[Contribution of a hospital pharmacy team to critical care of patients infected with SARS-CoV-2]. / Contribution d'une équipe de pharmacie hospitalière à la prise en charge en réanimation des patients infectés par le SARS-CoV-2.

With regard to the hospital drug supply chain, the safest system is the individual automated drug dispensing one provided by the pharmacy. For several years we have been trying to convince hospital decision-makers to set it up. In the meantime, to mitigate the risks of medication errors incurred by patients and caregivers, we have set up several work teams within the care units. These teams, made up of one pharmacist and one or two hospital pharmacy technicians, who notably manage the medicine cabinets in care units. The close collaboration with doctors and nurses developed over the years was a determining factor when it became necessary to provide the newly created additional intensive care units with drugs and medical devices (MDs) in order to cope with the crisis triggered by the SARS-CoV-2 epidemic. Daily monitoring of the drugs consumed by each patient, particularly neuromuscular blocking agents and MDs was a key element in managing stocks and anticipating changes of drugs, packaging and/or devices references. These facts give weight to the Claris report published in France which recognizes that the interactions of pharmacy technicians and pharmacists in the care units have positive effects in terms of quality and safety of patient care. They highlight the dangers to which patients and caregivers are exposed on Saturdays, Sundays and holidays when the pharmacy is closed. They legitimize the question of extending the opening of the pharmacy with a full team 365 days a year.

Overnight cross-coverage on hospital medicine services: perceived workload based on patient census, pager volumes, and patient acuity.

OBJECTIVE: Little is understood about what contributes to perceived workload for those providing overnight coverage to hospitalized patients overnight, which limits the ability to modify these factors or to proactively identify appropriate staffing levels. The objective of this study is to understand the major contributors to perceived overnight cross-coverage workload. METHODS: Cross-covering advanced practice providers (APPs) in a large academic hospitalist group completed the National Aeronautics and Space Administration Task Load Index (NASA-TLX) at the end of each night shift. Other shift characteristics were collected, including patient load, assigned action items, watcher/unstable patients, newly admitted patients, number of units covered, total pages, peak pager density, rapid response team (RRT) activations, and intensive care unit (ICU) transfers. RESULTS: For 14 APP participants, who completed 271 post-shift surveys, the mean (SD) patient load was 49.9 (6.4) patients per night, and providers received a mean (SD) of 40.8 (13.7) total pages per shift. Mean (SD) NASA-TLX score was 35.1 (19.0). In multivariate modeling, total pages, action items, and any RRT or ICU transfer were associated with significant increases in the mean NASA-TLX score, with estimated effect sizes of 0.5, 0.8, and 14.3, respectively, per 1-unit increase in each shift characteristic. The greatest cumulative contributor to perceived workload was total number of pages, followed by the presence of any RRT activation/ICU transfer, with estimated effect sizes of 20.4 and 14.9, respectively. CONCLUSIONS: Total number of pages was the greatest contributor to perceived workload. This study suggests that quality improvement initiatives designed to improve pager communication may considerably improve provider-perceived workload.

The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes.

BACKGROUND: Various intensivist staffing models have been suggested, but the long-term sustainability and outcomes vary and may not be sustained. We examined the impact of implementing a high-intensity intensivist coverage model with a nighttime in-house nocturnist (non-intensivist) and its effect on intensive care unit (ICU) outcomes. METHODS: We obtained historical control baseline data from 2007 to 2011 and compared the same data from 2011 to 2015. The Acute Physiological and Chronic Health Evaluation outcomes system was utilized to collect clinical, physiological, and outcome data on all adult patients in the medical ICU and to provide severity-adjusted outcome predictions. The model consists of a mandatory in-house daytime intensivist service that leads multidisciplinary rounds, and an in-house nighttime coverage is provided by nocturnist (nonintensivists) with current procedural skills in airways management, vascular access, and commitment to supervise house staff as needed. The intensivist continues to be available remotely at nighttime for house staff and consultation with the nocturnist. A backup intensivist is available for surge management. RESULTS: First year yielded improved throughput (2428 patients/year to 2627 then 2724 at fifth year). Case mix stable at 53.7 versus 55.2. The ICU length of stay decreased from 4.7 days (predicted 4.25 days) to 3.8 days (4.15) in first year; second year: 3.63 days (4.29 days); third year: 3.24 days (4.37), fourth year: 3.34 days (4.45), and fifth year: 3.61 days (4.42). Intensive care unit <24 hours readmission remained at 1%; >24 hours increased from 4% to 6%. Low-risk monitoring admissions remained at an average 17% (benchmark 17.18%). Intensive care unit mortality improved with standardized mortality ration averaging at 0.84. Resident satisfaction surveys improved. CONCLUSIONS: Implementing an intensivist service with nighttime nocturnist staffing in a high-intensity large teaching hospital is feasible and improved ICU outcomes in a sustained manner that persisted after the initial implementation phase. The model resulted in reduced and sustained observed-to-predicted length of ICU stay.

Nighthawk: Making Night Float Education and Patient Safety Soar.

BACKGROUND: Some residency programs responded to duty hour restrictions by implementing night rotations. Night supervision models can vary, resulting in potential patient safety issues and educational voids for residents. OBJECTIVE: We evaluated the impact of multiple evidence-based interventions on resident satisfaction with supervision, perception of the education value of night rotations, and residents' use of online educational materials. METHODS: The night team was augmented with an intern to assist with admissions and a senior resident (the "nighthawk") to supervise inpatient care and deliver a night medicine curriculum. We instituted a "must-call" list, with specific clinical events requiring mandatory attending notification, and reduced conflict in the role of the night float team. We studied patient contact, online curriculum use, residents' perceptions of nighthawk involvement, exposure to educational materials, and satisfaction with supervision. RESULTS: During the first half of academic year 2016-2017, 51% (64 of 126) of trainees were on the night medicine rotation. The nighthawk reviewed 1007 intern plans (15 per night; range, 6-36) and supervised 215 hands-on evaluations, including codes and rapid responses (3 per night; range, 0-12). The number of users of the online education materials increased by 85% (13 to 24), and instances of use increased 35% (85 to 115). The majority of residents (79%, 27 of 34) favored the new system. CONCLUSIONS: A nighthawk rotation, a must-call list, and reducing conflict in night team members' roles improved resident satisfaction with supervision and the night medicine rotation, resulting in increased communication.

Intervención para reducir la repercusión en el sueño de la luz y el ruido en áreas de observación de urgencias / Intervention to reduce the impact of light and noise on sleep in an emergency department observation area

Objetivo: Conocer la calidad del descanso nocturno tras una intervención para minimizar la presencia de luz y el ruido nocturnos en las áreas de observación de urgencias (AOU) de un hospital urbano. Método: Se realiza un ensayo clínico cuasiexperimental con un grupo preintervención (Grupo PRE) y otro posterior (Grupo POS) a la intervención, mediante cuestionario ad hoc sobre repercusión de luz y ruido en la calidad del descanso nocturno en el AOU del Hospital Clinic de Barcelona. La intervención consistió en cambios estructurales para reducir luz y el ruido ambientales, así como la instauración de un procedimiento normalizado de trabajo para modificar los planes de cuidados nocturnos. Resultados: Se incluyeron en el Grupo PRE 50 enfermos y 371 en el Grupo POS. El grupo PRE declaró haber tenido un buen descanso en un 72% de los casos frente al 91% del grupo POS (p < 0,001). Factores como el dolor, las intervenciones enfermeras o el sueño diurno no repercutieron en la calidad del sueño. Conclusiones: La luz y el ruido ambientales influyen en el descanso nocturno en AOU más que otras variables conocidas. Intervenciones sobre la luz y el ruido pueden mejorar objetivamente el descanso nocturno de los pacientes (AU)

Objective: To study quality of patient rest before and after an intervention to reduce nighttime light and noise in the emergency department observation area of an urban hospital. Methods: Quasi-experimental study in 2 groups before and after the intervention in the observation area of the Hospital Clinic de Barcelona. We administered a questionnaire about the quality of nighttime rest to assess the effect of light and noise on sleep. Light and noise were reduced by means of structural changes to the environment and through the introduction of protocols to modify how care plans were carried out at night. Results: Fifty nurses participated in the pre-intervention study and 371 in the post-intervention study. Seventy-two percent and 91.37% of the patients reported resting well before and after the intervention, respectively (P<.001). Factors like pain, nursing care, or daytime naps do not affect sleep quality. Conclusions: Nighttime rest in emergency department observation areas is affected by ambient light and noise more than by other variables. Reducing light and noise at night can measurably improve patients’ rest (AU)

Best Practice for After-Hours Hospice Symptom Management: A Literature Review.

Medicare-certified hospice home care agencies must provide a 24/7 on-call system to respond to patient and caregiver concerns. How these calls are handled impacts patient and family outcomes and satisfaction. Ideally, hospice nurses provide adequate caregiver education during routine visits to minimize the need for after-hours calls. A literature review provided evidence that hospice nurse education and appropriate telephone support improves symptom management, enhances family support, provides a sense of security, reduces anxiety, and promotes comfort.

Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study.

INTRODUCTION: Research has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England. METHODS: We conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital. RESULTS: The analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation. CONCLUSIONS: We found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.

Perceptions of nurses and physicians of their communication at night about intensive care patients' pain, agitation, and delirium.

BACKGROUND: Ineffective daytime nurse-physician communication in intensive care adversely affects patients' outcomes. Nurses' and physicians' communications and perceptions of this communication at night are unknown. OBJECTIVES: To determine perceptions of nurses and physicians of their communication with each other at night in the intensive care unit about patients' pain, agitation, and delirium and to develop a qualitative survey instrument to investigate this topic. Methods A validated survey was distributed to nighttime nurses and physicians in 2 medical intensive care units. RESULTS: Most nurses (30/45; 67%) and physicians (56/75; 75%) responded. Nurses (35%) and physicians (31%) thought that a similar proportion of communications was related to pain, agitation, and delirium. Most nurses (70%) and physicians (80%) agreed that nurses used good judgment when paging physicians at night because of patients' pain, agitation, and delirium, but physicians (72%) were more likely than nurses (48%) to think that these pages did not portray the situation accurately (P = .004). For many text pages, physicians attributed a heightened level of urgency more often than did the nurses who sent the texts. Nurses often thought that physicians did not appreciate the urgency (33%) or complexity (33%) of the situations the nurses communicated via pages. More physicians (41%) than nurses (14%) agreed that nurses exceeded medication orders for pain, agitation, and delirium before contacting a physician (P = .008). CONCLUSIONS: Perceptual differences between physicians and nurses about nurse-physician communications at night regarding pain, agitation, and delirium were numerous and should be studied further.

Nursing work at night in palliative oncology care.

OBJECTIVE: to understand the meaning baccalaureate nurses and nursing technicians attribute to night work in the context of clinical palliative oncology nursing care services, as well as how nursing works to attend to clients and caregivers' needs in this period. METHOD: in this exploratory and qualitative study, grounded theory was used. Seven nurses and four nursing technicians were interviewed, who composed two sample groups. Nine categories were produced and, in their comparative content analysis, a knowledge emphasis was evidenced with implications for nighttime nursing work. In this study, these aspects were discussed in two of the categories, which are: to describe care practice in order to understand nursing care management and to point out the difficulties in care practice and nursing care management. RESULTS: The results evidence the complexity in the nighttime care context, considering the clients' clinical conditions and clients and caregivers' psychological demands, mainly because of the threat of death. CONCLUSION: The team attempts to respond to these needs through communication, but reveals a lack of assistential services and an overload. Interdisciplinarity is a palliative care premise, favoring holistic care delivery, and cannot be neglected at, which requires attention and investment to develop better practices.

Nursing work at night in palliative oncology care / O trabalho noturno da enfermagem no cuidado paliativo oncológico / El trabajo nocturno de la enfermería en el cuidado paliativo oncológico

OBJECTIVE: to understand the meaning baccalaureate nurses and nursing technicians attribute to night work in the context of clinical palliative oncology nursing care services, as well as how nursing works to attend to clients and caregivers' needs in this period. METHOD: in this exploratory and qualitative study, grounded theory was used. Seven nurses and four nursing technicians were interviewed, who composed two sample groups. Nine categories were produced and, in their comparative content analysis, a knowledge emphasis was evidenced with implications for nighttime nursing work. In this study, these aspects were discussed in two of the categories, which are: to describe care practice in order to understand nursing care management and to point out the difficulties in care practice and nursing care management. RESULTS: The results evidence the complexity in the nighttime care context, considering the clients' clinical conditions and clients and caregivers' psychological demands, mainly because of the threat of death. CONCLUSION: The team attempts to respond to these needs through communication, but reveals a lack of assistential services and an overload. Interdisciplinarity is a palliative care premise, favoring holistic care delivery, and cannot be neglected at, which requires attention and investment to develop better practices. .

OBJETIVO: compreender o significado atribuído pelos enfermeiros e técnicos de enfermagem acerca do trabalho noturno, no contexto das enfermarias clínicas de cuidado paliativo oncológico, bem como o modo de trabalho da enfermagem em busca do atendimento das necessidades dos clientes e cuidadores, nesse período. MÉTODO: estudo exploratório, qualitativo, utilizando-se a Grounded Theory. Foram entrevistados sete enfermeiros e quatro técnicos de enfermagem, compondo dois grupos amostrais. Geraram-se nove categorias e na análise do conteúdo das mesmas, comparativamente, evidenciou-se conhecimento de destaque, com implicações no trabalho noturno da enfermagem. Tais aspectos foram discutidos no presente estudo em duas das categorias, a saber: descrevendo a prática para compreensão do gerenciamento do cuidado de enfermagem e apontando as dificuldades da prática e do gerenciamento do cuidado de enfermagem. RESULTADOS: evidenciam-se a complexidade do contexto no noturno, considerando o quadro clínico dos clientes e a demanda psicológica desses e dos seus cuidadores, principalmente pela ameaça da morte. CONCLUSÃO: a equipe busca atender tais necessidades a partir da comunicação, mas evidencia carência dos serviços assistenciais e sobrecarga. A interdisciplinaridade é uma premissa do cuidado paliativo, em prol da integralidade, e não pode ser negligenciada no trabalho noturno, o que requer atenção e investimento para o desenvolvimento de melhores práticas. .

OBJETIVO: comprender el significado atribuido por los enfermeros y técnicos de enfermería acerca del trabajo nocturno en el contexto de las enfermarías clínicas de cuidado paliativo oncológico, y también el modo de trabajo de la enfermería en el intento de atender a las necesidades de los clientes y cuidadores en este período. MÉTODO: estudio exploratorio, cualitativo, que utilizó la Grounded Theory (Teoría Fundamentada en los Datos). Fueron entrevistados siete enfermeros y cuatro técnicos de enfermería, incluidos en dos grupos de muestreo. Fueron generadas nueve categoría y, en el análisis de contenido de las mismas, comparativamente, fue evidenciado un conocimiento de destaque, con implicaciones en el trabajo nocturno de la enfermería. Tales aspectos fueron discutidos en el presente estudio en dos de las categorías, a saber: describiendo la práctica para comprensión de la gestión del cuidado de enfermería y indicando las dificultades de la práctica y gestión del cuidado de enfermería. RESULTADOS: los resultados evidencian la complejidad del contexto en el trabajo nocturno, considerando el cuadro clínico de los clientes y la demanda psicológica de estos y de sus cuidadores, principalmente debido a la amenaza de la muerte. CONCLUSÍON: el equipo busca atender a tales necesidades a partir de la comunicación, pero evidencia carencia de los servicios asistenciales y sobrecarga. La interdisciplinariedad es una premisa del cuidado paliativo, a favor de la integralidad, y no se la puede ignorar en el trabajo nocturno, lo que demanda atención e inversiones para el desarrollo de mejores prácticas. .

Effects of night-float and 24-h call on resident psychomotor performance.

INTRODUCTION: Night-float work schedules were designed to address growing concerns of the affect of fatigue on resident psychomotor and cognitive skills after traditional 24-h call work schedules. Whether this transition has achieved these results is debatable. This study was designed to compare the psychomotor performance of general surgery residents on both work schedule types. We hypothesized that when measured with novel laparoscopic simulator tasks, residents on a 24-h call schedule would exhibit worse psychomotor performance compared with those on a night-float work schedule. METHODS: Nine general surgery residents at the post-graduate year (PGY) 2, 3, and 5 levels were recruited and trained on the Simbionix LAP Mentor Simulator (Simbionix, Cleveland, OH). Performance on two tasks was tested before and after a 24-h call work shift and a night-float shift. A survey assessing levels of work shift activity and fatigue were administered after all work shifts. RESULTS: There was no statistically significant difference in resident accuracy, speed of movement, economy of movement, and time to completion of the two simulation tasks. The only measures of work shift activity achieving statistically significant difference were number of patients seen and numbers of steps walked on call. There was no statistically significant difference in subjective evaluation of fatigue. CONCLUSIONS: In this study of general surgery residents, a statistically significant difference in psychomotor performance between residents working 24-h call shift versus a 12-h night-float shift could not be found. Psychomotor performance does not appear to suffer after a work shift. Additionally, post-shift subjective evaluations of fatigue are comparable regardless of shift type.

Enhancing communication between night shift RNs and hospitalists: an opportunity for performance improvement.

In a rapid cycle quality improvement project, the creation of a nurse-physician task force defined guidelines for nurse-physician communication between hospitalists and night shift nurses. Benefits include creating a structured presentation of patient information, reduced nonurgent pager interruptions, and formation of a collaborative team to smooth future communication concerns.

Experiences implementing a 6-month pilot of a 7-day community CNS service in an urban hospice in Scotland.

BACKGROUND: Patients and carers may face challenges in the out-of-hours period, with inadequate support and variations in service provision, including access to specialist palliative care. A pilot was undertaken to extend availability of the community clinical nurse specialist (CNS) team to include weekends and public holidays. AIM: To examine the need for a 7-day community CNS service. METHOD: Activity data was collected for 6 months and feedback was sought from service users and the CNS team. RESULTS: There were 132 out-of-hours telephone contacts in the 6-month period, generating 35 home visits. Almost two thirds of these calls were proactive, 'planned' contacts. Most unplanned calls (68%) were from a carer for advice about symptom management and support as the patient's condition changed. CONCLUSION: The pilot demonstrated the need for a CNS service 7 days a week, and the service is now embedded in practice. Seven-day working benefits patients and families while being valued by the professional team.

Twenty-four/seven: a mixed-method systematic review of the off-shift literature.

AIM: This article is a report of a review that aimed to synthesize qualitative and quantitative evidence of 'off-shifts' (nights, weekends and/or holidays) on quality and employee outcomes in hospitals. BACKGROUND: Healthcare workers provide 24-hour-a-day, 7-day-a-week service. Quality and employee outcomes may differ on off-shifts as compared to regular hours. DATA SOURCES: Searches for studies occurred between the years 1985-2011 using computerized databases including Business Source Complete, EconLit, ProQuest, PubMed and MEDLINE. REVIEW DESIGN AND METHODS: Design was a mixed-method systematic review with quantitative and qualitative studies. To be included, studies met the following criteria: (1) the independent variable was an off-shift; (2) the article was a research study and peer-reviewed; (3) the article could be obtained in English; and (4) the article pertained to health care. Studies were not excluded on design. RESULTS: Sixty studies were included. There were 37 quality outcome, 19 employee outcome and four qualitative studies. In the quality outcome studies, researchers often used quantitative, longitudinal study designs with large sample sizes. Researchers found important differences between patients admitted on weekends and mortality. Important differences were also found between nighttime birth and mortality and rotating night work and fatigue, stress and low mental well-being. Most studies (9 of 12) did not find an important association between patients admitted at night and mortality. CONCLUSION: Patient outcomes on weekends and employee outcomes at night are worse than during the day. It is important to further investigate why care on off-shifts differs from weekly day shifts.