Improving the systematic screening and documentation of mental capacity for patients with severe brain injury: The Mental Capacity Screening assessment tool (MCScreen).

For patients who may lack capacity, the Mental Capacity Act 2005 requires capacity to be assessed for each decision at the time that treatment is offered, but this is not practical for every element of basic care and intervention delivered to patients undergoing rehabilitation following acquired brain injury, especially if their needs are changing. In this quality improvement project, we introduced a system for screening Mental Capacity and documentation to identify patients with a) largely intact cognition for whom capacity may be reasonably be presumed, and b) those in prolonged disorders of consciousness who clearly lacked capacity for all decisions. This enabled the multidisciplinary team to concentrate on evaluation of capacity in the third group who had more nuanced ability and required detailed assessment or support for decision-making. Two rounds of audit demonstrated that implementation improved the consistency of assessment and documentation. Multicentre roll-out of this approach is now required.

Development and implementation of a COVID-19 near real-time traffic light system in an acute hospital setting.

Common causes of death in COVID-19 due to SARS-CoV-2 include thromboembolic disease, cytokine storm and adult respiratory distress syndrome (ARDS). Our aim was to develop a system for early detection of disease pattern in the emergency department (ED) that would enhance opportunities for personalised accelerated care to prevent disease progression. A single Trust's COVID-19 response control command was established, and a reporting team with bioinformaticians was deployed to develop a real-time traffic light system to support clinical and operational teams. An attempt was made to identify predictive elements for thromboembolism, cytokine storm and ARDS based on physiological measurements and blood tests, and to communicate to clinicians managing the patient, initially via single consultants. The input variables were age, sex, and first recorded blood pressure, respiratory rate, temperature, heart rate, indices of oxygenation and C-reactive protein. Early admissions were used to refine the predictors used in the traffic lights. Of 923 consecutive patients who tested COVID-19 positive, 592 (64%) flagged at risk for thromboembolism, 241/923 (26%) for cytokine storm and 361/923 (39%) for ARDS. Thromboembolism and cytokine storm flags were met in the ED for 342 (37.1%) patients. Of the 318 (34.5%) patients receiving thromboembolism flags, 49 (5.3% of all patients) were for suspected thromboembolism, 103 (11.1%) were high-risk and 166 (18.0%) were medium-risk. Of the 89 (9.6%) who received a cytokine storm flag from the ED, 18 (2.0% of all patients) were for suspected cytokine storm, 13 (1.4%) were high-risk and 58 (6.3%) were medium-risk. Males were more likely to receive a specific traffic light flag. In conclusion, ED predictors were used to identify high proportions of COVID-19 admissions at risk of clinical deterioration due to severity of disease, enabling accelerated care targeted to those more likely to benefit. Larger prospective studies are encouraged.

How do we build a picture of a patient in prolonged disorder of consciousness?

Accurate diagnosis of prolonged disorders of consciousness can be challenging and requires the input of a specialist interdisciplinary team who are experienced in informal assessment as well as the administration of formal validated observational assessment tools. There is limited guidance on the selection of these assessment tools. This study examines the factors involved in a team's choice making and how choice of assessment helps build a picture of a patient. Twelve clinicians working within a specialist prolonged disorders of consciousness unit participated in the study. Five took part in an individual structured interview and seven took part in a focus group. Data were evaluated using thematic analysis. The results show that there was a range of factors which influenced decisions over choice of assessment tools. No one assessment tool is perfect and therefore participants favour combining the characteristics of two assessment tools in order to achieve a higher-quality assessment. The use of two assessment tools rather than one, is thought to be key in helping to build an overall picture of the patient. The findings of this study may be useful in the training of clinicians working with this specialist caseload, in the future development of tools themselves and in guiding further research into using a combination of assessment tools for best outcome in this patient group.

Emotional labour: the challenges of working with children and cancer.

This article explains the concept of emotional labour and applies it to working with children with cancer. Emotional labour describes active management of the emotions, and the use of emotion as part of the work that is required in many jobs, particularly nursing. Although emotional labour is an important part of nursing work, it is often neglected or taken for granted.