Goals of the Morbidity and Mortality meeting in acute care: A scoping review.

OBJECTIVE: The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting. REVIEW METHODS USED: The study utilised scoping review methodology. DATA SOURCES: Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers. REVIEW METHODS: Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories. RESULTS: Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support. CONCLUSIONS: There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

CoVID-19: Parent and caregiver concerns about reopening New Zealand schools.

AIM: Children generally have a milder CoVID-19 disease course and better prognosis than adults. Many countries have closed schools as part of measures to limit transmission and this has had a considerable impact on children world-wide. This includes New Zealand (NZ), where rates of CoVID-19 have been very low. The aims of this study were to investigate parents' and caregivers' knowledge of CoVID-19 in children, to understand their levels of concern and to identify their most trusted sources of information. METHODS: Participants were recruited via NZ parenting support and interest groups on Facebook.com. Knowledge was assessed by way of a self-administered questionnaire during the 10 days prior to NZ schools reopening on 18 May 2020. RESULTS: Of the 1191 study participants, 721 (60%) expressed some level of worry (14.5% very or extremely worried) that their child would catch CoVID-19 at school. A high proportion (79%, 941) thought it likely or very likely that their child would catch CoVID-19 at school if there were to be widespread community transmission. Fear scores for CoVID-19 were generally high, and 828 (80%) of participants said they would vaccinate their child if a newly developed vaccine were available. CONCLUSIONS: Parents and caregivers were generally fearful of their children acquiring CoVID-19 at school. This was despite messaging from multiple trusted sources that transmission in schools is unlikely, and the number of NZ CoVID-19 cases being extremely low. These findings have implications for policy development and public health messaging both in NZ and in countries with ongoing community transmission of CoVID-19.

Using a citizens' jury approach to determine a good nutrition resource for pregnant women.

OBJECTIVE: The development of user-friendly nutrition resources for pregnant women seldom involves end-users. This qualitative study used a citizens' jury approach to determine if our modification of a longstanding, frequently used dietitian-informed diet and diabetes booklet was deemed to be a good healthy eating resource for pregnant women. DESIGN: Midwives recruited thirteen first-time pregnant women not requiring specialist obstetric care or specialist dietetic advice for any reason. Participants were sent a copy of the modified healthy eating in pregnancy booklet prior to 'jury day'. Five women were unable to attend the citizens' jury citing reasons such as early labour. At the jury, five experts presented evidence. Participants adjourned, with an independent facilitator, to 'deliberate' as to whether the resource was suitable or not. The verdict was presented, and subsequent discussion was audio-recorded, transcribed and inductively content analysed. SETTING: Southland, New Zealand. PARTICIPANTS: Pregnant women aged 19-35 years (n 8), of whom half had a household income <$NZ30 000. RESULTS: The verdict was 'Yes'; the resource was good. Three themes were derived: communication of health information, resource content and harm reduction in pregnancy. Based on these data, ways to enhance the quality and usability of the booklet were evident. CONCLUSIONS: Citizens' juries can be used to obtain an independent assessment by end-users of health resources. Our modified diet and diabetes booklet was considered suitable for providing healthy eating advice to pregnant women. Inclusion of end-users' perspectives is critical for end-user relevant content, comprehension and resource credibility.

The epidemiology of listeriosis in pregnant women and children in New Zealand from 1997 to 2016: an observational study.

BACKGROUND: Listeria monocytogenes causes the foodborne infection listeriosis. Pregnant women, infants and immunocompromised children are at increased risk for infection. The aim of this study was to describe the trends in the epidemiology of disease notifications and hospital admissions due to listeriosis in pregnant women aged 15 to 45 years and children aged less than 15 years in New Zealand (NZ) from 1997 to 2016. METHODS: In this population-based descriptive study, listeriosis notification and hospitalization rates from 1997 to 2016 were analyzed. Notification data were extracted from the Institute of Environmental Science and Research (ESR) Notifiable Diseases Database (EpiSurv) and hospitalization data were extracted from the National Minimum Dataset (NMDS). Pregnant women aged 15 to 45 years and children less than 15 years of age were included. Subgroup analysis was conducted for age and ethnicity. Outcomes of infection were described. RESULTS: In the 20-year period considered, there were 147 pregnancy-associated cases of listeriosis either notified to ESR (n = 106) and/or coded in the NMDS (n = 99), giving a crude incidence rate of 12.3 (95% CI 10.4, 14.4) per 100,000 births. In addition, there were 22 cases in children aged 28 days to < 15 years (incidence =0.12, 95% CI 0.08 to 0.19 per 100,000). There were no trends observed over time in the incidence of pregnancy-associated listeriosis. Incidence rates of pregnancy-associated and childhood listeriosis were highest in people of Pacific and Asian ethnicity. CONCLUSIONS: NZ has a low incidence of listeriosis in pregnant women and children, however, the consequences of infection are frequently severe. Those of Pacific and Asian ethnicity have the highest rates of disease and future messaging around food safety should target these groups. This study provides important insights into the epidemiology of listeriosis in pregnant women and children in NZ.

A qualitative exploration of escalation of care in the acute ward setting.

BACKGROUND: "Failure to Rescue" includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes. AIMS AND OBJECTIVE: The aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. DESIGN: A total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust. METHODS: Observations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care. RESULTS: Clinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re-escalate low-level scores. Patient and non-patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover. CONCLUSION: This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re-escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams. RELEVANCE TO CLINICAL PRACTICE: This service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways.

Measuring Sleep in the Intensive Care Unit: A Critical Appraisal of the Use of Subjective Methods.

OBJECTIVES: To collate and appraise the use of subjective measures to assess sleep in the intensive care unit (ICU). DESIGN: A systematic search and critical review of the published literature. DATA SOURCES: Medline, Scopus, and Cumulative Index to Nursing and Allied Health Literature were searched using combinations of the key words "Sleep," "Critical Care," "Intensive Care," and "Sleep Disorders," and this was complemented by hand searching the most recent systematic reviews on related topics. STUDY ELIGIBILITY CRITERIA: Papers were limited to non-gray English-language studies of the adult population, published in the last 10 years. OUTCOME MEASURES: Primary outcomes were the number and categorization of quantitative studies reporting measures of sleep, the number of participants for each data collection method, and a synthesis of related material to appraise the use of survey tools commonly used for sleep measurement in the ICU. RESULTS: Thirty-eight papers reported quantitative empirical data collection on sleep, 17 of which used a primary method of subjective assessment of sleep by the patient or nurse. Thirteen methods of subjective sleep assessment were identified. Many of these tools lacked validity and reliability testing. CONCLUSIONS: Research using questionnaires to assess sleep is commonplace in light of practical barriers to polysomnography or other measures of sleep. A methodologically sound approach to tool development and testing is crucial to gather meaningful data, and this robust approach was lacking in many cases. Further research measuring sleep subjectively in ICU should use the Richards Campbell Sleep Questionnaire, and researchers should maintain a commitment to transparency in describing methods.

The epidemiology of non-viral gastroenteritis in New Zealand children from 1997 to 2015: an observational study.

BACKGROUND: Acute gastroenteritis is a substantial cause of hospitalization in children. Shigella, Salmonella, Campylobacter, Yersinia, enterotoxigenic Escherichia coli (ETEC), Giardia and Cryptosporidium are gastrointestinal pathogens that are notifiable in New Zealand (NZ). The impact of these infections in the pediatric population has not yet been analyzed. The aim of this study was to describe the epidemiological trends in disease notifications and hospital admissions due to non-viral gastroenteritis in NZ children. METHODS: In this population-based descriptive study, age-specific and age-standardized notification and hospital admission rates were analyzed from 1997-to-2015 for Shigella, Salmonella, Campylobacter, Yersinia, ETEC, Giardia and Cryptosporidium infections in children < 15 years of age. Variations in disease by gender, age, ethnicity and geography were described. RESULTS: From 1997-to-2015 there were 74,454 notifications (57.6% male) and 3192 hospitalizations (56.4% male) due to non-viral gastroenteritis in NZ children aged < 15 years. There was an overall trend towards a reduction in disease notifications and hospitalizations, however each disease showed a unique pattern of change over time. Campylobacter was the pathogen most frequently notified, accounting for 51.7% of notifications and 43.4% of hospitalizations. The hospitalization-to-notification ratios were, from highest to lowest, Salmonella typhi (1:1.09), Shigella (1:4.0), ETEC (1:7.81), nontyphoidal Salmonella (1:13.1), Campylobacter (1:27.8), Yersinia (1:29.2), Cryptosporidium (1,33.4), and Giardia (1,72.5). Compared to females, male notification rates were approximately 40% higher for Campylobacter, 25% higher for Giardia and Yersinia, and 15% higher for Cryptosporidium and nontyphoidal Salmonella (p < 0.001). Notification rates were highest in children 1-4 years, with the exceptions of nontyphoidal Salmonella, Salmonella typhi and Yersinia. Notification rates for nontyphoidal Salmonella and Yersinia were highest in children < 1 year, and for Salmonella typhi those aged 5-9 years. Children < 1 year were most likely to be hospitalized. CONCLUSIONS: The incidence of non-viral gastroenteritis in NZ children reduced during the 19-year period considered. The burden of disease was highest in the community, with only a small percentage of cases requiring hospitalization. This study provides important insight into the non-viral causes of gastroenteritis in NZ children and how environmental influences and changes in food safety practices may have helped to reduce the burden of these diseases in children.

Wearable monitors for patients following discharge from an intensive care unit: practical lessons learnt from an observational study.

AIMS: To identify the practical challenges encountered when using wearable monitors for patients discharged from the intensive care unit. BACKGROUND: Patients discharged from intensive care units are a high-risk group that might benefit from continuing observation using 'wearable' monitors to enable faster identification of physiological deterioration and facilitate timely clinical action. This area of technological innovation is of key interest to nurses who manage this group of patients. DESIGN: A prospective observational study. METHODS: An observational study conducted in 2013-2014 used wearable monitors to record continuous observations for patients discharged from an intensive care unit to develop a predictive model of patients likely to deteriorate. Screening data for study eligibility and case report form data to assess monitor tolerance and comfort were collected daily and analysed using Microsoft Access. RESULTS/FINDINGS: Patients (n = 2704) were discharged from an intensive care unit during the study, 208 consented to wearing the monitor. Of the 192 included in analysis, 130 (67·7%) removed the monitor before the trial finished. Reasons cited for removal included 'discomfort and irritation' 61 (31·8%) and 'feeling too unwell' 8 (4·2%). Five hundred seventeen patients were screened following adaption of the wearable monitor. Despite design changes, 56 (10·8%) patients were unable to wear monitors for reasons related to their anatomy or condition. Of 124 patients, 65 patients (52·4%) who were approached refused participation. CONCLUSION: Work is needed to understand wireless monitor comfort and design for acutely unwell patients. Product design needs to develop further, so patients are catered for in flexibility of monitor placement and improved comfort for long-term wear.

Scimitar syndrome, bronchiectasis, haemoptysis and a pneumonectomy.

Scimitar syndrome is a rare condition characterized by partial or complete anomalous pulmonary venous drainage of the lung to the inferior vena cava, right lung hypoplasia and dextroposition of the heart. Haemoptysis is uncommon in adults, although the clinical spectrum is wide. We report a case of a 38-year-old male with scimitar syndrome who had low grade haemoptysis persisting over several years secondary to bronchiectatic changes in his hypoplastic right lung. Conservative measures to manage haemoptysis were unsuccessful and the patient proceeded to bronchial artery embolization. The post-procedure course was complicated by lung infarction and the patient ultimately required pneumonectomy. Deformities of the blood vessels and lungs are complex in scimitar syndrome. Bronchial artery embolization should be approached cautiously to protect pulmonary perfusion.

Goals of Morbidity and Mortality meetings in paediatric acute care. A qualitative case study.

Morbidity and Mortality meetings are conducted in varied clinical contexts including paediatrics. Widely cited as an educational or quality improvement tool, the reality is more complex. In this qualitative study, the aim was to explore the perceived goals of the paediatric acute care Morbidity and Morbidity meeting. This study used semi-structured interviews and observation within a qualitative case study methodology. Data were collected in a large paediatric quaternary hospital. Analysis generated themes related to meeting observations and the participant's interpretation of meeting goals. A total of 44 interviews were conducted with 14 nurses, 29 doctors, and 1 allied health professional. Thirty-two meetings in six clinical departments were observed. Two themes were developed: complex and nuanced goals; and tensions and contest between and within goals. Meeting goals to evaluate care, learn, support, adhere, and change and respond were sometimes in competition and had varied interpretations. Morbidity and Mortality meetings in this setting are valued and occupy a complex role which reaches beyond identification of measurable patient safety interventions. Understanding goals more fully can lead to optimised conduct and meaningful measurement of efficacy. The strength in these meetings may be the way they promote an embedded safety culture, and an informed and skilled workforce.

Pregnant women's knowledge of, and adherence to, New Zealand Food Safety in Pregnancy guidelines.

AIM: Pregnant women are at increased risk for contracting foodborne illness. Simple food safety precautions can prevent illness. The aim of this study was to examine pregnant women's knowledge of, and adherence to, the New Zealand Food Safety in Pregnancy guidelines. METHOD: Participants were recruited when attending antenatal clinics, and via online pregnancy support groups. Knowledge and behaviours were assessed by way of a self-administered questionnaire. RESULTS: In total, 205 women participated in this study; 100 from antenatal clinics, 105 via Facebook. The median knowledge score was 95% (interquartile range (IQR) 83-100%, minimum = 17.4%). Only 25% of participants answered all questions correctly. The median adherence score was 77% (IQR = 62-92%, minimum = 8%); 13% of participants reported complete adherence to the food safety guidelines. Mean knowledge scores in participants of Maori ethnicity (76.6%) were lower than in participants of European/other ethnicity (91.7%, p=0.004). Maori participants had the lowest mean adherence scores (63.2%) and this requires further investigation. CONCLUSIONS: The majority of participants reported continuing to consume foods considered unsafe in pregnancy. This study highlights the need for improved food safety education during pregnancy. The results also suggest a need for food safety guidance to be made more accessible and relevant to the needs of Maori women.

Epidemiology of Campylobacter Gastroenteritis in New Zealand Children and the Effect of The Campylobacter Strategy: A 20-year Observational Study.

BACKGROUND: Campylobacter species are a common cause of gastroenteritis in New Zealand (NZ) as well as worldwide. This study aimed to describe epidemiologic trends in disease notifications and hospital admissions because of Campylobacter gastroenteritis in NZ children from 1997 to 2016. METHODS: In this population-based descriptive study, age-specific and age-standardized notification and hospitalization rates were analyzed for Campylobacter infections in children <15 years of age. Variations in disease by time, sex, age, ethnicity and geography were described. RESULTS: During the 20-year period considered, there were 39,970 notifications (59.1% male) and 1458 hospitalizations (61.8% male) because of Campylobacter gastroenteritis in NZ children. Before 2006, notification rates increased by 3.4% annually [95% confidence interval (CI): 0.7%-6.2%], with a peak of 340 notifications per 100,000 children in 2003. The average percentage change (APC) in hospitalizations was 7.4% (95% CI: 4.0%-10.9%) in the same period. From 2006 to 2008, notification and hospitalization rates fell by 25% and 30%, respectively. Since 2008, age-standardized incidence rates have been stable at 161 notifications (APC: -3.1; 95% CI: 0.82 to -6.9) and 6.73 hospitalizations (APC: 2.2; 95% CI: -2.0 to 6.5) per 100,000 children per year. Notification rates were highest in children 1-4 years of age. Hospitalizations rates were highest in children <1 year of age. CONCLUSIONS: NZ has previously had high rates of Campylobacter gastroenteritis in children. Implementation of a national strategy to reduce foodborne Campylobacter infection appears to have contributed to an observed reduction in rates between 2006 and 2008. The burden of Campylobacter disease is highest in the community health setting, with only a small proportion of cases needing hospitalization.

Pregnant women lack accurate knowledge of their BMI and recommended gestational weight gain.

AIM: To investigate pregnant women's knowledge of their body mass index (BMI) and their knowledge of gestational weight gain guidelines. METHODS: Participants were recruited when attending their nuchal translucency scan at between 11 and 13 weeks, 6-days gestation in Dunedin or Christchurch, New Zealand. Recruitment staff measured participants' weight and height. By way of a self-administered, paper-based survey, participants were asked to identify their body size (including: underweight (BMI <18.5 kg/m2); normal weight (18.5-24.9); overweight (25-29.9); and obese (≥30)), and recommended gestational weight gain (including the 2009 Institute of Medicine guidelines for healthy weight gain in pregnancy, along with the options: "I should not gain any weight in my pregnancy", plus "It does not matter how much weight I gain"). Participant-measured BMI was compared to responses for perceived BMI and recommended gestational weight gain to assess accuracy. Demographic predictors of accuracy were also investigated. RESULTS: In total, 644 women were included. Sixty-six percent of these correctly identified their BMI category, however only 31% identified their correct gestational weight gain recommendation. Overweight and obese women were much more likely to underestimate their BMI than normal weight women (p<0.001 for both). Overweight and obese women were also more likely to overestimate their weight gain recommendation (OR=4, p<0.001; OR=18, p<0.001, respectively) while normal weight women were more likely to underestimate their weight gain recommendation (p<0.001). Independent of BMI, women of New Zealand European ethnicity were less likely to underestimate their recommended gestational weight gain compared to other women of non-Maori/non-Pacific Island ethnicity (p=0.001), whereas younger women (p=0.012) were more likely to underestimate recommended gestational weight gain. CONCLUSION: The present study indicates that New Zealand women, particularly those who are overweight and obese, lack accurate knowledge of their own body size, and this may lead to an under- or over-estimation of appropriate gestational weight gain, which may in turn lead to increased risk of poor health outcomes in pregnancy. Education strategies related to healthy weight gain in pregnancy are urgently required.

Weight and height measurement: potential impact in obstetric care.

AIM: To assess the accuracy of reported weight and height in a pregnant population. METHODS: Participants were recruited when attending their nuchal translucency scan if they attended with an 'antenatal screening for Down syndrome and other conditions' laboratory form (used for the maternal serum screening in the first trimester (MSS1) blood test) that had weight and/or height recorded. Participants' weight and height were measured by trained recruitment centre staff and body mass index (BMI) was calculated. Differences in reported (MSS1) and measured weight, height and BMI were analysed using Bland-Altman plots. RESULTS: 248 women participated. Only 23% (n=56) of participants had a weight recorded on the MSS1 laboratory form that was within plus or minus 0.5 kg of measured weight: 62% (n=155) had an under-reported weight, and 15% (n=37) an over-reported weight. 30% (n=74) of participants had a correctly reported height: 26% (n=63) an under-reported height, and 44% (n=107) an over-reported height. 6% (n=14) of participants had a correctly reported BMI: 69% (n=166) had an under-reported BMI, and 25% (n=60) an over-reported BMI. 17% of participants (n=40) were incorrectly classified by BMI category based on MSS1 data. CONCLUSION: Our study suggests that there are considerable inaccuracies in the recording of weight and height during pregnancy in New Zealand. This results in a false reduction in BMI in many women which can affect clinical care.