How much is enough? Using Delphi to explore the clinical-contact-time and return-to-practice needs of military nurses.

Aim Military nurses are required to deploy worldwide at any time to support British forces. They must maintain military and clinical skills, and fulfil other military commitments as required. These diverse responsibilities make it challenging for military nurses to maintain the level of clinical expertise they require for short-notice deployments. A service evaluation was conducted to investigate issues related to clinical contact time (CCT) and to return to practice (RTP) for military nurses. Method A consultative approach was taken in the form of a modified Delphi study, followed by a military judgement panel (focus group). Results Two aspects of the study are reported here: CCT and RTP. Panellists considered that policy rather than guidance is needed to ensure military nurses achieve the requisite CCT to prepare them for operational deployment. Additionally, there was a broad consensus on a range of issues, including minimum CCT for specific groups and mechanisms to support those returning to practice. Conclusion Maintaining clinical skills, and the challenges of returning to practice, require careful consideration in a mobile workforce with wide-ranging commitments. Prescribing CCT, ensuring assignment orders specify CCT and the introduction of job plans should help military nurses maintain their core and specialist nursing skills, guide commanders and reinforce the culture of 'hands-on nursing' as a valid use of time.

False cardiac arrests: the right time to turn away?

AIM: Cardiac arrest teams may be activated only to find that the patient does not require cardiac or respiratory resuscitation. Members of the cardiac arrest team are drawn from medical personnel with other responsibilities who may disperse quickly, leaving ongoing care of the patient to existing ward staff. The outcome for such false cardiac arrests, however, is rarely reported. The objective of this study was to determine the causes of false cardiac arrest team alerts (FCAs) and to assess the outcome of these patients relative to the general hospital population. SETTING: Tertiary care hospital. PARTICIPANTS: Patients subject to a cardiac arrest call who were found not to require basic or advanced cardiac life support on arrival. RESULTS: In 512 events over a 1-year period, patients suffering FCAs were more likely to survive compared to patients suffering cardiac arrest (15% vs 73%, odds ratio (OR) 14.95; chi2 p< or =0.0001), but significantly less likely to survive than the general hospitalised population (73% vs 97%, OR 14.15; chi2 p< or =0.0001). The cause of the FCA was often minimised as collapse or vasovagal syncope; in 58% (87/150) of cases no further action was taken by the attending medical team. Patients suffering FCAs tended to be long-stay patients with a worse outcome at weekends. CONCLUSION: In areas lacking a medical alert, outreach or patient at risk system, particular attention should be paid to optimising care of those suffering FCAs.

Nurses training doctors: evaluation of a fifth year medical school pilot.

In October 2004 a request was made to the Royal Centre for Defence Medicine to support a pilot project for a leading Midlands medical school. The aim of the project was to standardize clinical skills training for medical students prior to House Officer jobs. Experienced military emergency nurses provided clinical training including cannulation, catheterization and phlebotomy in a simulated environment. All fifth year medical students attending clinical skills training were invited to complete post-training evaluation questionnaires. The project was evaluated positively and there was an excellent response to nurses training doctors. There was a statistically significant improvement in post-training confidence. All medical students passed their practical assessment following the training programme. This pilot project has been highly successful and has subsequently been extended to all fifth year students at the medical school. The range of clinical skills taught by nurses has also been widened.

Confidence vs competence: basic life support skills of health professionals.

The provision of prompt effective resuscitation is fundamental in ensuring successful outcomes following cardiac arrest but historically nurses and doctors have lacked competence in performing basic life support (BLS), despite being confident in their abilities. The object of this study was to assess BLS confidence as assessed against competence of doctors' in-training, qualified nurses and healthcare assistants (HCAs) following the development of structured resuscitation training. This study has highlighted that the introduction of a structured resuscitation training programme has resulted in a noticeable improvement in BLS skills, particularly with regard to doctors. Registered nurses have improved with regular training compared with previously published data but HCAs tend to perform poorly and are under-confident. There remains a mismatch between confidence and competence, with only doctors demonstrating both confidence and competency and therefore changes to training programmes may be required to address this mismatch.

Using a Delphi approach to develop a strategy for A&E in defence nursing.

The Armed Forces has seen an increase in the number of operational deployments overseas and a greater demand for Accident and Emergency (A&E) trained nurses. This article describes a modified Delphi study used to contribute to the development of a strategy for emergency nursing in the Defence Nursing Services. Twenty-eight A&E specialists took part and the key issues raised were recruitment and retention, staff development, new roles, research priorities, increased internal recruitment of A&E nurses to meet operational demands, and the need for a structured career pathway to help retention. The most pressing areas requiring research were evaluation of the nurse practitioner role, clinical competencies and managing heat injuries in the operational setting. The modified Delphi study provided a valuable and detailed insight into the challenges and aspirations of the military A&E nursing cadre and has assisted in developing a strategy for emergency nursing.

Experiences of military nurses in Iraq and Afghanistan.

Since 2001 military nurses have successfully supported military operations in deployed field hospitals in both Iraq and Afghanistan. These deployments have presented unique challenges for military nurses. This article reviews the literature on the experience of nurses during these deployments and, using a thematic analysis approach, aims to understand their experience. The results provide an insight into the lives of military nurses who served in Iraq and Afghanistan and highlight some of the coping strategies adopted by nurses in conflict situations. The discussion outlines the key themes and, using excerpts from the literature, explores the challenges and coping strategies used.

Pre-printed 'do not attempt resuscitation' forms improve documentation?

OBJECTIVE: Do not-attempt-resuscitate orders are fundamental for allowing patients to die peacefully without inappropriate resuscitation attempts. Once the decision has been made it is imperative to record this information accurately. However, during a related research projected we noted that documentation was poor and we thought that the introduction of a pre-printed Do Not Attempt Resuscitation (DNAR) form would improve the documentation process. DESIGN: Two sets of identical research questions were applied retrospectively, 12-months apart, to notes of adult patients (>18 years) who had died during a hospital admission without under-going a resuscitation attempt. Between the first and the second audit, a new resuscitation policy that incorporated a pre-printed DNAR form was introduced into our hospital. RESULTS: A pre-printed DNAR form improved documentation when measured against; clarity of DNAR order (P=0.05), date decision was made/implementation (P=0.014), presence of clinician's signature (P=0.001), identification of the senior clinician making the decision (P< or =0.001) and justification for the DNAR decision (P< or =0.001). However, the pre-printed form made little improvement in encouraging patient involvement in the DNAR decision-making process (P=0.348). CONCLUSION: A pre-printed DNAR form can improve documentation significantly but it has little effect in encouraging patient involvement in the decision-making process.

Evaluation of a medical emergency team one year after implementation.

AIM: To evaluate the activity and impact of a Medical Emergency Team (MET) one year after implementation. SETTING AND POPULATION: A 700-bed District General Hospital (DGH) in Southeast England with approximately 53,500 adult admissions per annum. The population studied included all adult admissions receiving intervention by the MET during a 12-month period between 1 October 2000 and 30 September 2001. METHODS: Analysis of the activation of the MET using both prospective and retrospectively acquired data. Routinely collected hospital data for admissions, discharges and deaths was used to compare outcomes for the 12 months before and after the introduction of the MET. RESULTS: There were 136 activations of MET over 1-year. Six cases were excluded. Mean age of patients was 73 years (range 20-97 years). 40% (52/130) survived to discharge following MET intervention. Of those who died 22% (28/130) were designated 'not for resuscitation'. Patients that died were more likely to have three or more physiological abnormalities present (odds ratio, OR 6.2, Chi-square (chi(2)) P = 0.004) and had higher MET scores (P = 0.004). Commonest interventions by the MET were initiation or increase of oxygen therapy or ventilatory support (80%), with or without the administration of intravenous fluids or medications. In 10% of cases, oxygen therapy was the sole intervention. One year after implementation of the MET a reduction in cardiac arrest rate and overall mortality was noted but this was not statistically significant. CONCLUSION: Often only simple interventions are only required to reverse deterioration. Initiating 'do not attempt resuscitation' (DNAR) decisions is a key part of MET activity. Multiple physiological abnormalities are associated with increased mortality and therefore wider and earlier application of the MET to the hospital population may save lives or expedite DNAR decisions. New systems need time to develop ("bed in") and further research is needed to observe significant reductions in cardiac arrests and overall mortality.

The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.

AIM: (1) To identify risk factors for in-hospital cardiac arrest; (2) to formulate activation criteria to alert a clinical response culminating in attendance by a Medical Emergency Team (MET); (3) to evaluate the sensitivity and specificity of the scoring system. METHODS: Quasi-experimental design to determine prevalence of risk factors for cardiac arrest in the hospitalised population. Weighting of risk factors and formulation of activation criteria to alert a graded clinical response. ROC analysis of weighted cumulative scores to determine their sensitivity and specificity. SETTING: An acute 700 bed district general hospital with 32,348 adult admissions in 1999 and a catchment population of around 365,000. SUBJECTS: 118 consecutive adult patients suffering primary cardiac arrest in-hospital and 132 non-arrest patients, randomly selected according to stratified randomisation by gender and age. RESULTS: Risk factors for cardiac arrest include: abnormal respiratory rate (P = 0.013), abnormal breathing indicator (abnormal rate or documented shortness of breath) (P < 0.001), abnormal pulse (P < 0.001), reduced systolic blood pressure (P < 0.001), abnormal temperature (P < 0.001), reduced pulse oximetry (P < 0.001), chest pain (P < 0.001) and nurse or doctor concern (P < 0.001). Multivariate analysis of cardiac arrest cases identified three positive associations for cardiac arrest: abnormal breathing indicator (OR 3.49; 95% CI: 1.69-7.21), abnormal pulse (OR 4.07; 95% CI: 2.0-8.31) and abnormal systolic blood pressure (OR 19.92; 95% CI: 9.48-41.84). Risk factors were weighted and tabulated. The aggregate score determines the grade of clinical response. ROC analysis determined that a score of 4 has 89% sensitivity and 77% specificity for cardiac arrest; a score of 8 has 52% sensitivity and 99% specificity. All patients scoring greater than 10 suffered cardiac arrest. CONCLUSION: Risk factors for cardiac arrest have been identified, quantified and formulated into a table of activation criteria to help predict and avert cardiac arrest by alerting a clinical response. A graded clinical response has resulted in a tool that has both sensitivity and specificity for cardiac arrest.

Health system costs of in-hospital cardiac arrest.

This paper reports on the health system resources used in the treatment of in-hospital cardiac arrests in a British district general hospital. The resources used in resuscitation attempts were recorded prospectively by observation of a convenience sample of 30 cardiac arrests. The post-resuscitation resource use by survivors was collected through a retrospective record review (n = 37) and by following survivor members in the prospective sample (n = 6). Financial data were used to translate resource use into costs (1999 prices). There was a non-significant trend for more resources to be used in daytime resuscitations than at night. Survivors had significantly fewer diagnostic tests during resuscitation than those who died (P = 0.004). Length of resuscitation attempt was positively and significantly related to resource use (P < 0.05). The average variable cost per resuscitation attempt (1999 prices) was 195.66 pounds sterling; 76.5% was for staff, and 13.1% for drugs and fluids. Emergency calls were attended by an average of 10.11 staff. The average fixed cost per resuscitation attempt was 928.81 pounds sterling; 12% for capital equipment and 73% for staff training. The average post-resuscitation costs attributable to the cardiac arrest of the 29 people surviving more than 24 h after cardio-pulmonary resuscitation (CPR) were estimated to be 1,589.72 pounds sterling. This is lower than other studies which estimated total costs of post-CPR lengths of stay. Reducing avoidable cardiac arrests would generate in-hospital savings in direct resuscitation care of survivors. Scope for reducing capital and training costs is discussed.

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital.

AIMS: To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy. METHODS: Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year. RESULTS: There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%. CONCLUSION: The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.

Avoidable cardiac arrest: lessons for an A&E department.

Deterioration to cardiac arrest is not always sudden and unexpected and on a significant number of occasions cardiac arrest could be prevented. This has important messages for the Accident and Emergency (A&E) department as the vast majority of emergency admissions originate via A&E.

A specialist team of A&E doctors and nurses establish emergency care units in Kosovo.

On June 12, 1999 NATO troops led by British paratroopers of 5 Airborne Brigade entered Kosovo and secured key military sites. This multinational operation (code named 'OP AGRICOLA') was in response to the ethnic cleansing of Kosovo-Albanians, and followed a sustained period of aerial attack in Kosovo and Serbia. The ground operation required substantial medical support, and the British hospital element was provided by 22 Field Hospital RAMC.

Nurse concern: a predictor of patient deterioration.

Nurses who have cared for a patient for some time often develop an intuitive sense of when that patient's condition is deteriorating. This article discusses how this intuition can be quantified and presented to medical staff so that patients receive timely and appropriate intervention.

Preparing to receive patients with trauma.

Appropriate preparation could prevent up to 70% of trauma-related deaths in hospital. In this article, a military trauma team discusses the infrastructure required to receive patients with major trauma. It explains who should be in a trauma team and the tools needed to ensure efficient communication between team members. Roles for nurses are explored under the following headings: control of environmental factors; pain management; prevention of pressure ulcers; and the care of patients' relatives. The reception of mass casualties is also considered.

Findings of the first consensus conference on medical emergency teams.

BACKGROUND: Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system. METHODS: In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experience with one of the three major forms of RRS. After preconference telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists convened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should outcome be measured? Panelists considered whether all hospitals should implement an RRS. RESULTS: Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, "crisis detection" and "response triggering" mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.