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Caring for the carers in a public health district: A well‐being initiative to support healthcare professionals

Abstract

Aims and Objectives

To assess the impact of the proactive organisational resource allocation in terms of a 6‐week well‐being initiative to support public healthcare professionals' workplace engagement, well‐being and job satisfaction.

Background

Burnout of healthcare professionals can be a major cost to the Australian economy and public healthcare sector. According to the social exchange theory, when healthcare professionals perceive that their organisation proactively allocates resources to caring for its employees, then they are more likely to reciprocate and become more engaged in their work roles.

Design

The study used a pre‐ and postsurvey of healthcare professionals who participated in the well‐being initiative.

Methods

Between February–June 2019, 172 healthcare professionals were surveyed before and after a well‐being initiative. The survey included questions on workplace engagement, workplace well‐being and job satisfaction. Paired t tests were used to determine whether the difference between before and after averages was significant. The TREND statement was used to ensure the quality reporting of this study.

Results

The well‐being initiative had a positive impact on the healthcare professionals involved in the initiative. Nursing staff benefitted the most from the well‐being initiative, while the full‐time staff members and highly experienced demonstrated an increase in engagement.

Conclusion

Well‐being initiatives can be a targeted strategy to help alleviate burnout amongst healthcare professionals and build a mutually beneficial relationship between management and employees.

Relevance to clinical practice

This study shows how implementing a staff well‐being initiative increases workplace engagement, which benefits both the individual and the organisation.

Self‐management programs for cirrhosis: a systematic review

Abstract

Background and aims

Liver cirrhosis severely decreases patients' quality of life. Since self‐management programs have improved quality of life and reduce hospital admissions in other chronic diseases, they have been suggested to decrease liver cirrhosis burden.

Methods

We performed a systematic review and meta‐analysis to evaluate the clinical impact of self‐management programs in patients with liver cirrhosis, which followed the Preferred Reporting for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Primary outcomes include health‐related quality of life (HRQOL) and hospitalization. We searched MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO and two trial registers to July 2017.

Results

We identified four randomized trials (299 patients) all rated at a high risk of bias. No difference was demonstrated for HRQOL (Standardized Mean Difference ‐0.01, 95% CI: ‐0.48 to 0.46) and hospitalization days (Incidence Rate Ratio 1.6, 95% CI: 0.5 to 4.8). For secondary outcomes, one study found a statistically significant improvement in patient knowledge (Mean Difference (MD) 3.68, 95% CI: 2.11 to 5.25) while another study found an increase in Model for End‐Stage Liver Disease scores (MD 2.8, 95% CI: 0.6 to 4.9) in the self‐management group. No statistical difference was found for the other secondary outcomes (self‐efficacy, psychological health outcomes, healthcare utilization, mortality). Overall, the quality of the evidence was low. The content of self‐management programs varied across studies with little overlap.

Conclusions

The current literature indicates that there is no evidence of a benefit of self‐management programs for people with cirrhosis.

Relevance to clinical practice

Practitioners should use self‐management programs with caution when delivering care to patients living with cirrhosis. Further research is required to determine what are the key features in a complex intervention like self‐management. This review offers a preliminary framework for clinicians to develop a new self‐management program with key features of effective self‐management interventions from established models.

Parents' experiences of transition from hospital to home of a child with complex health needs: A systematic literature review

Abstract

Aims and objectives

To critically appraise primary research on the views and experiences of parents of children with complex health needs during the transition from hospital to home.

Background

Children with complex health needs frequently transition across and within healthcare systems, due to their age, care needs and ongoing health conditions. Repeated and unplanned admissions are significantly higher for children with complex health needs. Yet parents, as the primary providers of care, report being unsupported and unprepared during the transition from hospital back to home due to poor communication, inadequate discharge planning and education, resulting in stress and anxiety within the home environment.

Design

Systematic review following PRISMA guidelines.

Methods

A systematic search was completed of the databases CINAHL, MEDLINE, PsycINFO, EMBASE and the Cochrane Library Review between January 2009 and September 2019. Data were extracted, categorised and analysed using a thematic analysis approach. An adapted CASP qualitative assessment tool was utilised for quality assessment. All included articles were marked for validity and relevance to current research with an overall score from 0–20.

Results

A total of 13 studies of mixed quality were identified. CASP quality scores ranged from 13–18. Four themes emerged highlighting parents' experiences of the emotional processes, communication, coordination and support and resources when transitioning from hospital to home.

Conclusions

Hospital discharge and transition from hospital to home is a complicated and at times frustrating process for parents of children with complex health needs. Parents report being exhausted and stressed during this often‐challenging period of adjustment which was perceived as a difficult and emotional process. There is a clear lack of support available for parents both from hospital and community services.

Attrition from specialised rehabilitation associated with an elevated mortality risk: results from a vital status tracing study in Swiss spinal cord injured patients

Por: Chamberlain · J. D. · Eriks-Hoogland · I. E. · Hug · K. · Jordan · X. · Schubert · M. · Brinkhof · M. W. G.
Introduction

Study drop-out and attrition from treating clinics is common among persons with chronic health conditions. However, if attrition is associated with adverse health outcomes, it may bias or mislead inferences for health policy and resource allocation.

Methods

This retrospective cohort study uses data attained through the Swiss Spinal Cord Injury (SwiSCI) cohort study on persons with spinal cord injury (SCI). Vital status (VS) was ascertained either through clinic medical records (MRs) or through municipalities in a secondary tracing effort. Flexible parametric survival models were used to investigate risk factors for going lost to clinic (LTC) and the association of LTC with subsequent risk of mortality.

Results

1924 individuals were included in the tracing study; for 1608 of these cases, contemporary VS was initially checked in the MRs. VS was ascertained for 704 cases of the 1608 cases initially checked in MRs; of the remaining cases (n=904), nearly 90% were identified in municipalities (n=804). LTC was associated with a nearly fourfold higher risk of mortality (HR=3.62; 95% CI 2.18 to 6.02) among persons with traumatic SCI. Extended driving time (ie, less than 30 min compared with 30 min and longer to reach the nearest specialised rehabilitation facility) was associated with an increased risk of mortality (HR=1.51, 95% CI 1.02 to 2.22) for individuals with non-traumatic SCI.

Conclusion

The differential risk of LTC according to sociodemographic and SCI lesion characteristics underscores the importance of accounting for attrition in cohort studies on chronic disease populations requiring long-term care. In addition, given the associated risk of mortality, LTC is an issue of concern to clinicians and policy makers aiming to optimise the long-term survival of community-dwelling individuals with traumatic SCI. Future studies are necessary to verify whether it is possible to improve survival prospects of individuals LTC through more persistent outreach and targeted care.

Relationships between the National Early Warning Score 2, clinical worry, and patient outcome at discharge: Retrospective observational study

Abstract

Aims and objectives

To examine the performance of the National Early Warning Score 2 and composite score for clinical worry in identifying patients at risk of clinical deterioration, and to determine relationships between National Early Warning Score 2, clinical worry score, and patient outcome at discharge.

Background

The efficacy of early warning systems depends on patient population and care settings. Based on a theoretical framework on factors affecting clinical deterioration and patient outcomes, studies exploring the relationship between early warning systems and patient outcomes at discharge are sparse.

Design

Retrospective observational study.

Methods

A random sample of 732 medical records were reviewed. The area under the receiver‐operating‐characteristic curve was calculated to evaluate predictive abilities regarding the events of unanticipated in‐hospital mortality, unplanned intensive care unit/ higher‐dependency bed admission, and cardiac arrest. Multiple logistic regression analyses were performed to determine relationships between National Early Warning Score 2, clinical worry score, and patient outcome. Reporting followed the STROBE checklist.

Results

National Early Warning Score 2 and clinical worry score significantly predicted the events within 24 hours of the assessment. After controlling for other patient, treatment, and organizational characteristics, National Early Warning Score 2 was a significant factor associated with patient outcome, but clinical worry score was not. Specifically, patients at high risk based on National Early Warning Score 2 were less likely to have improved outcome.

Conclusions

National Early Warning Score 2 and clinical worry score performed well for predicting deteriorating condition of patients. National Early Warning Score 2 was significantly associated with patient outcome. It can be used for efficient patient management for safe, quality care.

Relevance to clinical practice

National Early Warning Score 2 can be used for early assessment of not only clinical deterioration but also patient outcome and provide timely intervention, when coupled with clinical worry score.

Parental Readiness for Hospital Discharge as a Mediator between Quality of Discharge Teaching and Parental Self‐Efficacy in Parents of Preterm Infants

Abstract

Aims and Objectives

To examine the extent to which parental readiness for hospital discharge mediates the relationship between quality of discharge teaching and parental self‐efficacy in parents of preterm infants.

Background

Parental readiness for hospital discharge and self‐efficacy should be considered to establish if preterm infants and their families are prepared for the discharge. High‐quality discharge teaching could facilitate a smooth discharge transition. However, little is known about how quality of discharge teaching influences parental readiness for hospital discharge and self‐efficacy.

Design

This was a descriptive cross‐sectional study of 202 parents with preterm infants in a tertiary hospital in Eastern China.

Methods

The key variables of interest were measured using the Chinese versions of the Quality of Discharge Teaching Scale, Readiness for Hospital Discharge Scale‐Parent Form, and Preterm Parenting and Self‐Efficacy Checklist. Path analyses were conducted to test the mediation models. STROBE checklist was used to compile the study’s report.

Results

Parental readiness for discharge (overall and knowledge dimension) partially mediated the relationship between the quality of discharge teaching and parental self‐efficacy. The two dimensions (content received and delivery) of quality of discharge teaching positively influenced parental self‐efficacy by improving parental readiness for discharge.

Conclusions

Parental readiness for hospital discharge, especially the knowledge dimension, was an important factor in quality of discharge teaching’s association with self‐efficacy in parents of preterm infants. Improving the quality of discharge teaching could increase parental readiness for discharge, and thus promote parental self‐efficacy.

Relevance to Clinical Practice

Improving discharge instructions is essential to help parents of preterm infants prepare for the transition to home care. Assessing readiness and confidence at an early stage and continuing to do so throughout the hospital stay may provide additional ways for nurses to identify parents’ knowledge gaps and to provide tailored interventions at more opportune times before hospital discharge.

Nursing teamwork in general ward settings: A mixed‐methods exploratory study among enrolled and registered nurses

Abstract

Aim

This study aimed to examine the perceived level of nursing teamwork and factors influencing teamwork among enrolled nurses (ENs) and registered nurses (RNs) in general ward settings.

Background

The nursing care delivery model includes RNs, ENs and others who work as a team to deliver patient care. The potential impact of teamwork on nursing care highlights the need to explore the work of nursing teams.

Design

A mixed‐methods exploratory study.

Method

Quantitative and qualitative data were collected concurrently from ENs and RNs in 2018. Two hundred and forty‐eight (n = 248) nurses completed the Nursing Teamwork Survey. Sixteen nurses participated in focus group discussions. Qualitative data were reported following COREQ guidelines, while quantitative data followed the STROBE guidelines.

Results

Both ENs and RNs scored highest for the shared mental model subscale but lowest for the team orientation subscale. Factors including qualification level, years of working experience, perceived job staffing adequacy and job satisfaction were found to influence teamwork. Three themes emerged from the qualitative findings: expectations of each other’s role, delegation practices, and interpersonal relationships. ENs and RNs differed in their expectations of their role in basic patient care activities and faced power struggles related to delegation practices. Open and structured communication was deemed essential in building interpersonal relationships.

Conclusion

The ENs and RNs have clear understanding of their personal roles and responsibilities towards achieving a common goal. However, teamwork may be improved with a shared mental model in performing basic nursing care tasks, mutual support for workload management, better delegation practices, effective communication, enhanced interpersonal relationships, and better team orientation.

Relevance to clinical practice

Nurse managers and educators need to work collaboratively to foster positive delegation practices in clinical practice supported by applicable team training that enhances mutual trust, backup behaviors, and collective orientation in nursing teams.

An exploration of the factors influencing career choice in mental health

Abstract

Aims and objectives

To identify the factors that are associated with considering a career in mental health.

Background

The mental health specialty is facing a recruitment crisis in the United Kingdom but there is limited evidence about which factors encourage and discourage people to consider a career in mental health

Design

Quantitative, observational, online survey using a multiple ordinal logistic regression model to identify if there were any significant predictors of the extent to which participants would consider a career in mental health. The design and write up of the study were guided by the STROBE checklist.

Method

We gathered the views of 231 participants (female = 188, 81.7%) aged between 16 and 65 (mean = 22.7, SD = 8.9), using an online survey, the majority of whom were studying on, or graduates of, psychology/social studies degrees. Information was gathered about the extent to which a range of factors influenced consideration of a career in mental health.

Results

The majority (71.2%) of participants reported that they would definitely or probably consider undertaking a career in mental health, and over half (51.4%) would consider a career as a mental health nurse. The ability to help others and receiving appropriate training required for the role were important career choice factors. Being female, having a mental health condition, and greater knowledge of mental health, were associated with a significantly greater likelihood of considering a career in mental health, while having had experience of working with people with mental health difficulties was significantly negatively associated.

Conclusions

Students and graduates of psychology and social studies degrees appear to be a large, untapped recruitment pool for mental health services.

Relevance to clinical practice

The results can inform more targeted recruitment strategies and development of suitable career pathways for those interested in a career in mental health.

Individualised risk prediction model for new-onset, progression and regression of chronic kidney disease in a retrospective cohort of patients with type 2 diabetes under primary care in Hong Kong

Por: Yang · L. · Chu · T. K. · Lian · J. · Lo · C. W. · Zhao · S. · He · D. · Qin · J. · Liang · J.
Objectives

This study is aimed to develop and validate a prediction model for multistate transitions across different stages of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus under primary care.

Setting

We retrieved the anonymised electronic health records of a population-based retrospective cohort in Hong Kong.

Participants

A total of 26 197 patients were included in the analysis.

Primary and secondary outcome measures

The new-onset, progression and regression of CKD were defined by the transitions of four stages that were classified by combining glomerular filtration rate and urine albumin-to-creatinine ratio. We applied a multiscale multistate Poisson regression model to estimate the rates of the stage transitions by integrating the baseline demographic characteristics, routine laboratory test results and clinical data from electronic health records.

Results

During the mean follow-up time of 1.8 years, there were 2632 patients newly diagnosed with CKD, 1746 progressed to the next stage and 1971 regressed into an earlier stage. The models achieved the best performance in predicting the new-onset and progression with the predictors of sex, age, body mass index, systolic blood pressure, diastolic blood pressure, serum creatinine, haemoglobin A1c, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides and drug prescriptions.

Conclusions

This study demonstrated that individual risks of new-onset and progression of CKD can be predicted from the routine physical and laboratory test results. The individualised prediction curves developed from this study could potentially be applied to routine clinical practices, to facilitate clinical decision making, risk communications with patients and early interventions.

A/C study protocol: a cross-sectional study of HIV epidemiology among African, Caribbean and Black people in Ontario

Por: Mbuagbaw · L. · Tharao · W. · Husbands · W. · Nelson · L. E. · Aden · M. · Arnold · K. · Baidoobonso · S. · Dabone · C. · Dryden · O. · Etowa · E. · Hamid · J. · Jackson-Best · F. · Kohoun · B. · Lawson · D. O. · Lofters · A. K. · Luyombya · H. · Mbulaheni · T. · Mkandawire · P. · Ndungu
Introduction

African, Caribbean and Black (ACB) communities are disproportionately infected by HIV in Ontario, Canada. They constitute only 5% of the population of Ontario yet account for 25% of new diagnoses of HIV. The aim of this study is to understand underlying factors that augment the HIV risk in ACB communities and to inform policy and practice in Ontario.

Methods and analysis

We will conduct a cross-sectional study of first-generation and second-generation ACB adults aged 15–64 in Toronto (n=1000) and Ottawa (n=500) and collect data on sociodemographic information, sexual behaviours, substance use, blood donation, access and use of health services and HIV-related care. We will use dried blood spot testing to determine the incidence and prevalence of HIV infection among ACB people, and link participant data to administrative databases to investigate health service access and use. Factors associated with key outcomes (HIV infection, testing behaviours, knowledge about HIV transmission and acquisition, HIV vulnerability, access and use of health services) will be evaluated using generalised linear mixed models, adjusted for relevant covariates.

Ethics and dissemination

This study has been reviewed and approved by the following Research Ethics Boards: Toronto Public Health, Ottawa Public Health, Laurentian University; the University of Ottawa and the University of Toronto. Our findings will be disseminated as community reports, fact sheets, digital stories, oral and poster presentations, peer-reviewed manuscripts and social media.

Prospective study to explore changes in quality of care and perinatal outcomes after implementation of perinatal death audit in Uganda

Por: Kirabira · V. N. · Aminu · M. · Dewez · J. E. · Byaruhanga · R. · Okong · P. · van den Broek · N.
Objective

To assess the effects of perinatal death (PND) audit on perinatal outcomes in a tertiary hospital in Kampala.

Design

Interrupted time series (ITS) analysis.

Setting

Nsambya Hospital, Uganda.

Participants

Live births and stillbirths.

Interventions

PND audit.

Primary and secondary outcome measures

Primary outcomes: perinatal mortality rate, stillbirth rate, early neonatal mortality rate. Secondary outcomes: case fatality rates (CFR) for asphyxia, complications of prematurity and neonatal sepsis.

Results

526 PNDs were audited: 142 (27.0%) fresh stillbirths, 125 (23.8%) macerated stillbirths and 259 (49.2%) early neonatal deaths. The ITS analysis showed a decrease in perinatal death (PND) rates without the introduction of PND audits (incidence risk ratio (IRR) (95% CI) for time=0.94, p

Conclusion

The introduction of PND audit showed no statistically significant effect on perinatal mortality or stillbirth rate, but a significant decrease in early neonatal mortality rate. No effect was detected on CFRs for prematurity, intrapartum-related hypoxia or infections. These findings should encourage more research to assess the effectiveness of PND reviews on perinatal deaths in general, but also on stillbirths and neonatal deaths in particular, in low-resource settings.

Provision of medical assistance in dying: a scoping review

Por: Zworth · M. · Saleh · C. · Ball · I. · Kalles · G. · Chkaroubo · A. · Kekewich · M. · Miller · P. Q. · Dees · M. · Frolic · A. · Oczkowski · S.
Objectives

The purpose of this study is to map the characteristics of the existing medical literature describing the medications, settings, participants and outcomes of medical assistance in dying (MAID) in order to identify knowledge gaps and areas for future research.

Design

Scoping review.

Search strategy

We searched electronic databases (MEDLINE, EMBASE, PsychINFO, CINAHL and CENTRAL), clinical trial registries, conference abstracts and professional guidelines from jurisdictions where MAID is legal, up to February 2020. Eligible report types included technical summaries, institutional policies, practice surveys, practice guidelines and clinical studies that describe MAID provision in adults who have provided informed consent for MAID.

Results

163 articles published between 1989 and 2020 met eligibility criteria. 75 studies described details for MAID administered by intravenous medications and 50 studies provided data on oral medications. In intravenous protocols, MAID was most commonly administered using a barbiturate (34/163) or propofol (22/163) followed by a neuromuscular blocker. Oral protocols most often used barbiturates alone (37/163) or in conjunction with an opioid medication (7/163) and often recommended using a prokinetic agent prior to lethal drug ingestion. Complications included prolonged duration of the dying process, difficulty in obtaining intravenous access and difficulty in swallowing oral agents. Most commonly, the role of physicians was prescribing (83/163) and administering medications (75/163). Nurses’ roles included administering medications (17/163) and supporting the patient (16/163) or family (13/163). The role of families involved providing support to the patient (17/163) and bringing medications from the pharmacy for self-administration (4/163).

Conclusions

We identified several trends in MAID provision including common medications and doses for oral and parenteral administration, roles of healthcare professionals and families, and complications that may cause patient, family and provider distress. Future research should aim to identify the medications, dosages, and administration techniques and procedures that produce the most predictable outcomes and mitigate distress for those involved.

Cohort profile: protocol and baseline survey for the Shanghai Suburban Adult Cohort and Biobank (SSACB) study

Por: Zhao · Q. · Chen · B. · Wang · R. · Zhu · M. · Shao · Y. · Wang · N. · Liu · X. · Zhang · T. · Jiang · F. · Wang · W. · Jiang · Y. · Zhao · G. · He · N. · Chen · W. · on behalf of the Shanghai suburban adult cohort and biobank study group
Purpose

The Shanghai Suburban Adult Cohort and Biobank (SSACB) was established to identify environmental, lifestyle and genetic risk factors for non-communicable chronic diseases (NCDs) in adults (20–74 years old) living in a suburban area of Shanghai with rapid urbanisation.

Participants

Two of eight suburban district were purposely selected according to participant willingness, health service facilities, population, geographic region and electronic medical record system. From these suburban districts, four communities were selected based on economic level and population size. At stage three, one-third of the committees/villages were randomly selected from each community. All residents aged 20–74 years old were invited as study participants.

Findings to date

The baseline data on demographics, lifestyle and physical health-related factors were collected using a face-to-face questionnaire interview. All participants completed physical examinations and had blood and urine tests. Blood and urine samples from these tests were stored in a biobank. From 6 April 2016 through 31 October 2017, we conducted face-to-face interviews and clinical examinations in 44 887 participants: 35 727 from Songjiang District and 9160 from Jiading District. The average age of participants was 56.4±11.2 years in Songjiang and 56.6±10.5 years in Jiading. The prevalence of hypertension, diabetes and dyslipidaemia was 34.0%, 8.2% and 11.1%, respectively.

Future plans

In-person surveys will be conducted every 5 years. For annual tracking, baseline data was linked to the local health information system, which was composed of an electronic medical record system, a chronic disease management system, a cancer registry system, an infectious disease report system and a death registry system. The data of the SSACB cohort is located in the School of Public Health, Fudan University. International and domestic collaborative research projects are encouraged and inherent in the project.

Cardiac arrest as a reportable condition: a cohort study of the first 6 years of the Norwegian out-of-hospital cardiac arrest registry

Por: Tjelmeland · I. B. M. · Alm-Kruse · K. · Andersson · L.-J. · Bratland · S. · Hafstad · A.-K. · Haug · B. · Langorgen · J. · Larsen · A. I. · Lindner · T. W. · Nilsen · J. E. · Olasveengen · T. M. · Soreide · E. · Skogvoll · E. · Kramer-Johansen · J.
Objectives

The Norwegian Cardiac Arrest Registry (NorCAR) was established in 2013 when cardiac arrest became a mandatory reportable condition. The aim of this cohort study is to describe how the world’s first mandatory, population-based cardiac arrest registry evolved during its first 6 years.

Setting

Norway has a total population of 5.3 million inhabitants with a population density that varies considerably. All residents are assigned a unique identifier number, giving nationally approved registries access to information about all births and deaths in the country. Data in the registry are entered by data processors; public employees with close links to the emergency medical services. All data processors undergo a standardised training and meet for yearly retraining and updates.

Participants

All events of cardiac arrest where bystanders or healthcare professionals have started cardiopulmonary resuscitation or performed defibrillation are included into the NorCAR.

Primary and secondary outcome measures

Since the establishment of the registry, the number of reporting health trusts, the number of reported events and the corresponding population at risk were followed year by year. Outcome is measured as changes in inclusion rate, incidence per 100 000 inhabitants and survival to 30 days after cardiac arrest.

Results

In total, 14 849 cases were registered over 6 years, between 2013 and 2018. The number of health trusts reporting rose steadily from 2013. Within 3 years, all trusts reported to the registry with an increasing number of events reported; going from 1101 to 3400 per year. The prevalence of bystander cardiopulmonary resuscitation increased slightly, but the population incidence of survival did not change.

Conclusion

Declaring cardiac arrest as a reportable condition and close follow-up of all reporting areas is essential when building a national registry.

Modelling patient flows and resource use within a sexual health clinic through discrete event simulation to inform service redesign

Por: Mohiuddin · S. · Gardiner · R. · Crofts · M. · Muir · P. · Steer · J. · Turner · J. · Wheeler · H. · Hollingworth · W. · Horner · P. J.
Objectives

Continuous improvement in the delivery of health services is increasingly being demanded in the UK at a time when budgets are being cut. Simulation is one approach used for understanding and assessing the likely impact of changes to the delivery of health services. However, little is known about the usefulness of simulation for analysing the delivery of sexual health services (SHSs). We propose a simulation method to model and evaluate patient flows and resource use within an SHS to inform service redesign.

Methods

We developed a discrete event simulation (DES) model to identify the bottlenecks within the Unity SHS (Bristol, UK) and find possible routes for service improvement. Using the example of the introduction of an online service for sexually transmitted infection (STI) and HIV self-sampling for asymptomatic patients, the impact on patient waiting times was examined as the main outcome measure. The model included data such as patient arrival time, staff availability and duration of consultation, examination and treatment. We performed several sensitivity analyses to assess uncertainty in the model parameters.

Results

We identified some bottlenecks under the current system, particularly in the consultation and treatment queues for male and female walk-in patients. Introducing the provision of STI and HIV self-sampling alongside existing services decreased the average waiting time (88 vs 128 min) for all patients and reduced the cost of staff time for managing each patient (£72.64 vs £88.74) compared with the current system without online-based self-sampling.

Conclusions

The provision of online-based STI and HIV self-sampling for asymptomatic patients could be beneficial in reducing patient waiting times and the model highlights the complexities of using this to cut costs. Attributing recognition for any improvement requires care, but DES modelling can provide valuable insights into the design of SHSs ensuing in quantifiable improvements. Extension of this method with the collection of additional data and the construction of more informed models seems worthwhile.

Interventions with Music in PECTus excavatum treatment (IMPECT trial): a study protocol for a randomised controlled trial investigating the clinical effects of perioperative music interventions

Por: Billar · R. J. · Kühlmann · A. Y. R. · Schnater · J. M. · Vlot · J. · Tomas · J. J. P. · Zijp · G. W. · Rad · M. · de Beer · S. A. · Stevens · M. F. · Poley · M. J. · van Rosmalen · J. · Jeekel · J. F. · Wijnen · R. M. H.
Introduction

Pectus excavatum repair is associated with substantial postoperative pain, despite the use of epidural analgesia and other analgesic regimens. Perioperative recorded music interventions have been shown to alleviate pain and anxiety in adults, but evidence for children and adolescents is still lacking. This study protocol describes a randomised controlled trial that evaluates the effects of recorded music interventions on postoperative pain relief in children and adolescents after pectus excavatum repair.

Methods

A multicentre randomised controlled trial was set up comparing the effects of perioperative recorded music interventions in addition to standard care with those of standard care only in patients undergoing a Nuss procedure for pectus excavatum repair. One hundred and seventy subjects (12–18 years of age) will be included in three centres in the Netherlands. Patient inclusion has started in November 2018, and is ongoing. The primary outcome is self-reported perceived pain measured on the visual analogue scale. Secondary outcomes are anxiety level, analgesics consumption, vital parameters such as heart rate, blood pressure and respiratory rate, length of hospital stay, postoperative complications, quality of life and cost-effectiveness.

Ethics and dissemination

This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Centre Rotterdam, The Netherlands, has approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations.

Trial registration number

NL6863

'Only twice a year: a qualitative exploration of 6-month antiretroviral treatment refills in adherence clubs for people living with HIV in Khayelitsha, South Africa

Por: Keene · C. M. · Zokufa · N. · Venables · E. C. · Wilkinson · L. · Hoffman · R. · Cassidy · T. · Snyman · L. · Grimsrud · A. · Voget · J. · von der Heyden · E. · Zide-Ndzungu · S. · Bhardwaj · V. · Isaakidis · P.
Objective

Longer intervals between routine clinic visits and medication refills are part of patient-centred, differentiated service delivery (DSD). They have been shown to improve patient outcomes as well as optimise health services—vital as ‘universal test-and-treat’ targets increase numbers of HIV patients on antiretroviral treatment (ART). This qualitative study explored patient, healthcare worker and key informant experiences and perceptions of extending ART refills to 6 months in adherence clubs in Khayelitsha, South Africa.

Design and setting

In-depth interviews were conducted in isiXhosa with purposively selected patients and in English with healthcare workers and key informants. All transcripts were audio-recorded, transcribed and translated to English, manually coded and thematically analysed. The participants had been involved in a randomised controlled trial evaluating multi-month ART dispensing in adherence clubs, comparing 6-month and 2-month refills.

Participants

Twenty-three patients, seven healthcare workers and six key informants.

Results

Patients found that 6-month refills increased convenience and reduced unintended disclosure. Contrary to key informant concerns about patients’ responsibility to manage larger quantities of ART, patients receiving 6-month refills were highly motivated and did not face challenges transporting, storing or adhering to treatment. All participant groups suggested that strict eligibility criteria were necessary for patients to realise the benefits of extended dispensing intervals. Six-month refills were felt to increase health system efficiency, but there were concerns about whether the existing drug supply system could adapt to 6-month refills on a larger scale.

Conclusions

Patients, healthcare workers and key informants found 6-month refills within adherence clubs acceptable and beneficial, but concerns were raised about the reliability of the supply chain to manage extended multi-month dispensing. Stepwise, slow expansion could avoid overstressing supply and allow time for the health system to adapt, permitting 6-month ART refills to enhance current DSD options to be more efficient and patient-centred within current health system constraints.

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