Improving Patient Flow on Adult Mental Health Units: A multimodal Study of Canberra Hospital's Acute Psychiatric Facilities.

BACKGROUND: Due to increasing demands on limited resources in the health care system, many hospitals are working to improve patient flow, thereby increasing their effective capacity. Identifying barriers to patient flow provides the best available evidence to improve such flow in The Canberra Hospital's acute psychiatric units. METHODS: This audit uses a multi-method design (combining focus groups, audits of flow in mental health units and retrospective data analysis on a cross-section of patients) to investigate current patterns of patient flow and barriers to discharge through the Canberra Hospital Mental Health Assessment & Adult Mental Health Units, and factors associated with increased length of stay. RESULTS: Mean LoS for MHAU and AMHU was 8.45 hours and 15 days respectively. Multiple factors were associated with an increased LoS including patient factors, certain hospital processes, and limited availability of community services. CONCLUSIONS: These findings inform recommendations on improving patient flow and future research to support increases in available funding, staffing and resources.

A systematic review of psychosocial suicide prevention interventions for youth.

Youth suicide is a significant public health problem. A systematic review was conducted to examine the effectiveness of school, community and healthcare-based interventions in reducing and preventing suicidal ideation, suicide attempts and deliberate self-harm in young people aged 12-25 years. PsycInfo, PubMed and Cochrane databases were searched to the end of December 2014 to identify randomised controlled trials evaluating the effectiveness of psychosocial interventions for youth suicide. In total, 13,747 abstracts were identified and screened for inclusion in a larger database. Of these, 29 papers describing 28 trials fulfilled the inclusion criteria for the current review. The results of the review indicated that just over half of the programs identified had a significant effect on suicidal ideation (Cohen's d = 0.16-3.01), suicide attempts (phi = 0.04-0.38) or deliberate self-harm (phi = 0.29-0.33; d = 0.42). The current review provides preliminary support for the implementation of universal and targeted interventions in all settings, using a diverse range of psychosocial approaches. Further quality research is needed to strengthen the evidence-base for suicide prevention programs in this population. In particular, the development of universal school-based interventions is promising given the potential reach of such an approach.

A tool to calculate safe nurse staffing levels.

A guideline from the National Institute for Health and Care Excellence and a NICE-endorsed tool on safer nursing care allow decisions on safe staffing levels to be made at a local level. Decisions must be based on sound evidence and factoring in patients' individual needs as well as numbers of patients. The Safer Nursing Care Tool helps nurses decide on safe nurse staffing for acute wards based on patients' level of sickness and dependency. It also includes quality indicators linked to nursing care to help ensure staffing levels achieve best patient care. The tool is easy to use by frontline nursing staff, but must be applied correctly and consistently for data to be valid, and to allow benchmarking against agreed standards. It should be combined with nurses' professional judgement and account for local factors.

Psychosocial interventions for suicidal ideation, plans, and attempts: a database of randomised controlled trials.

BACKGROUND: Research in suicide prevention using psychosocial interventions is rapidly advancing. However, randomised controlled trials are published across a range of medical, psychological and sociology journals, and it can be difficult to locate a full set of research studies. In this paper, we present a database of randomised controlled outcome studies on psychosocial interventions targeting suicidal behaviour. The database is updated annually and can be accessed by contacting the corresponding author. DESCRIPTION: A comprehensive literature search of the major bibliographical databases (PsycINFO; PubMed; Cochrane Central Register of Controlled Trials) was conducted for articles published between 1800 to July 30 2013, and examined reference lists of previous relevant reviews and included papers to locate additional references. Studies were included if they featured a randomised controlled design in which the effects of a psychosocial intervention were compared to a control condition (no intervention, attention placebo, wait-list, treatment-as-usual [TAU]), another psychosocial intervention or a pharmacological intervention. In total, 12,250 abstracts were identified. Of these, 131 studies met eligibility criteria and were included. Each paper was then coded into categories of participant characteristics (age, gender, formal diagnosis, primary reason for recruitment); details of the intervention (recruitment setting, content, intervention setting, administering individual, delivery type, delivery format, delivery frequency, delivery length); and study characteristics (control and experimental conditions, primary outcome/s, secondary outcome/s, follow-up period). One paper has been published from the database using studies collected and coded prior to 2012. CONCLUSION: The database and listing of 131 studies is available for use by suicide prevention researchers. It provides a strong starting point for systematic reviews and meta-analyses of treatments and interventions. It will be updated yearly by researchers funded through the Australian National Health and Medical Research Council Centre for Research Excellence for Suicide Prevention (CRESP), located at the Black Dog Institute, Australia. This database adds to the evidence base of best-practice psychosocial interventions for suicidal behaviour and prevention.

Learning from the design and development of the NHS Safety Thermometer.

QUALITY ISSUE: Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available. INITIAL ASSESSMENT: We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally. CHOICE OF SOLUTION: We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients. IMPLEMENTATION: The NHS ST survey instrument was developed in a learning collaborative involving 161 organizations (e.g. hospitals and other delivery organizations) using a Plan, Do, Study, Act method. EVALUATION: Testing of operational definitions, technical capability and use were conducted and feedback systems were established by site coordinators in each participating organization. During the 17-month pilot, site coordinators reported a total of 73,651 patient entries. LESSONS LEARNED: It is feasible to obtain national data through standardized reporting by site coordinators at the point of care. Some caution is required in interpreting data and work is required locally to ensure data collection systems are robust and data collectors were trained. Sampling is an important strategy to optimize efficiency and reduce the burden of measurement.

Developing skills in clinical leadership for ward sisters.

The Francis report has called for a strengthening of the ward sister's role. It recommends that sisters should operate in a supervisory capacity and should not be office bound. Effective ward leadership has been recognised as being vital to high-quality patient care and experience, resource management and interprofessional working. However, there is evidence that ward sisters are ill equipped to lead effectively and lack confidence in their ability to do so. University College London Hospitals Foundation Trust has recognised that the job has become almost impossible in increasingly large and complex organisations. Ward sisters spend less than 40% of their time on clinical leadership and the trust is undertaking a number of initiatives to support them in this role.

Implementing the eight high impact actions to transform healthcare and boost efficiency.

Nurses and midwives could improve care and save billions of pounds a year by implementing the eight high impact actions unveiled by the chief nursing officer for England Dame Christine Beasley in 2009. We explore how staff can implement the actions through leadership and knowledge of change management processes.

The high impact actions for nursing and midwifery 4: your skin matters.

Pressure ulcers can occur in any patient but are most commonn in high risk groups such as: older people; those who are obese, malnourished orwith continence problems; people with certain skin types; andthose with certain underlying conditions. Pressure ulcers increase morbidityand mortality, and represent a significant proportion of NHS expenditure, yet the vast majority are avoidable. This article, the fifth in our series on the high impact actions for nursing and midwifery, looks at how nurses can prevent pressure ulcers in their patients.

The high impact actions for nursing and midwifery 5: protection from infection.

Four out of every five urinary tract infections can be traced to indwellng catheters. If the number of these infections is to be reduced significantly, nurses need to implement best practice for catheter care, and only catheterise patients when absolutely necessary.

How nurses can implement the high impact actions to improve quality and cost effectiveness.

In November 2009 the NHS Institute for Innovation and Improvement published a list of eight high impact actions for nursing and midwifery and stated that, if implemented across the NHS, the actions could save over pounds 9 bn a year while improving the quality of care. The NHS Institute has now published a selection of case studies from different settings demonstrating successful initiatives relating to each action and a range of other supporting material. This article, the first in a Nursing Times series summarising the main information on how the high impact actions can be achieved, sets the context for the initiative. Subsequent articles will discuss the individual actions and offer practical information on implementation.

The high impact actions for nursing and midwifery. 3: Staying safe, preventing falls.

The National Patient Safety Agency reported 152,000 falls in England and Wales in acute hospitals in 2009, 26,000 in mental health trusts and 28,000 in community hospitals. The number of falls is due to rise in line with increasing numbers of older and frail people who have more complex health needs. Many of these falls are preventable; the challenge for the NHS is to improve patient safety while protecting independence patients' rights to make informed choices.

The high impact actions for nursing and midwifery 1: keeping nourished--getting better.

Approximately one in four patients in NIIS hospitals are either malnourished or at risk of malnurition and as much as 70% of malnutrition in acute hospital admission is unrecognised and unmanaged. Although most of those who are malnourished live in the community, malnutrition and dehydration are key challenges for NHS organisations. Well hydrated and nourished patients get better more quickly, have a shorter length of stay and a more positive experience of care. Ensuring patients receive all of the nutrients they need is vital to the delivery of good care. This article, the second in our series on the high impact actions for nursing and midwifery, looks at how nurses can reduce malnutrition in their patients.

The high impact actions for nursing and midwifery 2: fit and well to care.

Each year in the health service in England, 10.3 million working days are lost to sickness absence (Chartered Institute of Personnel and Development, 2009). This is the equivalent of 4.5% of the current workforce, or 45,000 whole time equivalent nurses. This article, the third in our series on the high impact a actions for nursing and midwifery, looks at how ward managers and team leaders can provide support and information to improve nurses' health and wellbeing.

The high impact actions for nursing and midwifery. 7: Promoting normal birth.

There is significant variation in rates of Caesarean section between maternity units. Higher rates appear to be associated with older mothers and women from certain ethnic groups. However, taking these and other demographic factors into account does not explain the differences between trusts. This eighth article in this series on the high impact actions for nursing and midwifery looks at how midwives and nurses can help to avoid unnecessary Caesarean sections.

The high impact actions for nursing and midwifery 8: ready to go--no delays.

In recent years, discharge initiatives that aim to free up hospital beds have become commonplace. However, new systems, such as bed management, have left many nurses feeling disengaged from the management of patient admission and discharge. They feel pressurised into speeding up discharge by the increasing focus on bed capacity and patient turnover, which can make them feel distanced from their primary role of caring for patients. Although new roles and initiatives can be valuable, changing the way nurses engage with discharge is key. Ensuring that the process is nurse led will lead to a faster discharge and less frustration for patients who are waiting to go home. This article, the last in our series on the high impact actions for nursing and midwifery, looks at how nursing staff can respond to the issue of discharge planning.

The high impact actions for nursing and midwifery 6: where to die when the time comes.

Around half of the 500,000 deaths in England each year occur in acute hospitals, while around half of all complaints made to acute trusts relate to an aspect of end of life care. Howaver, research suggest that 40% of people who die in hospital have no medical need to be there, and that 55% of people with cancer would prefer to die at home while only around 25% do so. When people die in hospital despite having a preference to die at home and no medical reason to be in hospital, it causes unnecessary distress to patients and their familes, and is costly to the NHS. This article, the seventh in our series on the high impact actions for nursing and midwifery, looks at how nurses can help to improve end of life care.

Developing, testing and applying instruments for measuring rising dependency-acuity's impact on ward staffing and quality.

PURPOSE: This paper aims to explains how relatively simple nurse staffing formulas from "best practice" ward dependency-acuity data can be used for nursing workforce planning and development. DESIGN/METHODOLOGY/APPROACH: The paper combines literature, detailed ward surveys, workshop and expert group/stakeholder information to generate and test care levels/nurse multipliers for setting ward establishments. FINDINGS: The paper finds that professional-judgement based ward staffing can be abandoned, while complex acuity-quality, timed-task and regression-based nurse staffing algorithms for setting ward establishments may be unnecessary since the new multipliers, underpinned by robust validity and reliability testing, seem to be remarkably accurate nurse-staffing determiners at a fraction of the cost. RESEARCH LIMITATIONS/IMPLICATIONS: As care levels and multipliers stand they are suitable only for UK National Health Service acute wards. Primary care, mental health, learning disability and other specialist group care levels and multipliers need developing. PRACTICAL IMPLICATIONS: Users, at a minimum, can adopt care level data and multiplier staffing recommendations for benchmarking purposes. Ultimately, the algorithms can be used to: adjust ward establishments according to workload; or set staffing for new, inpatient services. ORIGINALITY/VALUE: The paper offers a simple system for assessing patients' nursing needs and setting ward staffing accordingly.