments, undertaken shortly before surgery, were delivered across eight different locations, 60% by a central nursing team and the remainder by other healthcare professionals. There was inconsistency in what and who were assessed, and inadequate time to optimise patients. There was difficulty finding capacity for urgent patient assessment, plus a lack of a pool of ‘ready-assessed’ patients to fill last-minute operating list gaps.MethodsA diagnostic phase using data analysis, root cause analyses and clinic observations identified multiple systemic issues confirming the need for system change.InterventionsOther trusts operating different models were visited and their processes were adapted to create a preassessment model relevant to our trust context. Key features included early preassessment, triage and streaming, in-clinic support from a prescribing pharmacist and consultant anaesthetist, a standardised outcome form documenting specific patient requirements needing action when a surgery date was agreed, surgery dating only on confirmation of patient optimisation, an administrative office (hub) with a tracking database to coordinate follow-up tasks and a patient hotline. A key enabler was a single, bespoke location. Where possible, testing took place in advance of the go-live. However, due to the transformational nature of the new model, some changes could only be tested and refined at scale in the new, single location.ResultsTwo months post implementation, a preliminary audit was positive, but clinic observations indicated that patient clinic flow was suboptimal. Further structural and process modifications were made. Ten months post implementation, a further root cause audit showed a near-elimination of on-the-day surgery cancellations for patients assessed in the redesigned service.ConclusionThe bundle of 17 interlinked interventions proved highly effective in delivering sustained improvements, which could be adopted by other trusts.

Remote outpatient follow-up of patients with arterial hypertenson: the role of a nurse

Highlights. Telehealth remote monitoring for patients with arterial hypertension has been developed and implemented. A nurse coaching approach has been reported.Aim. To develop and implement the technology of remote dispensary observation of patients with arterial hypertension (AH) using telemedicine, in which the main performer is a clinic nurse.Methods. The research object is patients with AH who are under dispensary observation at the territorial polyclinic. The study included 183 patients aged 53±12.5 years, of which 64.5% were women. The duration of observation is from 30 to 90 days. The effectiveness was evaluated on the basis of the achievement of target values of blood pressure (BP), number of visits to the doctor for hypertension decompensation, patient compliance. The program used data processing technology applying telemedicine devices for automatic BP measurement.Results. In 75.5% of cases, there was a decrease in the average level of systolic and diastolic BP in comparison with the initial levels. A decrease in the maximum systolic BP and in the frequency of decompensation episodes of BP above 160 mm Hg was recorded in 15.8% of patients. Achievement of the target BP level was identified in 64.2% of patients, in 11.3% there was a positive dynamic in the clinical condition without achieving the target figures, in 24.5% of cases, no dynamics was found. The majority of patients (84.2%) preferred remote forms of counseling while maintaining a stable level of indicators. Among 15.8% of patients, the number of visits to a doctor decreased from 2.0 to 0.75 visits per month. High adherence to preventive measures was observed in 88.7% of cases; 100% of patients in the observation group confirmed the use of prescribed antihypertensive drugs.Conclusion. The original technology of remote dispensary observation of patients with AH using telemedicine devices enhances the continuity in “doctor-nurse-patient” interactions, which contributes to the improvement of medical efficiency by increasing the proportion of patients in the dispensary group who have reached the target level of BP and increase the patients' adherence to preventive measures. Telemedicine technologies reduce the number of scheduled and urgent patient visits to a polyclinic, which is relevant in the context of the shortage of medical personnel and the transition to remote consultation due to the restrictions caused by the epidemic threat [17].

Use of Semantic Interoperability to Improve the Urgent Continuity of Care in Danish ERs

Reuse of patient data from prehospital electronic health record (EHR) to EHRs in emergency rooms is currently non-existing. In Danish EHRs, access to patient data recorded in prehospital settings is either not available or accessible in a PDF file. The amount of patient and administrative data registered at the prehospital unit is high and includes a rich representation of the accident, the patient and treatment. By applying emphasis framing to the representation of data, information overload can be diminished. Several international studies have investigated the suboptimal reuse of data within this field. Hence, the aim of this pre-study was to develop webservices based on emphasis framing to increase interoperability between the prehospital health record and the emergency room’s EHR. In this study, requirements engineering and emphasis framing was applied. Iterative linear requirement specification process was chosen as a frame to address the aim. The five included phases were revisited due to the iterative nature of this study. Tools used in the requirement engineering process were semi structured interviews and direct observations. The pre-study resulted in 12 Fast Healthcare Interoperability Resources (FHIR) profiles using SNOMED CT terminology bindings. The profiles contained elements which represented primarily patient data recorded in the prehospital setting. The profiles were compared to a case representing the urgent continuity of care to validate their ability to standardize data from prehospital health records. Conclusively, FHIR profiles can be modelled to standardize prehospital urgent patient data to support the patient trajectory. With the applied emphasis framing, the clinical context and content have been maintained.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

A local dental network approach to COVID-19 pandemic: innovation through collaboration

The coronavirus pandemic has had significant effects on individuals, healthcare systems and governments. In the UK, whilst routine dentistry was suspended, an urgent dental care system was required to support urgent patient need. Using an adapted model of Donabedians’ framework, a critical evaluation of the services developed and implemented is provided and the various innovative approaches involved in this work are discussed. The three domains of the framework are structure, process and outcome. Structure: We present the principles for selecting and initiating hubs, the integration with secondary care services and the supply of personal protective equipment. Process: The main elements are communication, the development of referral processes to manage complex cases and data collection. Outcome: Through work with local dental stakeholders, 23 clusters and 36 hubs were set up covering a large geographical area. The integrated network of hubs and clusters has strengthened collaboration between providers and policy makers. Various leadership approaches facilitated the readiness for the transition to recovery. The new local collaborative structures could be used to support local programmes such as flexible commissioning, peer-led learning and integration with primary care networks.

Differences in SARS-CoV-2 recommendations from major ophthalmology societies worldwide

ObjectiveSince the WHO declared the COVID-19 outbreak as a public health emergency, medical societies around the world published COVID-19 recommendations to physicians to ensure patient care and physician safety. During this pandemic, ophthalmologists around the world adapted their clinical and surgical practice following such guidelines. This original research examines all publicly available COVID-19 recommendations from twelve major ophthalmology societies around the world.Methods and analysisTwelve ophthalmology societies recognised by the International Council of Ophthalmology were included in this study. One society per each WHO region was included: the society selected was the one who had the highest number of national COVID-19 confirmed cases on 11 May 2020. In addition to these countries, the major ophthalmology society in each G7 country was included.ResultsTen out of 12 major international ophthalmology societies from countries covering all six WHO regions have given recommendations regarding urgent patient care, social distancing, telemedicine and personal protective equipment when caring for ophthalmic patients during the COVID-19 pandemic. While all guidelines emphasise the importance of postponing non-urgent care and taking necessary safety measures, specific recommendations differ between countries.ConclusionsAs there is no clear consensus on ophthalmology guidelines across countries, this paper highlights the differences in international ophthalmic care recommendations during the COVID-19 pandemic. Knowledge of the differences in ophthalmic management plans will allow ophthalmologists and all eye care providers to consider the variety of international approaches and apply best practices following evidence-based recommendations during pandemics.

Leading the charge: Identifying stressors in nursing leadership

Objective: This study aimed to examine and identify specific stressors for charge nurses at a rural Midwestern hospital.Methods: The Charge Nurses Stress Questionnaire (CNSQ) was administered to charge nurses of all units at a small Midwestern hospital. A total of 30 charge nurses completed the survey. The charge nurses completed 25 questions on four stress subscales, in addition to 11 demographic questions.Results: Study results revealed the highest stressors were primarily related to being unable to meet patient needs. This situation includes when a nurse cannot reach the provider when an urgent patient need arises; when the unit is at capacity with high acuity patients and receives notification another patient has been assigned to the unit; and when the patient is in pain or otherwise suffering, and care is delayed because orders are needed.Conclusions: Stress was noted by all charge nurses. The levels of different stressors from subscales correlate with each other, and thus an increase in one subscale of stress directly affects the level of stress of another subscale. The level of stress among charge nurses was not statistically significant among the nurses of different age, different units, different shifts, and different years of experience.

Can Surgical Registrars Accurately Identify the Urgent from the Non-Urgent Patient Presenting with Acute Abdominal Pain?

Background: Acute abdominal pain is a common surgical presentation with a wide range of causes. Differentiating urgent patients from non-urgent patients is important to optimise patient outcomes and the use of hospital resources. The aim of this study was to determine how accurately urgent and non-urgent patients presenting with abdominal pain can be identified. Methods: A prospective study of consecutive patients admitted with abdominal pain was undertaken. Urgent patients were classified as requiring treatment (theatre, intensive care unit, endoscopy, or radiologic drainage) within 24 h. Differentiation between urgent and non-urgent was made on the basis of the initial assessment prior to the use of advanced imaging. Outcomes were compared to a final classification based on final diagnosis as adjudicated by an expert panel. Results: Of the 301 patients included, 93 (30.9%) were deemed urgent based on initial assessment, compared to 83 (27.6%) on final diagnosis. Overall sensitivity for recognising urgent patients was 74.7% and specificity 89.9%, and overall accuracy was higher for senior registrars compared to junior registrars (p = 0.015). Urgent patients more often looked unwell or had peritonism on examination (39.8 vs. 17.4% and 56.6 vs. 14.7%, respectively, p < 0.001 for both). Conclusions: Registrars can accurately differentiate urgent from non-urgent patients with acute abdominal pain in the majority of cases. Accuracy was higher amongst senior registrars. The “end-of-the-bed-o-gram” and clinical examination are the most important features used for making this differentiation. This demonstrates that there is no substitute for exposure to acute presentations to improve a trainee’s diagnostic skill.