Telenurses’ experiences of working with computerized decisionsupport : supporting, inhibiting and quality improving

/pdf/telenurses-experiences-of-working-with-computerized-decision-1ymtrf975h.pdf

Telenurses’ experiences of working with computerized decision support: supporting, inhibiting and quality improving

Objective
The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis
Methods
We have conducted a rapid framework-based evidence synthesis approach Five separate reviews were conducted linked to themes in the NHS England review A general and five theme specific database searches were conducted for the years 1995-2014 Relevant systematic reviews and additional primary research papers were included with narrative assessment of evidence quality was conducted for each review
Results
The review was completed in six months In total 45 systematic reviews and 102 primary research studies have been included across all 5 reviews The key findings for each reviews were 1) Demand - there is little empirical evidence to explain increases in demand for urgent care, 2) Telephone triage - Overall, these services provide , appropriate and safe decision making with high patient satisfaction but required clinical skill mix and effectiveness in a system is unclear , 3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital 4)ED – The evidence on co-location of GP services with ED indicates there is potential to improve care The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed 5) There is no empirical evidence to support the design and development of urgent care networks
Limitations
Although there is a large body of evidence on relevant interventions much of it is weak with only very small numbers of randomised controlled trials identified Evidence is dominated by single site studies many of which were uncontrolled
Conclusions
The evidence gaps of most relevance to the delivery of services are 1) more detailed understanding and mapping of the characteristics of demand to inform service planning, 2) assessment of the current state of urgent care network development and evaluation of effectiveness of different models, and 3) Expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning

https://www.sheffield.ac.uk/polopoly_fs/1.560680!/file/FullReport-hsdr03430EUC.pdf

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Objective To determine what components of a checklist contribute to effective detection of medication errors at the bedside. Design High-fidelity simulation study of outpatient chemotherapy administration. Setting Usability laboratory. Participants Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors. Main outcome measures Rates of specified types of errors related to medication administration. Results As few as 0% and as many as 90% of each type of error were detected. Error detection varied as a function of error type and checklist used. Specific stepby-step instructions were more effective than abstract general reminders in helping nurses to detect errors. Adding a specific instruction to check the patient’s identification improved error detection in this category by 65 percentage points. Matching the sequence of items on the checklist with nurses’ workflow had a positive impact on the ease of use and efficiency of the checklist. Conclusions Checklists designed with explicit step-bystep instructions are useful for detecting specific errors when a care provider is required to perform a long series of mechanistic tasks under a high cognitive load. Further research is needed to determine how best to assist clinicians in switching between mechanistic tasks and

/pdf/checking-it-twice-an-evaluation-of-checklists-for-detecting-2ozsdkxa2u.pdf

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model

Over the past decade, emergency department (ED) crowding has occurred and progressed. It has become a major topic of discussion at emergency medicine (EM) conferences, such as those held annually by the Society for Academic Emergency Medicine and the American College of Emergency Physicians. There has been much recent media coverage, such as the Newsweek article, “Code Blue for the ER.”1 Recently the Institute of Medicine published an extensive report on the topic.2 While there is no question that many EDs are crowded, the myriad causes of and solutions to crowding have been widely debated. In our opinion, multiple factors contribute to ED crowding, and the relative contribution of each factor varies between EDs. Circumstances differ between urban and rural hospitals, as well as between county, academic, and private hospitals.3 We believe multiple simultaneous steps are necessary to solve ED crowding. We present 10 putative solutions with commentary on actions at our institution to counter the problem.

1) Expand Hospital Capacity
In 1946, at the end of World War II, the United States Congress addressed concerns with deficiencies in hospital bed capacity and health services by passing the Hill-Burton Act.4 This provided billions of dollars for hospital construction across the country, with the goal of five inpatient beds per1,000 persons. This wave of hospital construction attracted more people to careers in healthcare. Major funding ended in 1966, when the Medicare and Medicaid programs became law. By providing increased hospital capacity for its citizens, communities successfully attracted physicians, nurses and ancillary staff.

Since 1970, the ratio of inpatient hospital beds per population has declined in the U.S. Unfortunately, with increasing numbers of uninsured and a requirement that hospitals run profitably, the number of hospital beds per 1,000 persons has diminished over the past 20 years. According to the California Healthcare Association, 70 hospitals closed in California between 1993 and 2003. California’s population grew by 13% during that time while acute care hospital bed capacity dropped by 14%. Today in California there are only 1.9 beds per 1,000 persons.5 As a result, many hospitals are perpetually full with admitted patients boarded in the ED. Boarding of inpatients in the ED is unquestionably the leading cause of crowding. At times the ED at the University of California, Davis has more boarded patients than new, ambulatory patients. We have contacted legislative staff locally and nationally about resurrecting the Hill-Burton Act to expand hospital capacity. This might be more appealing to Americans rather than radical reform of the healthcare system, advocated by some. Many health systems would welcome federal support to make this possible.

Some might argue that increasing the number of hospital beds is not needed because of decreased length of stay for patients admitted to hospital more recently. We believe this is offset by the aging population and the number of complex medical conditions not considered and/or treated shortly after World War II. These includes chronic renal failure/dialysis, transplants, Hepatitis C, Acquired Immune Deficiency Syndrome, cancer chemotherapy, acute coronary syndrome and coronary artery bypass grafts, pacemakers, and many others. Many patients who would have died quickly or at home decades ago are kept alive for days to months, only to die in hospitals today.

/pdf/ten-solutions-for-emergency-department-crowding-5aa1je8gka.pdf

Ten Solutions for Emergency Department Crowding

BACKGROUND: Most Australian and all New Zealand residents now have 24 hour access to free telephone advice and symptom triage. Australasia is following an international trend triggered by a perceived need for standardised advice, demand management (primary care and emergency department), and equity of access. A growing literature describes the impact of this new service on existing primary health services. OBJECTIVE: This article summarises the results of telephone triage projects in Australia and New Zealand to acquaint Australian general practitioners with nurse led telephone triage services that have health call centre technology. DISCUSSION: Australian and New Zealand services are similar with respect to the demographics of callers, when they call, and the issues on which they seek advice. Further study is needed in order to understand how telenursing can best be integrated with general practice and other primary care services. (author abstract)

Universal telenursing triage in Australia and New Zealand - a new primary health service.

Aim: To evaluate a telephone nurse triage model in terms of appropriateness of referrals to the appropriate level of care, patient's compliance with given advice and costs. Background: A key concern in each telephonic consultation is to evaluate if appropriate. Method: An evaluative design in primary health care with consecutive patients ( N = 362) calling telephone nurse triage between November 2002 and February 2003. Results: The advice was considered adequate in 325 (97.6%) cases. The patients’ compliance with self-care was 81.3%, to primary health care 91.1% and to Accident and Emergency department 100%. The nurses referred self-care cases (64.7%) and Accident and Emergency cases (29.6%) from a less adequate to an appropriate level of care. The cost saving per call leading to a recommendation of self-care was €70.3, to primary health care €24.3 and to Accident and Emergency department €22.2. Conclusions The telephone nurse triage model showed adequate guidance for the patients concerning level of care and released resources for the benefit of both patients and the health care system.

Computer‐supported telephone nurse triage: an evaluation of medical quality and costs

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Computer‐supported telephone nurse triage: an evaluation of medical quality and costs