How do doctors, nurses and healthcare assistants in the acute medical unit look after patients who have diarrhoea and vomiting?

Abstract

Background: Outbreaks of infectious diarrhoea and vomiting are a worldwide problem, with detrimental human and economic costs. In the United Kingdom, despite well-publicised guidelines and a plethora of recommended infection prevention and control strategies, hospital outbreaks are problematic - affecting patients and organisational operations. At present however, little is known about how hospital-based clinicians actually assess the infective status of patients with symptoms of diarrhoea and vomiting, whilst awaiting stool (faeces) microbiology results. Little is also known about the infection prevention and control measures that these clinicians employ in non-outbreak situations to prevent the spread of infection when infectious causes are suspected. These gaps in knowledge impede the ability of clinical leaders to appropriately support frontline staff in order to minimise incidences of avoidable outbreaks. This study therefore aimed to answer this question: How do clinicians in the Acute Medical Unit (AMU) assess and manage patients with symptoms of diarrhoea and vomiting - and what factors affect these processes?

Methods: An 11-month ethnographic study was undertaken in the AMU of a local teaching hospital. Purposive sampling was used to identify relevant clinician and patient participants. Data collection methods included observations of relevant clinical activities; clinician-led photo walks; interviews with clinicians and patients; reviews of patients’ notes and reviews of pertinent local hospital infection prevention and control policies. Techniques from the constant comparative method and the framework method were used to support data analysis and synthesis.

Findings: The process of assessing the infectious status of patients with symptoms of diarrhoea and vomiting in the absence of stool microbiology results was found to be complex. It was mainly dependant on the accuracy and detail of the patient’s medical history and the maturity of the assessing clinician’s clinical judgement. When infectious causes were suspected, clinicians employed various infection prevention and control measures. However, the successful implementation and performance of these measures was challenging, because of the complex, multifaceted socio-technical elements in the AMU; where people interacted in different ways with the environment, policies, artefacts, tasks and each other. Although affected patients described satisfaction with the care they were receiving in the AMU, their knowledge of, and involvement in, infection prevention and control related aspects of care, was poor.

Conclusion and implications for practice: Much needs to be done to improve the assessment and infection prevention and control management of patients with symptoms of diarrhoea and vomiting in clinical practice. Steps need to be taken to improve patient assessment practice, through developing clinicians’ clinical judgement and history taking skills. Clinical leaders also need to be aware of, and account for, clinical human factors affecting patient assessment practice and the implementation and performance of infection prevention and control measures. Finally, clinicians need to consider patients as partners in infection prevention and control activities and offer them adequate information, education and support in this aspect of care.

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Identifiers

ORCID for Matsikachando Rodgers Moyo: orcid.org/0000-0002-6834-5238

ORCID for Jacqueline Prieto: orcid.org/0000-0002-5524-6775

ORCID for Carl May: orcid.org/0000-0002-0451-2690

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