Older people are one of the biggest populations requiring hospital care, and the demand is expected to rise. There is a compelling need to transform hospital environments to meet older-people physical, psychological, and emotional needs. In the UK, certain hospital circumstances such as ward configuration, mealtimes, noise levels, and visiting hours can be detrimental to patients admitted with delirium and to those living with dementia. In rehabilitation settings, lack of meaningful activities, isolation, and boredom are additional key challenges.

Models of good hospital practice catering for old people exist, both in the UK and internationally, and there is strong evidence for their clinical effectiveness. Environmental strategies to maintain orientation and enhance safety in hospital are crucial for a positive experience. Arts-based programmes in acute care settinsg can improve the experience of a hospital admission.

A cultural shift is warranted to champion the delivery an elderly-friendly service. Creating the right environment requires a hospital-wide system, a ward-based service, and a specially trained clinical team. In this chapter we will present examples of essential ingredients for hospitals and wards, and desirable qualities in clinicians who work in collaboration to deliver the best outcomes for an older population.

Chapter 2 analyzes the life histories and experiences of métis children who were wards of the colonial state in the 1930s in Senegal and Gabon. They received government funding and management of their education. The daily lives of métis wards became a battleground through which fictive and blood kin, métis activists, emerging African political leaders, French colonial administrators, and Catholic missionaries debated the meanings of race, culture, and child welfare. In Senegal, African stakeholders mediated métis children’s access to French education, living conditions, and colonial welfare payments based on their parentage from French and European men. The state was obliged to provide access to education for all children born in Africa, with métis as a distinct group. In Gabon, an association of adult métis lobbied for access to favorable material conditions for métis children and for them to attend a school for European children and reside in a boarding home without black children. Contestations around their welfare hinged on the French republican rhetoric of universal rights and equality and racialized hierarchies within African societies.

The debate surrounding the ‘degradation’ (removal of degrees) of the Revd William George Ward by fellow graduates of Oxford University in February 1845 raised fundamental questions: Who teaches the true faith and on what authority? This chapter focuses upon two means of communication that came to the fore in response to the Ward case, which was more to do with theological beliefs and principles than liturgical practices: first, the almost daily exchange of private letters between key individuals, enabling anxieties to be expressed and party tactics worked out; and second, the printing of pamphlets, often in the form of open letters, which provided a means by which more fully developed arguments could be circulated rapidly. Once again, the communication revolution associated with the uniform penny post and the expansion of the railways changed the pace of events and of the exchange of ideas. Opposing sides in the battle for votes in the Ward case shared drafts of pamphlets by post, offered moral support to colleagues and vented strong emotions on ecclesiastical matters that meant the world to them.

This chapter explains how the imperial urban system expanded into south China. After the fall of the Han Dynasty, fighting in the north caused southern migration, particularly after the An Lushan Rebellion in 755. This led to the growth of commercial cities in the Lower Yangzi Delta, which were linked to the northern capitals via the Grand Canal after the reunification of China under the Sui Dynasty. At the same time, Chinese cities were linked to the medieval international world over land along the Silk Road, and over sea via Guangzhou. In northern capitals, which reflected the influence of the Kaogongji, cities continued to be walled and divided into wards. However, in the Lower Yangzi Delta commercial cities were more open plan. Meanwhile, the arrival of Buddhism and Daoism into China brought monasteries and temples into cities, while monks began to take responsibility for aspects of urban governance along with imperial officials. Wards divided cities socially as well as physically. The wealthy enjoyed lavish lifestyles, built palaces and mansions, donated to monasteries, and constructed gardens. Goods and people from outside China made cities more cosmopolitan, and writers reflected on this and other aspects of urban life in their poetry.

During the Tang-Song transition, urbanization created regionally distinct hierarchical networks of large and small cities, market towns, and villages, which were closely connected in complex economic, social, and political relationships. The Lower Yangzi Delta was the most urbanized region of China, and remained linked to northern capitals via the Grand Canal. Within Chinese capitals, emperors, aristocrats, and officials remained enclosed within palace and imperial cities. Outside, the ward system broke down, and in many smaller cities there were no walls at all. Now commerce could be found along every street, and it also brought new forms of social organization and governance. Merchants organized different trades into guilds and took their place alongside the state and religious institutions in governing urban life. In capital cities, imperial families continued to assert their symbolic right to rule through participation in now well-established rituals. Elsewhere, people from all social classes were more invested in the urban life of their city, and distinct urban cultures emerged. Local gentry wrote urban histories and guides, bought and sold property, and invested in businesses or religious institutions. They describe lives of urban men and women in levels of detail that do not exist for earlier eras.

Many surgical patients spend time in an intensive care unit and on the wards. Medication errors are one of the most frequent causes of preventable harm in ICU and wards, and occur predominately in the dispensing and administration phases. Despite a plethora of publications and studies of medication errors in these locations, significant differences in definitions, study methods, and local workflows lead to remarkable differences in the rates of error reported. Increasing number of medications per patient, nurse to patient ratios, and patient age contribute to medication errors in the ICU. Pediatric ICUs tend to have higher rates of error, and this often is due to mis-calculation of a dilution or a weight based dose. On the wards, administration errors are common, especially when exact timing is expected for a given administration. Prescribing errors are often the result of lack of knowledge, whether related to diagnosis or medication; administration errors are more frequently skill based errors such as slips or lapses.

Many studies from around the world, especially NAP4 in the UK, have demonstrated that airway management in critically ill patients, whether in the intensive care unit, emergency department or general wards, is fraught with danger. Serious morbidity or mortality may be 50-fold more common than in anaesthetic practice. This chapter describes the essential features of airway management specific to critical care intubation. The importance of an intubation bundle approach is emphasised, such as the UK’s Difficult Airway Society guidelines for tracheal intubation in the critically ill adult. Components include: (i) deliberate and thoughtful application of human factors science to optimise team performance and sharing the airway plan; (ii) assessment of potential difficulty based on the MACOCHA scoring system; (iii) pre-oxygenation using continuous positive airway pressure (CPAP) or non-invasive ventilation, high flow nasal oxygen, or a combination of these; (iv) a modified rapid sequence induction with continuous peroxygenation; (v) optimising laryngoscopy and intubation with early videolaryngoscopy by a trained operator; (vi) airway rescue with an amalgamated Plan B/C, borrowing from the Vortex approach; (vii) use of second generation supraglottic airways (SGAs); (viii) priming for front of neck airway (FONA) and (ix) a scalpel-bougie-tube cricothyroidotomy when managing cannot intubate, cannot oxygenate (CICO).