Latest from Q&S

Systematic simulation-based team training in a Swedish intensive care unit: a diverse response among critical care professions [ORIGINAL RESEARCH]

Sat, 1 Jun 2013 00:00:00 +0000

BackgroundTeamwork--that is, collaboration and communication--is an important factor for safe healthcare, but professions perceive the quality of teamwork differently. ObjectiveTo examine the relationship between simulation-based team training (SBTT) and different professions' self-efficacy, experienced quality of collaboration and communication, perceptions of teamwork and safety, together with staff turnover. MethodsAll staff (n=151; physicians, nurses and nurse assistants) in an intensive care unit (ICU) at a university hospital were systematically trained over 2 years. Data on individual self-efficacy were measured using the self-efficacy questionnaire; the experienced quality of collaboration and communication, teamwork climate, safety climate and perception of working conditions were sampled using the ICU version of the safety attitudes questionnaire (SAQ). Staff turnover and sick leave was measured using the hospital's staff administration system for the intervention ICU and a control ICU in the same hospital. ResultsThe perception of safety differed between professions before training. Nurses' and physicians' mean self-efficacy scores improved, and nurse assistants' perceived quality of collaboration and communication with physician specialists improved after training. Nurse assistants' perception of the SAQ factors teamwork climate, safety climate and working conditions were more positive after the project as well as nurses' perception of safety climate. The number of nurses quitting their job and nurse assistants' time on sick leave was reduced in comparison to the control ICU during the study period. LimitationsResults for SAQ factors must be interpreted with caution given that Cronbach's and inter-correlations for the SAQ factors showed lower values than benchmarking data. ConclusionsAll team members benefited from the SBTT in an authentic composed team, but this was expressed differently for the respective professions.

The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessments of data quality, test-retest reliability and hospital-level reliability [ORIGINAL RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

BackgroundThe objective of this study was to test the data quality, test-retest reliability and hospital-level reliability of the Patient-Reported Incident in Hospital Instrument (PRIH-I). Methods13 incident questions were included in a national patient-experience survey in Norway during the spring of 2011. All questions and a composite incident index were assessed by calculating missing-item rates, test-retest reliability and hospital-level reliability. A multivariate linear regression on a global item regarding incorrect treatment was used to assess the main sources of variation in patient-perceived incorrect treatment at hospitals. ResultsFive of the 13 patient-incident questions had a missing-item rate of >20%. Only one item met the criterion of 0.7 for test-retest reliability (wrong or delayed diagnosis), seven items had a score of >0.5, while the remainder had a reliability score of <0.5. However, the reliability was >0.7 for six of 10 items tested at the hospital level, and >0.6 for the remaining four items. A patient-incident index based on 12 of the incident items had no missing data, the test-retest reliability was 0.6 and the hospital-level reliability was 0.85. ConclusionsThe PRIH-I comprises 13 questions about patient-perceived incidents in hospitals, and can be easily and cost-effectively included in national patient-experience surveys with an acceptable increase in respondent burden. Although the missing-item rate and test-retest reliability were poor for several items, the hospital-level reliability was satisfactory for most of the items. The incident items contribute to a patient-reported incident index, with excellent data quality and hospital-level reliability.

An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions [ORIGINAL RESEARCH]

Tue, 7 May 2013 00:00:00 +0000

BackgroundHospital patient-to-nurse staffing ratios are associated with quality outcomes in adult patient populations but little is known about how these factors affect paediatric care. We examined the relationship between staffing ratios and all-cause readmission (within 14 days, 15-30 days) among children admitted for common medical and surgical conditions. MethodsWe conducted an observational cross-sectional study of readmissions of children in 225 hospitals by linking nurse surveys, inpatient discharge data and information from the American Hospital Association Annual Survey. Registered Nurses (N=14 194) providing direct patient care in study hospitals (N=225) and children hospitalised for common conditions (N=90 459) were included. ResultsEach one patient increase in a hospital's average paediatric staffing ratio increased a medical child's odds of readmission within 15-30 days by a factor of 1.11, or by 11% (95% CI 1.02 to 1.20) and a surgical child's likelihood of readmission within 15-30 days by a factor of 1.48, or by 48% (95% CI 1.27 to 1.73). Children treated in hospitals with paediatric staffing ratios of 1 : 4 or less were significantly less likely to be readmitted within 15-30 days. There were no significant effects of nurse staffing ratios on readmissions within 14 days. DiscussionChildren with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. Lower patient-to-nurse ratios hold promise for preventing unnecessary hospital readmissions for children through more effective predischarge monitoring of patient conditions, improved discharge preparation and enhanced quality improvement success.

Differences in drug utilisation between men and women: a cross-sectional analysis of all dispensed drugs in Sweden [RESEARCH]

Fri, 3 May 2013 00:00:00 +0000

ObjectivesAscertain the extent of differences between men and women in dispensed drugs since there is a lack of comprehensive overviews on sex differences in the use of prescription drugs. DesignCross-sectional population database analysis. MethodsData on all dispensed drugs in 2010 to the entire Swedish population (9.3 million inhabitants) were obtained from the Swedish Prescribed Drug Register. All pharmacological groups with ambulatory care prescribing accounting for >75% of the total volume in Defined Daily Doses and a prevalence of >1% were included in the analysis. Crude and age-adjusted differences in prevalence and incidence were calculated as risk ratios (RRs) of women/men. ResultsIn all, 2.8 million men (59%) and 3.6 million women (76%) were dispensed at least one prescribed drug during 2010. Women were dispensed more drugs in all age groups except among children under the age of 10. The largest sex difference in prevalence in absolute numbers was found for antibiotics that were more common in women, 265.5 patients (PAT)/1000 women and 191.3 PAT/1000 men, respectively. This was followed by thyroid therapy (65.7 PAT/1000 women and 13.1 PAT/1000 men) and antidepressants (106.6 PAT/1000 women and 55.4 PAT/1000 men). Age-adjusted relative sex differences in prevalence were found in 48 of the 50 identified pharmacological groups. The pharmacological groups with the largest relative differences of dispensed drugs were systemic antimycotics (RR 6.6 CI 6.4 to 6.7), drugs for osteoporosis (RR 4.9 CI 4.9 to 5.0) and thyroid therapy (RR 4.5 CI 4.4 to 4.5), which were dispensed to women to a higher degree. Antigout agents (RR 0.4 CI 0.4 to 0.4), psychostimulants (RR 0.6 CI 0.6 to 0.6) and ACE inhibitors (RR 0.7 CI 0.7 to 0.7) were dispensed to men to a larger proportion. ConclusionsSubstantial differences in the prevalence and incidence of dispensed drugs were found between men and women. Some differences may be rational and desirable and related to differences between the sexes in the incidence or prevalence of disease or by biological differences. Other differences are more difficult to explain on medical grounds and may indicate unequal treatment.

Coronary revascularisation in stable patients after an acute coronary syndrome: a propensity analysis of early invasive versus conservative management in a register-based cohort study [RESEARCH]

Wed, 24 Apr 2013 00:00:00 +0000

ObjectivesTo compare the effectiveness of in-hospital medical therapy versus coronary revascularisation added to medical therapy in patients who stabilised after an acute coronary syndrome (ACS). DesignPropensity score-matched cohort study from the database of the Tampere ACS registry. SettingA single academic hospital in Finland. Participants1149 patients with a recent ACS, but no serious coexisting conditions: recurrent ischaemic episodes despite adequate medical therapy, haemodynamic instability, overt congestive heart failure and serious ventricular arrhythmias. Primary and secondary outcome measuresThe composite endpoint of major acute cardiovascular events (MACEs): unstable angina requiring rehospitalisation, stroke, myocardial infarction and all-cause mortality, at 6-month follow-up. ResultsCompared with standard medical treatment, revascularisation was associated with a lower rate of MACEs at 6 months in patients of the first quintile (HR 0.81; 95% CI 0.66 to 0.99), but a higher rate of MACEs in the fifth quintile (HR 4.74, CI 1.36 to 16.49; p=0.014). There were no significant differences in the rates of MACEs in the remaining three quintiles. Patients of the first quintile were the oldest (79.7{+/-}8.3 years) and had a more significant (p<0.001) history of prior myocardial infarction (37%) and poor renal function (creatine, {micro}mol/l: 114.9{+/-}70.7). They also showed the highest C reactive protein (7.3{+/-}9.5 mg/l) levels. ConclusionsOur findings suggest that in-hospital coronary revascularisation did not lead to any advantage with signal of possible harm in the great majority of patients who stabilised after an ACS. An early invasive management strategy may be best reserved for elderly patients having high-risk clinical features and biochemical evidence of a strong inflammatory activity.

Assessing the efficacy of the electronic patient record system EDeR: implementation study--study protocol [PROTOCOL]

Wed, 10 Apr 2013 00:00:00 +0000

IntroductionDespite many innovations in information technology, many clinics still rely on paper-based medical records. Critics, however, claim that they are hard to read, because of illegible handwriting, and uncomfortable to use. Moreover, a chronological overview is not always easily possible, content can be destroyed or get lost. There is an overall opinion that electronic medical records (EMRs) should solve these problems and improve physicians' efficiency, patients' safety and reduce the overall costs in practice. However, to date, the evidence supporting this view is sparse. Methods and analysisIn this protocol, we describe a study exploring differences in speed and accuracy when searching clinical information using the paper-based patient record or the Elektronische DateneRfassung (EDeR). Designed as a randomised vignette study, we hypothesise that the EDeR increases efficiency, that is, reduces time on reading the patient history and looking for relevant examination results, helps finding mistakes and missing information quicker and more reliably. In exploratory analyses, we aim at exploring factors associated with a higher performance. Ethics and disseminationThe ethics committee of the Canton Lucerne, Switzerland, approved this study. We presume that the implementation of the EMR software EDeR will have a positive impact on the efficiency of the doctors, which will result in an increase of consultations per day. We believe that the results of our study will provide a valid basis to quantify the added value of an EMR system in an ophthalmological environment.

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia [ORIGINAL RESEARCH]

Wed, 10 Apr 2013 00:00:00 +0000

Objectives(1) To determine the distribution of formal patient complaints across Australia's medical workforce and (2) to identify characteristics of doctors at high risk of incurring recurrent complaints. MethodsWe assembled a national sample of all 18 907 formal patient complaints filed against doctors with health service ombudsmen ( Commissions') in Australia over an 11-year period. We analysed the distribution of complaints among practicing doctors. We then used recurrent-event survival analysis to identify characteristics of doctors at high risk of recurrent complaints, and to estimate each individual doctor's risk of incurring future complaints. ResultsThe distribution of complaints among doctors was highly skewed: 3% of Australia's medical workforce accounted for 49% of complaints and 1% accounted for a quarter of complaints. Short-term risks of recurrence varied significantly among doctors: there was a strong dose-response relationship with number of previous complaints and significant differences by doctor specialty and sex. At the practitioner level, risks varied widely, from doctors with <10% risk of further complaints within 2 years to doctors with >80% risk. ConclusionsA small group of doctors accounts for half of all patient complaints lodged with Australian Commissions. It is feasible to predict which doctors are at high risk of incurring more complaints in the near future. Widespread use of this approach to identify high-risk doctors and target quality improvement efforts coupled with effective interventions, could help reduce adverse events and patient dissatisfaction in health systems.

Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians [RESEARCH]

Tue, 9 Apr 2013 00:00:00 +0000

ObjectivesTo determine the low back pain beliefs of Aboriginal Australians; a population previously identified as protected against the disabling effects of low back pain due to cultural beliefs. DesignQualitative study employing culturally appropriate methods within a clinical ethnographic framework. SettingOne rural and two remote towns in Western Australia. ParticipantsThirty-two Aboriginal people with chronic low-back pain (CLBP; 21 men, 11 women). Participants included those who were highly, moderately and mildly disabled. ResultsMost participants held biomedical beliefs about the cause of CLBP, attributing pain to structural/anatomical vulnerability of their spine. This belief was attributed to the advice from healthcare practitioners and the results of spinal radiological imaging. Negative causal beliefs and a pessimistic future outlook were more common among those who were more disabled. Conversely, those who were less disabled held more positive beliefs that did not originate from interactions with healthcare practitioners. ConclusionsFindings are consistent with research in other populations and support that disabling CLBP may be at least partly iatrogenic. This raises concerns for all populations exposed to Western biomedical approaches to examination and management of low back pain. The challenge for healthcare practitioners dealing with people with low back pain from any culture is to communicate in a way that builds positive beliefs about low back pain and its future consequences, enhancing resilience to disability.

Competition in collaborative clothing: a qualitative case study of influences on collaborative quality improvement in the ICU [ORIGINAL RESEARCH]

Mon, 1 Apr 2013 00:00:00 +0000

BackgroundMultiorganisational quality improvement (QI) collaborative networks are promoted for improving quality within healthcare. Recently, several large-scale QI initiatives have been conducted in the intensive care unit (ICU) environment with successful quantitative results. However, the mechanisms through which such networks lead to QI success remain uncertain. We aim to understand ICU staff perspectives on collaborative QI based on involvement in a multiorganisational improvement network and hypothesise about theoretical constructs that might explain the effect of collaboration in such networks. MethodsQualitative study using a modified grounded theory approach. Key informant interviews were conducted with staff from 12 community hospital ICUs that participated in a cluster randomized control trial (RCT) of a QI intervention using a collaborative approach between 2006 and 2008. Data analysis followed the standard procedure for grounded theory using constant comparative methodology. ResultsThe collaborative network was perceived to promote increased intrateam cooperation over interorganisational cooperation, but friendly competition with other ICUs appeared to be a prominent driver of behaviour change. Bedsides, clinicians reported that belonging to a collaborative network provided recognition for the high-quality patient care that they already provided. However, the existing communication structure was perceived to be ineffective for staff engagement since it was based on a hierarchical approach to knowledge transfer and project awareness. ConclusionsQI collaborative networks may promote behaviour change by improving intrateam communication, fostering competition with other institutions, and increasing recognition for providing high-quality care. Other commonly held assumptions about their potential impact, for instance, increasing interorganisational legitimisation, communication and collaboration, may be less important.

Study protocol for a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques [PROTOCOL]

Thu, 21 Mar 2013 00:00:00 +0000

IntroductionPaediatric shock is a life-threatening condition with many possible causes and a global impact. Current resuscitation guidelines require rapid fluid administration as a cornerstone of paediatric shock management. However, little evidence is available to inform clinicians how to most effectively perform rapid fluid administration where this is clinically required, resulting in suboptimal knowledge translation of current resuscitation guidelines into clinical practice. ObjectivesThis study aims to determine which of the two commonly used techniques for paediatric fluid resuscitation (disconnect-reconnect technique and push-pull technique) yields a higher fluid administration rate in a simulated clinical scenario. Secondary objectives include determination of catheter dislodgement rates, subjective and objective measures of provider fatiguability and descriptive information regarding any technical issues encountered with performance of each method under the study. Methods and analysisThis study will utilise a randomised crossover trial design. Participants will include consenting healthcare providers from McMaster Children's Hospital. Each participant will administer 900 ml (60 ml/kg) of normal saline to a simulated 15 kg infant as quickly as possible on two separate occasions using the manual fluid administration techniques under the study. The primary outcome, rate of fluid administration, will be evaluated using a paired two-tailed Student t test. Ethics and disseminationThis protocol has been approved by the Hamilton Health Sciences Research Ethics Board. ResultsThese will be published in a peer-reviewed scientific journal and presented at one or more scientific conferences. Protocol RegistrationProtocol Registered on ClinicalTrials.gov NCT01774214

Anaemia management with C.E.R.A. in routine clinical practice: OCEANE (Cohorte Mircera patients non-dialyses), a national, multicenter, longitudinal, observational prospective study, in patients with chronic kidney disease not on dialysis [RESEARCH]

Sat, 9 Mar 2013 00:00:00 +0000

ObjectiveThe aim of this study was to describe the management of anaemia with a continuous erythropoietin receptor activator (C.E.R.A., methoxy polyethylene glycol epoetin-{beta}), in patients with chronic kidney disease (CKD) not on dialysis, naive or non-naive to treatment with erythropoiesis-stimulating agents (ESAs) at inclusion. DesignNational, multicentre, longitudinal, observational prospective study. Setting133 nephrologists practicing in France selected patients during their routine follow-up visits. The study was non-interventional. ParticipantsThey were adult CKD patients not on dialysis or kidney transplant patients, naive or not to ESA treatment: 524 patients not on dialysis (48% ESA-naive) and 92 kidney transplant patients (24% ESA-naive) were included and followed up every 3 months during 1 year. Outcome measuresThe two main endpoints were the percentage of patients who achieved target haemoglobin (Hb) levels as per European Medicines Agency guidelines (10-12 g/dl) around 6 months of treatment and modalities of treatment. ResultsApproximately one in two patients had an Hb level within 10-12 g/dl at baseline, and around 6 and 12 months of treatment. Ninety per cent of ESA-naive patients achieved at least +1 g/dl increase over baseline Hb levels or had Hb within 10-12 g/dl around 6 and 12 months. The Hb level remained at approximately 11.5 g/dl during the 12 months of follow-up. Around 6 months: almost all patients were receiving a once-monthly subcutaneous dose of C.E.R.A. (patients not on dialysis: 95{+/-}54 {micro}g; kidney transplant patients: 121{+/-}70 {micro}g); approximately half the patients did not require a change in C.E.R.A. dose. Adverse effects related to C.E.R.A. were observed in less than 5% of patients and led to modification or discontinuation of treatment in 2%. ConclusionsThe efficacy and safety of C.E.R.A. in CKD patients not on dialysis, with or without kidney transplantation, were confirmed in routine clinical practice.

Personalised performance feedback reduces narcotic prescription errors in a NICU [QUALITY IMPROVEMENT REPORTS]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectiveNeonates are at high risk for significant morbidity and mortality from medication prescribing errors. Despite general awareness of these risks, mistakes continue to happen. Alerts in computerised physician order entry intended to help prescribers avoid errors have not been effective enough. This improvement project delivered feedback of prescribing errors to prescribers in the neonatal intensive care unit (NICU), and measured the impact on medication error frequency. MethodsA front-line multidisciplinary team doing multiple Plan Do Study Act cycles developed a system to communicate prescribing errors directly to providers every 2 weeks in the NICU. The primary outcome measure was number of days between medication prescribing errors with particular focus on antibiotic and narcotic errors. ResultsA T-control chart showed that the number of days between narcotic prescribing errors rose from 3.94 to 22.63 days after the intervention, an 83% improvement. No effect in the number of days between antibiotic prescribing errors during the same period was found. ConclusionsAn effective system to communicate mistakes can reduce some types of prescribing errors.

Leadership of healthcare commissioning networks in England: a mixed-methods study on clinical commissioning groups [RESEARCH]

Wed, 27 Feb 2013 00:00:00 +0000

ObjectiveTo explore the relational challenges for general practitioner (GP) leaders setting up new network-centric commissioning organisations in the recent health policy reform in England, we use innovation network theory to identify key network leadership practices that facilitate healthcare innovation. DesignMixed-method, multisite and case study research. SettingSix clinical commissioning groups and local clusters in the East of England area, covering in total 208 GPs and 1 662 000 population. MethodsSemistructured interviews with 56 lead GPs, practice managers and staff from the local health authorities (primary care trusts, PCT) as well as various healthcare professionals; 21 observations of clinical commissioning group (CCG) board and executive meetings; electronic survey of 58 CCG board members (these included GPs, practice managers, PCT employees, nurses and patient representatives) and subsequent social network analysis. Main outcome measuresCollaborative relationships between CCG board members and stakeholders from their healthcare network; clarifying the role of GPs as network leaders; strengths and areas for development of CCGs. ResultsDrawing upon innovation network theory provides unique insights of the CCG leaders' activities in establishing best practices and introducing new clinical pathways. In this context we identified three network leadership roles: managing knowledge flows, managing network coherence and managing network stability. Knowledge sharing and effective collaboration among GPs enable network stability and the alignment of CCG objectives with those of the wider health system (network coherence). Even though activities varied between commissioning groups, collaborative initiatives were common. However, there was significant variation among CCGs around the level of engagement with providers, patients and local authorities. Locality (sub) groups played an important role because they linked commissioning decisions with patient needs and brought the leaders closer to frontline stakeholders. ConclusionsWith the new commissioning arrangements, the leaders should seek to move away from dyadic and transactional relationships to a network structure, thereby emphasising on the emerging relational focus of their roles. Managing knowledge mobility, healthcare network coherence and network stability are the three clinical leadership processes that CCG leaders need to consider in coordinating their network and facilitating the development of good clinical commissioning decisions, best practices and innovative services. To successfully manage these processes, CCG leaders need to leverage the relational capabilities of their network as well as their clinical expertise to establish appropriate collaborations that may improve the healthcare services in England. Lack of local GP engagement adds uncertainty to the system and increases the risk of commissioning decisions being irrelevant and inefficient from patient and provider perspectives.

What intervention is best practice for vestibular schwannomas? A systematic review of controlled studies [RESEARCH]

Fri, 22 Feb 2013 00:00:00 +0000

ObjectiveLargely, watchful waiting is the initial policy for patients with small-sized or medium-sized vestibular schwannoma, because of slow growth and relatively minor complaints, that do not improve by an intervention. If intervention (microsurgery, radiosurgery or fractionated radiotherapy) becomes necessary, the choice of intervention appears to be driven by the patient's or clinician's preference rather than by evidence based. This study addresses the existing evidence based on controlled studies of these interventions. DesignA systematic Boolean search was performed focused on controlled intervention studies. The quality of the retrieved studies was assessed based on the Sign-50 criteria on cohort studies. Data sourcesPubmed/Medline, Embase, Cochrane Central Register of Controlled Trials and reference lists. Study selectionSix eligibility criteria included a controlled intervention study on a newly diagnosed solitary, vestibular schwannoma reporting on clinical outcomes. Two prospective and four retrospective observational, controlled studies published before November 2011 were selected. Data analysisTwo reviewers independently assessed the methodological quality of the studies and extracted the outcome data using predefined formats. ResultsNeither randomised studies, nor controlled studies on fractionated radiotherapy were retrieved. Six studies compared radiosurgery and microsurgery in a controlled way. All but one were confined to solitary tumours less than 30 mm in diameter and had no earlier interventions. Four studies qualified for trustworthy conclusions. Among all four, radiosurgery showed the best outcomes: there were no direct mortality, no surgical or anaesthesiological complications, but better facial nerve outcome, better preservation of useful hearing and better quality of life. ConclusionsThe available evidence indicates radiosurgery to be the best practice for solitary vestibular schwannomas up to 30 mm in cisternal diameter.

Meniere's disease: a reappraisal supported by a variable latency of symptoms and the MRI visualisation of endolymphatic hydrops [RESEARCH]

Thu, 21 Feb 2013 00:00:00 +0000

ObjectivesTo evaluate the onset of vertigo, hearing loss and tinnitus in Meniere's disease and the associated endolymphatic hydrops (EH) of the inner ear. DesignMulticentre evaluation of three patient groups. SettingsDisease-specific symptoms were reviewed among referred patients in a tertiary referral hospital in Finland and in members of a Finnish Meniere Association in Finland. The MRI of a separate group of patients was undertaken in a tertiary referral centre in Japan. Participants340 patients were reviewed in the referral hospital along with 740 members of the Meniere Association. MRI was undertaken in 224 patients in Japan. Primary and secondary outcome measuresLatency and symptom development in Meniere's disease, and the appearance of EH of the inner ear in monosymptomatic patients and in Meniere's disease. ResultsThe mean age of the first symptom was 43.8 years, with 10% of the patients being older than 65 years. The time delay between hearing loss and vertigo was more than 5 years in 20% of the members and of the patients. Gadolinium-contrasted MRI demonstrated EH in 90% of the patients with Meniere's disease, in which 75% was bilateral among patients with unilateral symptoms. In monosymptomatic patients with vertigo, tinnitus or hearing loss; EH was demonstrated in 55-90% of the patients either in the cochlea and/or the vestibulum of the symptomatic ear. ConclusionsMeniere's disease often shows bilateral EH and comprises a continuum from a monosymptomatic disease to the typical symptom complex of the disease. We suggest that a 3T MRI measurement should be carried out in patients with sensory-neural hearing loss, vertigo and tinnitus, 4 h after the intravenous injection of a gadolinium-contrast agent to verify the inner ear pathology. This may lead to a better management of the condition.

Competition in collaborative clothing: a qualitative case study of influences on collaborative quality improvement in the ICU [ORIGINAL RESEARCH]

Fri, 15 Feb 2013 00:00:00 +0000

Systematic simulation-based team training in a Swedish intensive care unit: a diverse response among critical care professions [ORIGINAL RESEARCH]

Thu, 14 Feb 2013 00:00:00 +0000

Development and reliability of the explicit professional oral communication observation tool to quantify the use of non-technical skills in healthcare [ORIGINAL RESEARCH]

Thu, 14 Feb 2013 00:00:00 +0000

BackgroundA lack of non-technical skills is increasingly recognised as an important underlying cause of adverse events in healthcare. The nature and number of things professionals communicate to each other can be perceived as a product of their use of non-technical skills. This paper describes the development and reliability of an instrument to measure and quantify the use of non-technical skills by direct observations of explicit professional oral communication (EPOC) in the clinical situation. MethodsIn an iterative process we translated, tested and refined an existing checklist from the aviation industry, called self, human interaction, aircraft, procedures and environment, in the context of healthcare, notably emergency departments (ED) and intensive care units (ICU). The EPOC comprises six dimensions: assertiveness, working with others; task-oriented leadership; people-oriented leadership; situational awareness; planning and anticipation. Each dimension is specified into several concrete items reflecting verbal behaviours. The EPOC was evaluated in four ED and six ICU. ResultsIn the ED and ICU, respectively, 378 and 1144 individual and 51 and 68 contemporaneous observations of individual staff members were conducted. All EPOC dimensions occur frequently, apart from assertiveness, which was hardly observed. Intraclass correlations for the overall EPOC score ranged between 0.85 and 0.91 and for underlying EPOC dimensions between 0.53 and 0.95. ConclusionsThe EPOC is a new instrument for evaluating the use of non-technical skills in healthcare, which is reliable in two highly different settings. By quantifying professional behaviour the instrument facilitates measurement of behavioural change over time. The results suggest that EPOC can also be translated to other settings.

A qualitative interview study: patient accounts of medication use in early rheumatoid arthritis from symptom onset to early postdiagnosis [RESEARCH]

Wed, 13 Feb 2013 00:00:00 +0000

ObjectiveTo examine accounts of medication use in participants with early rheumatoid arthritis (RA) from symptom onset to early postdiagnosis. DesignQualitative study with in-depth, personal interviews. Participants37 women and one man, aged 30-70s, with a diagnosis of RA <12 months. Main outcome measureParticipants' experiences and feelings of medication use in early RA. SettingBritish Columbia, Canada. ResultsMedications were central to how people managed symptoms and disease. Two main themes were identified, showing that optimum medication use was hampered, and how this related to delayed diagnosis and effective care. The first theme, paradox of prediagnosis reliance on over the counter (OTC) medications', describes how people's self-management with OTC medications was effective'. Participants relied extensively on OTC medications for pain relief and to maintain normal life'. However, as this contributed to delayed medical consultation, diagnosis and effective treatment, OTC medication was also potentially detrimental to disease outcome. The second theme, ambivalence around prescription medications post diagnosis', describes how adherence was hindered by patient beliefs, priorities and ambivalence towards medications. ConclusionsThis study highlights how people use medications in early RA and contributes to a better understanding of medication use that may transfer to other conditions. Given the drive towards active self-management in healthcare and patients' ambivalence about using strong medications, an in-depth understanding of how these combined factors impact patient experiences will help healthcare providers to support effective medication practices. The reported extensive reliance on OTC medications may speak to a care gap needing further investigation in the context of health behaviours and outcomes of patient self-management.

Life-event stress induced by the Great East Japan Earthquake was associated with relapse in ulcerative colitis but not Crohn's disease: a retrospective cohort study [RESEARCH]

Fri, 8 Feb 2013 00:00:00 +0000

ObjectiveStress is thought to be one of the triggers of relapses in patients with inflammatory bowel disease (IBD). We examined the rate of relapse in IBD patients before and after the Great East Japan Earthquake. DesignA retrospective cohort study. Settings13 hospitals in Japan. Participants546 ulcerative colitis (UC) and 357 Crohn's disease (CD) patients who received outpatient and inpatient care at 13 hospitals located in the area that were seriously damaged by the earthquake. Data on patient's clinical characteristics, disease activity and deleterious effects of the earthquake were obtained from questionnaires and hospital records. Primary outcomeWe evaluated the relapse rate (from inactive to active) across two consecutive months before and two consecutive months after the earthquake. In this study, we defined active' as conditions with a partial Mayo score=2 or more (UC) or a Harvey-Bradshaw index=6 or more (CD). ResultsAmong the UC patients, disease was active in 167 patients and inactive in 379 patients before the earthquake. After the earthquake, the activity scores increased significantly (p<0.0001). A total of 86 patients relapsed (relapse rate=15.8%). The relapse rate was about twice that of the corresponding period in the previous year. Among the CD patients, 86 patients had active disease and 271 had inactive disease before the earthquake. After the earthquake, the activity indices changed little. A total of 25 patients experienced a relapse (relapse rate=7%). The relapse rate did not differ from that of the corresponding period in the previous year. Multivariate analyses revealed that UC, changes in dietary oral intake and anxiety about family finances were associated with the relapse. ConclusionsLife-event stress induced by the Great East Japan Earthquake was associated with relapse in UC but not CD.

'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England [ORIGINAL RESEARCH]

Fri, 1 Feb 2013 00:00:00 +0000

BackgroundBloodstream infections from central venous catheters (CVC-BSIs) increase morbidity and costs in intensive care units (ICUs). Substantial reductions in CVC-BSI rates have been reported using a combination of technical and non-technical interventions. MethodsWe conducted a 2-year, four-cluster, stepped non-randomised study of technical and non-technical (behavioural) interventions to prevent CVC-BSIs in adult and paediatric ICUs in England. Random-effects Poisson regression modelling was used to compare infection rates. A sample of ICUs participated in data verification. ResultsOf 223 ICUs in England, 215 (196 adult, 19 paediatric) submitted data on 2479 of 2787 possible months and 147 (66%) provided complete data. The exposure rate was 438 887 (404 252 adult and 34 635 paediatric) CVC-patient days. Over 20 months, 1092 CVC-BSIs were reported. Of these, 884 (81%) were ICU acquired. For adult ICUs, the mean CVC-BSI rate decreased over 20 months from 3.7 in the first cluster to 1.48 CVC-BSIs/1000 CVC-patient days (p<0.0001) for all clusters combined, and for paediatric ICUs from 5.65 to 2.89 (p=0.625). The trend for infection rate reduction did not accelerate following interventions training. CVC utilisation rates remained stable. Pre-ICU infections declined in parallel with ICU-acquired infections. Criterion-referenced case note review showed high agreement between adjudicators ({kappa} 0.706) but wide variation in blood culture sampling rates and CVC utilisation. Generic infection control practices varied widely. ConclusionsThe marked reduction in CVC-BSI rates in English ICUs found in this study is likely part of a wider secular trend for a system-wide improvement in healthcare-associated infections. Opportunities exist for greater harmonisation of infection control practices. Future studies should investigate causal mechanisms and contextual factors influencing the impact of interventions directed at improving patient care.

The role of chief executive officers in a quality improvement initiative: a qualitative study [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectivesTo identify the critical dimensions of hospital Chief Executive Officers' (CEOs) involvement in a quality and safety initiative and to offer practical guidance to assist CEOs to fulfil their leadership role in quality improvement (QI). DesignQualitative interview study. Setting20 organisations participating in the main phase of the Safer Patients Initiative (SPI) programme across the UK. Participants17 CEOs overseeing 19 organisations participating in the main phase of the SPI programme and 36 staff (20 workstream leads, 10 coordinators and 6 managers) involved in SPI across all 20 participating organisations. Main outcome measureSelf-reported perceptions of CEOs on their contribution and involvement within the SPI programme, supplemented by staff peer-reports. ResultsThe CEOs recognised the importance of their part in the SPI programme and gave detailed accounts of the perceived value that their involvement had brought at all stages of the process. In exploring the parts played by the CEOs, five dimensions were identified: (1) resource provision; (2) staff motivation and engagement; (3) commitment and support; (4) monitoring progress and (5) embedding programme elements. Staff reports confirmed these dimensions; however, the weighting of the dimensions differed. The findings stress the importance of particular actions of support and monitoring such as constant communication through leadership walk rounds and reviewing programme progress and its related clinical outcomes at Board meetings. ConclusionsThis study addressed the call for more research-informed practical guidance on the role of senior management in QI initiatives. The findings show that the CEOs provided key participation considered to significantly contribute towards the SPI programme. CEOs and staff identified a number of clear and consistent themes essential to organisation safety improvement. Queries raised include the tangible benefits of executive involvement in changing structures and embedding for sustainability and the practical steps to creating the right' environment for QI.

Framework of policy recommendations for implementation of evidence-based practice: a systematic scoping review [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectivesEvidence-based practice (EBP) may help improve healthcare quality. However, not all healthcare professionals and managers use EBP in their daily practice. We systematically reviewed the literature to summarise self-reported appreciation of EBP and organisational infrastructure solutions proposed to promote EBP. DesignSystematic review. Two investigators independently performed the systematic reviewing process. Information sourcesMEDLINE, EMBASE and Cochrane Library were searched for publications between 2000 and 2011. Eligibility criteria for included studiesReviews and surveys of EBP attitude, knowledge, awareness, skills, barriers and facilitators among managers, doctors and nurses in clinical settings. ResultsWe found 31 surveys of fairly good quality. General attitude towards EBP was welcoming. Respondents perceived several barriers, but also many facilitators for EBP implementation. Solutions were proposed at various organisational levels, including (inter)national associations and hospital management promoting EBP, pregraduate and postgraduate education, as well as individual support by EBP mentors on the wards to move EBP from the classroom to the bedside. ConclusionsMore than 20 years after its introduction, the EBP paradigm has been embraced by healthcare professionals as an important means to improve quality of patient care, but its implementation is still deficient. Policy exerted at microlevel , middlelevel and macrolevel, and supported by professional, educational and managerial role models, may further facilitate EBP.

Direct treatment comparison of DAbigatran and RIvaroxaban versus NAdroparin in the prevention of venous thromboembolism after total knee arthroplasty surgery: design of a randomised pilot study (DARINA) [PROTOCOL]

Thu, 24 Jan 2013 00:00:00 +0000

IntroductionTwo novel agents, dabigatran and rivaroxaban, recently gained market authorisation for prevention of venous thromboembolism (VTE) after hip and knee arthroplasty. However, safety data of the new oral anticoagulants with a long-term use of 42 days are not available for total knee arthroplasty (TKA). Furthermore, there are no clinical trials comparing dabigatran and/or rivaroxaban with nadroparin, which is used in most Dutch departments of orthopaedic surgery. Our aim is to compare the 42-day use of dabigatran and rivaroxaban versus nadroparin after TKA in a clinical explorative pilot study by assessing the incidence of major bleeding and clinically relevant non-major bleeding using a standardised model of bleeding definitions. Methods and analysisA randomised open-label pilot study was conducted. Patients [≥]18 years and weighing more than 40 kg who were scheduled for a primary elective TKA were included. Patients were randomly assigned to three groups. Patients took either a daily oral dose of dabigatran etexilate 220 mg (n=50), 10 mg of oral rivaroxaban (n=50) or subcutaneous nadroparin 0.3 ml (n=50) for 42 days. The primary safety outcome measure was the incidence of bleeding events. Major bleeding events and clinically relevant non-major bleeding events were defined according to accepted guidelines. The secondary measures of this study were the occurrence of VTE, time until the bleeding event, compliance, duration of hospital stay, rehospitalisation, outpatient clinic visits and interventions following complications. Additionally, coagulation monitoring, knee flexion range of motion and Knee injury and Osteoarthritis Outcome Score were evaluated. DisseminationThe results of this trial provided insight into the validity of design for an adequately powered multicentre study investigating the safety of the new oral anticoagulants compared with nadroparin, an anticoagulant applied for prevention of VTE after knee arthroplasty in the Dutch situation. Trial registration numberClinicalTrials.gov: NCT01431456.

Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study [RESEARCH]

Fri, 11 Jan 2013 00:00:00 +0000

BackgroundRefeeding syndrome is a potentially life-threatening condition characterised by severe intracellular electrolyte shifts, acute circulatory fluid overload and organ failure. The initial symptoms are non-specific but early clinical features are severely low-serum electrolyte concentrations of potassium, phosphate or magnesium. Risk factors for the syndrome include starvation, chronic alcoholism, anorexia nervosa and surgical interventions that require lengthy periods of fasting. The causes of the refeeding syndrome are excess or unbalanced enteral, parenteral or oral nutritional intake. Prevention of the syndrome includes identification of individuals at risk, controlled hypocaloric nutritional intake and supplementary electrolyte replacement. ObjectiveTo determine the occurrence of refeeding syndrome in adults commenced on artificial nutrition support. DesignProspective cohort study. SettingLarge, single site university teaching hospital. Recruitment period 2007-2009. Participants243 adults started on artificial nutrition support for the first time during that admission recruited from wards and intensive care. Main outcome measuresPrimary outcome: occurrence of the refeeding syndrome. Secondary outcome: analysis of the risk factors which predict the refeeding syndrome. Tertiary outcome: mortality due to refeeding syndrome and all-cause mortality. Results133 participants had one or more of the following risk factors: body mass index <16-18.5[≥](kg/m2), unintentional weight loss >15% in the preceding 3-6 months, very little or no nutritional intake >10 days, history of alcohol or drug abuse and low baseline levels of serum potassium, phosphate or magnesium prior to recruitment. Poor nutritional intake for more than 10 days, weight loss >15% prior to recruitment and low-serum magnesium level at baseline predicted the refeeding syndrome with a sensitivity of 66.7%: specificity was >80% apart from weight loss of >15% which was 59.1%. Baseline low-serum magnesium was an independent predictor of the refeeding syndrome (p=0.021). Three participants (2% 3/243) developed severe electrolyte shifts, acute circulatory fluid overload and disturbance to organ function following artificial nutrition support and were diagnosed with refeeding syndrome. There were no deaths attributable to the refeeding syndrome, but (5.3% 13/243) participants died during the feeding period and (28% 68/243) died during hospital admission. Death of these participants was due to cerebrovascular accident, traumatic injury, respiratory failure, organ failure or end-of-life causes. ConclusionsRefeeding syndrome was a rare, survivable phenomenon that occurred during hypocaloric nutrition support in participants identified at risk. Independent predictors for refeeding syndrome were starvation and baseline low-serum magnesium concentration. Intravenous carbohydrate infusion prior to artificial nutrition support may have precipitated the onset of the syndrome.

Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital [RESEARCH]

Thu, 10 Jan 2013 00:00:00 +0000

ObjectiveTo evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits. MethodPublished data from the LIMM project group were used to design a probabilistic decision tree model for evaluating tools for (1) a systematic medication reconciliation and review process at initial hospital admission and during stay (admission part) and (2) a medication report for patients discharged from hospital to primary care (discharge part). The comparator was standard care. Inpatient, outpatient and staff time costs (Euros, 2009) were calculated during a 3-month period. Dis-utilities for hospital readmissions and outpatient visits due to medication errors were taken from the literature. ResultsThe total cost for the LIMM model was {euro}290 compared to {euro}630 for standard care, in spite of a {euro}39 intervention cost. The main cost offset arose from avoided drug-related readmissions in the Admission part ({euro}262) whereas only {euro}66 was offset in the Discharge part as a result of fewer outpatient visits and correction time. The reduced disutility was estimated to 0.005 quality-adjusted life-years (QALY), indicating that LIMM was a dominant alternative. The probability that the intervention would be cost-effective at a zero willingness to pay for a gained QALY compared to standard care was estimated to 98%. ConclusionsThe LIMM medication reconciliation (at admission and discharge) and medication review was both cost-saving and generated greater utility compared to standard care, foremost owing to avoided drug-related hospital readmissions. When implementing such a review process with a multidisciplinary team, it may be important to consider a learning curve in order to capture the full advantage.

Trends in the prevalence of antipsychotic drug use among patients with Alzheimer's disease and other dementias including those treated with antidementia drugs in the community in the UK: a cohort study [RESEARCH]

Mon, 7 Jan 2013 00:00:00 +0000

ObjectiveTo investigate the pattern and trends of use of antipsychotics, antidepressants, hypnotics and anxiolytics in Alzheimer's disease and other dementias and in patients treated with antidementia medications. DesignCohort study with dementia patients formed in the UK Clinical Practice Research Datalink. Participants Patients with incident dementia, between 1995 and 2011 and a reference non-dementia cohort matched on age, gender and date of dementia diagnosis. Two subcohorts included new users of acetylcholinesterase inhibitors (AChEIs) and memantine. The study endpoint was use of antipsychotics, antidepressants, hypnotics and anxiolytics up to 10 years before and 4 years after dementia diagnosis, and for up to 5 years before and 1 year after first use of AChEI or memantine. Results50 349 patients with incident dementia diagnosis and 50 349 matched controls, 10 794 first-time users of AChEI and 669 of memantine. The mean prevalence of antipsychotic use from 1995 to 2011 on diagnosis of dementia was 12.5%, decreasing from 19.9% in 1995 to 7.4% in 2011. There was an increase in antidepressant use (10.7-26.3%) and a small increase in anxiolytic use. The matched cohort showed a lower use of antipsychotics and anxiolytics but a rise in antidepressants (5.9-13.4%). Both groups showed a decrease in hypnotic use. 10.6% of AChEI and 26.3% of memantine users were prescribed antipsychotics, 34.1% and 26.3% antidepressants, 13.2% and 4.1% anxiolytics and 18.4% and 8.3% hypnotics. The slopes for monthly use of antipsychotics were positive in the year leading up to AChEI and memantine use; after treatment initiation the slope for AChEI users continued to increase but at a reduced rate whereas antipsychotic use declined for memantine users. ConclusionsThe marked reduction in antipsychotic use in dementia is to be welcomed while there was a steady increase in antidepressant use. There was a decline in antipsychotic use after the initiation of memantine.

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report [RESEARCH]

Tue, 18 Dec 2012 00:00:00 +0000

ObjectiveAdministering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and settingFive multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcomeTo identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. ResultsIn all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. ConclusionsFMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.

Synergistic prognostic values of cardiac sympathetic innervation with left ventricular hypertrophy and left atrial size in heart failure patients without reduced left ventricular ejection fraction: a cohort study [RESEARCH]

Fri, 30 Nov 2012 00:00:00 +0000

ObjectivesThis study tested whether cardiac sympathetic innervation assessed by metaiodobenzylguanidine (MIBG) activity has long-term prognostic value in combination with left ventricular hypertrophy (LVH) and left atrial size in heart failure (HF) patients without reduced left ventricular ejection fraction (LVEF). DesignA single-centre prospective cohort study. Setting/participantsWith primary endpoints of cardiac death and rehospitalisation due to HF progression, 178 consecutive symptomatic HF patients with 74% men, mean age of 56 years and mean LVEF of 64.5% were followed up for 80 months. The entry criteria consisted of LVEF more than 50%, completion of predischarge clinical evaluations including cardiac MIBG and echocardiographic studies and at least more than 1-year follow-up when survived. ResultsThirty-four patients with cardiac evens had larger left atrial dimension (LAD), increased LV mass index, reduced MIBG activity quantified as heart-to-mediastinum ratio (HMR) than did the others. Multivariable Cox analysis showed that LAD and HMR were significant predictors (HR of 1.080 (95% CI 1.00 to 1.16, p=0.044) and 0.107 (95% CI 0.01 to 0.61, p=0.012, respectively). Thresholds of HMR (1.65) and LAD (37 mm) were closely related to identification of high-risk patients. In particular, HMR was a significant determinant of cardiac events in both patients with and without LV hypertrophy. Reduced HMR with enlarged LAD or LV hypertrophy identified patients at most increased risk; overall log-rank value, 11.5, p=0.0032 for LAD and 17.5, p=0.0002, respectively. ConclusionsIn HF patients without reduced LV ejection fraction, impairment of cardiac sympathetic innervation is related to cardiac outcomes independently and synergistically with LA size and LV hypertrophy. Cardiac sympathetic innervation assessment can contribute to better risk-stratification in combination with evaluation of LA size and LV mass but is needed to be evaluated for establishing aetiology-based risk assessment in HF patients at increased risk.

How are drug regimen changes during hospitalisation handled after discharge: a cohort study [RESEARCH]

Mon, 19 Nov 2012 00:00:00 +0000

ObjectivesTo investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs). DesignCohort study. SettingPatients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients' GPs 4-5 months after patient discharge and recorded any additional drug regimen changes. ResultsIn total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0-16) and 7.6 drugs at discharge (range 1-17). On average, 4.4 drug changes per patient (SD 2.7, range 1-16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0-14) within 4-5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0-13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge ([≥] 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days. ConclusionsIn addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study [RESEARCH]

Thu, 27 Sep 2012 00:00:00 +0000

ObjectivesTo compare the risk profile of women giving birth in private and public hospitals and the rate of obstetric intervention during birth compared with previous published rates from a decade ago. DesignPopulation-based descriptive study. SettingNew South Wales, Australia. Participants691 738 women giving birth to a singleton baby during the period 2000 to 2008. Main outcome measuresRisk profile of women giving birth in public and private hospitals, intervention rates and changes in these rates over the past decade. ResultsAmong low-risk women rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk primiparous women giving birth in a private hospital compared to a public hospital had higher rates of induction (31% vs 23%); instrumental birth (29% vs 18%); caesarean section (27% vs 18%), epidural (53% vs 32%) and episiotomy (28% vs 12%) and lower normal vaginal birth rates (44% vs 64%). Low-risk multiparous women had higher rates of instrumental birth (7% vs 3%), caesarean section (27% vs 16%), epidural (35% vs 12%) and episiotomy (8% vs 2%) and lower normal vaginal birth rates (66% vs 81%). As interventions were introduced during labour, the rate of interventions in birth increased. Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital. ConclusionsLow-risk primiparous women giving birth in private hospitals have more chance of a surgical birth than a normal vaginal birth and this phenomenon has increased markedly in the past decade.

Effectiveness of telemedicine and distance learning applications for patients with chronic heart failure. A protocol for prospective parallel group non-randomised open label study [PROTOCOL]

Tue, 25 Sep 2012 00:00:00 +0000

IntroductionChronic heart failure in Baltic Sea Region is responsible for more hospitalisations than all forms of cancer combined and is one of the leading causes of hospitalisations in elderly patients. Frequent hospitalisations, along with other direct and indirect costs, place financial burden on healthcare systems. We aim to test the hypothesis that telemedicine and distance learning applications is superior to the current standard of home care. Methods and analysisProspective parallel group non-randomised open label study in patients with New York Heart Association (NYHA) II-III chronic heart failure will be carried out in six Baltic Sea Region countries. The study is organised into two 6-month follow-up periods. The first 6-month period is based on active implementation of tele-education and/or telemedicine for patients in two groups (active run period) and one standard care group (passive run period). The second 6-month period of observation will be based on standard care model (passive run period) to all three groups. Our proposed practice change is based on translational research with empirically supported interventions brought to practice and aims to find the home care model that is most effective to patient needs. Ethics and disseminationThis study has been approved by National Bioethics Committee (2011-03-07; Registration No: BE-2-11). Trial RegistrationThis study has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) with registration number ACTRN12611000834954.

Derivation and validation of a clinical prediction rule for delirium in patients admitted to a medical ward: an observational study [RESEARCH]

Fri, 14 Sep 2012 00:00:00 +0000

ObjectivesTo develop and validate a simple clinical prediction rule, based on variables easily measurable at admission, to identify patients at high risk of developing delirium during their hospital stay on an internal medicine ward. DesignProspective study of two cohorts of patients admitted between 1 May and 30 June 2008 (derivation cohort), and between 1 May and 30 June 2009 (validation cohort). SettingA tertiary hospital in Donostia-Gipuzkoa (Spain). ParticipantsIn total 397 patients participated in the study. The mean age and incidence of delirium were 75.9 years and 13%, respectively, in the derivation cohort, and 75.8 years and 25% in the validation cohort. Main outcome measuresThe predictive variables analysed and finally included in the rule were: being aged 85 years old or older, being dependent in five or more activities of daily living, and taking two or more psychotropic drugs (antipsychotics, benzodiazepines, antidepressants, anticonvulsant and/or antidementia drugs). The variable of interest was delirium as defined by the short Confusion Assessment Method, which assesses four characteristics: acute onset and fluctuating course, inattention, disorganised thinking and altered level of consciousness. ResultsWe developed a rule in which the individual risk of delirium is obtained by adding one point for each criterion met (age[≥]85, high level of dependence, and being on psychotropic medication). The result is considered positive if the score is [≥]1. The rule accuracy was: sensitivity=93.4% (95% CI 85.5% to 97.2%), specificity=60.6% (95% CI 54.1% to 66.8%), positive predictive value=44.4% (95% CI 36.9% to 52.1%) and negative predictive value=96.5% (95% CI: 92% to 98.5%). The area under the receiver operator characteristic (ROC) curve was 0.85 for the validation cohort. ConclusionsThe presence or absence of any of the three predictive factors (age[≥]85, high level of dependence and psychotropic medication) allowed us to classify patients on internal medicine wards according to the risk of developing delirium. The simplicity of the variables in our clinical prediction rule means that the data collection required is feasible in busy medicine units.

Prospective analysis of neutralising antibody titres in secondary non-responders under continuous treatment with a botulinumtoxin type A preparation free of complexing proteins--a single cohort 4-year follow-up study [RESEARCH]

Wed, 22 Aug 2012 00:00:00 +0000

ObjectivesIn long-term botulinum neurotoxin treatment, loss of therapeutic efficacy may occur due to neutralising antibody formation. Preliminary results with incobotulinumtoxinA, a preparation free of complexing/accessory proteins, have indicated a low antigenicity. We hypothesised that continuous treatment with this botulinum neurotoxin preparation would not result in an increase in neutralising antibody titres (NABTs) in patients with pre-existing NABTs. DesignProspective, blinded cohort study. SettingSingle centre in Germany. ParticipantsThirty-seven cervical dystonia patients with NABTs and partial secondary non-responsiveness to their previous botulinum neurotoxin type A treatment. InterventionThree-monthly intramuscular injections of incobotulinumtoxinA with a constant dose of 200 MU per injection during the first year; thereafter up to 500 MU for the next 36 months. Outcome measuresPrimary outcome measure: number of patients in whom NABTs declined below the initial titre after 48 months of incobotulinumtoxinA treatment or in whom titres had become negative within the 48 months. Secondary outcome measure: steepness of changes in NABT. NABTs were determined by mouse hemidiaphragm assay. Findings were compared to long-term data from 24 cervical dystonia patients who had developed NABTs and in whom treatment had been discontinued. ResultsFollowing a transient increase in the first 24 months under incobotulinumtoxinA treatment in some patients, NABTs declined well below the initial titre in the majority of patients. Test assay results were negative in most of the patients followed for more than 36 months. NABTs seemed to decline into the negative detection range as rapidly under incobotulinumtoxinA treatment as after cessation of botulinum neurotoxin therapy. ConclusionsThe reduction of NABTs despite continuous treatment with incobotulinumtoxinA indicates low antigenicity of incobotulinumtoxinA. This might have implications on restrictions such as minimum injection intervals of [≥]10 weeks currently in place for maintaining successful long-term application of botulinum neurotoxin.

Clinical implications and validity of nursing assessments: a longitudinal measure of patient condition from analysis of the Electronic Medical Record [RESEARCH]

Tue, 21 Aug 2012 00:00:00 +0000

ObjectivesThis study investigates risk of mortality associated with nurses' assessments of patients by physiological system. We hypothesise that nursing assessments of in-patients performed at entry correlate with in-hospital mortality, and those performed just before discharge correlate with postdischarge mortality. DesignCohort study of in-hospital and postdischarge mortality of patients over two 1-year periods. SettingAn 805-bed community hospital in Sarasota, Florida, USA. Subjects42 302 inpatients admitted for any reason, excluding obstetrics, paediatric and psychiatric patients. Outcome measuresAll-cause mortalities and mortality OR. ResultsPatients whose entry nursing assessments, other than pain, did not meet minimum standards had significantly higher in-hospital mortality than patients meeting minimums; and final nursing assessments before discharge had large OR for postdischarge mortality. In-hospital mortality OR were found to be: food, 7.0; neurological, 9.4; musculoskeletal, 6.9; safety, 5.6; psychosocial, 6.7; respiratory, 8.1; skin, 5.2; genitourinary, 3.0; gastrointestinal, 2.3; peripheral-vascular, 3.9; cardiac, 2.8; and pain, 1.1. CI at 95% are within {+/-}20% of these values, with p<0.001 (except for pain). Similar results applied to postdischarge mortality. All results were comparable across the two 1-year periods, with 0.85 intraclass correlation coefficient. ConclusionsNursing assessments are strongly correlated with in-hospital and postdischarge mortality. No multivariate analysis has yet been performed, and will be the subject of a future study, thus there may be confounding factors. Nonetheless, we conclude that these assessments are clinically meaningful and valid. Nursing assessment data, which are currently unused, may allow physicians to improve patient care. The mortality OR and the dynamic nature of nursing assessments suggest that nursing assessments are sensitive indicators of a patient's condition. While these conclusions must remain qualified, pending future multivariate analyses, nursing assessment data ought to be incorporated in risk-related health research, and changes in record-keeping software are needed to make this information more accessible.

Observational evidence that urbanisation and neighbourhood deprivation are associated with escalation in chronic pharmacological pain treatment: a longitudinal population-based study in the Netherlands [RESEARCH]

Thu, 19 Jul 2012 00:00:00 +0000

ObjectiveTo examine, in the light of the association between urban environment and poor mental health, whether urbanisation and neighbourhood deprivation are associated with analgesic escalation in chronic pharmacological pain treatment and whether escalation is associated with prescriptions of psychotropic medication. DesignLongitudinal analysis of a population-based routine dispensing database in the Netherlands. SettingRepresentative sample of pharmacies, covering 73% of the Dutch nationwide medication consumption in the primary care and hospital outpatient settings. Participants449 410 patients aged 15-85 years were included, of whom 166 374 were in the Starter group and 283 036 in the Continuation group of chronic analgesic treatment. Main outcome measureEscalation of analgesics (ie, change to a higher level of analgesic potency, classified across five levels) in association with urbanisation (five levels) and dichotomous neighbourhood deprivation was analysed over a 6-month observation period. MethodsOrdered logistic multivariate model evaluating analgesic treatment. ResultsIn both Starter and Continuation groups, escalation was positively associated with urbanisation in a dose-response fashion (Starter group: OR (urbanisation level 1 compared with level 5): 1.24, 95% CI 1.18 to 1.30; Continuation group: OR 1.18, 95% CI 1.14 to 1.23). An additional association was apparent with neighbourhood deprivation (Starter group: OR 1.07, 95% CI 1.02 to 1.11; Continuation group: OR 1.04, 95% CI 1.01 to 1.08). Use of somatic and particularly psychotropic co-medication was associated with escalation in both groups. ConclusionsEscalation of chronic analgesic treatment is associated with urban and deprived environments and occurs in a context of adding psychotropic medication prescriptions. These findings suggest that pain outcomes and mental health outcomes share factors that increase risk and remedy suffering.

The impact of a novel franchise clinic network on access to medicines and vaccinations in Kenya: a cross-sectional study [RESEARCH]

Tue, 10 Jul 2012 00:00:00 +0000

ObjectivesTo study the impact of a new franchise health clinic model (The HealthStore Foundation's CFWShops) on access to vaccinations and treatment for acute illnesses in a nationally representative sample of children in Kenya. DesignThe authors used multivariate linear and count regressions to examine associations between receipt of vaccinations or treatment and proximity to a franchise health clinic, adjusting for individual, household and clinic attributes as well as region fixed effects. SettingDemographic and Health Survey data from Kenya, 2008-2009. Participants6079 Kenyan children younger than 5 years, of whom 2310 reported recent acute illness. Main outcome measuresOutcomes for all children were number of polio doses received, number of DPT doses received, receipt of BCG vaccine, receipt of measles vaccine and number of total vaccinations received. Outcomes for acutely ill children were receipt of any medical treatment, treatment for fever, treatment for malaria and treatments specifically stocked by CFWShops. ResultsChildren living within 30 km of a CFWShop received 0.129 (p=0.017) and 0.113 (p=0.025) more DPT and polio doses, respectively; and 0.285 more total vaccinations (p=0.023). Among acutely ill children, CFWShop proximity was associated with significant increases in the probabilities of receiving any medical treatment (0.142; p<0.001), treatment for fever (0.117; p=0.007) and treatments specifically stocked by CFWShops (0.064; p=0.015). Use of CFWShop services was not significantly different for lower-income vis-a-vis higher-income households. ConclusionsThe franchise health clinic model could substantially increase access to essential vaccinations and treatments in low-income countries. Moreover, the model's benefits may accrue to lesser- and higher-income households alike.

Open-source point-of-care electronic medical records for use in resource-limited settings: systematic review and questionnaire surveys [RESEARCH]

Wed, 4 Jul 2012 00:00:00 +0000

BackgroundPoint-of-care electronic medical records (EMRs) are a key tool to manage chronic illness. Several EMRs have been developed for use in treating HIV and tuberculosis, but their applicability to primary care, technical requirements and clinical functionalities are largely unknown. ObjectivesThis study aimed to address the needs of clinicians from resource-limited settings without reliable internet access who are considering adopting an open-source EMR. Study eligibility criteriaOpen-source point-of-care EMRs suitable for use in areas without reliable internet access. Study appraisal and synthesis methodsThe authors conducted a comprehensive search of all open-source EMRs suitable for sites without reliable internet access. The authors surveyed clinician users and technical implementers from a single site and technical developers of each software product. The authors evaluated availability, cost and technical requirements. ResultsThe hardware and software for all six systems is easily available, but they vary considerably in proprietary components, installation requirements and customisability. LimitationsThis study relied solely on self-report from informants who developed and who actively use the included products. Conclusions and implications of key findingsClinical functionalities vary greatly among the systems, and none of the systems yet meet minimum requirements for effective implementation in a primary care resource-limited setting. The safe prescribing of medications is a particular concern with current tools. The dearth of fully functional EMR systems indicates a need for a greater emphasis by global funding agencies to move beyond disease-specific EMR systems and develop a universal open-source health informatics platform.

Multimodal observational assessment of quality and productivity benefits from the implementation of wireless technology for out of hours working [RESEARCH]

Tue, 29 May 2012 00:00:00 +0000

ObjectivesThe authors investigated if a wireless system of call handling and task management for out of hours care could replace a standard pager-based system and improve markers of efficiency, patient safety and staff satisfaction. DesignProspective assessment using both quantitative and qualitative methods, including interviews with staff, a standard satisfaction questionnaire, independent observation, data extraction from work logs and incident reporting systems and analysis of hospital committee reports. SettingA large teaching hospital in the UK. ParticipantsHospital at night co-ordinators, clinical support workers and junior doctors handling approximately 10 000 tasks requested out of hours per month. Outcome measuresLength of hospital stay, incidents reported, co-ordinator call logging activity, user satisfaction questionnaire, staff interviews. ResultsUsers were more satisfied with the new system (satisfaction score 62/90 vs 82/90, p=0.0080). With the new system over 70 h/week of co-ordinator time was released, and there were fewer untoward incidents related to handover and medical response (OR=0.30, p=0.02). Broad clinical measures (cardiac arrest calls for peri-arrest situations and length of hospital stay) improved significantly in the areas covered by the new system. ConclusionsThe introduction of call handling software and mobile technology over a medical-grade wireless network improved staff satisfaction with the Hospital at Night system. Improvements in efficiency and information flow have been accompanied by a reduction in untoward incidents, length of stay and peri-arrest calls.

Palliative care for the management of chronic illness: a systematic review study protocol [PROTOCOL]

Mon, 21 May 2012 00:00:00 +0000

IntroductionChronic illnesses are marked by fluctuations and variations over time. Individuals with chronic illness experience pain and other symptoms that are not always adequately managed. Their caregivers often have to deal with enormous burden as the illness progresses. Palliative care can serve as an intervention to manage chronic illness, not just at the end of life but also in the early phases of illness. Methods and analysisRandomised and non-randomised studies will be included in the systematic review. The focus will be on non-cancer chronic illness. Sources of data will be from PubMed and other databases and will include the reference list of studies included in the systematic review. The primary outcome will be to assess the efficacy of palliative care on chronic illness. Secondary outcomes will include health-related quality of life, care giver burden, quality of care and cost-effectiveness of interventions. The study population will consist of patients aged 18 years or over. Ethics and disseminationFor purposes of privacy and confidentiality, the systematic review will be limited to studies with de-identified data. The systematic review will be published in a peer-reviewed journal. It will also be disseminated electronically and in print. Brief reports of review findings will be disseminated directly to appropriate audiences via email and other modes of communication. Updates of the review will be conducted to inform and guide healthcare practice and policy. Trial registration numberPROSPEROCRD42011001794.

Discontinuation of statin therapy in older people: does a cancer diagnosis make a difference? An observational cohort study using data linkage [RESEARCH]

Mon, 21 May 2012 00:00:00 +0000

ObjectiveThe aim was to examine statin discontinuation rates in a cohort of elderly Australians with newly diagnosed cancer using population-based secondary health data. DesignObservational cohort study. SettingNew South Wales, the largest jurisdiction in Australia. The Pharmaceutical Benefits and Repatriation Pharmaceutical Benefits Schemes are national programmes subsidising prescription drugs to the Australian population and Australian Government Department of Veterans' Affairs clients. ParticipantsThe cohort comprised 1731 cancer patients aged [≥]65 years with evidence of statin use in the 90 days prior to diagnosis. They were matched to 3462 non-cancer patients prescribed statins in the same period. Main outcome measureThe authors compared statin discontinuation rates up to 4 years post-diagnosis and examined the factors associated with statin discontinuation. ResultsThe proportion of cancer patients discontinuing statin therapy at 4 years (27%) was comparable to the comparison cohort; however, significantly higher proportions of the cancer cohort discontinued statins than the comparison cohort at 3, 6 and 12 months of follow-up (9.7% vs 7.4% at 12 months, respectively). More than 30% of cancer patients who died were dispensed statins within 30 days of death. Discontinuation of statin therapy in cancer patients was associated with regionalised and distant disease spread at diagnosis (p<0.001), older age (p=0.006), upper gastrointestinal organs and liver cancer (aHR 2.95, 95% CI 1.92 to 4.53) and cancer of the lung, bronchus and trachea (aHR 1.99, 95% CI 1.32 to 3.00) and poorer survival. ConclusionsMedications should be rationalised at the time of a cancer diagnosis, especially in the setting of a poor prognosis. At least for some patients in our cohort, statin therapy may be inappropriately continued which adds unnecessarily to therapeutic burden.

Efficacy and tolerability of a {beta}-1 selective {beta} blocker, bisoprolol, as a first-line antihypertensive in Indian patients diagnosed with essential hypertension (BRIGHT): an open-label, multicentric observational study [RESEARCH]

Mon, 14 May 2012 00:00:00 +0000

ObjectivesThis study was aimed to evaluate the efficacy and tolerability of bisoprolol, in Indian patients diagnosed with stage I essential hypertension as first-line drug. DesignThis was an open-label, phase IV, multicentric prospective study. Settings239 outpatient centres across India. ParticipantsAfter ethical approval, patients who were willing to sign informed consent, who are newly diagnosed with JNC VII stage I essential hypertension (systolic blood pressure 140-159 mm Hg or diastolic blood pressure 90-99 mm Hg) and who are prescribed bisoprolol were enrolled in the study. Patients with significant organ disease or complications, women of childbearing age refusing reliable contraceptive method, patients with known contraindications (like symptomatic bradycardia, significant atrioventricular blockade, sick sinus syndrome) and patients with known hypersensitivity reactions to bisoprolol and unwilling patients were excluded. Primary and secondary outcomes measuresThe primary outcome measure was percentage of patients achieving blood pressure (BP) [≤]140/90 mm Hg at the end of 12 weeks, while multiple secondary outcome measures were assessed. ResultsOf 2418 patients screened, 2161 patients were recruited (66.64% men, mean age 51.7{+/-}9.8 years, smokers 19.19%) and 2131 (96.44%) patients achieved BP control. There was significant reduction in systolic blood pressure (-25.29; SD: 13.22 mm Hg), diastolic blood pressure (-14.14; SD: 7.67 mm Hg) and heart rate (-12/min; SD: 6.15) compared with baseline (all p values <0.05). The median dose of bisoprolol and average period required for the response were 5 mg/day and 33 days, respectively. Bisoprolol was found to be well tolerated in the patients up to 10 mg/day. A total of 1.9% patients showed adverse events, which were mild to moderate in severity without any severe adverse event. None required treatment withdrawal. ConclusionBisoprolol is an effective and safe option to control BP. Thus, it can be used as one of the first-line antihypertensive in Indian patients.

Templates for reporting pre-hospital major incident medical management: systematic literature review [PROTOCOL]

Thu, 3 May 2012 00:00:00 +0000

IntroductionIn 2010, a total of 385 natural disasters killed more than 297 000 people worldwide and affected over 217 million others. More standardised reporting of major incident management have been advocated in the previous years. Prevention, mitigation, preparedness and major incident response may be improved through collection and analysis of high-quality standardised data on medical management of major incidents. Standardised data may elevate the level of scientific evidence within disaster medicine research. Methods and analysisA systematic literature review will be conducted to identify templates for reporting pre-hospital major incident medical management. The first set of entry terms aims to describe major incidents published during the last 20 years. The second set aims to focus the number of search results from the first set to those publications that describe templates based on data collections from these major incidents. Predefined free search phases will be combined with the first two sets. Ethics and disseminationThe results will be submitted for publication in an open access, peer-reviewed scientific journal. The PRISMA checklist will be applied. No ethics approval is considered indicated, as this is a literature review only. Registration detailsThis review is registered in PROSPERO (registration number: CRD42012002051).

Technology adoption and implementation in organisations: comparative case studies of 12 English NHS Trusts [RESEARCH]

Wed, 4 Apr 2012 00:00:00 +0000

ObjectivesTo understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process. DesignQualitative, multisite, comparative case study design. SettingOne primary care and 11 acute care organisations (trusts) across all health regions in England in the context of infection prevention and control. Participants and data analysis121 semistructured individual and group interviews with 109 informants, involving clinical and non-clinical staff from all organisational levels and various professional groups. Documentary evidence and field notes were also used. 38 technology adoption processes were analysed using an integrated approach combining inductive and deductive reasoning. Main findingsThose involved in the process variably accessed three types of innovation knowledge: awareness' (information that an innovation exists), principles' (information about an innovation's functioning principles) and how-to' (information required to use an innovation properly at individual and organisational levels). Centralised (national, government-led) and local sources were used to obtain this knowledge. Localised professional networks were preferred sources for all three types of knowledge. Professional backgrounds influenced an asymmetric attention to different types of innovation knowledge. When less attention was given to how-to' compared with principles' knowledge at the early stages of the process, this contributed to 12 cases of incomplete implementation or discontinuance after initial adoption. ConclusionsPotential adopters and change agents often overlooked or undervalued how-to' knowledge. Balancing principles' and how-to' knowledge early in the innovation process enhanced successful technology adoption and implementation by considering efficacy as well as strategic, structural and cultural fit with the organisation's context. This learning is critical given the policy emphasis for health organisations to be innovation-ready.

Tracking the impact of research on policy and practice: investigating the feasibility of using citations in clinical guidelines for research evaluation [RESEARCH]

Fri, 30 Mar 2012 00:00:00 +0000

ObjectivesTo investigate the feasibility of using research papers cited in clinical guidelines as a way to track the impact of particular funding streams or sources. SettingIn recent years, medical research funders have made efforts to enhance the understanding of the impact of their funded research and to provide evidence of the value' of investments in particular areas of research. One of the most challenging areas of research evaluation is around impact on policy and practice. In the UK, the National Institute of Health and Clinical Excellence (NICE) provide clinical guidelines, which bring together current high-quality evidence on the diagnosis and treatment of clinical problems. Research referenced in these guidelines is an indication of its potential to have real impact on health policy and practice. DesignThis study is based on analysis of the authorship and funding attribution of research cited in two NICE clinical guidelines: dementia and chronic obstructive pulmonary disease. ResultsAnalysis identified that around a third of papers cited in the two NICE guidelines had at least one author based in the UK. In both cases, about half of these UK attributed papers contained acknowledgements which allowed the source of funding for the research to be identified. The research cited in these guidelines was found to have been supported by a diverse set of funders from different sectors. The study also investigated the contribution of research groups based in universities, industry and the public sector. ConclusionsThe study found that there is great potential for guidelines to be used as sources of information on the quality of the research used in their development and that it is possible to track the source of the funding of the research. The challenge is in harnessing the relevant information to track this in an efficient way.

Leadership competencies for medical education and healthcare professions: population-based study [RESEARCH]

Tue, 27 Mar 2012 00:00:00 +0000

ObjectiveTo identify and empirically investigate the dimensions of leadership in medical education and healthcare professions. DesignA population-based design with a focus group and a survey were used to identify the perceived competencies for effective leadership in medical education. SettingThe focus group, consisting of five experts from three countries (Austria n=1; Germany n=2; Switzerland n=2), was conducted (all masters of medical education), and the survey was sent to health professionals from medical schools and teaching hospitals in six countries (Austria, Canada, Germany, Switzerland, the UK and the USA). ParticipantsThe participants were educators, physicians, nurses and other health professionals who held academic positions in medical education. A total of 229 completed the survey: 135 (59.0%) women (mean age=50.3 years) and 94 (41.0%) men (mean age=51.0 years). MeasuresA 63-item survey measuring leadership competencies was developed and administered via electronic mail to participants. ResultsExploratory principal component analyses yielded five factors accounting for 51.2% of the variance: (1) social responsibility, (2) innovation, (3) self-management, (4) task management and (5) justice orientation. There were significant differences between physicians and other health professionals on some factors (Wilk's {lambda}=0.93, p<0.01). Social responsibility was rated higher by other health professionals (M=71.09) than by physicians (M=67.12), as was innovation (health professionals M=80.83; physicians M=76.20) and justice orientation (health professionals M=21.27; physicians M=20.46). ConclusionsThe results of the principal component analyses support the theoretical meaningfulness of these factors, their coherence, internal consistency and parsimony in explaining the variance of the data. Although there are some between-group differences, the competencies appear to be stable and coherent.

A case-control study examining whether neurological deficits and PTSD in combat veterans are related to episodes of mild TBI [RESEARCH]

Sun, 18 Mar 2012 00:00:00 +0000

BackgroundMild traumatic brain injury (mTBI) is a common injury among military personnel serving in Iraq or Afghanistan. The impact of repeated episodes of combat mTBI is unknown. ObjectiveTo evaluate relationships among mTBI, post-traumatic stress disorder (PTSD) and neurological deficits (NDs) in US veterans who served in Iraq or Afghanistan. MethodsThis was a case-control study. From 2091 veterans screened for traumatic brain injury, the authors studied 126 who sustained mTBI with one or more episodes of loss of consciousness (LOC) in combat. Comparison groups: 21 combat veterans who had definite or possible episodes of mTBI without LOC and 21 veterans who sustained mTBI with LOC as civilians. ResultsAmong combat veterans with mTBI, 52% had NDs, 66% had PTSD and 50% had PTSD and an ND. Impaired olfaction was the most common ND, found in 65 veterans. The prevalence of an ND or PTSD correlated with the number of mTBI exposures with LOC. The prevalence of an ND or PTSD was >90% for more than five episodes of LOC. Severity of PTSD and impairment of olfaction increased with number of LOC episodes. The prevalence of an ND for the 34 combat veterans with one episode of LOC (4/34=11.8%) was similar to that of the 21 veterans of similar age and educational background who sustained civilian mTBI with one episode of LOC (2/21=9.5%, p-NS). ConclusionsImpaired olfaction was the most frequently recognised ND. Repeated episodes of combat mTBI were associated with increased likelihood of PTSD and an ND. Combat setting may not increase the likelihood of an ND. Two possible connections between mTBI and PTSD are (1) that circumstances leading to combat mTBI likely involve severe psychological trauma and (2) that altered cerebral functioning following mTBI may increase the likelihood that a traumatic event results in PTSD.

Will more restrictive indications decrease rates of urinary catheterisation? An historical comparative study [RESEARCH]

Thu, 8 Mar 2012 00:00:00 +0000

ObjectivesTo determine if more restrictive indications for urinary catheterisation reinforced by daily chart review will lower catheterisation rates. DesignAn historical comparative observational study. SettingAn internal medicine department in a regional hospital in Israel. ParticipantsThe authors compared 882 patients hospitalised after a change in policy to an historical cohort of 690 hospitalised patients. Exclusions included patients less than age 30 and those with bladder outlet obstruction. InterventionEmergency and internal medicine department physicians received instruction on a more restricted urinary catheterisation policy. During daily chart rounds, admissions were discussed with an emphasis on the appropriateness of all new urinary catheter insertions. Main outcome measuresThe primary outcome measure was catheterisation rate by admission diagnosis. Secondary outcome measures were the need for post-admission in hospital catheterisations and the rate of indwelling catheters 14 or more days after discharge. ResultsThere was a reduction in catheterisation rate in patients with congestive heart failure from 30/106 (29.3%) to 3/107 (2.8%) (p<0.001), in patients with an admission diagnosis of fever unable to provide a urine sample for culture from 35/132 (26.5%) to 12/153 (7.8%) (p<0.001) and in patients admitted for palliative care from 51.7% (15/29) to 12.0% (3/25) (p=0.002). The overall rate of catheterisation decreased from 17.5% (121/690) to 6.6% (58/882) (p<0.001). There was only one indicated catheterisation after admission due to the change in policy, and the proportion of patients discharged with catheters decreased. ConclusionThe use of more restrictive indications for urinary catheterisation along with daily chart rounds can reduce the rate of urinary catheterisation in an internal medicine department without adverse consequences.

Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message-based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol [PROTOCOL]

Thu, 19 Jan 2012 00:00:00 +0000

BackgroundAlthough supporting lifestyle change is an effective way of preventing further events in people with cardiovascular disease, providing access to such interventions is a major challenge. This study aims to investigate whether simple reminders about behaviour change sent via mobile phone text message decrease cardiovascular risk. Methods and analysisRandomised controlled trial with 6 months of follow-up to evaluate the feasibility, acceptability and effect on cardiovascular risk of repeated lifestyle reminders sent via mobile phone text messages compared to usual care. A total of 720 patients with coronary artery disease will be randomised to either standard care or the TEXT ME intervention. The intervention group will receive multiple weekly text messages that provide information, motivation, support to quit smoking (if relevant) and recommendations for healthy diets and exercise. The primary end point is a change in plasma low-density lipoprotein cholesterol at 6 months. Secondary end points include a change in systolic blood pressure, smoking status, quality of life, medication adherence, waist circumference, physical activity levels, nutritional status and mood at 6 months. Process outcomes related to acceptability and feasibility of TEXT ME will also be collected. Ethics and disseminationPrimary ethics approval was received from Western Sydney Local Health Network Human Research Ethics Committee--Westmead. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences. Clinical trials registration numberACTRN12611000161921.

Decline of meticillin-resistant Staphylococcus aureus in Oxfordshire hospitals is strain-specific and preceded infection-control intensification [RESEARCH]

Fri, 2 Sep 2011 00:00:00 +0000

BackgroundIn the past, strains of Staphylococcus aureus have evolved, expanded, made a marked clinical impact and then disappeared over several years. Faced with rising meticillin-resistant S aureus (MRSA) rates, UK government-supported infection control interventions were rolled out in Oxford Radcliffe Hospitals NHS Trust from 2006 onwards. MethodsUsing an electronic Database, the authors identified isolation of MRS among 611 434 hospital inpatients admitted to acute hospitals in Oxford, UK, 1 April 1998 to 30 June 2010. Isolation rates were modelled using segmented negative binomial regression for three groups of isolates: from blood cultures, from samples suggesting invasion (eg, cerebrospinal fluid, joint fluid, pus samples) and from surface swabs (eg, from wounds). FindingsMRSA isolation rates rose rapidly from 1998 to the end of 2003 (annual increase from blood cultures 23%, 95% CI 16% to 30%), and then declined. The decline accelerated from mid-2006 onwards (annual decrease post-2006 38% from blood cultures, 95% CI 29% to 45%, p=0.003 vs previous decline). Rates of meticillin-sensitive S aureus changed little by comparison, with no evidence for declines 2006 onward (p=0.40); by 2010, sensitive S aureus was far more common than MRSA (blood cultures: 2.9 vs 0.25; invasive samples 14.7 vs 2.0 per 10 000 bedstays). Interestingly, trends in isolation of erythromycin-sensitive and resistant MRSA differed. Erythromycin-sensitive strains rose significantly faster (eg, from blood cultures p=0.002), and declined significantly more slowly (p=0.002), than erythromycin-resistant strains (global p<0.0001). Bacterial typing suggests this reflects differential spread of two major UK MRSA strains (ST22/36), ST36 having declined markedly 2006-2010, with ST22 becoming the dominant MRSA strain. ConclusionsMRSA isolation rates were falling before recent intensification of infection-control measures. This, together with strain-specific changes in MRSA isolation, strongly suggests that incompletely understood biological factors are responsible for the much recent variation in MRSA isolation. A major, mainly meticillin-sensitive, S aureus burden remains.