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To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

BackgroundIndependent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study.AimTo describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices.Design and methodsAcross 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written (n=132) by nurses and b) the record of the prescribing episode in patient records (n=118).Sample and setting118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England.FindingsNurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records.ConclusionThe findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.

IntroductionPlanning and communicating treatment decisions in a context of clinical uncertainty presents a key challenge. Increasing evidence supports the desirability of documenting a care-plan that addresses options about treatment escalation (Treatment Escalation Plan (TEP)) ensuring quality of healthcare for patients, in line with their wishes, prevention from distressing treatments and unnecessary harm as end of life approaches (Dalgaard et al., 2010, Carey et al., 2015, Obolensky et al., 2010, Gott et al., 2011, National Confidential Enquiry into Patient Outcome and Death, 2012, Fritz et al., 2013).AimsTo ascertain current procedures for recording treatment decisions in situations of clinical uncertainty. To identify and characterise key components of TEPs and understand the implications of these when incorporated into clinical practice.MethodA scoping exercise of all UK NHS adult acute Trusts. Telephone interviews were conducted to gain more indepth knowledge of processes and analysed using directed content analysis. Where a TEP was in use, content analysis was conducted to understand the structure and information required to complete them.Results55/150 Trusts provided details of systems used. Of these 43 had experience of using a TEP, 29 of which had been formally evaluated. A further 6 were sourced through online searches. There was wide variation in the processes used. Forms consistently attended to seven key components: Resuscitation; Communication; ceilings of care; supportive care; capacity; transferability; colour/format.ConclusionTEPs are valuable in ensuring patients’ dignity and comfort when faced with acute pathophysiological deterioration at end of life and have potential to minimise harm from unnecessary and/or unwanted investigations and treatment. However, inconsistency in availability and incorporation into practice has implications for quality and consistency of patient care.References. CAREY, I., SHOULS, S., BRISTOWE, K., MORRIS, M., BRIANT, L., ROBINSON, C., CAULKIN, R., GRIFFITHS, M., CLARK, K., KOFFMAN, J. & HOPPER, A. 2015. Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation. BMJ Supportive & Palliative Care, 5, 405–411.. DALGAARD, K. M., THORSELL, G. & DELMAR, C. 2010. Identifying transitions in terminal illness trajectories: a critical factor in hospital-based palliative care. International Journal Of Palliative Nursing, 16, 87–92.. FRITZ, Z., MALYON, A., FRANKAU, J. M., PARKER, R. A., COHN, S., LAROCHE, C. M., PALMER, C. R. & FULD, J. P. 2013. The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation of the effects on clinical practice and patient care. Plos One, 8, e70977–e70977.. GOTT, M., INGLETON, C., BENNETT, M. I. & GARDINER, C. 2011. Transitions to palliative care in acute hospitals in England: qualitative study. BMJ Supportive & Palliative Care, 1, 42–48.. NATIONAL CONFIDENTIAL ENQUIRY INTO PATIENT OUTCOME AND DEATH2012. Time to interevene? : NCEPOD.. OBOLENSKY, L., CLARK, T., MATTHEW, G. & MERCER, M. 2010. A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process. J Med Ethics, 36, 518–20.

OBJECTIVE: To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality. Design Ethnographic case study. Setting Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing. Participants 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally. MAIN OUTCOME MEASURES: Potential threats to patient safety and characteristics of good practice. METHODS: Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. RESULTS: Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as "exceptions" by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. CONCLUSION: Receptionists and administrative staff make important "hidden" contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.