Have You SCAND MMe Please? A Framework for Nurses to Prevent Harm During Acute Hospitalisation

Preventable harms pose a significant problem for health systems worldwide, contributing to unnecessary burdens and substantial human and economic costs (Slawomirski, Auraaen, & Klazinga, 2017). Within the multidisciplinary care team, nurses central role in preventing harms associated with acute hospitalisation is explicit in their continuous presence with patients, responsibilities for surveillance and meeting the ‘fundamentals of care’ (Kitson, Muntlin Athlin, & Conroy, 2014). As patient safety knowledge improves and the population ages, the challenge of preventing harm during acute hospitalisation has become increasingly complex. The evidence available to support nurses’ roles to prevent harms is abundant; as patient treatments and safety knowledge have advanced, so has the volume and complexity of nursing work. Hospital harm prevention strategies often do not comprehensively address the multiple interrelated factors that contribute to common preventable harms affecting older hospitalised patients (Redley & Raggatt, 2017).

This paper presents a novel framework ‘Have you SCAND MMe Please?’ that integrates eight factors sensitive to the quality of nursing care that contribute to preventable harms common among older hospitalised patients. The mnemonic draws on national and international recommendations and best practice guidelines for the care of older people in hospital (Australian Commission on Safety and Quality in Health Care, 2012; Department of Health and Human Services, 2015; Royal College of Physicians, 2012). Each of the eight factors has evidence based recommendations for assessments and management, but these are seldom integrated into a comprehensive plan for nursing care.

The aim of this paper is to present the mnemonic ‘Have you SCAND MMe Please?’ as a framework to guide comprehensive high quality nursing care to prevent harms common to older patients in hospital.

Methods

We draw on findings from an examination of the standard assessment forms used in hospitals and a retrospective audit of nursing care documented in medical records of older medical inpatients at four hospitals. The framework was useful to examine the quality of nursing care: a number of gaps and duplication in nursing care were identified.

The preventable harms addressed by standard forms used to screen and assess older people were examined using a cross-sectional audit of the standard risk screening and assessment forms used at 11 Victorian health services. Nine focus groups with a purposive sample of 69 participants at 9 health services were used to examine how these forms were operationalized in harm prevention strategies.

A random selection of 400 medical records of inpatients over 65 years of age with an unplanned admission of longer than 72 hours in acute medical wards at four hospitals in Victoria, Australia were examined for frequency of documented evidence of assessments, interventions or new problems related to the eight factors contributing to common preventable harms during hospitalisation.

Results

Examination of 152 standard assessment forms from 11 Victorian health services identified over 3700 data collection items. 17% of items were duplicated across multiple forms. Assessments of skin integrity and mobility loss (including falls) were consistently included in forms; however, nutrition, cognitive state, pain and medication risks were inconsistent; and continence, venous thromboembolism risk and hospital acquired infection from invasive devices were infrequent.

No patient record had evidence of all eight factors being assessed. Assessments of Skin integrity (94-97%), Mobility (95-98%) and Pain (93-97%) were most often documented. Gaps in assessment of Continence (4-31%), Nutrition (9-49%), Cognition (Delirium, Depression & Dementia) (10-24%) were most common. Almost 80% of records had interventions documented for one or more factors that contribute to preventable harms. In almost 20% of patient records, a new preventable harm was documented during hospitalisation.

Discussion

The mnemonic ‘Have you SCAND MMe Please?’ represents eight factors that contribute to preventable harms common in older hospitalised patients. This framework provides a model for harm prevention to assist nurses to implement comprehensive harm prevention to improve quality of care and safety for older hospitalised patients.

Consistent high quality nursing care can avoid or minimise harms to older persons in hospitals. The mnemonic ‘Have you SCAND MMe Please?’ brings together eight factors known to contribute to preventable harms common in older hospitalised patients. This framework was useful in an audit to identify gaps in nursing assessment and interventions revealing no patients received comprehensive assessment, few receives nursing interventions for common risk factors and up to 20% of patients experienced a new harm that could be presented by nursing care.

Two issues impacting the delivery of comprehensive harm prevention by nurses were identified: 1) the high workload and cognitive burden of harm prevention; 2) poor integration of harm prevention strategies for multiple risks.

Within the setting of high workloads, skills shortages, resource constraints, multi-tasking and task switching, interruptions and distractions found in acute hospitals, nurses are increasingly unable to complete their work (Jones, Hamilton, & Murry, 2015; Needleman, 2017; Walter, Li, Dunsmuir, & Westbrook, 2014). Nurses report the workload and administrative burden associated with harm prevention, such as completing numerous assessment forms, is cognitively taxing, time demanding, confusing and overwhelming (Redley & Raggatt, 2017; Vincent & Amalberti, 2015).

The best practice recommendations for the eight factors that contribute to common preventable harms are not only overwhelming when considered together, they are can also be contradictory in the presence of multiple risk factors. This requires nurses to balance priorities, individual patient factors and the resource available.

Successful harm prevention requires a strategy that comprehensively incorporates the factors that contribute to common harms in a way that makes it easy for nurses to provide comprehensive integrated harm prevention in the context of their busy and complex work environments.

Future research should evaluate if the framework can be used in tools to assist nurses to systematically and efficiently recall the complex information needed for comprehensive harm prevention for older patients during acute hospitalisation. Future studies can use the framework as a model to integrate best practice recommendations into work processes to assist nurses to deliver safe, high quality acute hospital care for older patients.