JBI database of systematic reviews and implementation reports
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JBI Database System Rev Implement Rep · Nov 2015
ReviewAssessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol.
The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments. ⋯ Acute coronary syndrome (ACS) is a group of clinical conditions that include myocardial infarction with or without elevation of the ST segment and unstable angina. The term acute myocardial infarction (AMI) can be applied when there is evidence of myocardium necrosis with a clinical sign compatible with myocardial ischaemia. Acute myocardial infarction can be identified using clinical methods including electrocardiography (ECG), elevation in myocardium necrosis biomarkers, and imaging. Acute myocardial infarction is one of the leading causes of death and disability worldwide, and may be the first manifestation of coronary artery disease.Estimating the prevalence of coronary diseases in the general population is quite a complex task. In 2010, the prevalence of coronary diseases was reported as 6.4% among the general population in the United States.One of the main manifestations of ACS is chest pain. However, even in the presence of this typical symptom, early diagnosis of ACS is a challenge for health care professionals who initially attend to these patients. Several authors have indicated the importance and difficulty of recognizing chest pain of cardiac origin, where immediate medical attention is required.Triage, or risk classification, is a clinical management tool used in emergency services to guide patient flow when the need for medical attention exceeds that available. The Manchester Triage Group was developed in 1994 in the United Kingdom. The aim was to establish a consensus among physicians and nurses in the emergency room by creating a triage pattern focused on the development of the following:Thus, the Manchester Triage System (MTS) was created. The MTS simplifies the clinical management of each patient, and consequently, the whole service, by utilizing a system that defines the clinical priority for adults and children. The assessment of clinical priority needs to be fast; therefore, it is separated from the process of medical diagnosis. Restricting the time allocated for patient classification prevents an attempt to make a medical diagnosis at the time of classification.The main goal of the MTS is to set a time limit for each patient to be attended to safely, that is, with no risk to the patient's health. One of the main principles of the system is the higher the perceived risk to the patient's health, the shorter the waiting time for medical attendance. The MTS comprises a scale of five priority levels ().(Table is included in full-text article.)The MTS is composed of 52 distinct flowcharts that "guide" the triage decision-making process. Based on the main presenting symptom of the patient seeking emergency care, the health care professional must choose one of the 52 flowcharts in order to proceed with evaluation. Classification into one of the five clinical priority levels is set for each patient using the selected flowchart.The lack of a risk classification system within an emergency room implies attendance on a first-come, first-served basis, which in many cases may jeopardize a patient's safety, as patients whose health status is more unstable or severe are not prioritized.The MTS is a tool that aims to define the degree of severity and associated safe waiting time for patients in the emergency department, establishing an order of priority for medical care. It determines the clinical priority of every patient who comes to the emergency department. It is possible to evaluate the sensitivity and specificity of the MTS by calculating the frequency of appropriately assigned clinical priority levels to patients presenting at the emergency department.A "diagnostic test" can be understood as a laboratory or imaging test: however, the concepts related to "test" also apply to clinical information from other findings, such as physical examination and patient history. The sensitivity of a test is understood as the capacity of the test to detect individuals who present with a particular condition, or the proportion of individuals with a particular condition who have been tested positive for this condition (true positive). Highly sensitive tests can be used at the beginning of the diagnostic process, when a great number of possibilities are being considered, with the intention of excluding as many options as possible. The specificity of a test is defined as the capacity of the test to identify individuals who do not have a particular medical condition, or the proportion of individuals without the condition who have a negative test (true negative). A triage system that presents a good sensitivity can minimize the occurrence of undertriage, the same way, systems with suitable specificity can avoid the occurrence of overtriage.The assessment of patients with ACS suspected using the MTS, can occur through different flow charts, since the patient does not always have typical symptoms and concerns such as chest pain as the main complaint. For this reason, in addition to the flowchart "chest pain", other flowcharts, including "shortness of breath in adults", "unwell adult", "collapsed adult", and "palpitations", enable distinguishing chest pain and other urgent conditions from non-urgent conditions, and can assist the appraiser to establish the highest priority level to treat patients with these urgent conditions.According to the algorithm from the American Heart Association, every patient who presents symptoms of chest discomfort suggestive of ischaemia must receive medical attention within 10 minutes. Therefore, in order to recognize patients in those conditions, the health care professional applying MTS must establish priority levels of "red" or "orange", thereby setting a safe waiting time for these patients.Although there are well-established criteria for the prioritization of patients with suspected ACS, several studies have reported the difficulties of evaluating patients with these conditions. Various factors can interfere with the outcome of this process, such as atypical presentation of symptoms, AMI classification, patient age, and professional skill.Primary studies have addressed the issue from different perspectives. Studies have been conducted to evaluate the ability of nurses using MTS to detect high-risk patients with chest pain, the impact of MTS on short-term mortality in AMI, and the sensitivity and specificity of MTS for patients with ACS, and to assess whether the MTS was used effectively in patients admitted to the hospital with a diagnosis of acute coronary syndrome.These studies concluded that use of the MTS by nurses is a sensitive method for identifying high risk cardiac chest pain, but further studies are required to assess whether additional training can improve the sensitivity of MTS. The MTS safeguards patients with typical AMI presentation and ST elevation during myocardial infarction, and who are under 70 years of age. The MTS has a high sensitivity in prioritization (immediate/very urgent) of patients with ACS. Additionally, most patients admitted for ACS are initially triaged as "orange" or "yellow", an indication for prompt assessment in the emergency department. This has a positive effect on time to first medical assessment, but has no effect on time to hospital admission.A systematic review addressing a similar theme was published. The review evaluated the efficacy of MTS for all groups of patients and included studies that evaluated the MTS in relation to different outcomes. This proposed review is different as it will include primary studies with a specific sub-population (patients with ACS). Another important difference lies in the fact that the published review did not include critical appraisal of the primary studies included in review. A systematic review that synthesizes the available evidence on the sensitivity of MTS to evaluate patients with an ACS medical diagnosis is necessary to guide decisions related to the use or adoption of the instrument, as well as providing data that can contribute to improvements to the system.
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JBI Database System Rev Implement Rep · Nov 2015
ReviewCharacteristics of Indigenous primary health care models of service delivery: a scoping review protocol.
The objective of the scoping review is to identify and describe within the existing literature the characteristics (values, principles, components and suggest practical applications) of primary health care models of service delivery for Indigenous people. More specifically, the review question is:What are the characteristics (values, principles, components and suggested practical applications) of primary health care models of service delivery for Indigenous people?Findings from this scoping review will inform two systematic reviews. One of these will explore the acceptability and the other the effectiveness of identified characteristics. ⋯ Indigenous populations in colonized countries experience worse health outcomes relative to their non-Indigenous counterparts. In Australia, in the period 2010 to 2012 the estimated gap in life expectancy between Aboriginal and Torres Strait Islander Australians compared to non-Indigenous Australians was 10 years Similar gaps in life expectancy between Indigenous and non-Indigenous have been demonstrated in other countries, such as New Zealand, Canada and the United StatesThe gap in life expectancy and the health disadvantage experienced by Indigenous people is in part the result of mainstream health services not adequately meeting the health needs of Indigenous people and Indigenous people's inability to access mainstream services Part of the solution has been the establishment of primary health care services for and in many cases run by Indigenous people. Indigenous primary health services have been developed to provide culturally appropriate services that meet the needs of local Indigenous communities.In Australia, the first Aboriginal medical service was established in 1971 in Redfern, New South Wales, by "community activists in response to ongoing discrimination against Aboriginal people within mainstream health services to address the poor health and premature deaths of Aboriginal people, and to provide a culturally appropriate system of health care". There are now over 150 Aboriginal Community Controlled Health Services in Australia. Aboriginal Community Controlled Health Services are underpinned by common values such as culture, cultural respect, integrity, inclusion, self-determination, community control, sovereignty and leadership.Similar models of Indigenous health services exist in other countries, such as Māori health providers in New Zealand, First Nations and Inuit Health Authorities in Canada, and the Indian Health Services in the US. In New Zealand, Māori health providers deliver health and disability services to Māori and non-Māori clients. The difference between Māori health providers and mainstream services in New Zealand is that Māori health services are based on kaupapa, a plan or set of principles and ideas that informs behavior and customs, and the delivery framework which is distinctively Māori. First Nations and Inuit Health Authorities in Canada coordinate and integrate health programs and services to achieve better health outcomes for First Nations people. These community-based services largely focus on health promotion and prevention. First Nations and Inuit Health Authorities work under a unique health governance structure that includes local First Nations' leadership, based on the philosophy of self-governance and self-determination, which represent and address the health needs of First Nation communities. The Indian Health Service (IHS) in the US is responsible for providing comprehensive health services to American Indians and Alaska Natives. The IHS aims to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level, and its goal is "to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people". The IHS "grew out of a special government-to-government relationship between the federal government and Indian Tribes".Evidence suggests that "a strong primary health care sector is essential to the health and wellbeing of a population, and that a strong primary health care sector is associated with better population health, reduced costs of health care provision, and greater efficiency within the system". A study of Aboriginal Canadians shows that poor access and ineffective primary health care services were directly related to increased avoidable hospital admissions. In addition, a recent study in Australia focusing on the costs and the health outcomes associated with primary care use by Indigenous people with diabetes in remote communities in the Northern Territory demonstrates that improved access to primary health care which is responsive to the needs of Aboriginal and Torres Strait Islander people is both cost-effective and associated with better health outcomes.Given the strong link between primary health care and health outcomes and the significant contribution Indigenous health services make towards reducing the health disadvantage experienced by Indigenous people, it is important to understand the characteristics that support the delivery of health provided by Indigenous health services and their unique models. While there is not a clear definition in the literature about what a model of care or model of service delivery is, for the purpose of this review, it will encompass all factors involved in the delivery of care including but not limited to the vision, values and strategies that underpin the delivery of care, healthcare services and programs, governance and leadership, workforce, organization and supply, and infrastructure and other resources.The aim of this scoping review is to determine the characteristics of Indigenous primary health care models of service delivery by drawing on existing literature that look at the way in which services are delivered in this setting.An initial search of literature was conducted to establish whether there are studies with findings available to answer the review question, and whether there is a systematic or scoping review addressing the knowledge gap currently underway or published. There are no systematic or scoping reviews published or underway that address the question proposed by this review.
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JBI Database System Rev Implement Rep · Nov 2015
ReviewThe experiences of midwives and nurses collaborating to provide birthing care: a systematic review.
Collaboration has been associated with improved health outcomes in maternity care. Collaborative relationships between midwives and physicians have been a focus of literature regarding collaboration in maternity care. However despite the front line role of nurses in the provision of maternity care, there has not yet been a systematic review conducted about the experiences of midwives and nurses collaborating to provide birthing care. ⋯ Qualitative evidence about the experiences of midwives and nurses collaborating to provide birthing care was identified, appraised and synthesized. Two synthesized findings were created from the findings of the five included studies. Midwives and nurses had negative experiences of collaboration which may be influenced by: distrust, unclear roles, or a lack of professionalism or consideration. Midwives and nurses had positive experiences of teamwork which can be a source of hope for overcoming the challenges of sharing care.There is clearly a gap in the literature about the collaborative experiences of midwives and nurses, given that only five studies were located for inclusion in the systematic review. More qualitative research exploring collaboration as a process and the interactional dynamics of midwives and nurses in a variety of practice and professional contexts is required.Distrust, unclear roles, and lack of professionalism and consideration must all be addressed. Strategies that address and minimize the occurrences of these three elements need to be developed and implemented in an effort to reduce negative collaborative experiences for midwives and nurses. Postive experiences of teamwork must be acknowleged and celebrated, and the challenges that sharing care present must be understood as a part of the collaborative process.More qualitative research is required to explore the collaborative process between midwives and nurses. Further exploration of their interactional dynamics, their relationship between power and collaboration, and the experiences of collaboration in a variety of professional and practice contexts is recommended.
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JBI Database System Rev Implement Rep · Nov 2015
ReviewHealthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions: a qualitative systematic review protocol.
The objective of this review is to identify and synthesize the best international qualitative evidence on healthcare users' experiences of communication with healthcare professionals about children who have life-limiting conditions. For the purposes of this review, "healthcare users" will be taken to include children who have life-limiting conditions and their families. The question to be addressed is:What are healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions? ⋯ The prospect of the death of a child from an incurable medical condition is harrowing, yet finding a way to discuss this prospect is crucial to maximize the quality of life for such children and their families. High-quality communication is well recognized as a core skill health care professionals need to maximize the quality of care they provide. This skill is valued by service users, who consistently rate it as one of the highest priorities for the care they receive. Evidence suggests, however, that healthcare professionals can feel ill-equipped or uncomfortable communicating with and about such children. Therefore, it is important to understand what represents high-quality communication and what is involved in accomplishing this within pediatric palliative care.In recent decades there has been an increased focus on providing palliative care for children who have life-limiting conditions. These are conditions for which no cure is available and for which the probable outcome is premature death. Palliative care may also be appropriate for children who have life-threatening conditions; these are conditions where there is not only a high probability of premature death but also a chance of long-term survival into adulthood Although pediatric palliative care is underpinned by the same philosophy as adult palliative care, children who have life-limiting conditions and their families have particular needs that distinguish them from users of adult palliative care. For example, at a physical level children are more likely than adults to have non-malignant conditions that follow trajectories in which children oscillate between feeling relatively well and acutely unwell. The social dynamic of their care is also radically different, particularly given the role of parents or guardians in making surrogate decisions about their child's care. Such factors warrant considering pediatric palliative care as distinct from palliative care more generally.Although the particular circumstances of children who have life-limiting conditions have led to development of pediatric palliative care, the particular provisions of this care differs among countries. One aspect of variation is the age range of patients. Pediatric palliative care is usually provided to neonates, infants, children, adolescents and young adults, but international variations in the definitions of these age ranges, particularly for adolescents and young adults, means pediatric palliative care is provided to different age groups in different countries. This review therefore adopts a pragmatic rather than an age-based definition of a pediatric palliative care, considering all studies relating to service users who are being cared for by pediatric rather than adult healthcare services.In catering for the unique needs of children who have life-limiting conditions and their families, pediatric palliative care aims to achieve pain and symptom management, enhanced dignity and quality of life, and psychosocial and spiritual care. It also seeks to incorporate care for patients' broader families and facilitating access to appropriate services and support. High-quality communication is crucial for achieving these aims. It enables healthcare users and providers to make decisions that underpin the care that is provided and the quality of the life that is possible for patients and their families.Although both users and providers recognize the value of high-quality communication with and about children who have life-limiting conditions, this does not mean that these stakeholders necessarily share the same perspective of what constitutes high-quality communication and the best way of accomplishing this. Focusing on healthcare users' experiences of communication with healthcare professionals about children who have life-limiting conditions, the present review will explore the subjective impact of professionals' communication on the people for whom they provide care.It may be necessary to consider a range of contextual factors to understand healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions. For instance, age, developmental stage, cognitive capacity, emotional and social strengths, and family dynamics can influence a child's level of involvement in discussions about their condition and care. Although there are factors that appear more consistent across the range of pediatric palliative care users, such as parents' preferences for being treated by healthcare professionals as partners in making decisions about the care of their child, there is not always such consistency. Nor is it clear whether such findings can be generalized across different cultural contexts. In appraising existing research, this systematic review will therefore consider the relationship between the context of individual studies and their reported findings.The primary aim of this review is to identify, appraise and synthesize existing qualitative evidence of healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions. The review will consider relevant details of these findings, particularly whether factors like age are relevant for understanding particular experiences of communication. An outcome of this review will be the identification of best available qualitative evidence that can be used to inform professional practice, as well as an identification of priorities for future research in pediatric palliative care.A preliminary search in MEDLINE and CINAHL found primary studies exploring healthcare users' experiences of aspects of communicating with healthcare professionals about children who have life-limiting conditions. A search was also conducted for existing systematic reviews in PubMed, CINAHL, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews, the JBI Database of Systematic Reviews and Implementation Reports, and PROSPERO. No systematic reviews on this topic were found.
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JBI Database System Rev Implement Rep · Nov 2015
Preoperative fasting among burns patients in an acute care setting: a best practice implementation project.
Major burn injury patients commonly fast preoperatively before multiple surgical procedures. The Societies of Anesthesiology in Europe and the United States recommend fasting from clear fluids for two hours and solids for six to eight hours preoperatively. However, at the Royal Adelaide Hospital, patients often fast from midnight proceeding the day of surgery. This project aims to promote evidence-based practice to minimize extended preoperative fasting in major burn patients. ⋯ These results demonstrate that education improves compliance with documentation and preoperative fasting that is more reflective of evidence-based practice. Collaboration with key stakeholders and a hospital wide fasting protocol is warranted to sustain change and further advance compliance with evidence-based practice at an organizational level.