Exploring family participation in patient care on acute care wards: A mixed-methods study.

BACKGROUND: Patient- and family-centred care practices are a recommended part of contemporary care for the acutely ill hospitalized adult patients. However, how patient- and family-centred care is enacted in an adult hospital setting is not well understood. AIMS AND OBJECTIVES: The aim of this study is to explore the perceptions of patients, family members and nurses regarding family participation and collaboration in patient care within an acute care setting, including the barriers and facilitators. DESIGN: This study used a mixed-methods sequential design. METHODS: Observer-as-participant observations and semistructured interviews were undertaken. Integration of the data was achieved through triangulation. RESULTS: Triangulation revealed two metathemes. The first metatheme, 'continuum of family involvement', explained the central viewpoint of how family participation and collaboration in the care of acutely ill hospitalized adult patients was enacted. The second metatheme, 'nurses value family involvement', helped to explain and understand the barriers and facilitators to enacting family participation in the acute care setting. CONCLUSION: Promoting family participation in the acute care setting requires supporting multiple levels of engagement. Developing a relationship, clear communication and open sharing of information amongst patients, family members and nurses is critical to supporting family involvement.

Routine activities in the intensive care unit provide opportunities for family engagement.

Manias, E., et al., Communicating with patients, families and health professionals about managing medications in intensive care: A qualitative observational study. Intensive and Critical Care Nursing, 2019. 54: p. 15-22.

Application of the READY framework supports effective communication between health care providers and family members in intensive care.

Effective communication between intensive care health care providers and family is crucial to support surrogate or shared decision-making and to individualise care. Despite its importance in health care standards and policy, the quality of communication with families in intensive care is regarded as suboptimal. Furthermore, an intensive care admission is an extremely stressful event for families, which may impact their understanding and subsequent decision-making. Communicating with family members is a routine practice in intensive care; however, health care providers often receive no formal communication training. To date, family-focused communication interventions in intensive care have targeted end-of-life care and are not generalisable across all types of family-health care provider communication interactions. Mugweni et al. recently reported the results of a multiprofessional training intervention involving 26 health care professionals to improve the delivery of different news to families during pregnancy and at birth. A critique of this article has been undertaken to inform routine communication with critically ill family members and optimise the delivery of care in intensive care units.

Patient and family members' perceptions of family participation in care on acute care wards.

BACKGROUND: Hospital leaders, policymakers and healthcare professionals are realising the benefits of delivering care that promotes family participation because it is known to enhance the quality of care, and improve patient satisfaction. AIM: The aim of this study was to explore, from the perspective of patients and family members within an adult acute care ward: (a) their beliefs and attitudes towards family participation in patient care and (b) staff behaviours that support or hinder family participation in patient care. DESIGN AND METHODS: A naturalistic approach with an exploratory sequential design was used in a medical assessment and planning unit of a regional referral hospital in Australia. Purposeful maximum variation sampling was used to recruit patients and family members who differed in age, ethnicity, relationship to patient and gender. Observer-as-participant observation data and semi-structured interviews were undertaken. Following separate inductive content analysis, data were triangulated. RESULTS: Thirty-two patients and 26 family members were recruited. Thirty hours of observational data were gathered. Eighteen patients and 15 family members were interviewed. Analysis uncovered two contrasting categories: (a) disconnected communication and (b) family influence quality. CONCLUSION: The findings of our study demonstrated that most patients and families perceived staff communication as disconnected and inadequate, which constrained them from engaging in care processes or decision-making. However, when family felt empowered and participated in patient care, the quality of health care was enhanced. Healthcare professionals can use these findings to make informed evidence-based changes to the way they practice and communicate to ensure family participation in patient care is optimised in the acute care setting.

Psychometric testing of the revised "Families' Importance in Nursing Care-Nurses' Attitudes instrument".

BACKGROUND: The validity of instruments is crucial in ensuring that data collected are sound and that these data represent what the instrument claims to measure. When an instrument is revised or used in a different population, it is useful to re-examine its construct validity. AIM: To test the psychometrics properties of an instrument-the revised Families' Importance In Nursing Care-Nurses' Attitudes, designed to measure nurse' attitudes towards involving family in nursing care in an adult acute care setting. DESIGN AND METHODOLOGY: A cross-sectional survey design was used in April-May 2016 with a sample of Enrolled and Registered Nurses (N = 212) to test the factor structure of the revised Families' Importance In Nursing-Nurses' Attitudes instrument. The instrument had 26 items with a five-point Likert response scale. Principle components analysis and exploratory factor analysis were performed with oblique rotations to assess the internal structure of the instrument. SETTING: A regional referral hospital in Queensland, Australia. RESULTS: Using Principal Components Analysis and Principal Axis Factoring, we obtained the same factor structure to that originally identified for the instrument. Our results suggested the removal of six items to refine the instrument and achieve simple structure. CONCLUSION: The removal of several items, relabeling of factors and residual cross-loading issues suggest that further revisions to the instrument are needed.

Acute care nurses' views on family participation and collaboration in fundamental care.

AIMS AND OBJECTIVES: To understand the beliefs, attitudes and perceptions of nurses regarding family participation and collaboration in the care of their hospitalized adult relative. BACKGROUND: Family participation in care is known to enhance the quality of patient care. Nurses are uniquely placed to support such participation, including the delivery of fundamental care. However, nurses' attitudes and beliefs may help or hinder participation. DESIGN: A mixed methods approach with an exploratory sequential design was used. SETTING: A regional referral hospital in Australia. PARTICIPANTS: Nurses were eligible to participate in the study if they were permanent staff of the hospital, and who in their day-to-day work had direct contact with adult patients and their families on acute care wards. METHODS: Observer-as-participant observation data and semi-structured interviews were undertaken. 30 hr of observational data were gathered, and 14 nurses were interviewed. Data collection occurred between September and December 2016. Following separate analysis, data were triangulated. RESULTS: Analysis uncovered two contrasting categories: (i) enacting family participation (four themes); and (ii) hindering family participation (five themes). CONCLUSION: The findings of our study demonstrated that the practices of nurses do not always align with healthcare policies, and strategies to support nurses to enact patient- and family-centred practices are needed. RELEVANCE TO CLINICAL PRACTICE: Nurses can use these findings to make informed evidence-based changes to the way they practice and communicate with families to ensure fundamental care is delivered.

Six habits to enhance MET performance under stress: A discussion paper reviewing team mechanisms for improved patient outcomes.

Effective team decision making has the potential to improve the quality of health care outcomes. Medical Emergency Teams (METs), a specific type of team led by either critical care nurses or physicians, must respond to and improve the outcomes of deteriorating patients. METs routinely make decisions under conditions of uncertainty and suboptimal care outcomes still occur. In response, the development and use of Shared Mental Models (SMMs), which have been shown to promote higher team performance under stress, may enhance patient outcomes. This discussion paper specifically focuses on the development and use of SMMs in the context of METs. Within this process, the psychological mechanisms promoting enhanced team performance are examined and the utility of this model is discussed through the narrative of six habits applied to MET interactions. A two stage, reciprocal model of both nonanalytic decision making within the acute care environment and analytic decision making during reflective action learning was developed. These habits are explored within the context of a MET, illustrating how applying SMMs and action learning processes may enhance team-based problem solving under stress. Based on this model, we make recommendations to enhance MET decision making under stress. It is suggested that the corresponding habits embedded within this model could be imparted to MET members and tested by health care researchers to assess the efficacy of this integrated decision making approach in respect to enhanced team performance and patient outcomes.

The experiences of rural and remote families involved in an inter-hospital transfer to a tertiary ICU: a hermeneutic study.

BACKGROUND: Inter-hospital transfers are necessary for critically ill patients to improve their chance of survival. Rural and remote families experience significant disruption to family life when critically ill patients are required to undergo a transfer to a tertiary hospital. What is not known is how ICU staff can assist these families who are involved in an inter-hospital transfer to a tertiary ICU. PURPOSE: To gain an understanding of rural and remote critical care families' experiences during an inter-hospital transfer to a tertiary ICU. METHOD: A hermeneutic phenomenological approach was adopted informed by the philosophical world views of Heidegger and Gadamer. Data collection occurred by in-depth conversational interviews from a purposeful sample of seven family members. Interview transcripts, field notes and diary entries formed the text which underwent hermeneutic analysis. FINDINGS: Being confused, being engaged, being vulnerable and being resilient emerged as significant aspects of the rural and remote family members' experience during a transfer event. CONCLUSION: A better understanding of the experiences of rural and remote families during an inter-hospital transfer journey can inform the practice of ICU nurses. This study highlights the specific experiences of rural and remote families during an inter-hospital transfer journey to a tertiary ICU. It also informs nurses of the meaningful ways in which they can support these families with the uncertainty and chaos experienced as part of this journey.

Relationship between blood and tissue-based rejection-related transcripts in heart transplantation.

BACKGROUND: The purpose of the study is to investigate the relationship between blood and tissue-derived rejection-related transcripts from blood gene expression profiling (GEP) and molecular microscope in the setting of allograft rejection in heart transplant. METHODS: All heart transplant patients from August 2021 to May 2022 with both circulating blood GEP (AlloMap) and endomyocardial biopsy with molecular microscope diagnostic system (MMDx) within 4 weeks were included (N = 173 samples). We obtained individual blood GEP-based messenger RNA transcript expression levels of the 11 target genes from CareDx. Student's t-test was performed to compare blood GEP transcript expression levels between no rejection and rejection as assessed by MMDx. A Scatter plot with Spearman correlation analysis was performed to compare the relationship between transcript expression levels from AlloMap and MMDx, with and without allograft rejection. RESULTS: There were 52 samples (30.1%) with antibody-mediated rejection (ABMR) and 15 samples (8.7%) with T-cell-mediated rejection (TCMR), as assessed by MMDx. Expression of one of the blood ITGA4 (Integrin alpha 4) expression level was elevated in ABMR, compared to no ABMR (4,607.5 vs 4,217.5; p = 0.019). Most tissue rejection-associated transcript expression levels were elevated in ABMR, and tissue ROBO4 expression correlated with the blood ITGA4 expression with moderate or greater effect size in all samples (Spearman's R = 0.31; p < 0.001). There was also a positive correlation between blood ITGA4 and tissue ROBO4 expression in samples without ABMR (Spearman's R = 0.33; p < 0.001), but no correlation between blood ITGA4 and tissue ROBO4 expression in samples with ABMR (Spearman's R = 0.009; p = 0.513). CONCLUSIONS: Circulating blood ITGA4 expression is elevated in antibody-mediated rejection (AMR) and correlates with myocardial expression of ROBO4. The knowledge of individual transcript expression levels in blood and in tissue may provide insights into various disease processes in heart transplant patients. Taken together, the results of our study reveal an overlap between 2 objective post-heart transplant rejection surveillance methods, identify potential novel markers for ABMR, and reveal the need for a deeper understanding of molecular mechanisms underlying allograft rejection.

Relationship between donor-derived cell-free DNA and tissue-based rejection-related transcripts in heart transplantation.

BACKGROUND: Endomyocardial biopsy (EMB)-based traditional microscopy remains the gold standard for the detection of cardiac allograft rejection, despite its limitation of inherent subjectivity leading to inter-reader variability. Alternative techniques now exist to surveil for allograft injury and classify rejection. Donor-derived cell-free DNA (dd-cfDNA) testing is now a validated blood-based assay used to surveil for allograft injury. The molecular microscope diagnostic system (MMDx) utilizes intragraft rejection-associated transcripts (RATs) to classify allograft rejection and identify injury. The use of dd-cfDNA and MMDx together provides objective molecular insight into allograft injury and rejection. The aim of this study was to measure the diagnostic agreement between dd-cfDNA and MMDx and assess the relationship between dd-cfDNA and MMDx-derived RATs, which may provide further insight into the pathophysiology of allograft rejection and injury. METHODS: This is a retrospective observational study of 156 EMB evaluated with traditional microscopy and MMDx. All samples were paired with dd-cfDNA from peripheral blood before EMB (up to 9 days). Diagnostic agreement between traditional histopathology, MMDx, and dd-cfDNA (threshold of 0.20%) was compared for assessment of allograft injury. In addition, the relationship between dd-cfDNA and individual RAT expression levels from MMDx was evaluated. RESULTS: MMDx characterized allograft tissue as no rejection (62.8%), antibody-mediated rejection (ABMR) (26.9%), T-cell-mediated rejection (TCMR) (5.8%), and mixed ABMR/TCMR (4.5%). For the diagnosis of any type of rejection (TCMR, ABMR, and mixed rejection), there was substantial agreement between MMDx and dd-cfDNA (76.3% agreement). All transcript clusters (group of gene sets designated by MMDx) and individual transcripts considered abnormal from MMDx had significantly elevated dd-cfDNA. In addition, a positive correlation between dd-cfDNA levels and certain MMDx-derived RATs was observed. Tissue transcript clusters were correlated with dd-cfDNA scores, including DSAST, GRIT, HT1, QCMAT, and S4. For individual transcripts, tissue ROBO4 was significantly correlated with dd-cfDNA in both nonrejection and rejection as assessed by MMDx. CONCLUSIONS: Collectively, we have shown substantial diagnostic agreement between dd-cfDNA and MMDx. Furthermore, based on the findings presented, we postulate a common pathway between the release of dd-cfDNA and expression of ROBO4 (a vascular endothelial-specific gene that stabilizes the vasculature) in the setting of antibody-mediated rejection, which may provide a mechanistic rationale for observed elevations in dd-cfDNA in AMR, compared to acute cellular rejection.

Strengthening emergency department response to chemical, biological, radiological, and nuclear disasters: A scoping review.

INTRODUCTION: Natural hazards resulting in disasters are increasing globally, impacting communities and disrupting industries. In addition to planning for these natural hazard disasters, emergency departments (EDs) should prepare for chemical, biological, radiological, and nuclear (CBRN) incidents that result in surges of patient presentations. Chemical, biological, radiological, and nuclear incidents differ in preparedness to natural hazards, requiring an understanding of patient management and health system-related challenges. METHODS: This scoping review used the Arksey and O'Malley five-step framework. Manuscripts were retrieved from four databases and search engines using keywords relating to impacts on the ED from real world CBRN event(s). Analysis focused on the characteristics of CBRN event, ED impact, and lessons learnt against four surge capacity domains that including staff, stuff, space, and systems. RESULTS: A total of 44 paper were included in this review. Most of the incidents were chemical in nature (n = 36/44, 81.8 %). The majority of CBRN incidents were accidental (n = 34/44, 77.3 %). Between 1 and 1470 people (Mdn=56, IQR: 18-228) presented to an ED from each event. Most patients were discharged from the ED, but this was variably reported. Some key lessons related to secondary exposure to ED staff, repurposing spaces, and coordination of CBRN incidents. CONCLUSION: With the increasing number of CBRN incidents, strategies to strengthen EDs and limit the impact from a surge in patient presentations are paramount. An understanding of local CBRN risk to inform a top-hazards approach to CBRN preparedness, and the implementation of pre-emptive CBRN clinical pathways is recommended. Additionally, strategies should be implemented to protect staff from the risk of secondary exposure to a CBRN event. These strategies may include adequate education, training, and personal protective equipment for staff.

Chemical, Biological, Radiological, or Nuclear Response in Queensland Emergency Services: A Multisite Study.

A disaster overwhelms the normal operating capacity of a health service. Minimal research exists regarding Australian hospitals' capacity to respond to chemical, biological, radiological, or nuclear (CBRN) disasters. This article, and the research supporting it, begins to fill that research gap. We conducted a descriptive quantitative study with 5 tertiary hospitals and 1 rural hospital in Queensland, Australia. The study population was the hospitals' clinical leaders for disaster preparedness. The 25-item survey consisted of questions relating to each hospital's current response capacity, physical surge capacity, and human surge capacity in response to a CBRN disaster. Data were analyzed using descriptive statistics. The survey data indicated that over the previous 12 months, each site reached operational capacity on average 66 times and that capacity to respond and create additional emergency, intensive care, or surgical beds varied greatly across the sites. In the previous 12 months, only 2 sites reported undertaking specific hospital-wide training to manage a CBRN disaster, and 3 sites reported having suitable personal protective equipment required for hazardous materials. There was a noted shortfall in all the hospitals' capacity to respond to a radiological disaster in particular. Queensland hospitals are crucial to CBRN disaster response, and they have areas for improvement in their response and capacity to surge when compared with international preparedness benchmarks. CBRN-focused education and training must be prioritized using evidence-based training approaches to better prepare hospitals to respond following a disaster event.

Adipositas Cordis: A Rare and Poorly Understood Cardiomyopathy.

Adipositas cordis is a rare cardiomyopathy characterized by diffuse fatty infiltration of the ventricular myocardium or interventricular septum. This occurs without myocardial cell destruction, unlike arrhythmogenic right ventricular cardiomyopathy. A 40-year-old obese woman was found to have a II/VI systolic murmur that worsened with standing. A transthoracic echocardiogram showed interventricular septal hypertrophy with a preserved left ventricular ejection fraction. Cardiac magnetic resonance imaging revealed a fatty mass in the interventricular septum. An endomyocardial biopsy revealed structurally normal myocytes with diffuse adipose cell infiltration and no evidence of malignant cells. Left and right cardiac catheterizations and stress echocardiography showed no abnormalities. This case shows the importance of considering a broad differential when approaching rare diseases. It also demonstrates the utility of noninvasive imaging and its impact on clinical decision making.

Monday, Wednesday, and Friday dosing of rosuvastatin in patients previously intolerant to statin therapy.

Statins are normally administered for the treatment of dyslipidemia on a daily basis. This standard dosing regimen is well tolerated by most patients. Occasionally, patients discontinue therapy secondary to side effects, most commonly myalgias. We describe 2 patients who were unable to tolerate daily atorvastatin therapy secondary to myalgias and were subsequently treated with rosuvastatin administered on Mondays, Wednesdays, and Fridays, with resolution of adverse effects. Significant reductions in serum low-density lipoprotein cholesterol levels were observed in the 2 patients despite the alternate-day dosing regimen. Rosuvastatin was chosen because of its long half-life (19 hours) and very high potency.

Atypical sarcoidosis: a case report and literature review.

An African American man was admitted with multiple systemic symptoms. The work-up revealed a unilateral cavitary lung mass with hilar adenopathy, sub-centimeter abdominal mesenteric lymph nodes, and a natural killer cell lymphocytosis in the bone marrow. Transbronchial biopsy revealed areas of noncaseating granulomas suspicious for sarcoidosis. Additional studies for infectious and malignant agents were negative.

Catastrophic systemic embolization from a left atrial myxoma.

We report the fatal course of a left atrial myxoma: its systemic embolization to the coronary, cerebral, renal, and peripheral vascular beds in a 39-year-old woman resulted in rapid clinical deterioration, multiorgan failure, and death. Among reported cases of left atrial myxoma, this degree of embolic burden is exceedingly rare. In addition to reporting the patient's case, we discuss the presentation and diagnosis of possible intracardiac sources of systemic emboli.

Left ventricular to coronary sinus fistula following multiple mitral valve replacement surgeries.

Development of left ventricular to coronary sinus fistula is a rare complication of mitral valve surgery. Three of the seven previously reported cases occurred following multiple valve replacement surgeries, all of which were thought to be secondary to a complication of surgery and all were treated with surgical closure of the fistula. We report a case of left ventricular to coronary sinus fistula occurring after two mitral valve replacement surgeries that was treated medically with favorable long-term results.