9 research outputs found
Exploring modifiable factors towards COPD guideline non-concordance and development of an electronic integrated COPD proforma to improve emergency department interdisciplinary staff concordance: Mixed methods and modified Delphi study
No full textChronic obstructive pulmonary disease is a prevalent chronic illness. It is a significant cause of avoidable hospital presentations and the fifth leading cause of death in Australia. An Electronic Integrated COPD Proforma (E-ICP), endorsed and informed by interdisciplinary staff from the Emergency Department (ED), was prioritised using frequency scores to be the most pragmatic solution to mitigate identified barriers of guideline non concordance. The unprecedented pace of clinical care in the ED often only facilitates acute management which exhausts patients, primary care givers and tertiary hospital resources with readmissions and exacerbations. Achieving a consistent pharmacological and nonpharmacological management concordant with the COPD-X plan guidelines is expected to improve health related quality of life in patients with COPD.
OBJECTIVES: This research explored barriers and modifiable factors causing guideline non-concordance that assist the development of an electronic integrated COPD care proforma (E-ICP), through a process of national interdisciplinary (Emergency departments and Respiratory departments), expert consensus.
METHODS: This mixed methods research involved a convergent integrated mixed methods approach that included a systematic review (phase-1), qualitative interdisciplinary staff interviews (phase-2), and an E-modified Delphi method (phase-3) for the development of an electronic proforma with guideline recommendations for use in emergency departments (EDs) in the Australian health system. Phase 2 of this research comprised qualitative interviews with data analysis aligning with Braun and Clarkes (2006), thematic analysis method. The Theoretical Domains Framework including capability, opportunity, motivation, and a behaviour change wheel (COM-B BCW) was adopted as a priori to systematically extract data through all phases. The outcomes propose a range of implementation strategies to the clinical stakeholders/policy makers on improved guideline concordance. In Phase 3, a modified Delphi study was employed to select interventions for the proforma. This phase used a consensus process of three iteration surveys including quantitative survey and qualitative interview thematic analysis on each indicator.
RESULTS: Barriers and modifiable factors explored in this study included lack of knowledge (guidelines and referral methods), skills, staffing, time constraints, memory attention and decision making, professional role identity confusion, and clinical behaviour regulation. Development of an electronic proforma with interdisciplinary staff/patient resources and direct referrals from national interdisciplinary experts from ED and respiratory departments was prioritised as an implementation strategy to address all modifiable factors. The E-ICP demonstrated acceptable and good internal consistency through all iterations from national emergency department and respiratory department interdisciplinary experts.
CONCLUSION: Future outcomes from the E-ICP are its potential to facilitate direct referrals from the ED, leading to reduced hospital admissions, reduced length of hospital stays, holistic care, improved health care and quality of life including improved interdisciplinary guideline concordance
Development of an Electronic Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Proforma (E-ICP) to Improve Interdisciplinary Guideline Adherence in the Emergency Department: Modified Delphi Study
No full textINTRODUCTION: Chronic obstructive pulmonary disease guideline non-adherence is associated with a reduction in health-related quality of life in patients (HRQoL). Improving guideline adherence has the potential to mitigate fragmented care thereby sustaining pulmonary function, preventing acute exacerbations, reducing economic health burdens, and enhancing HRQoL. The development of an electronic proforma stemming from expert consensus, including digital guideline resources and direct interdisciplinary referrals is hypothesised to improve guideline adherence and patient outcomes for emergency department (ED) patients with COPD. AIM: The aim of this study was to develop consensus among ED and respiratory staff for the correct composition of a COPD electronic proforma that aids in guideline adherence and management in the ED. METHODS: This study adopted a mixed-method design to develop the most important indicators of care in the ED. The study involved three phases: (1) a systematic literature review and qualitative interdisciplinary staff interviews to assess barriers and solutions for guideline adherence and qualitative interdisciplinary staff interviews, (2) a modified Delphi panel to select interventions for the proforma, and (3) a consensus process through three rounds of scoring through a quantitative survey (ED and Respiratory consensus) and qualitative thematic analysis on each indicator. RESULTS: The electronic proforma achieved acceptable and good internal consistency through all iterations from national emergency department and respiratory department interdisciplinary experts. Cronbach’s alpha score for internal consistency (α) in iteration 1 emergency department cohort (EDC) (α = 0.80 [CI = 0.89%]), respiratory department cohort (RDC) (α = 0.95 [CI = 0.98%]). Iteration 2 reported EDC (α = 0.85 [CI = 0.97%]) and RDC (α = 0.86 [CI = 0.97%]). Iteration 3 revealed EDC (α = 0.73 [CI = 0.91%]) and RDC (α = 0.86 [CI = 0.95%]), respectively. CONCLUSION: Electronic proformas have the potential to facilitate direct referrals from the ED leading to reduced hospital admissions, reduced length of hospital stays, holistic care, improved health care and quality of life and improved interdisciplinary guideline adherence
Mapping of modifiable barriers and facilitators with interdisciplinary chronic obstructive pulmonary disease (COPD) guidelines concordance within hospitals to the Theoretical Domains Framework: a mixed methods systematic review protocol
No full textINTRODUCTION: Multifarious chronic obstructive pulmonary disease (COPD) guidelines have been published by local, national and global respiratory societies. These guidelines subsume holistic evidence based on recommendations to diagnose, treat, prevent and manage acute exacerbation with COPD. Despite the existing comprehensive recommendations, readmission rates and hospitalisations have increased in the last decade. Evidence to date has reported suboptimal clinical guidelines concordance. Acute exacerbations of COPD (AECOPD) is a common hospital presentation due to varied causes such as infective exacerbations, worsening disease condition, medication non-adherence, lack of education and incomprehensive discharge planning. AECOPD directly and indirectly causes economic burden, disrupts health-related quality of life (HRQol), hasten lung function decline and increases overall morbidity and mortality. COPD being a multimodal chronic disease, consistent interdisciplinary interventions from the time of admission to discharge may reduce readmissions and enhance HRQol among these patients and their families. METHODS AND ANALYSIS: This protocol adheres to the Joanna Briggs Institute methodology for mixed methods systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. Qualitative, quantitative and mixed methods studies will append this study to explore determinants of COPD guidelines concordance. Comprehensive three-tier search strategies will be used to search nine databases (COCHRANE, EBSCO HOST, MEDLINE, SCIENCE DIRECT, JBI, SCOPUS, WEB OF SCIENCE, WILEY and DARE) in May 2020. Two independent reviewers will screen abstracts and full-text articles in consonance with inclusion criteria. The convergent integrative method narrative review will contribute a deeper understanding of any discrepancies found in the existing evidence. Quality of the studies will be reported and Theoretical Domains Framework (TDF) will be used as a priori to synthesis data. Identified barriers, facilitators and corresponding clinical behavioural change solutions will be categorised using TDF indicators to provide future research and implementation recommendations. ETHICS AND DISSEMINATION: Ethical approval is not required and results dissemination will occur through peer-reviewed publication
Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review
No full textBackground: COPD guidelines non-concordance is a challenge frequently highlighted by respiratory experts. Despite the provision of comprehensive evidence-based national and international guidelines, the COPD burden to frontline healthcare services has increased in the last decade. Suboptimal guidelines concordance can be disruptive to health-related quality of life (HRQoL), hastening pulmonary function decline and surging overall morbidity and mortality. A lack of concordance with guidelines has created an escalating economic burden on health-care systems. Identifying interdisciplinary interventions to facilitate improved adherence to guidelines may significantly reduce re-admissions, enhance HRQoL amongst patients and their families, and facilitate economic efficiency. Materials and Methods: This review adhered to the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews and the PRISMA ScR reporting guidelines. Two independent reviewers screened abstracts and full text articles in consonance with inclusion criteria. The convergent integrative JBI method collated quantitative, qualitative and mixed methods studies from nine databases. JBI critical appraisal tools were utilised to assess the quality of research papers. The theoretical domains framework (TDF) along with a specifically developed COPD data extraction tool were adopted as a priori to collect and collate data. Identified barriers and corresponding clinical behavioural change solutions were categorised using TDF domains and behavior change wheel (BCW) to provide future research and implementation recommendations. Results: Searches returned 1068 studies from which 37 studies were included (see Figure 1). COPD recommendations identified to be discordant with clinical practice included initiating non-invasive ventilation, over-or under-prescription of corticosteroids and antibiotics, and a lack of discharging patients with a smoking cessation plan or pulmonary rehabilitation. TDF domains with highest frequency scores were knowledge, environmental resources, and clinical behaviour regulation. Electronic order sets/digital proforma with guideline resources at point of care and easily accessible digital community referrals to target both pharmacological and non-pharmacological management appear to be a solution to improve concordance. Conclusion: Implementation of consistent quality improvement intervention within hospitals for patients with COPD may exclude any implementation gap and prevent readmissions. Electronic proformas with digital referrals will assist with future evaluation audits to prioritise and target interventions to improve guidelines concordance
Exploring factors contributing to chronic obstructive pulmonary disease (COPD) guideline non-adherence and potential solutions in the emergency department: interdisciplinary staff perspective
No full textPurpose: Acute exacerbations of chronic obstructive pulmonary disease (COPD) have a significant and prolonged impact on health-related quality of life, patient outcomes, and escalation of pulmonary function decline. COPD-X guidelines published in 2003 subsist to facilitate a shift from the emphasis on pharmacological treatment to a more holistic multi-disciplinary interventions approach. Despite the existing comprehensive recommendations, readmission rates have increased in the last decade. Evidence to date has reported sub-optimal COPD guidelines adherence in emergency departments. This qualitative study explored contributing factors to interdisciplinary staff non-adherence and utilisation of COPD-X guidelines in a major Southern Queensland Emergency Department. Methods: Semi-structured qualitative interviews with interdisciplinary staff were conducted in an emergency department. A purposive sample of doctors, nurses, physiotherapists, pharmacist and a social worker were recruited. Interviews were digitally recorded, de-identified and transcribed verbatim. Data analysis followed a coding process against the Theoretical Domains Framework (TDF) to examine implementation barriers and potential solutions. Identified factors affecting non-adherence and underutilisation of guidelines were then mapped to the capability, opportunity, motivation, behaviour model (COM-B) and behaviour change wheel (BCW) to inform future implementation recommendations. Results: Prominent barriers influencing the clinical uptake of COPD guidelines were identified using TDF analysis and included knowledge, professional role clarity, clinical behaviour regula-tion, memory, attention, and decision process, beliefs about departmental capabilities, environ-mental context and resources. Potential interventions included education, training, staffing, funding and time-efficient digitalised referrals and systems management reminders to prevent COPD readmissions, remissions and improve patient health-related quality of life. Conclusion: Implementation strategies such as electronic interdisciplinary COPD proforma that facilitates a multimodal approach with appropriate patient/staff resources and referrals prior to discharge from an ED require further exploration. Greater clarity around which components of the COPD X guidelines must be applied in ED settings needs to stem from future research
Understanding aged care emergency department presentations: The voices of nurses from residential aged care facilities
No full textObjective: To explore the perceptions of registered nurses and personal care workers in residential aged care facilities (RACFs) regarding factors contributing to early clinical deterioration and potentially unnecessary hospital presentations.
Background: Persistent workforce shortages, inadequate staffing levels, inconsistent care standards, and suboptimal communication in RACFs contribute to increased hospital transfers. However, many hospital presentations from RACFS are unwarranted and avoidable, and many residents could be better treated by alternative means in place.
Study design and methods: This study used a qualitative methodology in which semi-structured focus groups with registered nurses and personal care workers from two private RACFs in Queensland were used to gather in-depth accounts of experience and perceptions. Data was analysed using Braun and Clarke's reflexive thematic analysis approach.
Results: Four major themes emerged: 1) Clinical decision-making and confidence under pressure, with RNs reporting low confidence and anxiety regarding whether or not to transfer; 2) Organisational and interprofessional dynamics, with staff describing tensions with emergency and ambulance services; 3) Clinical reasoning and support structures, where staff described the value of Nurse Practitioners and clinical guidelines in decision making; 4) PCW role clarity and communication, where uncertainty about scope of practice and fragmented handover procedures were described.
Conclusion: Hospital transfer decisions in aged care are complex and heavily influenced by the experience and confidence of Registered Nurses (RNs). Less experienced RNs tend to make more cautious decisions, sometimes leading to avoidable transfers. Nurse Practitioners (NPs) help support better decisions, but organisational pressures and unclear roles, especially for Personal Care Workers (PCWs), create challenges. These factors collectively promoted risk-averse decision-making and increased reliance on hospital transfers. Improving training, clarifying roles, and fostering teamwork can reduce unnecessary transfers and improve care quality.
Implications for research, policy, and practice: There is a need to further investigate the impact of RN experience levels on hospital transfer rates. More attention needs to be given to developing effective models for integrating NPs into aged care teams. Further study the role and training needs of PCWs in early detection and decision-making
Recommendations and practices for holistic chronic obstructive pulmonary disease (COPD) assessment and optimal referral patterns in emergency department presentations: a scoping review protocol
No full textIntroduction Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that causes persistent respiratory symptoms and decline in lung function over many years. This chronic disease significantly affects health-related quality of life and is known to contribute to frequent emergency department (ED) presentations. Multidimensional management of these patients, including interconnecting health disciplinarians will allow holistic care provision in the ED. The purpose of this scoping review is to synthesise current evidence on holistic management and assessment, and referral practices stemming from acute COPD presentation in the ED. Specifically, to determine: (1) What are the known causal factors associated with COPD ED presentations and (2) Is there an identified connection with appropriate healthcare professional assessment within ED presentations and reported referral pathways? Methods and analysis The iterative stages of the Arskey and O'Malley, and Levac advanced scoping review framework informs this review. Using published and unpublished studies in English, a three-tiered search strategy will be applied. After duplicates are removed, screen 1 (title and abstract) and screen 2 (full-text) will be conducted by two independent reviewers to determine eligibility of articles. Disputes will be settled through discussion or by using a third reviewer. A data collection tool developed by the authors will inform the data extraction process. Schematic tabular format of results with a narrative summary will depict how the results link with the scoping review objectives. Categorisation of results will be narrowed down as key conceptual findings and will align with the strategic intent of this review. Ethics and dissemination Ethics approval was not required for this study. A multidisciplinary team of authors will participate in dissemination activities (publications, reports, conference presentations, framework development)
Corrigendum to "Understanding COPD Emergency Department presentations: using thematic analysis to explore the voices of patients, nurses, and doctors on the lived experience of managing COPD '' [Australian Journal of Advanced Nursing, volume 40, issue 1
No full textFollowing publication of this article the authors notified the editorial team that an author who had facilitated data collection and contributed to an original version of the manuscript had unintentionally been omitted from the author list. The authors confirmed that this oversight occurred following a change in corresponding author and associated responsibilities and have endorsed the subsequent amendment to the author list
Associated factors, assessment, management, and outcomes of patients who present to the emergency department for acute exacerbation of chronic obstructive pulmonary disease: a scoping review
No full textObjective: The purpose of the scoping review was to examine the extant literature for factors contributing to presentations of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) to Emergency Departments (ED). Methods: The review followed Arksey and O'Malley, and Levac's frameworks supplemented with the PRISMA-ScR checklist. We searched Cochrane Library, CINAHL, JBI, and PubMed from January 1, 2008 to March 23, 2020 for inclusions. We included studies reporting ED presentations for AECOPD among adults (≥18 years). The investigation included: pre-hospital factors; ED-related assessment, management and referral practices; holistic management (i.e., interdisciplinary); patient outcomes, admission/discharge status, and readmission. Results: Forty-four studies were included. Environmental factors (e.g., air pollution, seasonal change); social determinants (e.g., poor literacy, ethnicity); and physical health (e.g., comorbidities, obesity, poor exercise capacity) contributed to ED presentation/re-presentation, and admission to hospital. Cigarette smoking was associated with hospital admission. Mortality was associated with longer-term oxygen therapy, poor exercise capacity, age, and loss of consciousness. Compliance with clinical guideline recommendations were generally low or mixed. Further, there was a lack of appropriate referral practices upon discharge. Conclusions: While there is considerable literature on factors contributing to AECOPD admission more research is required that investigates the impact that inter-professional care models can have on the discharge planning cycles for patients with COPD who are regular presenters to an ED
