Cultures that collide: an ethnographic study of the introduction of a palliative care consultation team on acute wards

Background Acute care and palliative care (PC) are described as different incompatible organisational care cultures. Few studies have observed the actual meeting between these two cultures. In this paper we report part of ethnographic results from an intervention study where a palliative care consultation team (PCCT) used an integrative bedside education approach, trying to embed PC principles and interventions into daily practice in acute wards. Purpose To study the meeting and interaction of two different care cultures, palliative care and curative acute wards, when a PCCT introduces consulting services to acute wards regarding end-of-life palliative care, focusing on the differences between the cultures. Methods An ethnographic study design was used, including observations, interviews and diary entries. A PCCT visited acute care wards during 1 year. The analysis was inspired by Spradleys ethnography. Results Three themes were found: 1) Anticipations meets reality; 2) Valuation of time and prioritising; and 3) The content and creation of palliative care. Conclusion There are many differences in values, and the way PC are provided in the acute care wards compared to what a PCCT expects. The didactic challenges are many and the PC require effort.

ANMCO POSITION PAPER: The reorganization of cardiology in times of the SARS-CoV-2 pandemic

The COVID-19 pandemic represents an unprecedented event that has brought deep changes in hospital facilities with reshaping of the health system organization, revealing inadequacies of current hospital and local health systems. When the COVID-19 emergency will end, further evaluation of the national health system, new organization of acute wards, and a further evolution of the entire health system will be needed to improve care during the chronic phase of disease. Therefore, new standards for healthcare personnel, more efficient organization of hospital facilities for patients with acute illnesses, improvement of technological approaches, and better integration between hospital and territorial services should be pursued. With experience derived from the COVID-19 pandemic,new models, paradigms, interventional approaches, values and priorities should be suggested and implemented.

Clinical Audit cycle of Mental Health Act (MHA) documentation for patients on section 3 staying 90 days and over in adult wards at Roseberry park hospital

AimsTo complete the audit cycle on compliance of MHA documentation (including MCA1 form at admission and 3 months, T2 form, SOAD request and T3 form authorization) on patients on section 3 staying 90 days and over in adult wards at Roseberry park hospitalMethodIn the initial audit, we collected data from all inpatients on section 3 staying 90 days and over, in Adult acute and rehab wards on Roseberry park hospital between the time period 28/10/19–04/11/19. Using a designated audit data collection tool, information was gathered from each patient's electronic record pertaining to the standards. The same method was used in re-audit where data were collected from all inpatients on section 3 staying 90 days and over in Adult acute wards on Roseberry park hospital between the time period 04/11/20–11/11/20. To note, the rehab ward at Roseberry park hospital was closed in Feb 2020. The data were analysed by the project lead.ResultIn the initial audit, 16 patients records were identified as meeting criteria,out of these 7 (44%) patients were on acute wards and 9 (56%) at rehab ward. Where as in re-audit 5 patients records were identified as meeting criteria and all were on acute wards. Days in Hospital - Ranged from 120 days to 664 days, average being 295 days and median of 186 days in the initial audit compared to121 days to 290 days, average being 170 days and median of 150 days in the reaudit. Percentage of patients records with documented capacity assessment at admission and 3 months were same at 80% and 60% respectively in both audits.T2 form was completed in all consenting patients in both audits. SOAD request sent was recorded in only 1 (25%) patient in the reaudit, which was lower than the initial audit, where in SOAD request was sent in 7 (78%) patients but recorded in 5 (56%) of them. For patients lacking capacity, T3 form was documented only in 4 (45%) patients but T3 form authorisation was discussed with patient and evidenced in case notes in only 1(11%) case in the initial audit, where as in reaudit T3 form was not documented or discussed for any patient.ConclusionThere needs to be improvement in MHA documentation for detained patients.

The Palliative Care Illusion on Acute Wards An Ethnographic Study of the Introduction of a Palliative Care Consultation Team

Acute care and palliative care are described as different incompatible organisational care cultures, with contrasts and contradictions. Few studies have observed the actual meeting between these two cultures. Purpose: To study the meeting and interaction of two different organisational care cultures, palliative care and curative acute wards, when a palliative care consultation team introduces consulting services to acute wards regarding end-of-life palliative care. Methods: An ethnographic study design was used, including observations, interviews and diary entries. A palliative care consultation team visited surgical and internal medicine wards during one year. An integrative bedside education approach was used, where physicians and nurses experienced in PC tried to embed PC principles and interventions into daily practice. The analysis was inspired by Spradley’s ethnography.Results: Three themes were found in the study: 1) Values, illusions, and wording in the acute care culture; 2) Didactic challenges and strategies, and 3) The palliative illusion becomes a fusion. On the acute wards, fast “turn over” was the goal of care: to treat patients quickly and send them home. Primary health care team members believed that they gave dying patients good care, a conclusion not supported by the palliative care team, who identified values problems and a knowledge shortage among all primary team members. Because the primary team did not have time for reflection regarding patients’ whole situation, and wanted to do as much as possible before “giving up”, their patients could be one hour from death before the primary team provided palliative care. After one year, primary team members wanted the palliative care consultation team to continue, since they felt they could not handle dying patients on their own.Conclusion: Palliative care consultation team make changes about end- of- life care when working with primary health care team members on acute wards. The didactic challenges are many and require efforts.

A Study on Appropriateness of Antibacterial Use in Acute Wards of a Teaching Hospital

Objective: A study to analyse the appropriateness of use of antibacterials in acute wards of a tertiary care hospital. Design: A pharmacoepidemiological research study. Intervention: Non-interventional descriptive study. Main Outcome Measure: The antibacterial prescriptions were analyzed for their adherence to or deviation from the standard national treatment guidelines. Results: There were a total of 207 patients comprising of 35 in acute medical ward, 65 in ICU, 53 in acute surgical ward and 54 in family ward, who were prescribed antibacterials. These consisted of a total of 383 prescription counts for appropriateness of AMA use. One third of the antibacterial prescriptions of inpatients surveyed were for prophylactic use followed by the treatment of respiratory and gastrointestinal diseases. The highest prescription counts were seen with carbapenems followed by nitroimidazoles, cephalosporins, aminoglycosides and penicillins. 99% of the prescriptions were appropriate for the dose used and 49.6% of the prescriptions were inappropriate for duration of use. 74.5% of the surgical prophylaxis prescriptions were used for more than 24 hours. Ceftriaxone and cefotaxime were used instead of the recommended cefazolin, for prophylaxis. High percentage of deviation was observed with prescriptions of cefotaxime and metronidazole for empirical use. No definitive use of antimicrobials for infections was observed in the ICU. Conclusion: A high percentage of appropriateness was observed for dose of antibiotic used. The main targets identified for improvement are duration of antimicrobial use, choice of drug for surgical prophylaxis and the definitive use of antimicrobial agents. Keywords: adherence to treatment guidelines, antibiotic audit, antimicrobials.