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This umbrella review aimed to examine and synthesize qualitative studies that explored the barriers and facilitators of advance care planning for persons with dementia, their families, and their healthcare professionals and caregivers. The modified umbrella review approach developed by the Joanna Briggs Institute was followed. Five major English databases were searched. Four reviews based on 38 primary qualitative studies were included. The methodological quality of the included reviews was moderate to high. The synthesis yielded 16 descriptive themes and five analytical themes: making the wishes/preferences of persons with dementia visible; constructive collaboration based on stakeholders having positive relationships; emotional chaos in facing end-of-life substitute decision-making; initiating the advance care planning process; and preparedness and commitment of healthcare providers to advance care planning. Comprehensive and workable strategies are required to overcome complex and interrelated barriers involving not only healthcare professionals but also organizational and systemic challenges. [ABSTRACT FROM AUTHOR]

Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs. The review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published in English, which collected AE data using the GTT and IRSs, were included. In total, 14 studies met the inclusion criteria. All studies were undertaken in hospitals and were published between 2006 and 2022. The studies were conducted in six countries, mainly in the USA (nine studies). Studies reviewed 22 589 medical records using the GTT across 107 institutions finding 7166 AEs. The percentage of AEs detected using the GTT that were also detected in corresponding IRSs ranged from 0% to 37.4% with an average of 7.0% (SD 9.1; median 3.9 and IQR 5.2). Twelve of the fourteen studies found <10% of the AEs detected using the GTT were also found in corresponding IRSs. The >10-fold gap between the detection rates of the GTT and IRSs is strong evidence that the rate of AEs collected in IRSs in hospitals should not be used to measure or as a proxy for the level of safety of a hospital. IRSs should be recognized for their strengths which are to detect rare, serious, and new incident types and to enable analysis of contributing and contextual factors to develop preventive and corrective strategies. Health systems should use multiple patient safety data sources to prioritize interventions and promote a cycle of action and improvement based on data rather than merely just collecting and analysing information. [ABSTRACT FROM AUTHOR]

Rationale: Increasing demand for hospital services can lead to overcrowding and delays in treatment, poorer outcomes and a high cost‐burden. The medical ambulatory care service (MACS) provides out of hospital patient care, including diagnostic and therapeutic interventions for patients that require urgent attention, but which can be safely administered in the ambulatory environment. The programme is yet to be rigorously evaluated. Aims/Objectives: The aim of this study is to evaluate the impact of the MACS programme on emergency department (ED) presentations, hospital admissions, length‐of‐stay and health service costs from a health system perspective. Method: We used a single group interrupted time series methodology with a multiple baseline approach to analyse the impact of the MACS clinic on ED presentations, hospital admissions, length‐of‐stay and cost outcomes for general practitioners (GP)‐referred, ED‐referred and ward‐referred patients under two counterfactual scenarios: an increasing trend in health utilization based on preperiod predictions or a stabilization of utilization rates. Results: The time trend of hospital utilization differed after attending MACS for all three referral groups. The time trend for the GP‐referred group declined significantly by 0.36 ED presentations per 100 patients per 30 days [95% confidence interval (CI): −0.52 to −0.2], while inpatient length of stay declined significantly by 1.56 and 3.70 days, respectively, per 100 ED‐referred and ward‐referred patients per 30 days (95% CI: −2.51 to −0.57 and −5.71 to −1.69, respectively). Under two different counterfactual scenarios, the predicted net savings for MACS across three patient groups were $78,685 (95% CI: $54,807−$102,563) and $547,639 (95% CI: $503,990−$591,287) per 100 patients over 18 months. Conclusion: MACS was found to be cost‐effective for GP and ward‐referred groups, but the expected impact for ED‐referred patients is sensitive to assumptions. Expansion of the service for GP‐referred patients is expected to reduce hospitalizations the most and generate the largest net cost savings. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to measure the level of missed nursing care and determine its relationship with nurse staffing and patient safety outcomes in acute care settings in Ethiopia. Background: Missed nursing care in hospitals increases the likelihood of patient adverse events, complications, disability and death. However, little is known about the level of missed nursing care and its impact on patient outcomes in low‐income countries. Methods: An observational study was conducted comprising of a survey of nurses at two time points (n = 74 and 80, respectively) and a medical record review of 517 patients in four units across two hospitals between September 2018 and March 2019. Results: The level of missed nursing care in the study units was very high. The hospital type and hours nurses worked during the last week were significantly associated with missed nursing care. A unit increase in missed nursing care score increased the incidence of adverse patient outcomes by 10%. Conclusion: There was a higher level of missed nursing care in the study units compared with similar studies from high‐income countries. Higher level of missed nursing care was significantly associated with higher incidence of adverse patient safety outcomes. Summary statement: What is already known about this topic? Literature shows nurses working in acute care miss important nursing care activities mainly due to lack of time to perform those nursing care activities. What this paper adds? The level of missed nursing care in the low‐income country acute care units of the study hospitals is very high compared with other settings.Higher levels of missed nursing care were statistically associated with increase adverse patient safety outcomes, whereas lower levels of missed nursing care were statistically associated with improved patient outcomes. The implication of this paper Hospital administrators and nurse managers should work towards reducing missed nursing care through regular monitoring of nursing practice and improved staffing levels.Mechanisms to improve staffing and resource are required to enable nurses enough time to perform all essential nursing care activities for patients. [ABSTRACT FROM AUTHOR]

Objective: The delivery of healthcare at home has expanded to intravenous infusions of monoclonal antibodies. A recently developed model of care for home infusions of natalizumab for people with relapsing‐remitting multiple sclerosis was evaluated. This pilot study of home infusions of natalizumab and usual care (attendance in a hospital out‐patients' clinic) compared safety, feasibility, patient satisfaction, effectiveness and costs. Methods: In this randomised AB/BA crossover trial, 37 adults were randomised to usual care (n = 19) or home infusions (n = 18). After three infusions, patients crossed over to the alternate treatment for another three infusions. Patient safety outcomes and adherence, satisfaction, quality of life, disability and costs were compared. Results: No adverse events were recorded from 207 infusions from 35 patients across both home and clinic infusions. There was no difference in adherence (p = 0.71) and infection rates (p = 0.84) between home and clinic settings. Satisfaction with "convenience" of home infusions was significantly greater (p = 0.008) but there were no differences in quality of life measures. Excluding pharmacy, costs were A$74 lower per infusion at home, including A$16 of patients" out‐of‐pocket costs. Interpretation: There were no differences in safety and effectiveness between clinic and home infusions of natalizumab. The home infusions were shown to be feasible, more convenient and less expensive than usual care. Larger scale studies are required to verify these preliminary findings, particularly around safety and management of hypersensitivity adverse events in the home setting and for equivalence of clinical outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background This study set out to achieve three objectives: to test the application of a context assessment tool in an acute hospital in South Australia; to use the tool to compare context in wards that had undergone an evidence implementation process with control wards; and finally to test for relationships between demographic variables (in particular experience) of nurses being studied (n = 422) with the dimensions of context. Methods The Alberta Context Tool (ACT) was administered to all nursing staff on six control and six intervention wards. A total of 217 (62%) were returned (67% from the intervention wards and 56% from control wards). Data were analysed using Stata (v9). The effect of the intervention was analysed using nested (hierarchical) analysis of variance; relationships between nurses' experience and context was examined using canonical correlation analysis. Results Results confirmed the adaptation and fit of the ACT to one acute care setting in South Australia. There was no difference in context scores between control and intervention wards. However, the tool identified significant variation between wards in many of the dimensions of context. Though significant, the relationship between nurses' experience and context was weak, suggesting that at the level of the individual nurse, few factors are related to context. Conclusions Variables operating at the level of the individual showed little relationship with context. However, the study indicated that some dimensions of context (e.g., leadership, culture) vary at the ward level, whereas others (e.g., structural and electronic resources) do not. The ACT also raised a number of interesting speculative hypotheses around the relationship between a measure of context and the capability and capacity of staff to influence it. We propose that context be considered to be dependent on ward- and hospital-level factors. Additionally, questions need to be considered about the unit of measurement of context in studies of knowledge implementation--is individual (micro), ward (meso) or hospital-level (macro) data most appropriate? The preliminary results also raise questions about how best to utilise this instrument in knowledge translation research.

Background: Rapid frailty screening remains problematic in primary care. The diagnostic test accuracy (DTA) of several screening instruments has not been sufficiently established. We evaluated the DTA of several screening instruments against two reference standards: Fried's Frailty Phenotype [FP] and the Adelaide Frailty Index [AFI]), a self-reported questionnaire.Methods: DTA study within three general practices in South Australia. We randomly recruited 243 general practice patients aged 75+ years. Eligible participants were 75+ years, proficient in English and community-dwelling. We excluded those who were receiving palliative care, hospitalized or living in a residential care facility.We calculated sensitivity, specificity, predictive values, likelihood ratios, Youden Index and area under the curve (AUC) for: Edmonton Frail Scale [EFS], FRAIL Scale Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC], Polypharmacy [POLY], PRISMA-7 [P7], Reported Edmonton Frail Scale [REFS], Self-Rated Health [SRH] and Timed Up and Go [TUG]) against FP [3+ criteria] and AFI [>0.21].Results: We obtained valid data for 228 participants, with missing scores for index tests multiply imputed. Frailty prevalence was 17.5% frail, 56.6% prefrail [FP], and 48.7% frail, 29.0% prefrail [AFI]. Of the index tests KC (Se: 85.0% [70.2-94.3]; Sp: 73.4% [66.5-79.6]) and REFS (Se: 87.5% [73.2-95.8]; Sp: 75.5% [68.8-81.5]), both against FP, showed sufficient diagnostic accuracy according to our prespecified criteria.Conclusions: Two screening instruments-the KC and REFS, show the most promise for wider implementation within general practice, enabling a personalized approach to care for older people with frailty. [ABSTRACT FROM AUTHOR]

Against a backdrop of aging populations worldwide, it has become increasingly important to identify frailty screening instruments suitable for community settings. Self‐reported and/or administered instruments might offer significant simplicity and efficiency advantages over clinician‐administered instruments, but their comparative diagnostic test accuracy has yet to be systematically examined. The aim of this systematic review was to determine the diagnostic test accuracy of self‐reported and/or self‐administered frailty screening instruments against two widely accepted frailty reference standards (the frailty phenotype and the Frailty Index) within community‐dwelling older adult populations. We carried out a systematic search of the Embase, CINAHL, MEDLINE, PubMed, Web of Science, PEDro, PsycINFO, ProQuest Dissertations, Open Grey and GreyLit databases up to April 2017 (with an updated search carried out over May–July 2018) to identify studies reporting comparison of self‐reported and/or self‐administered frailty screening instruments against an appropriate reference standard, with a minimum sensitivity threshold of 80% and specificity threshold of 60%. We identified 24 studies that met our selection criteria. Four self‐reported screening instruments across three studies met minimum sensitivity and specificity thresholds. However, in most cases, study design considerations limited the reliability and generalizability of the results. Additionally, meta‐analysis was not carried out, because no more than three studies were available for any of the unique combinations of index tests and reference standards. Although the present study has shown that a number of self‐reported frailty screening instruments reported sensitivity and specificity within a desirable range for community application, additional diagnostic test accuracy studies are required. Geriatr Gerontol Int 2020; 20: 14–24. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Patients with acute abdominal pain are a common presentation in hospital emergency departments; however, international studies have demonstrated that hospitals often lack clinical protocols to guide care. This study aimed to investigate whether Australian hospital emergency departments have acute abdominal pain clinical protocols, identify hospital‐level predictors of the presence of these clinical protocols, and assess the quality of protocols. Methods: A survey was sent to all Australian hospitals with emergency departments, collecting data on hospital characteristics and the presence of acute abdominal pain clinical protocols. Participating hospitals (n = 73, 26% response rate) were also asked to provide a copy of these protocols. The quality of these protocols was assessed using Appraisal of Guidelines for REsearch & Evaluation (AGREE) II. Results: Slightly more than half (n = 40) of the hospitals surveyed had acute abdominal pain clinical protocols, while 16 had a general pain protocol. In binomial logistic regression, two independent variables were related to the presence of a protocol, geographic region (P = 0.008) and advanced practice nurses/nurse practitioners' presence on staff (P = 0.024). The mean score for the overall quality assessment of these protocols was 4.2 on a seven‐point Likert scale; in terms of the six domains of quality, "Clarity of presentation" and "Scope and purpose" were highest. The overall quality of clinical protocols increased with remoteness, χ2 (3) = 8.341, P = 0.039, and was lower in hospitals with medical staff on site (U = 2.5, P = 0.007). Conclusion: There is a documented standard for pain management of acute abdominal pain in about three quarters of participating Australian emergency departments. The use and quality of clinical protocols is influenced by the physical location of hospitals and staff and skill mix of clinicians. [ABSTRACT FROM AUTHOR]

Background: Although knowledge translation is one of the most widely used concepts in health and medical literature, there is a sense of ambiguity and confusion over its definition. The aim of this paper is to clarify the characteristics of KT. This will assist the theoretical development of it and shape its implementation into the health care system Methods: Walker and Avant's framework was used to analyze the concept and the related literature published between 2000 and 2010 was reviewed. A total of 112 papers were analyzed. Results: Review of the literature showed that "KT is a process" and "implementing refined knowledge into a participatory context through a set of challenging activities" are the characteristics of KT. Moreover, to occur successfully, KT needs some necessary antecedents like an integrated source of knowledge, a receptive context, and preparedness. The main consequence of successful process is a change in four fields of healthcare, i.e. quality of patient care, professional practice, health system, and community. In addition, this study revealed some empirical referents which are helpful to evaluate the process. Conclusion: By aiming to portray a clear picture of KT, we highlighted its attributes, antecedents, consequences and empirical referents. Identifying the characteristics of this concept may resolve the existing ambiguities in its definition and boundaries thereby facilitate distinction from similar concepts. In addition, these findings can be used as a knowledge infrastructure for developing the KT-related models, theories, or tools. [ABSTRACT FROM AUTHOR]

Background: Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.Methods/design: A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient's body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.Discussion: Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.Trial Registration: ACTRN12611000020987. [ABSTRACT FROM AUTHOR]

The appropriate handover of patients, whereby responsibility and accountability of care is transferred between healthcare providers, is a critical component of quality healthcare delivery. This paper examines data from recent incidents relating to clinical handover in acute care settings, in order to provide a basis for the design and implementation of preventive and corrective strategies. A sample of incidents ( n = 459) relating to clinical handover was extracted from an Australian health service's incident reporting system using a manual search function. Incident narratives were subjected to classification according to the system safety and quality concepts of failure type, error type, and failure detection mechanism. The most prevalent failure types associated with clinical handover were those relating to the transfer of patients without adequate handover 28.8% ( n = 132), omissions of critical information about the patient's condition 19.2% ( n = 88), and omissions of critical information about the patient's care plan during the handover process 14.2% ( n = 65). The most prevalent failure detection mechanisms were those of expectation mismatch 35.7% ( n = 174), clinical mismatch 26.9% ( n = 127), and mismatch with other documentation 24.0% ( n = 117). The findings suggest the need for a structured approach to handover with a recording of standardized sets of information to ensure that critical components are not omitted. Limitations of existing reporting processes are also highlighted. [ABSTRACT FROM AUTHOR]

Objectives: To assess the utility of Australian health care incident reporting systems and determine the depth of information available within a typical system.Design and Setting: Incidents relating to patient misidentification occurring between 2004 and 2008 were selected from a sample extracted from a number of Australian health services' incident reporting systems using a manual search function.Main Outcome Measures: Incident type, aetiology (error type) and recovery (error-detection mechanism). Analyses were performed to determine category saturation.Results: All 487 selected incidents could be classified according to incident type. The most prevalent incident type was medication being administered to the wrong patient (25.7%, 125), followed by incidents where a procedure was performed on the wrong patient (15.2%, 74) and incidents where an order for pathology or medical imaging was mislabelled (7.0%, 34). Category saturation was achieved quickly, with about half the total number of incident types identified in the first 13.5% of the incidents. All 43 incident types were classified within 76.2% of the dataset. Fifty-two incident reports (10.7%) included sufficient information to classify specific incident aetiology, and 288 reports (59.1%) had sufficient detailed information to classify a specific incident recovery mechanism.Conclusions: Incident reporting systems enable the classification of the surface features of an incident and identify common incident types. However, current systems provide little useful information on the underlying aetiology or incident recovery functions. Our study highlights several limitations of incident reporting systems, and provides guidance for improving the use of such systems in quality and safety improvement. [ABSTRACT FROM AUTHOR]

The article focuses on a study according to which TeamSTEPPS implementation had a substantial impact on patient safety culture, teamwork and communication at an Australian mental health facility.

We studied the physiological ecology of bluetongue lizards (Tiliqua scincoides) on the Adelaide River floodplain in tropical Australia to determine the seasonal patterns of energy expenditure and to determine the mechanisms by which seasonal differences were achieved. Field metabolic rates (FMR) were significantly lower in the dry season (37.6 kJ kg-1 day-1; n=9) than in the wet (127.3 kJ kg-1 day-1; n=7). Water flux was also lower in the dry season (6.8 ml kg-1 day-1; n=9) than in the wet (39.4 ml kg-1 day-1; n=7). Measurements of body temperatures (Tb) and movements of free-ranging animals, and standard metabolic rate (SMR) of recently caught animals, allowed a detailed analysis of energy budgets for wet and dry seasons. In the dry, bluetongue lizards expended 90 kJ kg-1 day-1 less energy than in the wet season. Unlike some other lizards of the wet-dry tropics, SMR did not differ between seasons. About 5% of the seasonal difference in FMR was due to lower night time Tb during the dry season, and about 7% was due to lower diurnal Tb. The remaining 88% of the decrease in energy expended in the dry season was due to a substantial decrease in other costs that may include reproduction, growth, digestion and activity. If we assume the animals fed daily and the costs of digestion are taken into account, the estimates are: 14% of the savings result from lower Tb at night, 20% from lower Tb in the day, and 66% result from decreased activity. It is therefore apparent that, unlike some agamid and varanid lizards that use a combination of behavioural and physiological mechanisms to conserve energy when food and water are limited, bluetongue lizards primarily use behavioural mechanisms to achieve a dramatic reduction in energy expenditure in the dry season. [ABSTRACT FROM AUTHOR]

Varanids in general exhibit greater aerobic capacities than other lizards. In a similar approach to the extensive investigations undertaken in mammals, the respiratory system in varanids is examined in terms of oxygen transfer from the air to the blood during rest and sustained locomotory activity. The parameters controlling the transfer of O2 through the various steps of the respiratory system are appropriate to meet the maximum demands for oxygen with one possible exception, circulatory convection. Ventilatory convection is maintained during maximal aerobic locomotion ensuring adequate pulmonary ventilation and the protection of alveolar PO2. Little evidence exists to indicate a mechanically imposed constraint to breathe and the possibility of a gular pump acting to assist ventilation, as a general feature of varanids remains to be determined. Alterations in the relative contributions of the ventilation–perfusion ratio, pulmonary diffusion, diffusion equilibrium and right–left shunts preserved the alveolar–arterial PO2 difference, ensuring that arterial oxygenation was maintained. In those species where increases in cardiac output were limited, maximum O2 transfer was achieved through increased extraction of oxygen at the tissues. Overall, the interrelationship of adjacent steps in the respiratory system ensures that one step cannot become limiting. Compensatory changes occur in various parameters to offset those parameters that are ‘limited’. The high aerobic activity of varanid lizards would not be achievable without a compensated circulatory convection. [Copyright &y& Elsevier]

Background: Nurse staffing models have been developed across different countries to address nursing shortages and improve quality of nursing care. However, there is no published study that describes nurse staffing models in Ethiopian hospitals. Aims: To describe the existing staffing models for nursing practice in acute care units of two hospitals (one public and one private) in Ethiopia. Methods: A cross‐sectional study was conducted from July to December 2018. A self‐administered questionnaire was used to collect data such as shift patterns, hours worked, and number of patients cared for per shift. Unit‐level data on nurse staffing were collected using a checklist developed specifically for this study. Results: Fifty‐nine percent (59.9%) of participants reported that they worked six or seven days per week. On average, they worked 50 hours per week and 12% working over 60 hours per week. The number of patients they provided care for during their last shift ranged from four to 45 with an average of 13 patients. Conclusion: This study demonstrates that nurses working in acute care settings in Ethiopia are typically working more than 40 hours per week and caring for many patients per shift, which has the potential to impact patient safety. SUMMARY STATEMENT: What is already known about this topic? Nurse staffing is a critical factor affecting patient safety and nurse workforce outcomes.There are different staffing models in which staff are assigned to give care for patients in different healthcare settings but much of the research is from high‐income countries. What this paper adds? This paper describes nurse staffing in acute care settings in Ethiopia, a low‐income country. The number of patients for whom nurses provide care per shift, and the number of hours nurses provide care per week, is very high compared with other settings.Nurses work very long hours, often more than 50 hours per week.Many nurses routinely work six or seven days per week and on average nurses care for 13 patients per shift The implication of this paper: Hospital managers should ensure that working more than 40 hours or more than five days per week should not be routine.Hospital policy that addresses the maximum number of patients who receive care by one nurse is necessary.The findings of this study support the consideration of mandated nurse‐to‐patient ratios in Ethiopia. [ABSTRACT FROM AUTHOR]