Effect of Intensive Nurse-Led Optimization of Heart Failure Medications in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Prescribing of recommended medications for heart failure (HF) is suboptimal, leaving patients at a high risk of death or rehospitalization post discharge. Nurse-led titration (NLT) clinics are one strategy that could potentially improve the prescription of these medications. OBJECTIVE: The aim of this article was to determine the effect of NLT clinics on all-cause mortality, all-cause or HF rehospitalizations, and adverse effects in patients with HF. METHODS: We searched MEDLINE, EMBASE, Cochrane CENTRAL, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify randomized controlled trials comparing NLT of ß-blocking agents, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, and/or angiotensin receptor blockers to optimization by another health professional in patients with HF. We used the fixed-effects Mantel-Haenszel method or meta-analyses. We assessed heterogeneity between studies using χ2 and I2. RESULTS: Eight studies with 2025 participants were included. Participants in the NLT group experienced a lower rate of all-cause rehospitalizations (relative risk, 0.76, 95% confidence interval, 0.68-0.85; moderate quality of evidence) and less HF-related rehospitalizations (relative risk, 0.47; 95% confidence interval, 0.33-0.66; high quality of evidence) compared with the usual care group. All-cause mortality was lower in the NLT group (relative risk, 0.67; 95% confidence interval, 0.48-0.92; moderate quality of evidence) compared with the usual care group. Authors of one study reported no adverse events, and another study found one adverse event. CONCLUSION: This meta-analysis indicates that NLT clinics may improve optimization of guideline-recommended medications with the potential to reduce rehospitalization and improve survival in a cohort of patients known for their poor outcomes.

Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review.

AIM(S): To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients. DESIGN: Scoping review of international, peer-reviewed research studies. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023. REPORTING METHOD: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. RESULTS: Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies). CONCLUSION: Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Nurses' perceptions of point-of-care ultrasound for haemodialysis access assessment and guided cannulation: A qualitative study.

AIM: To explore nurses' perceptions of using point-of-care ultrasound for assessment and guided cannulation in the haemodialysis setting. BACKGROUND: Cannulation of arteriovenous fistulae is necessary to perform haemodialysis. Damage to the arteriovenous fistula is a frequent complication, resulting in poor patient outcomes and increased healthcare costs. Point-of-care ultrasound-guided cannulation can reduce the risk of such damage and mitigate further vessel deterioration. Understanding nurses' perceptions of using this adjunct tool will inform its future implementation into haemodialysis practice. DESIGN: Descriptive qualitative study. METHODS: Registered nurses were recruited from one 16-chair regional Australian haemodialysis clinic. Eligible nurses were drawn from a larger study investigating the feasibility of implementing point-of-care ultrasound in haemodialysis. Participants attended a semistructured one-on-one interview where they were asked about their experiences with, and perceptions of, point-of-care ultrasound use in haemodialysis cannulation. Audio-recorded data were transcribed and inductively analysed. FINDINGS: Seven of nine nurses who completed the larger study participated in a semistructured interview. All participants were female with a median age of 54 years (and had postgraduate renal qualifications. Themes identified were as follows: (1) barriers to use of ultrasound; (2) deficit and benefit recognition; (3) cognitive and psychomotor development; and (4) practice makes perfect. Information identified within these themes were that nurses perceived that their experience with point-of-care ultrasound was beneficial but recommended against its use for every cannulation. The more practice nurses had with point-of-care ultrasound, the more their confidence, dexterity and time management improved. CONCLUSIONS: Nurses perceived that using point-of-care ultrasound was a positive adjunct to their cannulation practice and provided beneficial outcomes for patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Haemodialysis clinics seeking to implement point-of-care ultrasound to help improve cannulation outcomes may draw on these findings when embarking on this practice change. REPORTING METHOD: This study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: Patients were not directly involved in this part of the study; however, they were involved in the implementation study. TRIAL AND PROTOCOL REGISTRATION: The larger study was registered with Australian New Zealand Clinical Trials Registry: ACTRN12617001569392 (21/11/2017) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373963&isReview=true.

Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study.

BACKGROUND: The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used. OBJECTIVE: This study aimed to explore clinicians' use of the pre-MET tier. METHODS: A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed. RESULTS: Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources. CONCLUSIONS: There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.

Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission.

OBJECTIVES: To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. DESIGN: Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. SETTING: A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. PATIENTS: A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. MEASUREMENTS AND MAIN RESULTS: The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. CONCLUSIONS: Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum.

BACKGROUND: For over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required. AIM: The aim of this study was to ascertain nurses' perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system. METHODS: An exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes. RESULTS: Seventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles. CONCLUSIONS: A curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

Australian critical care nurses' knowledge, preparedness, and experiences of managing SARS-COV-2 and COVID-19 pandemic.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has again highlighted the crucial role of healthcare workers in case management, disease surveillance, policy development, and healthcare education and training. The ongoing pandemic demonstrates the importance of having an emergency response plan that accounts for the safety of frontline healthcare workers, including those working in critical care settings. OBJECTIVES: The aim of the study was to explore Australian critical care nurses' knowledge, preparedness, and experiences of managing patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) and COVID-19. METHODS: An exploratory cross-sectional study of Australian critical care nurses was conducted between June and September 2020. An anonymised online survey was sent to Australian College of Critical Care Nurses' members to collect information about their knowledge, preparedness, and experiences during the COVID-19 pandemic. Descriptive statistics were used to summarise and report data. RESULTS: A total of 157 critical care nurses participated, with 138 fully complete surveys analysed. Most respondents reported 'good' to 'very good' level of knowledge about COVID-19 and obtained up-to-date COVID-19 information from international and local sources. Regarding managing patients with COVID-19, 82.3% felt sufficiently prepared at the time of data collection, and 93.4% had received specific education, training, or instruction. Most participants were involved in assessing (89.3%) and treating (92.4%) patients with COVID-19. Varying levels of concerns about SARS-CoV-2 infection were expressed by respondents, and 55.7% thought the pandemic had increased their workload. The most frequent concerns expressed by participants were a lack of appropriate personal protective equipment (PPE) and fear of PPE shortage. CONCLUSIONS: While most nurses expressed sufficient preparedness for managing COVID-19 patients, specific education had been undertaken and experiential learning was evident. Fears of insufficient or lack of appropriate PPE made the response more difficult for nurses and the community. Preparedness and responsiveness are critical to successful management of the COVID-19 pandemic and future outbreaks of emerging infectious diseases.

Team-based learning in nursing education: A scoping review.

AIMS AND OBJECTIVES: To explore the use and student outcomes of Team-Based Learning in nursing education. BACKGROUND: Team-Based Learning is a highly structured, evidence-based, student-centred learning strategy that enhances student engagement and facilitates deep learning in a variety of disciplines including nursing. However, the breadth of Team-Based Learning application in nursing education and relevant outcomes are not currently well understood. DESIGN: A scoping review of international, peer-reviewed research studies was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. METHODS: The following databases were searched on 7 May 2020: Cumulative Index of Nursing and Allied Health Literature, MEDLINE Complete, PsycINFO and Education Resources Information Center. Search terms related to nursing, education and Team-Based Learning. Original research studies, published in English, and reporting on student outcomes from Team-Based Learning in nursing education programmes were included. RESULTS: Of the 1081 potentially relevant citations, 41 studies from undergraduate (n = 29), postgraduate (n = 4) and hospital (n = 8) settings were included. The most commonly reported student outcomes were knowledge or academic performance (n = 21); student experience, satisfaction or perceptions of Team-Based Learning (n = 20); student engagement with behaviours or attitudes towards Team-Based Learning (n = 12); and effect of Team-Based Learning on teamwork, team performance or collective efficacy (n = 6). Only three studies reported clinical outcomes. CONCLUSIONS: Over the last decade, there has been a growing body of knowledge related to the use of Team-Based Learning in nursing education. The major gaps identified in this scoping review were the lack of randomised controlled trials and the dearth of studies of Team-Based Learning in postgraduate and hospital contexts. RELEVANCE TO CLINICAL PRACTICE: This scoping review provides a comprehensive understanding of the use and student outcomes of Team-Based Learning in nursing education and highlights the breadth of application of Team-Based Learning and variability in the outcomes reported.

Evidence-practice gaps in initial neuro-protective nursing care: A mixed methods study of Thai patients with moderate or severe traumatic brain injury.

AIMS: This paper aims to identify the frequency and nature of evidence-practice gaps in the initial neuro-protective nursing care of patients with moderate or severe traumatic brain injury provided by Thai trauma nurses. BACKGROUND: Little is known about how Thai trauma nurses use evidence-based practice when providing initial neuro-protective nursing care to patients with moderate or severe traumatic brain injury. DESIGN: A mixed methods design was used to conduct this study. METHODS: Data were collected from January to March 2017 using observations and audits of the clinical care of 22 patients by 35 nurses during the first 4 h of admission to trauma ward. The study site was a regional hospital in Southern Thailand. RESULTS: The major evidence-practice gaps identified were related to oxygen and carbon dioxide monitoring and targets, mean arterial pressure and systolic blood pressure targets and management of increased intracranial pressure through patient positioning and pain and agitation management. CONCLUSION: There were evidence-practice gaps in initial neuro-protective nursing care provided by Thai trauma nurses that need to be addressed to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury.

Understanding the pre-medical emergency team tier of a mature rapid response system: A content analysis of guidance documents.

BACKGROUND: The pre-medical emergency team (pre-MET) tier of rapid response systems (RRSs) includes extended activation criteria to identify earlier clinical deterioration and a ward-based patient review that is undertaken by the affected patient's admitting team or covering doctors. There is limited understanding of the structure and processes of the pre-MET RRS tier that are expected to guide clinicians' actions and subsequent patient safety outcomes. OBJECTIVE: The aim of the study was to describe the structure and processes of the pre-MET RRS tier in one acute care setting. METHODS: An exploratory descriptive design involving document analysis was used. Guidance documents (policies, procedures, guidelines, charts, educational materials) were obtained from one health service with a mature, multitiered RRS in Melbourne, Australia. Documents were analysed using content analysis. Concept- and data-driven approaches were used to construct a coding frame. RESULTS: Nineteen guidance documents supporting the pre-MET RRS tier on general wards were analysed. The coding frame consisted of seven main categories: Defining the Pre-MET RRS Tier, Essential Resources for Operationalisation, Recognising Pre-MET Events, Pathways for Activation, Exceptions to the Rule, Clinician Responses to Pre-MET Events, and Recording Pre-MET Events. The structures and processes of the pre-MET RRS tier were largely consistent with national guidelines, but there were internal inconsistencies in pre-MET activation criteria and unclear recommendations for modifying criteria. Pathways for activating the pre-MET RRS tier were complex and involved many steps, including validation processes before escalation of care to doctors. Responses to pre-MET events were seldom aligned to specific clinician types or groups, with nurses and allied health clinicians being under-represented. CONCLUSIONS: We identified opportunities to improve guidance documents supporting the pre-MET RRS tier that may assist other health services engaged in planning or evaluating pre-MET strategies. Further research is needed to understand clinicians' use of the pre-MET RRS tier to inform targeted strategies to optimise its design and implementation.

Modifications to medical emergency team activation criteria and implications for patient safety: A point prevalence study.

BACKGROUND: Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood. OBJECTIVES: The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria. METHODS: This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death. RESULTS: Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications. CONCLUSIONS: In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes.

Point-of-care ultrasound use for vascular access assessment and cannulation in hemodialysis: A scoping review.

Point-of-care ultrasound (POCUS) for access assessment and guided cannulation has become more common in hemodialysis units. The aims of this scoping review were to determine: circumstances in which renal nurses and technicians use POCUS; the barriers and facilitators; and evidence of the effects of POCUS in guiding assessment and cannulation. A search was conducted of CINAHL, Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ProQuest, Trove and Google Scholar as grey literature sources. Of 1904 publications, 21 studies met inclusion criteria (11 full text and 10 abstracts). These included primary research publications (n = 5), clinical observational cohort studies (n = 5), case studies (n = 3), published guidelines (n = 2), and published position papers (n = 6). POCUS was used for: assessing arteriovenous fistula (AVF) maturation; identifying landmarks and abnormalities; assessing alternate cannulation sites; performing new AVF cannulation; performing difficult cannulation; increasing cannulation accuracy; performing cannulation through stents; and patient self-cannulation training. There were scant data on the barriers to, and facilitators of the use of POCUS, and a distinct lack of empirical evidence to support its use. These knowledge gaps highlight the need for further clinical studies, particularly randomized clinical trials, to test the effectiveness of POCUS in hemodialysis for assessment and guided cannulation.

Thai trauma nurses' knowledge of neuroprotective nursing care of traumatic brain injury patients: A survey study.

Thai trauma nurses play a vital role in neuroprotective nursing care of patients with moderate or severe traumatic brain injury. Nurses' knowledge of the evidence underpinning initial neuroprotective nursing care vital to safe and high-quality patient care. However, the current state of knowledge of Thai trauma nurses is poorly understood. In this study, we investigated Thai nurses' knowledge of neuroprotective nursing care of patients with moderate or severe traumatic brain injury. Data were collected by a survey, comprising a section on participant characteristics and series of multiple-choice questions. All registered nurses (n = 22) and nursing assistants (n = 13) from the trauma ward of a regional Thai hospital were invited to participate: the response rate was 100%. Participants had limited knowledge of carbon dioxide monitoring; causes and implications of hypercapnia; mean arterial pressure and cerebral perfusion pressure targets; management of sedatives and analgesics; and management of hyperthermia. Improving their knowledge focusing on knowledge deficits through educational training and implementation of evidence-based practice is essential to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury.

Clinical deterioration in patients with ST-elevation myocardial infarction during and for 24 h after percutaneous coronary intervention: An observational study.

BACKGROUND: In-hospital adverse events such as cardiac arrest are preceded by abnormalities in physiological data and are associated with high mortality. Healthcare institutions have implemented rapid response systems such as the medical emergency team for early recognition and response to clinical deterioration. Yet, most cardiac catheterisation laboratories, have yet to formally implement a rapid response system, so the nature and frequency of clinical deterioration is unclear and no published data exist. OBJECTIVES: To explore the nature and frequency of clinical deterioration in ST- elevation myocardial infarction patients in a cardiac catheterisation laboratory without a Medical emergency team, and 24 hours after percutaneous coronary intervention and the immediate nursing responses to clinical deterioration. METHOD: An exploratory descriptive study using retrospective medical audit was conducted in a public tertiary teaching hospital in Melbourne, Australia. In 2014, there were 327 ST- elevation myocardial infarction presentations of which 75 were randomly selected. Descriptive statistics were used to analyse the data. RESULTS: In the cardiac catheterisation laboratory, 82.6% of patients fulfilled medical emergency team activation criteria and deterioration was predominantly cardiovascular. Respiratory rate was not documented for all patients in cardiac catheterisation laboratory. Post percutaneous coronary intervention, 31% of patients fulfilled medical emergency team activation criteria and this deterioration occurred secondary to hypoxia. There were no documented abnormalities in respiratory rate. CONCLUSION: The ST- elevation myocardial infarction patients admitted to the cardiac catheterisation laboratory are critically ill patients. Failure to monitor for signs of respiratory dysfunction such as respiratory rate in cardiac catheterisation laboratory may delay recognition of clinical deterioration and timely escalation of care. Further research is required to inform changes in the system to improve patient safety.

Patient acceptability of wearable vital sign monitoring technologies in the acute care setting: A systematic review.

AIMS AND OBJECTIVES: To examine patient acceptability of wearable vital sign monitoring devices in the acute setting. BACKGROUND: Wearable vital sign monitoring devices may improve patient safety, yet hospital patients' acceptability of these devices is largely unreported. DESIGN: A systematic review. METHODS: Cumulative Index to Nursing and Allied Health Literature Complete, MEDLINE Complete and EMBASE were searched, supplemented by reference list hand searching. Studies were included if they involved adult hospital patients (≥18 years), a wearable monitoring device capable of assessing ≥1 vital sign, and measured patient acceptability, satisfaction or experience of wearing the device. No date restrictions were enforced. Quality assessments of quantitative and qualitative studies were undertaken using the Downs and Black Checklist for Measuring Study Quality and the Critical Appraisal Skills Programme Qualitative Research Checklist, respectively. Meta-analyses were not possible given data heterogeneity and low research quality. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was completed. RESULTS: Of the 427 studies screened, seven observational studies met the inclusion criteria. Six studies were of low quality and one was of high quality. In two studies, patient satisfaction was investigated. In the remaining studies, patient experience, patient opinions and experience, patient perceptions and experience, device acceptability, and patient comfort and concerns were investigated. In four studies, patients were mostly accepting of the wearable devices, reporting positive experiences and satisfaction relating to their use. In three studies, findings were mixed. CONCLUSION: There is limited high-quality research examining patient acceptability of wearable vital sign monitoring devices as an a priori focus in the acute setting. Further understanding of patient perspectives of these devices is required to inform their continued use and development. RELEVANCE TO CLINICAL PRACTICE: The provision of patient-centred nursing care is contingent on understanding patients' preferences, including their acceptability of technology use.

Nursing handover of vital signs at the transition of care from the emergency department to the inpatient ward: An integrative review.

AIM: To examine nursing handover of vital signs during patient care transition from the emergency department (ED) to inpatient wards. BACKGROUND: Communication failures are a leading cause of patient harm making communication through clinical handover an international healthcare priority. The transition of care from ED to ward settings is informed by nursing handover. Vital sign abnormalities in the ED are associated with clinical deterioration following hospital admission. Understanding the role and perceived value of vital sign content in clinical handover is important for patient safety. METHODS: An integrative design was used. A search of electronic databases was undertaken using MEDLINE, CINAHL, EMBASE, Cochrane, Web of Science and SCOPUS. Identified records were screened to elicit further studies for inclusion. A comprehensive peer-review screening process was performed. Studies were included that described the surrounding issues of handover, vital signs, ED, transition of care and ward. RESULTS: Five studies were included in the final review, one specific to nursing and four specific to emergency medicine. Vital signs were perceived to be an important inclusion in clinical handover, and the communication of vital signs in handover was perceived to be indicators for patient safety and risk factors for future clinical deterioration. The ED environment had an influence on effective communication within handover. CONCLUSIONS: Vital signs were an important inclusion for clinical handover. Deficiencies in vital sign content were perceived to be risk factors for patient adverse events following hospital admission. The quality of vital sign information in clinical handover may be important for accurate decision-making. RELEVANCE TO CLINICAL PRACTICE: Vital signs are an important component of clinical handover and are perceived to be indicators for patient safety and risk of future adverse events.

Specialty cardiac nurses' work satisfaction is influenced by the type of coronary care unit: A mixed methods study.

BACKGROUND: Many dedicated Coronary Care Units (CCUs) in Victoria, Australia, have been decommissioned and replaced with larger combined generic medical/cardiac precincts called hybrid units. Hybrid units are staffed with a low proportion of specialist critical care nurses. These changes may pose risks to nurse satisfaction and retention, and quality of patient care. The aims of this study were to explore specialist cardiac nurses' perceived work satisfaction across four CCUs, and differences in satisfaction between dedicated and hybrid CCUs. METHODS: This concurrent mixed methods study comprised two Phases in four Victorian CCUs (2 dedicated, 2 hybrid). In Phase 1, 74 specialist cardiac nurses completed the Professional Practice Environment (PPE) Scale. In Phase 2, 17 specialist cardiac nurses were interviewed to further explore elements of the PPE subscales. Descriptive, inferential (Phase 1), and content analyses (Phase 2) were performed. RESULTS: Survey participants' median age was 38 years (IQR 30, 45). The median PPE Scale score was 3.10 (IQR 2.90, 3.10) indicating high levels of satisfaction with their workplaces. Specialist cardiac nurses in one hybrid unit were significantly less satisfied compared with each of the other three units (p < 0.05). There were no significant differences in overall satisfaction or in any subscale of the PPE Scale between dedicated and hybrid units. Qualitative data revealed nurses in hybrid units felt they had less control over practice, lacked autonomy, had poor relationships with physicians, and experienced inadequate nurse leadership. CONCLUSIONS: Specialist cardiac nurses' workplace satisfaction overall is high, with no significant differences between dedicated and hybrid CCUs. However, the structure of specialist cardiac units and NUM leadership skill level can impact nurses' satisfaction with their workplace and collegial relationships. Strong nursing leadership that is respectful of nursing expertise and places patient safety foremost positively impacts nurses' satisfaction. Further studies should assess the impact of the types of CCUs and NUM leadership on workforce factors such as nurse retention rates and patient outcomes such as adverse events.

Nurses' recognition and response to clinical deterioration in the cardiac catheterisation laboratory.

BACKGROUND: Patients presenting to the cardiac catheter laboratory for treatment of unstable acute coronary syndromes (ACS) experience a mismatch in myocardial oxygen supply and demand, causing vital sign abnormalities prior to neurological, cardiac and respiratory deterioration. Delays in detecting clinical deterioration and escalating care increases risk of adverse events, unplanned intensive care (ICU) admission, cardiac arrest, and in-hospital mortality. OBJECTIVES: The objective of the study was to explore how nurses in the cardiac catheter laboratory (CCL) recognise and respond to clinical deterioration in patients with unstable ACS undergoing primary percutaneous coronary intervention (PCI). METHODS: A prospective exploratory descriptive design was used with 30 participants completing 10 written clinical scenarios. Participants scored their level of concern for each physiological cue and then then ranked their preferred immediate response based on the deterioration identified. RESULTS: Hypotension and the presence of pain were the physiological cues of highest concern. The most common responses to clinical deterioration were to increase vital sign assessment to 5-minutely intervals, administer pain relief or provide reassurance. Despite the presence of clinical deterioration fulfilling organisational escalation of care criteria, calling cardiac arrest or rapid response team (RRT) were not commonly selected responses. CONCLUSION: Nurses most commonly use hypotension and the presence of pain to recognise clinical deterioration in patients presenting to the CCL with an unstable ACS. Once clinical deterioration is identified, interventional cardiac nurses delay the escalation of care to the RRT or cardiac arrest team, preferring to implement local nurse initiated interventions.

Hospital in the Home nurses' recognition and response to clinical deterioration.

AIMS AND OBJECTIVES: To obtain an understanding of how Hospital in the Home (HITH) nurses recognise and respond to clinical deterioration in patients receiving care at home or in their usual place of residence. BACKGROUND: Recognising and responding to clinical deterioration is an international safety priority and a key nursing responsibility. Despite an increase in care delivery in home environments, how HITH nurses recognise and respond to clinical deterioration is not yet fully understood. DESIGN: A prospective, descriptive exploratory design was used. A survey containing questions related to participant characteristics and 10 patient scenarios was used to collect data from 47 nurses employed in the HITH units of three major health services in Melbourne, Australia. The 10 scenarios reflected typical HITH patients and included medical history and clinical assessment findings (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, conscious state and pain score). RESULTS: The three major findings from this study were that: (i) nurse and patient characteristics influenced HITH nurses' assessment decisions; (ii) the cues used by HITH nurses to recognise clinical deterioration varied according to the clinical context; and (iii) although HITH nurses work in an autonomous role, they engage in collaborative practice when responding to clinical deterioration. CONCLUSION: Hospital in the Home nurses play a fundamental role in patient assessment, and the context in which they recognise and respond to deterioration is markedly different to that of hospital nurses. RELEVANCE TO CLINICAL PRACTICE: The assessment, measurement and interpretation of clinical data are a nursing responsibility that is crucial to early recognition and response to clinical deterioration. The capacity of HITH services to care for increasing numbers of patients in their home environment, and to promptly recognise and respond to clinical deterioration should it occur, is fundamental to safety within the healthcare system. Hospital in the Home nurses are integral to a sustainable healthcare system that is responsive to dynamic changes in public health policies, and meets the healthcare needs of the community.

Critical care clinician perceptions of factors leading to Medical Emergency Team review.

BACKGROUND: The introduction of rapid response systems has reduced the incidence of in-hospital cardiac arrest; however, many instances of clinical deterioration are unrecognised. Afferent limb failure is common and may be associated with unplanned intensive care admissions, heightened mortality and prolonged length of stay. Patients reviewed by a Medical Emergency Team are inherently vulnerable with a high in-hospital mortality. OBJECTIVE: To explore perceptions of intensive care unit (ICU) staff who attend deteriorating acute care ward patients regarding current problems, barriers and potential solutions to recognising and responding to clinical deterioration that culminates in a Medical Emergency Team review. METHODS: A descriptive exploratory design was used. Registered intensive care nurses and medical staff (N=207) were recruited during a professional conference using purposive sampling for experience in attending deteriorating patients. Written response surveys were used to address the study aim. Data were analysed using content analysis. RESULTS: Four major themes were identified: Governance, Teamwork, Clinical Care Delivery and End of Life Care. Participants perceived there was a lack of sufficient and senior staff with the required theoretical knowledge; and inadequate assessment and critical thinking skills for anticipating, recognising and responding to clinical deterioration. Senior doctors were perceived to inappropriately manage End of Life Care issues and displayed Teamwork behaviours rendering ward clinicians feeling fearful and intimidated. A lack of System and Clinical Governance hindered identification of clinical deterioration. CONCLUSIONS: To improve patient safety related to recognising and responding to clinical deterioration, suboptimal care due to professionals' knowledge, skills and behaviours need addressing, along with End of Life Care and Governance.