RESUMO
BACKGROUND: Delirium is a common condition in hospitalized patients, associated with adverse outcomes such as longer hospital stay, functional decline and higher mortality, as well as higher rates of nursing home placement. Nurses often fail to recognize delirium in hospitalized patients, which might be due to a lack of knowledge of delirium diagnosis and treatment. The objective of the study was to test the effectiveness of an e-learning course on nurses' delirium knowledge, describe nursing staff's baseline knowledge about delirium, and describe demographic factors associated with baseline delirium knowledge and the effectiveness of the e-learning course. METHODS: A before-and-after study design, using an e-learning course on delirium. The course was introduced to all nursing staff of internal medicine and surgical wards of 17 Dutch hospitals. RESULTS: 1,196 invitations for the e-learning course were sent to nursing staff, which included nurses, nursing students and healthcare assistants. Test scores on the final knowledge test (mean 87.4, 95% CI 86.7 to 88.2) were significantly higher than those on baseline (mean 79.3, 95% CI 78.5 to 80.1). At baseline, nursing staff had the most difficulty with questions related to the definition of delirium: what are its symptoms, course, consequences and which patients are at risk. The mean score for this category was 74.3 (95% CI 73.1 to 75.5). CONCLUSIONS: The e-learning course significantly improved nursing staff's knowledge of delirium in all subgroups of participants and for all question categories. Contrary to other studies, the baseline knowledge assessment showed that, overall, nursing staff was relatively knowledgeable regarding delirium. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR). TRIAL NUMBER: NTR 2885 , 19 April 2011.
Assuntos
Educação Baseada em Competências , Instrução por Computador , Delírio , Educação em Enfermagem , Recursos Humanos de Enfermagem Hospitalar/educação , Adulto , Competência Clínica , Delírio/diagnóstico , Delírio/etiologia , Delírio/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países BaixosRESUMO
BACKGROUND: Delirium occurs frequently in older hospitalised patients and is associated with several adverse outcomes. Ignorance among healthcare professionals and a failure to recognise patients suffering from delirium have been identified as the possible causes of poor care. The objective of the study was to determine whether e-learning can be an effective means of improving implementation of a quality improvement project in delirium care. This project aims primarily at improving the early recognition of older patients who are at risk of delirium. METHODS: In a stepped wedge cluster randomised trial an e-learning course on delirium was introduced, aimed at nursing staff. The trial was conducted on general medical and surgical wards from 18 Dutch hospitals. The primary outcome measure was the delirium risk screening conducted by nursing staff, measured through monthly patient record reviews. Patient records from patients aged 70 and over admitted onto wards participating in the study were used for data collection. Data was also collected on the level of delirium knowledge of these wards' nursing staff. RESULTS: Records from 1,862 older patients were included during the control phase and from 1,411 patients during the intervention phase. The e-learning course on delirium had a significant positive effect on the risk screening of older patients by nursing staff (OR 1.8, p-value <0.01), as well as on other aspects of delirium care. The number of patients diagnosed with delirium was reduced from 11.2% in the control phase to 8.7% in the intervention phase (p = 0.04). The e-learning course also showed a significant positive effect on nurses' knowledge of delirium. CONCLUSIONS: Nurses who undertook a delirium e-learning course showed a greater adherence to the quality improvement project in delirium care. This improved the recognition of patients at risk and demonstrated that e-learning can be a valuable instrument for hospitals when implementing improvements in delirium care. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR). TRIAL NUMBER: NTR2885.
Assuntos
Delírio/terapia , Educação a Distância/tendências , Cuidados de Enfermagem/tendências , Recursos Humanos de Enfermagem/educação , Melhoria de Qualidade/tendências , Idoso , Idoso de 80 Anos ou mais , Delírio/diagnóstico , Delírio/epidemiologia , Educação a Distância/métodos , Educação a Distância/normas , Feminino , Humanos , Masculino , Países Baixos/epidemiologia , Cuidados de Enfermagem/normas , Recursos Humanos de Enfermagem/normas , Recursos Humanos de Enfermagem/tendências , Melhoria de Qualidade/normas , Fatores de RiscoRESUMO
OBJECTIVE: To gain insight into which factors impede, and which facilitate, the implementation of a complex multi-component improvement initiative in hospitalized older patients. DESIGN: A qualitative study based on semi-structured interviews. The three dimensions of Pettigrew and Whipp's theoretical framework, namely, Process, Content and Context, were used to undertake a structured data analysis. SETTING: The study was conducted in 19 Dutch hospitals implementing the Frail Elderly Project. PARTICIPANTS: Sixty-five members of staff, including physicians, nurses and members of the policy team. INTERVENTION: The Frail Elderly Project, a Dutch quality improvement program, aims to decrease adverse events in frail older hospitalized people by implementing screening instruments and interventions targeting delirium, falls, malnutrition and physical impairment. MAIN OUTCOME MEASURES: The management of the process of implementation, participants' opinions of the program elements and contextual factors which influence the implementation. RESULTS: Barriers to implementation included two process factors (insufficient involvement of clinicians and lack of time), two content factors (having divergent objectives and concerns about recommended program elements) and two contextual factors (a lack of knowledge of delirium and minimal insight into the purposes and effects of the program). Facilitating factors included one process factor (leadership), one content factor (flexibility in choosing methods) and two contextual factors (the program's guidance and the use of digital patient records). CONCLUSION: We identified the barriers and the factors which facilitate implementing complex multi-component improvement programs concerning care for older patients. These barriers must be resolved in future improvement programs in order to ensure successful implementation.
Assuntos
Hospitais/normas , Melhoria de Qualidade/organização & administração , Idoso , Idoso Fragilizado , Serviços de Saúde para Idosos/organização & administração , Serviços de Saúde para Idosos/normas , Administração Hospitalar/métodos , Administração Hospitalar/normas , Humanos , Entrevistas como Assunto , Liderança , Países Baixos/epidemiologia , Segurança do Paciente , Recursos Humanos em Hospital , Desenvolvimento de Programas , Pesquisa QualitativaRESUMO
PURPOSE: The purpose of this study was to examine if the characteristics of patients influence nursing adherence to a quality improvement guideline. This guideline consists of delirium risk screening and preventive care, including the use of the Delirium Observation Screening Scale (DOSS). DESIGN: A retrospective patient record review study was performed in 18 Dutch hospitals that were implementing a quality improvement project regarding delirium care. The records of patients 70 years of age or older were reviewed over an 11-month period. METHODS: Patient characteristics, as well as the extent of risk screening and the application of the DOSS within the screened and nonscreened groups, were recorded by experienced research nurses. Characteristics were compared between these groups and within the high-risk group using multilevel logistic regression analysis. FINDINGS: A total of 1,881 patient records were analyzed. In 55% of the total sample, a risk screening was conducted, of which 44% were identified as patients with a high risk for delirium. Acute admissions were screened significantly less often. The DOSS was used in 48% of the patients in the high-risk group, but also in 13% of the patients without an identified risk and in 15% of the nonscreened patients. The factors influencing the use of the DOSS in screened and nonscreened patients included age, domestic circumstances, suffering from dementia, and acute admission. In the nonscreened group, comorbidity also showed significance. CONCLUSIONS: Patient characteristics influence nursing in preventive delirium care. CLINICAL RELEVANCE: The findings can help to improve preventive delirium care by nurses.
Assuntos
Delírio/enfermagem , Fidelidade a Diretrizes/estatística & dados numéricos , Programas de Rastreamento/enfermagem , Pacientes/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Idoso , Idoso de 80 Anos ou mais , Delírio/prevenção & controle , Feminino , Humanos , Masculino , Prontuários Médicos , Pesquisa em Avaliação de Enfermagem , Estudos Retrospectivos , Medição de RiscoRESUMO
RATIONALE, AIMS AND OBJECTIVES: Guidelines are intended as a means of getting research evidence into practice and ensuring provided care is of sufficient quality. However, the effect of guidelines is hindered by limited guideline adherence. The aim of this study is to identify and classify barriers to adherence by nurses to a guideline on delirium care. METHODS: Open-ended interviews were conducted with a purposive sample of 63 research participants. The sample included 28 nurses, 18 doctors and 17 policy advisors working in 19 hospitals in the Netherlands. The interviews were conducted between June and September 2011. The data were analysed using thematic analysis. RESULTS: Barriers to guideline adherence that were identified could be grouped into four themes: motivation and goals, knowledge and skills, professional role and identity, and context and resources. While the interviews with nurses, doctors and policy advisors produced similar views of the current situation, doctors and policy advisors placed a higher importance on education as a means of stimulating adherence. CONCLUSIONS: This study illustrates that individual, social and organizational factors play a role in nurse's adherence to a delirium guideline. The potential benefits of following a guideline, both for patients and for nursing staff, need to be highlighted in order to motivate nurses. When formulating new guidelines, nurses' perceptions of their professional role and patient care need to be taken into account to ensure that policy makers and managers are realistic about guideline adherence and engage with nurses from a position of mutual respect and trust.
Assuntos
Delírio/terapia , Fidelidade a Diretrizes , Equipe de Assistência ao Paciente/organização & administração , Guias de Prática Clínica como Assunto , Fatores Etários , Idoso , Delírio/diagnóstico , Feminino , Seguimentos , Hospitalização/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Masculino , Países Baixos , Papel do Profissional de Enfermagem , Papel do Médico , Pesquisa Qualitativa , Melhoria de Qualidade , Medição de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: To determine the change in adverse event (AE) rates and preventable AE rates over time, identify certain patient risk groups and discuss factors influencing the outcome. DESIGN: Longitudinal retrospective patient record review study. SETTING AND PARTICIPANTS: A random sample of 21 hospitals in The Netherlands in 2004, and 20 hospitals in 2008. In each hospital, 400 patient admissions were included in 2004, and 200 in 2008. MAIN OUTCOME MEASURES: AEs and preventable AEs. RESULTS: Multilevel analyses of 11 883 patient records (7.887 in 2004, 3.996 in 2008) showed that the rate of patients experiencing an AE increased from 4.1% (95% CI 3.3% to 5.1%) in 2004 to 6.2% (95% CI 5.0% to 7.6%) in 2008. The preventable AE rate remained relatively stable at 1.8% (95% CI 1.3% to 2.4%) in 2004 and 1.6% (95% CI 1.2% to 2.3%) in 2008. The risk of experiencing a preventable AE was increasingly higher for patients admitted to a surgical unit (OR 1.54 (95% CI 1.10 to 2.16) in 2004 and 3.32 (95% CI 2.17 to 5.07)) in 2008. More than 50% of all AEs were related to surgery. Indications were found that differences in the risk of experiencing a preventable AE between hospital departments were larger in 2008 than in 2004, while differences between hospitals themselves were smaller. CONCLUSIONS: Patient harm related to healthcare is a persistent problem that is hard to influence. Measuring AEs over time stresses the continuing urgency, and also identifies possible areas for improvement.
Assuntos
Erros Médicos/estatística & dados numéricos , Prontuários Médicos/estatística & dados numéricos , Segurança do Paciente , Garantia da Qualidade dos Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Feminino , Humanos , Estudos Longitudinais , Masculino , Erros Médicos/prevenção & controle , Erros de Medicação/prevenção & controle , Erros de Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Países Baixos , Estudos RetrospectivosRESUMO
BACKGROUND: Delirium occurs frequently in elderly hospitalised patients and is associated with higher mortality, increased length of hospital stay, functional decline, and admission to long-term care. Healthcare professionals frequently do not recognise delirium, indicating that education can play an important role in improving delirium care for hospitalised elderly. Previous studies have indicated that e-learning can provide an effective way of educating healthcare professionals and improving quality of care, though results are inconsistent. METHODS AND DESIGN: This stepped wedge cluster randomised trial will assess the effects of a complementary delirium e-learning course on the implementation of quality improvement initiative, which aims to enhance the recognition and management of delirium in elderly patients. The trial will be conducted in 18 Dutch hospitals and last 11 months. Measurements will be taken in all participating wards using monthly record reviews, in order to monitor delivered care. These measurements will include the percentage of elderly patients who were screened for the risk of developing delirium, use of the Delirium Observation Screening scale, use of nursing or medical interventions, and the percentage of elderly patients who were diagnosed with delirium. Data regarding the e-learning course will be gathered as well. These data will include user characteristics, information regarding use of the course, delirium knowledge before and after using the course, and the attitude and intentions of nurses concerning delirium care. SETTING: The study will be conducted in internal medicine and surgical wards of eighteen hospitals that are at the beginning stages of implementing the Frail Elderly Project in the Netherlands. DISCUSSION: Better recognition of elderly patients at risk for delirium and subsequent care is expected from the introduction of an e-learning course for nurses that is complementary to an existing quality improvement project. This trial has the potential to demonstrate that e-learning can be a vital part of the implementation process, especially for quality improvement projects aimed at complex health issues such as delirium. The study will contribute to a growing body of knowledge concerning e-learning and the effects it can have on knowledge as well as delivered care. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2885.