Putting ICU triage guidelines into practice: A simulation study using observations and interviews.

BACKGROUND: The COVID-19 pandemic has prompted many countries to formulate guidelines on how to deal with a worst-case scenario in which the number of patients needing intensive care unit (ICU) care exceeds the number of available beds. This study aims to explore the experiences of triage teams when triaging fictitious patients with the Dutch triage guidelines. It provides an overview of the factors that influence decision-making when performing ICU triage with triage guidelines. METHODS: Eight triage teams from four hospitals were given files of fictitious patients needing intensive care and instructed to triage these patients. Sessions were observed and audio-recorded. Four focus group interviews with triage team members were held to reflect on the sessions and the Dutch guidelines. The results were analyzed by inductive content analysis. RESULTS: The Dutch triage guidelines were the main basis for making triage decisions. However, some teams also allowed their own considerations (outside of the guidelines) to play a role when making triage decisions, for example to help avoid using non-medical criteria such as prioritization based on age group. Group processes also played a role in decision-making: triage choices can be influenced by the triagists' opinion on the guidelines and the carefulness with which they are applied. Intensivists, being most experienced in prognostication of critical illness, often had the most decisive role during triage sessions. CONCLUSIONS: Using the Dutch triage guidelines is feasible, but there were some inconsistencies in prioritization between teams that may be undesirable. ICU triage guideline writers should consider which aspects of their criteria might, when applied in practice, lead to inconsistencies or ethically questionable prioritization of patients. Practical training of triage team members in applying the guidelines, including explanation of the rationale underlying the triage criteria, might improve the willingness and ability of triage teams to follow the guidelines closely.

Communication between Dutch community nurses and general practitioners lacks structure: An explorative mixed methods study .

BACKGROUND: Community nurses and general practitioners evaluate their patient-related communication to be poor. However, their actual communication has hardly been investigated and specific strategies for improvement are unclear. OBJECTIVES: To explore actual community nurse-general practitioner communication in primary care and gain insights into communication style, and conversation structure and their determinants. METHODS: A mixed-methods design was applied. Telephone conversations between community nurses and general practitioners in the Netherlands were recorded and transcribed verbatim. We measured structure and the duration of their conversations, and community nurses' self-confidence towards general practitioners and their trust in and familiarity with the conversation partner. A thematic analysis was applied to the transcripts of the conversations. Correlations between these determinants were calculated using Spearman's correlation coefficient. RESULTS: The 18 community nurses recorded 23 conversations with general practitioners. Qualitative analysis revealed that many conversations lacked structure and conciseness, i.e. the nurses started conversations without a clearly articulated question and did not provide adequate background information. The mean duration of their conversations with doctors was 8.8 min. Community nurses with higher self-confidence towards doctors communicated in a more structured way (p = 0.01) and general practitioners were more satisfied about the conversations (p = 0.01). CONCLUSION: This exploratory study of actual community nurse-doctor telephone conversations in primary care identified communication structure and nurse self-confidence towards general practitioners as key targets for the improvement of interprofessional communication, which may increase the effectiveness of community nurse-general practitioner collaboration.

Identification of influencing factors and strategies to improve communication between general practitioners and community nurses: a qualitative focus group study.

Background: As the number of patients with complex healthcare needs grows, inter-professional collaboration between primary care professionals must be constantly optimized. General practitioners (GPs) and community nurses (CNs) are key professions in primary care; however, poor GP-CN communication is common, and research into the factors influencing its quality is limited. Objective: To explore patient-related GP-CN communication and facilitating and hindering factors, and to identify strategies to enhance this communication. Method: A qualitative focus group design was used to identify the facilitating and hindering factors and strategies for improvement. In a Dutch primary care setting, 6 mono-professional focus group interviews (3 meetings of 13 GPs; 3 meetings of 18 CNs) were organized between June 2015 and April 2016, recorded and transcribed verbatim. Two independent researchers performed the coding of these interviews, identifying their categories and themes. Results: Results show that, despite the regular contact between GPs and CNs, communication was generally perceived as poor in effectiveness and efficiency by both professions. Mutual trust was considered the most important facilitating factor for effective communication. Profession-specific factors (e.g. differences in responsibility and profession-specific language) and organizational factors (e.g. lack of shared care plans, no in-person communication, lack of time) may be of influence on communication. Participants' suggestions for improvement included organizing well-structured and reimbursed team meetings and facilitating face-to-face contact. Conclusion: GP-CN patient-related communication benefits most from trusting inter-personal relationships. Inter-professional training programmes should address both professional and organizational factors and should be evaluated for their effect on quality of care.

Determinants of the sustained employment of physician assistants in hospitals: a qualitative study.

OBJECTIVES: To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment. DESIGN: We conducted a qualitative study with semistructured interviews with care providers. Interviews continued until data saturation was achieved. All interviews were transcribed verbatim. A framework approach was used for data analysis. Codes were sorted by the themes, bringing similar concepts together. SETTING: This study was conducted between June 2014 and May 2015 within 11 different hospital wards in the Netherlands. The wards varied in medical speciality, as well as in hospital type and the organisational model for inpatient care. PARTICIPANTS: Participant included staff physicians, residents, PAs and nurses. RESULTS: The following themes emerged to be important for the initial employment of PAs and the sustainability of their employment: the innovation, individual factors, professional interactions, incentives and resources, capacity for organisational change and social, political and legal factors. CONCLUSIONS: 10 years after the introduction of PAs, there was little discussion among the adopters about the added value of PAs, but organisational and financial uncertainties played an important role in the decision to employ and continue employment of PAs. Barriers to employ and continue PA employment were mostly a consequence of locally arranged restrictions by hospital management and staff physicians, as barriers regarding national laws, PA education and competencies seemed absent.

A systematic approach towards the development of a set of quality indicators for public reporting in community-based maternity care.

OBJECTIVE: to demonstrate the process and outcome of a systematic approach towards the development of a set of quality indicators for public reporting on quality of community-based maternity care. DESIGN AND SETTING: a four-stepped approach was adopted. Firstly, we defined key elements of community-based maternity care, by performing a systematic search on care guidelines/ standards. Secondly, the literature was searched for existing indicators for maternity care, which were subsequently categorised according to the key elements and systematically selected on suitability of public presentation. The emerging set of indicators suitable for public reporting was presented to five health-care professionals using a Delphi technique (step 3). Based on the comments of the professionals, the set was adjusted and subsequently presented to the health-care consumers (a sample of pregnant women) in step four to test its validity, after which the final set was composed. PARTICIPANTS: health-care professionals in the field of maternity care and pregnant women. FINDINGS: key elements of community-based maternity care were extracted from eight guidelines and care standards. We then extracted 10 documents with 223 indicators in total, from which 19 indicators covering the key elements were included in the first set and presented to experts. Based on their comments three indicators were deleted and four indicators were added to the set or slightly rephrased. These were subsequently judged by 13 pregnant women. Seventy-five per cent of the indicators were judged positively by them; no indicator was judged negatively. The set of indicators was thus left unchanged after this final step. KEY CONCLUSIONS AND IMPLICATIONS FOR CLINICAL PRACTICE: the systematic approach adopted in this study resulted in an indicator set that was considered valid by both maternity care professionals and pregnant women, and is likely to satisfy the essential requirements on clinimetric properties. The next step will be to pilot test the indicator set on feasibility in daily clinical practice and to refine the set when necessary. In the future, maternity care professionals may use the set to present the quality of care they provide and to define issues of improvement. Pregnant women may use the information to make a founded choice between maternity care professionals, which ultimately should result in improved safety and quality of maternity care as well as patient satisfaction. Although we focused on the Dutch, community-based maternity care system, the approach used may be extrapolated to other care processes and health-care systems. Extrapolation of the results itself (i.e. the indicator set) may need to be limited to systems with an emphasis on community-based maternity care.