To examine the relationship between resuscitation status and i) patient characteristics, ii) transfer characteristics and iii) patient outcomes following an emergency inter‐hospital transfer from a subacute to an acute care hospital.
Patients who experience emergency inter‐hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in‐hospital mortality (15%).
This prospective, exploratory cohort study was a subanalysis of data from a larger case‐time‐control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of Observational studies in Epidemiology guidelines.
Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not‐for‐cardiopulmonary resuscitation (CPR) orders) were compared using Chi‐square or Kruskal Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect.
Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order and 13.4% not‐for‐CPR. Compared to patients for full resuscitation, patients with not‐for‐CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not‐for‐CPR were less likely to be readmitted to acute care and more likely to return to subacute care.
Two‐thirds of patients in subacute care who experienced an emergency inter‐hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not‐for‐CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients.
As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.
Controversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this practice variation on patient outcome is unknown. Here, we present the protocol for a prospective multicentre observational study aimed at comparing the effectiveness of different treatment strategies in patients with ASDH and/or t-ICH. Specifically, the aims are to compare (1) an acute surgical approach to an expectant approach and (2) craniotomy to decompressive craniectomy when evacuating the haematoma.
Patients presenting to the emergency room with an ASDH and/or an t-ICH are eligible for inclusion. Standardised prospective data on patient and injury characteristics, treatment and outcome will be collected on 1000 ASDH and 750 t-ICH patients in 60–70 centres within two multicentre prospective observational cohort studies: the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Neurotraumatology Quality Registry (Net-QuRe). The interventions of interest are acute surgery, defined as surgery directly after the first CT at presentation versus late or no surgery and craniotomy versus decompressive craniectomy. The primary outcome measure is the Glasgow Outcome Score-Extended at 6 months. Secondary outcome measures include in-hospital mortality, quality of life and neuropsychological tests. In the primary analysis, the effect of treatment preference (eg, proportion of patients in which the intervention under study is preferred) per hospital will be analysed with random effects ordinal regression models, adjusted for casemix and stratified by study. Such a hospital-level approach reduces confounding by the indication. Sensitivity analyses will include propensity score matching, with treatment defined on patient level. This study is designed to determine the best acute management strategy for ASDH and t-ICH by exploiting the existing between-hospital variability in surgical management.
Ethics approval was obtained in all participating countries. Results of surgical management of ASDH and t-ICH/contusion will separately be submitted for publication in a peer-reviewed journal.
NCT02210221 and NL 5761.
Individualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines.
CPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intracranial pressure monitoring are randomised within the first 24 hours of admission in neurocritical care unit. For the control arm, the CPP target is the Brain Trauma Foundation guidelines target (60–70 mm Hg); for the intervention group an automated CPP target is provided as the CPP at which the patient’s cerebrovascular reactivity is best preserved (CPPopt). For a maximum of 5 days, attending clinicians review the CPP target 4-hourly. The main hypothesis of COGiTATE are: (1) in the intervention group the percentage of the monitored time with measured CPP within a range of 5 mm Hg above or below CPPopt will reach 36%; (2) the difference in between groups in daily therapy intensity level score will be lower or equal to 3.
Ethical approval has been obtained for each participating centre. The results will be presented at international scientific conferences and in peer-reviewed journals.
To identify how social return on investment (SROI) analysis—traditionally used by business consultants—has been interpreted, used and innovated by academics in the health and social care sector and to assess the quality of peer-reviewed SROI studies in this sector.
Community and residential settings.
A wide range of demographic groups and age groups.
The following databases were searched: Web of Science, Scopus, CINAHL, Econlit, Medline, PsychINFO, Embase, Emerald, Social Care Online and the National Institute for Health and Care Excellence. Limited uptake of SROI methodology by academics was found in the health and social care sector. From 868 papers screened, 8 studies met the criteria for inclusion in this systematic review. Study quality was found to be highly variable, ranging from 38% to 90% based on scores from a purpose-designed quality assessment tool. In general, relatively high consistency and clarity was observed in the reporting of the research question, reasons for using this methodology and justifying the need for the study. However, weaknesses were observed in other areas including justifying stakeholders, reporting sample sizes, undertaking sensitivity analysis and reporting unexpected or negative outcomes. Most papers cited links to additional materials to aid in reporting. There was little evidence that academics had innovated or advanced the methodology beyond that outlined in a much-cited SROI guide.
Academics have thus far been slow to adopt SROI methodology in the evaluation of health and social care interventions, and there is little evidence of innovation and development of the methodology. The word count requirements of peer-reviewed journals may make it difficult for authors to be fully transparent about the details of their studies, potentially impacting the quality of reporting in those studies published in these journals.
(a) Describe the co‐development of a point‐of‐care App to promote uptake of best practice recommendations and consolidate nurses' knowledge for managing symptoms of neurocognitive disorders. (b) Report acceptability, usability and feasibility of the App to nurses for patient care in hospital.
Strategies used in hospitals to reduce symptoms, risk of harm, or complications of behavioural and psychological symptoms associated with neurocognitive disorders are frequently inconsistent with best practice recommendations.
Three‐stage, mixed‐methods, process and outcome evaluation.
The App was co‐developed with experts, nurse end‐users and a consumer. Evaluation data were collected from a convenience sample of nurses observed during delivery of 80.5 hr of care to 38 patients; the App (n = 32 patients); and individual and focus group interviews with nurses (n = 25). Reporting adhered to an adapted STROBE checklist.
The App included three components: cognition and risk assessment; tailored evidence‐based strategies; and monitoring and evaluation of effectiveness. Observation data captured nurses using the App with 44.7% (n = 17) of eligible inpatients. Cognitive screening was completed at least once for each patient, with 146 risk assessments recorded. Interview data indicated the App's acceptability was enhanced by familiarity and perceived benefits, but hindered by perceived increases in workload, inconsistent use, pressure to use the App and resistance to change. Feasibility and usability were enhanced by easy navigation, and clear and useful content, but hindered by unclear expectations, unfamiliarity and device‐related factors.
The App provided an evidence‐based tool that was, overall, considered feasible and acceptable to support best practice. Findings provide guidance to enhance usability for future implementation.
Co‐development using best evidence and key stakeholders enabled creation of a novel, feasible and acceptable technology. Real‐time access to assessment tools and tailored knowledge supported nurses' clinical decision‐making; workload and unfamiliarity were barriers to use.
The aim of this study was to identify patient preferences for involvement in medication management during hospitalization.
A qualitative descriptive study.
This is a study of 20 inpatients in two medical and two surgical wards at an academic health science centre in Melbourne, Australia. Semi‐structured interviews were recorded and analysed using content analysis.
Three themes were identified: (a) ‘understanding the medication’ established large variation in participants’ understanding of their pre‐admission medication and current medication; (b) ‘ownership of medication administration’ showed that few patients had considered an alternative to their current regimen; only some were interested in taking more control; and (c) ‘supporting discharge from hospital’ showed that most patients desired written medication instructions to be explained by a health professional. Family involvement was important for many.
There was significant diversity of opinion from participants about their involvement in medication management in hospital. Patient preferences for inclusion need to be identified on admission where appropriate. Education about roles and responsibilities of medication management is required for health professionals, patients and families to increase inclusion and engagement across the health continuum and support transition to discharge.
Little is known about patient preferences for participation in medication administration and hospital discharge planning. Individual patient understanding of and interest in participation in medication administration varies. In accordance with individual patient preferences, patients need to be included more effectively and consistently in their own medication management when in hospital.
To explore the role of coping moderators in self‐management of breathlessness crises by people with advanced respiratory disease.
A secondary analysis of semi‐structured interview data.
Interviews with patients who had advanced respiratory disease, chronic breathlessness and at least one experience where they considered presenting to Emergency but self‐managed instead (a “near miss”). Participants were recruited from New South Wales, Queensland, Victoria, South Australia or Tasmania. Eligible caregivers were those who contributed to Emergency‐related decision‐making. Interviews were coded inductively and then deductively against the coping moderators social support and dispositional coping style, defined by the Transactional Model of Stress and Coping.
Interviews were conducted between October 2015 ‐ April 2016 with 20 patients and three caregivers. Social networks offered emotional and practical support but also had potential for conflict with patients' ‘hardy’ coping style. Patient hardiness (characterized by a sense of ‘commitment’ and ‘challenge’) promoted a proactive approach to self‐management but made some patients less willing to accept support. Information‐seeking tendencies varied between patients and were sometimes shared with caregivers. An optimistic coping style appeared to be less equivocally beneficial.
This study shows that social support and coping style may influence how people self‐manage through their breathlessness crises and identified ways coping moderators can facilitate or hinder effective self‐management.
This study confers insights into how social‐support and coping style can be supported and optimized to facilitate breathlessness self‐management. Acknowledging coping moderator interactions is beneficial for developing resources and strategies that recognise patient mastery.
To describe nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in acute hospital settings.
Medication errors cause unintended harm to patients. Nurses have a major role in ensuring patient safety in medication administration practices in hospital settings. Investigating nurses’ medication administration decision‐making and practices and their perceptions of patient involvement, may assist in developing interventions by revealing how and when to involve patients during medication administration in hospital.
A descriptive exploratory study design.
Twenty nurses were recruited from two surgical and two medical wards of a major metropolitan hospital in Australia. Each nurse was observed for four hours then interviewed after the observation. Data were collected over six months in 2015. Observations were captured on an electronic case report form; interviews were audio‐recorded and transcribed verbatim. Data were analysed using descriptive statistics and content and thematic analysis.
Ninety‐five medication administration episodes, of between two and eight episodes per nurse, were observed. A total of fifty‐six interruptions occurred with twenty‐six of the interruptions being medication related. Four major themes emerged from the interviews: dealing with uncertainty; facilitating, framing and filtering information; managing interruptions and knowing and involving patients.
Nurses work in complex adaptive systems that change moment by moment. Acknowledging and understanding the cognitive workload and complex interactions are necessary to improve patient safety and reduce errors during medication administration. Knowing and involving the patient is an important part of a nurses’ medication administration safety strategies.
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It has been suggested that exposure to heavy metal cadmium (Cd) may contribute to a high risk of developing rheumatoid arthritis (RA). This study was to investigate the association of RA prevalence and serum concentrations of Cd and other heavy metals through large survey data analysis.
A retrospective cross-sectional survey study.
Large population survey in Korea.
53 829 subjects participated in Korean National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2013.
Heavy metals were measured in different time periods of the survey programme which resulted in three different data sets for analysis: Cd, mercury (Hg) and lead (Pb) from 2008 to 2012 survey; serum manganese (Mn) and urine arsenic (As) from 2008 to 2009 survey; and serum zinc (Zn) from 2010 survey. RA prevalence and its associations with serum heavy metals were analysed using a general linear/logistic regression model of complex sample design.
Serum Cd was elevated in patients with RA (RA vs control: 1.30±0.07 µg/L vs 1.17±0.01 µg/L, p
There was an increased prevalence of RA in females associated with increased serum levels of Cd in the Korean population.
To undertake an assessment of preferences as to how, where and by whom ultrasounds (US) should be performed in: (1) patients undergoing surveillance of abdominal aortic aneurysm (AAA) size (AAA group); and (2) patients being scanned for general abdominal conditions (general group).
A discrete choice experiment (DCE) questionnaire was administered to patients attending US appointments. Analysis of questionnaire responses used conditional logit models and included validity checks.
West Midlands, England.
524 patients (223 in the AAA group and 301 in the general group) were recruited from the US outpatient department at University Hospital Coventry and Warwickshire.
Coefficients for attributes in relation to their reference levels.
The AAA group preferred to have their US performed in hospital while the general group had a preference for portable US at general practice surgeries. All patients had a strong preference for scanning by specialists, devices with a lower risk of underdiagnosis and receiving their results at the appointment where the scan takes place. The general group had a strong preference for the person performing the scan to know their medical history.
Patients being scanned for general abdominal conditions prefer to be scanned in a general practice by practitioners who know their medical history. Patients undergoing surveillance of AAA size prefer to be scanned in a hospital setting. Both groups would prefer to be informed of the scan results as soon as possible. Further research is required to explore the clinical scenarios in which targeted scanning by community practitioners would be of benefit to patients.
Unlike other forms of evaluation, social return on investment (SROI) methodology offers a way of placing values on personal, social and community outcomes, not just economic outcomes. Developed in 2000, there have been calls for greater academic involvement in development of SROI, which to date has been more typically implemented in-house or by consultants. This protocol describes a systematic review of SROI analysis conducted on health and social care programmes which represent a significant sector of social enterprise internationally. The aims of the systematic review are to (1) identify the extent to which academics have adopted SROI methodology, (2) how academics have interpreted, used and developed SROI methodology and (3) to assess the quality of studies published under peer review.
The systematic review will include peer-reviewed studies since 2000 published in English. Search terms will be ‘social return on investment’ or ‘SROI’. Health and social care interventions will be identified in the initial screening given the proliferation of possible key words in these areas. Databases to be searched include Web of Science, Scopus, Medline, Social Care Online and National Institute for Health and Care Excellence. Two reviewers will independently conduct initial screening based on titles and abstracts against the inclusion criteria. Data extracted will include date of intervention, country, study design, aim of intervention/programme, participants and setting, health and social care measures used, and SROI ratio. The quality of studies will be assessed by two reviewers using a SROI quality framework designed for the purpose of this study.
The systematic review will review existing published academic literature; as such, ethics approval is not required for this study. A paper of the systematic review will be submitted to a peer-reviewed journal.
Neurogenic claudication due to spinal stenosis is common in older adults. The effectiveness of conservative interventions is not known. The aim of the study is to estimate the clinical and cost-effectiveness of a physiotherapist-delivered, combined physical and psychological intervention.
This is a pragmatic, multicentred, randomised controlled trial. Participants are randomised to a combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme) or best practice advice (control). Community-dwelling adults, 65 years and over, with neurogenic claudication are identified from community and secondary care services. Recruitment is supplemented using a primary care-based cohort. Participants are registered prospectively and randomised in a 2:1 ratio (intervention:control) using a web-based service to ensure allocation concealment. The target sample size is a minimum of 402. The BOOST programme consists of an individual assessment and twelve 90 min classes, including education and discussion underpinned by cognitive behavioural techniques, exercises and walking circuit. During and after the classes, participants undertake home exercises and there are two support telephone calls to promote adherence with the exercises. Best practice advice is delivered in one to three individual sessions with a physiotherapist. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the 6 Minute Walk Test, Short Physical Performance Battery, Fear Avoidance Beliefs Questionnaire and Gait Self-Efficacy Scale. Outcomes are measured at 6 and 12 months by researchers who are masked to treatment allocation. The primary statistical analysis will be by ‘intention to treat’. There is a parallel health economic evaluation and qualitative study.
Ethical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials checklist. The results will be reported at conferences and in peer-reviewed publications using the Consolidated Standards of Reporting Trials guidelines. A plain English summary will be published on the BOOST website.