Patient aggression in intensive care: A qualitative study of staff experiences.

BACKGROUND: Workplace violence comprises abuse, assaults, threats, and harassment. Reaching epidemic proportions in healthcare, workplace violence compromises staff and patient safety and service efficiency and effectiveness. Although workplace violence is a nontrivial problem in intensive care, little is known about circumstances in which violence occurs in this setting. OBJECTIVE: The objective of this study was to describe and reflect upon aggression towards staff in the intensive care unit (ICU) from the perspectives of staff members. METHODS: We investigated workplace violence in a qualitative study with data collected from semistructured interviews with 19 staff members of a 10-bed ICU, analysed using a framework approach. FINDINGS: All participants reported witnessing or experiencing physical and/or verbal aggression. While acknowledging that 'any patient' could become aggressive, participants differentiated 'any patients admitted for treatment of somatic illnesses' from 'dangerous' patients and interpreted violence differently dependent on characteristics of perpetrators. 'Dangerousness' was associated with patients who had a comorbid mental illness. Aggression of 'dangerous patients' was construed as intentional and/or 'normal aberrant' behaviour for the individual. Staff reported feeling ill-prepared to work effectively with this cohort and having difficulty responding empathically. Mental health services were considered 'responsible' for managing patients' drug use, personality, and psychiatric problems. CONCLUSION: Perceived knowledge and skill deficits, as well as stigma when engaging with certain subpopulations, contribute to workplace violence in the ICU setting. ICU staff members seek education and support to improve management of patients and reduce risk of violence. However, effectiveness depends on robust service and organisational commitment and strategies to promote workplace health and safety.

Impact of the COVID-19 pandemic on the use of an inpatient and community palliative care service.

BACKGROUND: The COVID-19 pandemic disrupted the usual provision of healthcare, changing models of care, clinical loads, service provision and patient behaviour. AIMS: This study assesses the impact of COVID-19 on community and inpatient palliative care service provision. METHODS: A retrospective audit and comparison of service use conducted over two defined periods, before and during the COVID-19 pandemic, 2019-2020. FINDINGS: The community palliative care service had a 9% increase in referrals, with a lower proportion of referrals (2.4%) from subacute/palliative care hospitals during the COVID-19 pandemic. Provision of care during the pandemic included less face-to-face contact with patients (24.1% versus 30.2% before), and markedly more contact with patients via videoconference (2.1% versus 0.1% before the pandemic). CONCLUSION: The community specialist palliative care service was busier during the pandemic period, and experienced a shift in mode of care delivery, while the inpatient unit experienced no difference in service use.

Diagnostic Accuracy of Infection Markers to Diagnose Infections in Neonates and Children Receiving Extracorporeal Membrane Oxygenation.

BACKGROUND: Infections represent one of the most common complications in patients managed on Extracorporeal Membrane Oxygenation (ECMO) and are associated with poorer outcomes. Clinical signs of infection in patients on ECMO are non-specific. We assessed the diagnostic accuracy of Procalcitonin (PCT), C-reactive protein (CRP) and White cell count (WCC) to diagnose infection on ECMO. METHODS: Retrospective single center observational study including neonates and children <18 years treated with ECMO in 2015 and 2016. Daily data on PCT, CRP and WCC were assessed in relation to microbiologically confirmed, and clinically suspected infection on ECMO using operating characteristics (ROC) curves. RESULTS: Sixty-five ECMO runs in 58 patients were assessed. CRP had the best accuracy with an area under the ROC curve (AUC) of 0.79 (95%-CI 0.66-0.92) to diagnose confirmed infection and an AUC of 0.72 (0.61-0.84) to diagnose confirmed and suspected infection. Abnormal WCC performed slightly worse with an AUC of 0.70 (0.59-0.81) for confirmed and AUC of 0.66 (0.57-0.75) for confirmed and suspected infections. PCT was non-discriminatory. CONCLUSION: The diagnosis of infections acquired during ECMO remains challenging. Larger prospective studies are needed that also include novel infection markers to improve recognition of infection in patients on ECMO.