Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study.

BACKGROUND: Intensive care (ICU) patients' burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AIMS: To understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. METHODS: Consecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. RESULTS: Overall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged. Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. CONCLUSIONS: Effective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Development of a position statement for Australian critical care nurse education.

Position statements are used by large organisations such as the Australian College of Critical Care Nurses to publically present an official philosophy or beliefs and to propose recommendations. Position statements are increasingly used by health departments and healthcare facilities to allocate resources and to guide and audit nursing practice, yet there are limited resources on the process of their development. A position statement should help readers better understand the issue, communicate solutions to problems, and inform decision-making. It should be supported by the highest level of evidence available and reflect the organisation's governing objectives and goals. In this article, we describe the structured approach used to develop a position statement for Australian critical care nurse education. The formation of an expert advisory panel, synthesis of available evidence using Whittemore and Knafl's integrative review methodology, use of Donabedian's structure-process-outcomes quality framework as a theoretical approach, and multiple layers of consensus building and consultation enabled the development of an important critical care document and informed an implementation plan. The framework and processes we have outlined in this discussion article may provide a useful starting point for other professional organisations wishing to develop similar position statements.

Structures, processes and outcomes of specialist critical care nurse education: An integrative review.

OBJECTIVES: The objective of this study was to review and synthesise international literature to reveal the contemporary structures, processes, and outcomes of critical care nurse (CCN) education. METHOD: An integrative review on specialist critical care education was guided by Whittemore and Knafl's integrative review steps: problem identification; literature search; and data evaluation, analysis, and presentation. Donabedian's Quality Framework (Structure-Process-Outcome) provided a useful analytical lens and structure for the reporting of findings. RESULTS: (1) Structures for CCN education incorporated transition-to-practice and ongoing education programs typically offered by hospitals and health services and university-level graduate certificate, diploma, and masters programs. Structural expectations included a standard core curriculum, clinically credible academic staff, and courses compliant with a higher education framework. Published workforce standards and policies were important structures for the practice learning environment. (2) Processes included incremental exposure to increasing patient acuity; consistent and appropriately supported and competent hospital-based preceptors/assessors; courses delivered with a flexible, modular approach; curricula that support nontechnical skills and patient- and family-centred care; stakeholder engagement between the education provider and the clinical setting to guide course planning, evaluation and revalidation; and evidence-based measurement of clinical capabilities/competence. (3) Outcomes included articulation of the scope and levels of graduate attributes and professional activities associated with each level. The role of higher degree research programs for knowledge creation and critical care academic leadership was noted. CONCLUSIONS: Provision of high-quality critical care education is multifaceted and complex. These findings provide information for healthcare organisations and education providers. This may enable best practice structures and processes for critical care specialist training that meets the needs of industry and safely supports developing CCN expertise. There is an acknowledged tension between the expectations of governing bodies for policies, standards, and position statements to enhance quality and reduce care variance and the availability of high-quality evidence to underpin these across international contexts.

Incidents resulting from staff leaving normal duties to attend medical emergency team calls.

OBJECTIVE: To determine the rate of adverse events and incidents occurring as a result of hospital staff leaving normal duties to attend medical emergency team (MET) calls. DESIGN, PARTICIPANTS AND SETTING: Single-centre, interview and questionnaire-based study of staff attending MET calls at a 650-bed university teaching hospital in Sydney, New South Wales, July to December 2013. MAIN OUTCOME MEASURE: The rate of adverse events and incidents directly related to MET staff leaving normal duties to attend MET calls. RESULTS: During the study period, 1490 structured interviews were conducted, and 279 written questionnaires were returned (overall response rate, 66.4%). There were no adverse events. There were 378 recorded incidents. The incident rate was 213.7 incidents per 1000 MET participant attendances (95% CI, 194.8-233.5), and 1.1 incidents per MET call. Using the severity assessment code, 99.5% of incidents were classified as minimum. The most commonly reported incidents were disruptions to normal duties, ward rounds, and patient reviews. Only 0.8% of incidents were reported on institutional incident reporting systems. CONCLUSION: Significant disruption to normal hospital routines and inconvenience to staff occurred, without causing major harm to patients, when MET staff temporarily left normal duties to attend MET calls. Normal hospital incident reporting systems cannot be used to monitor for these problems, as they are underreported.