The role of patients and their relatives in 'speaking up' about their own safety - a qualitative study of acute illness.

BACKGROUND: Poor recognition of and response to acute illness in hospitalized patients continues to cause significant harm despite the implementation of safety strategies such as early warning scores. Patients and their relatives may be able to contribute to their own safety by speaking up about changes in condition, but little is known about the factors that influence this. This study examined the experiences and views of patients and their relatives to determine the potential for involvement in promoting their own safety. METHODS: This data set is drawn from a wider ethnographic study of the management of the acutely ill patient in hospital. Thirteen patients and seven relatives from two medical settings in two UK NHS Trusts were interviewed. Thematic analysis identified factors likely to influence patients' and their relatives' ability to contribute to the management of deterioration. RESULTS: All patients interviewed had experienced their acute illness within the context of a long-term health problem. Speaking up was influenced by the ability to recognize changes in clinical condition, self-monitoring, confidence and trust, and culture and system of health care. When patients or relatives did raise concerns, health-care staff had a mediating effect on their comfort with and the effectiveness of speaking up. IMPLICATIONS: Safety strategies based on patient involvement must take account of the complexities of acute illness. Those that promote partnership may be more acceptable to patients, their families and staff than those that promote challenging behaviour and may ultimately prove to be most safe and effective.

Chronic kidney disease: understanding its association with other long-term conditions.

Chronic kidney disease (CKD) is a common long-term condition and is associated with increased mortality and a reduction in healthy years of life. Early identification and appropriate treatment of CKD can reduce these risks. The inclusion of CKD in any discussions with people about other long-term health conditions such as cardiovascular disease and diabetes mellitus is also essential. All nurses need to understand the risks associated with CKD so that they can develop the confidence to routinely discuss the condition with patients and support them to improve their health.

Republished original research: Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline.

INTRODUCTION: Rapid response systems (RRSs) have been introduced to facilitate effective 'rescue' of seriously ill patients on hospital wards. While research has demonstrated some benefit, uncertainty remains regarding impact on patient outcomes. Little is known about the relationship between social contexts and the application of the RRS. DESIGN: This comparative case study of the RRS within the medical services of two UK hospitals used ethnographic methods over a 12-month period in 2009, including observation (ward work and shadowing medical staff = 150 h), interviews with doctors, ward and critical care nurses, healthcare assistants, safety leads and managers (n=35), documentary review and analysis of routine data. Data were analysed using NVivo software. RESULTS: The RRS reduced variability in recording, recognition and response behaviour. The RRS formalised understandings of deterioration and provided a mandate for escalating care across professional and hierarchical boundaries. However, markers of deterioration not assimilated into risk scores were marginalised and it was harder for staff to escalate care without the 'objective evidence' provided by the score. Contextual features (eg, leadership, organisational culture and training) shaped implementation, utilisation and impact of the RRS. Reporting and feedback of audit data enabled learning about 'selected' escalation work on the wards. Difficulties with referral upwards and across medical boundaries were reported by junior medical staff. CONCLUSION: Locating a RRS within a pathway of care for the acutely ill patient illustrates the role of these safety strategies within the social organisation of clinical work. There is a need to broaden the focus of inquiry from detection and initiation of escalation (where the strategies are principally directed) towards team response behaviour and towards those medical response practices which to date have escaped scrutiny and monitoring.

Health and Social Care Reform in Scotland - What Next?

INTRODUCTION: This paper analyses the important enablers, barriers and impacts of country-wide implementation of integrated health and social care in Scotland. It offers insights for other systems seeking to advance similar policy and practice. DESCRIPTION: Landmark legislation was based on a shared vision and narrative about improving outcomes for people and communities. Implementation has involved coordination of multiple policies and interventions for different life stages, care groups, care settings and local context within a dynamic and complex system. DISCUSSION: Relational and citizen led approaches are critical for success, but it takes time to build trusting relationships, influence organisational and professional cultures and cede power. Assessing national impacts is challenging and progress at a national level can seem slower than local experience suggests, due in part to the relative immaturity of national datasets for community interventions. Five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. However, inequalities continue to increase. CONCLUSION: Realising the true value from integration will require a stronger focus on place-based prevention and early intervention to achieve a fairer Scotland where everybody thrives. Solidarity, equity, and human rights must guide the next phase of Scotland's story.

Innovative education for people with chronic kidney disease: an evaluation study.

BACKGROUND: An innovative Community Kidney Service has been running since 2016 in four health regions in East London, United Kingdom. This paper focuses on the patient education (self-management) programme within the service. OBJECTIVE: To understand the experiences of people with stage 1-3b chronic kidney disease invited to individual or group education sessions. To assess the usefulness of the programme's educational resources to primary care nurses. DESIGN: A mixed-method project. A steering group involving patients shaped both survey and interview questions. PARTICIPANTS: Paper surveys (n = 266) were sent to patients 7-19 months after they had attended. Semi-structured interviews were undertaken with patients who returned the survey and indicated they were willing to be interviewed (n = 9). Survey links were sent electronically to primary care nurses. RESULTS: Fifty-four surveys were returned from patients. The education session increased self-reported knowledge about kidney disease and two-thirds of patients reported making lifestyle changes. Analysis of interview data identified recognition of kidney disease, motivation to change and reliance on "experts" as key themes. Surveys were returned from 21 nurses. Most were aware of the community kidney service but only one-third had used the education resources with their patients. CONCLUSION: Secondary care nursing involvement in primary care-based education for people with kidney disease is rare in the United Kingdom and internationally. This educational intervention, developed with patients, supports people to make changes that have the potential to reduce progression of kidney disease and our findings have significance for other teams working in chronic kidney disease management.

Improving coding and primary care management for patients with chronic kidney disease: an observational controlled study in East London.

BACKGROUND: The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission. AIM: To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk. DESIGN AND SETTING: Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs). METHOD: Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention. RESULTS: Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P<0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P<0.001) over the 2-year study period. Differences in statin prescribing were not significant. CONCLUSION: Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention.

Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline.

INTRODUCTION: Rapid response systems (RRSs) have been introduced to facilitate effective 'rescue' of seriously ill patients on hospital wards. While research has demonstrated some benefit, uncertainty remains regarding impact on patient outcomes. Little is known about the relationship between social contexts and the application of the RRS. DESIGN: This comparative case study of the RRS within the medical services of two UK hospitals used ethnographic methods over a 12-month period in 2009, including observation (ward work and shadowing medical staff = 150 h), interviews with doctors, ward and critical care nurses, healthcare assistants, safety leads and managers (n=35), documentary review and analysis of routine data. Data were analysed using NVivo software. RESULTS: The RRS reduced variability in recording, recognition and response behaviour. The RRS formalised understandings of deterioration and provided a mandate for escalating care across professional and hierarchical boundaries. However, markers of deterioration not assimilated into risk scores were marginalised and it was harder for staff to escalate care without the 'objective evidence' provided by the score. Contextual features (eg, leadership, organisational culture and training) shaped implementation, utilisation and impact of the RRS. Reporting and feedback of audit data enabled learning about 'selected' escalation work on the wards. Difficulties with referral upwards and across medical boundaries were reported by junior medical staff. CONCLUSION: Locating a RRS within a pathway of care for the acutely ill patient illustrates the role of these safety strategies within the social organisation of clinical work. There is a need to broaden the focus of inquiry from detection and initiation of escalation (where the strategies are principally directed) towards team response behaviour and towards those medical response practices which to date have escaped scrutiny and monitoring.