Implementation of clinical decision support to manage acute kidney injury in secondary care: an ethnographic study.

BACKGROUND: Over the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing AKI CDSSs within routine hospital care. METHODS: An ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption. RESULTS: The two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation and the wider system of care. A common tension was associated with attempts to maximise benefit while minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice. CONCLUSIONS: Our analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (eg, digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work.

The role of boundary spanners in delivering collaborative care: a process evaluation.

BACKGROUND: On average, people with schizophrenia and psychosis die 13-30 years sooner than the general population (World Psychiatry 10 (1):52-77, 2011). Mental and physical health care is often provided by different organisations, different practitioners and in different settings which makes collaborative care difficult. Research is needed to understand and map the impact of new collaborative ways of working at the primary/secondary care interface (PloS One 7 (5); e36468). The evaluation presented in this paper was designed to explore the potential of a Community and Physical Health Co-ordinator role (CPHC) (CPHCs were previously Care Co-ordinators within the Community Mental Health Team, Community in the title CPHC refers to Community Mental Health) and Multi-Disciplinary Team (MDT) meetings across primary and community care, with the aim of improving collaboration of mental and physical health care for service users with Severe Mental Illness (SMI). METHODS: Data collection took place across five general practices (GPs) and a Community Mental Health Team (CMHT) in the Northwest of England, as part of a process evaluation. Semi-structured interviews were conducted with a purposive sample of GP staff (n= 18) and CMHT staff (n=4), a focus group with CMHT staff (n=8) and a survey completed by 13 CMHT staff, alongside cardiovascular risk data and MDT actions. Framework analysis was used to manage and interpret data. RESULTS: The results from the evaluation demonstrate that a CPHC role and MDT meetings are effective mechanisms for improving the collaboration and co-ordination of physical health care for SMI service users. The findings highlight the importance of embedding and supporting the CPHC role, with an emphasis on protected time and continuing professional roles and integrating multiple perspectives through MDT meetings. Considering the importance of physical health care for SMI service users and the complex environment, these are important findings for practitioners, researchers and policy makers in the field of primary care and mental health. CONCLUSION: There is an increasing focus on integration and collaborative working to ensure the delivery of quality care across the whole patient pathway, with a growing need for professionals to work together across service and professional boundaries. The introduction of a two pronged approach to collaboration has shown some important improvements in the management of physical health care for service users with SMI.

There is another way: empowering frontline staff caring for acutely unwell adults.

QUALITY PROBLEM OR ISSUE: It is estimated that only 17% of patients survive an in-hospital cardiac arrest. Medical evidence indicates that many patients show signs of deterioration during the 24 h period prior to their cardiac arrest. INITIAL ASSESSMENT: At Salford Royal NHS Foundation Trust (SRFT) 135 patients (outside critical care areas) suffered a cardiac arrest between March 2007 and April 2008. CHOICE OF SOLUTION: Quality improvement method-The breakthrough series (BTS) collaborative approach, change package-reliable manual vital signs, nurse-led response to the deteriorating patient, code red, structured ward round, ceilings of care, nurse-led do not attempt cardiopulmonary resuscitation (DNA-CPR) protocol and allocated roles. IMPLEMENTATION: The project was delivered over two phases with a total of 23 wards (12 wards in Phase One and 11 wards in Phase Two). Frontline teams worked to develop changes with the aim of reducing cardiac arrests by 50%. EVALUATION: The primary outcome measure was the number of cardiac arrests per 1000 admissions outside of critical care areas. Process and balancing measures were also used to evaluate the impact of the intervention. LESSONS LEARNED: The results showed a positive relationship between the change package and a reduction of 41% in cardiac arrests outside of critical care areas from the baseline period (April 2007-March 2008) to December 2012. The BTS model has the potential to reduce cardiac arrests without the need for initial large-scale financial investment.

How a quality improvement initiative can be used to promote single sex accommodation.

The NHS is committed to delivering privacy and dignity to all patients. To this end, the Department of Health has implemented initiatives to eliminate mixed sex wards. Salford Royal Foundation Trust is committed to three guiding principles of clean, safe and personal care. In April 2008, the trust launched its quality improvement strategy, and the single sex project within this aims to ensure that 95% of patients are admitted directly to single sex accommodation. This initiative implemented a number of tests of change relating to workforce and culture, facilities and planning, and communication. To examine whether these tests had resulted in an improvement, outcome, process and balancing measures were designed. The outcome measures showed the trust reached a compliancerate of 93% of all patients admitted to three clinical areas.