234 results found
Marinova M, Bell LM, Watkin S, et al., 2020, A prospective audit of bed utilisation and delays in care across London, JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, Vol: 50, Pages: 365-371, ISSN: 1478-2715
Barker RE, Jones SE, Banya W, et al., 2020, Reply to: one step at a time: a phased approach to behavioral treatment development in pulmonary rehabilitation, American Journal of Respiratory and Critical Care Medicine, Vol: 202, Pages: 775-777, ISSN: 1073-449X
Barker RE, Jones SE, Banya W, et al., 2020, The effects of a video intervention on post-hospitalization pulmonary rehabilitation uptake: a randomized controlled trial., American Journal of Respiratory and Critical Care Medicine, Vol: 201, Pages: 1517-1524, ISSN: 1073-449X
RATIONALE: Pulmonary rehabilitation following hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life, and reduces readmissions. However, post-hospitalization pulmonary rehabilitation uptake is low. To date, no trials of interventions to increase uptake have been conducted. OBJECTIVE: Effect of a co-designed education video as an adjunct to usual care on post-hospitalization pulmonary rehabilitation uptake. METHODS: An assessor- and statistician-blinded randomized controlled trial with nested qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including pulmonary rehabilitation information leaflet) or usual care plus the co-designed education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, forced expiratory volume in 1 second (FEV1) % predicted, frailty, transport availability and previous pulmonary rehabilitation experience. MEASUREMENTS AND MAIN RESULTS: The primary outcome was pulmonary rehabilitation uptake within 28 days of hospital discharge. 200 patients were recruited with 196 randomized (51% female, median (interquartile range) FEV1 % predicted 36(27, 48)). Pulmonary rehabilitation uptake was 41% and 34% in the usual care and intervention groups respectively (p=0.37), with no differences in secondary (pulmonary rehabilitation referral and completion) or safety (readmissions and death) endpoints. Six of the fifteen participants interviewed could not recall receiving the video. CONCLUSION: A co-designed education video delivered at hospital discharge did not improve post-hospitalization pulmonary rehabilitation uptake, referral or completion. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0
Sakonidou S, Andrzejewska I, Webbe J, et al., 2020, Interventions to improve quantitative measures of parent satisfaction in neonatal care: a systematic review, BMJ Paediatrics Open, Vol: 4, ISSN: 2399-9772
Objective: Interventions improving parent satisfaction can reduce parent stress, may improve parent-infant bonding and infant outcomes. Our objective was to systematically review neonatal interventions relating to parents of infants of all gestations where an outcome was parent satisfaction. Methods: We searched the databases MEDLINE, EMBASE, PsychINFO, Cochrane Central Register of Controlled Trials, CINAHL, HMIC, Maternity and Infant Care between 1 January 1946 and 1 October 2017. Inclusion criteria were randomised controlled trials (RCT), cohort studies and other non-randomised studies if participants were parents of infants receiving neonatal care, interventions were implemented in neonatal units (of any care level) and ≥1 quantitative outcome of parent satisfaction was measured. Included studies were limited to the English language only. We extracted study characteristics, interventions, outcomes and parent involvement in intervention design. Included studies were not sufficiently homogenous to enable quantitative synthesis. We assessed quality with the Cochrane Collaboration risk of bias tool (randomised) and the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) (non-randomised studies). Results: We identified 32 studies with satisfaction measures from over 2800 parents and grouped interventions into 5 themes. Most studies were non-randomised involving preterm infants. Parent satisfaction was measured by 334 different questions in 29 questionnaires (only 6/29 fully validated). 18/32 studies reported higher parent satisfaction in the intervention group. The intervention theme with most studies reporting higher satisfaction was parent involvement (10/14). Five (5/32) studies reported involving parents in intervention design. All studies had high risk of bias. Conclusions: Many interventions, commonly relating to parent involvement, are reported to improve parent satisfaction. Inconsistency in satisfaction measurements and high risk of b
Soong JT, Rolph G, Poots AJ, et al., 2020, Validating a methodology to measure frailty syndromes at hospital level utilising administrative data., Clinical medicine (London, England), Vol: 20, Pages: 183-188, ISSN: 1470-2118
BACKGROUND: Identifying older people with clinical frailty, reliably and at scale, is a research priority. We measured frailty in older people using a novel methodology coding frailty syndromes on routinely collected administrative data, developed on a national English secondary care population, and explored its performance of predicting inpatient mortality and long length of stay at a single acute hospital. METHODOLOGY: We included patient spells from Secondary User Service (SUS) data for those ≥65 years with attendance to the emergency department or admission to West Middlesex University Hospital between 01 July 2016 to 01 July 2017. We created eight groups of frailty syndromes using diagnostic coding groups. We used descriptive statistics and logistic regression to explore performance of diagnostic coding groups for the above outcomes. RESULTS: We included 17,199 patient episodes in the analysis. There was at least one frailty syndrome present in 7,004 (40.7%) patient episodes. The resultant model had moderate discrimination for inpatient mortality (area under the receiver operating characteristic curve (AUC) 0.74; 95% confidence interval (CI) 0.72-0.76) and upper quartile length of stay (AUC 0.731; 95% CI 0.722-0.741). There was good negative predictive value for inpatient mortality (98.1%). CONCLUSIONS: Coded frailty syndromes significantly predict outcomes. Model diagnostics suggest the model could be used for screening of elderly patients to optimise their care.
Adeleke Y, Matthew D, Porter B, et al., 2019, Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices, Open Heart, Vol: 6, ISSN: 2053-3624
Objective Atrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative.Methods Using the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018.Results When comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change.Conclusion Implementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.
Kremers MNT, Nanayakkara PWB, Levi M, et al., 2019, Strengths and weaknesses of the acute care systems in the United Kingdom and the Netherlands: what can we learn from each other?, BMC EMERGENCY MEDICINE, Vol: 19, ISSN: 1471-227X
Sakonidou S, Andrzejewska I, Kotzamanis S, et al., 2019, Better use of data to improve parent satisfaction (BUDS): protocol for a prospective before-and-after pilot study employing mixed methods to improve parent experience of neonatal care, BMJ Paediatrics Open, Vol: 3, ISSN: 2399-9772
Introduction Having a baby that requires neonatal care is stressful and traumatic. Parents often report dissatisfaction with communication of clinical information. In the UK neonatal care data are recorded daily using electronic patient record systems (EPR), from which deidentified data form the National Neonatal Research Database (NNRD). We aim to evaluate the impact of sharing neonatal EPR data with parents, on parent-reported satisfaction, parent–staff interactions, staff workload and data completeness.Methods A prospective, before-and-after, mixed-method study. Participants are parents of inpatient babies (maximum 90) and staff in a tertiary neonatal intensive care unit, London, UK. The intervention was developed by former neonatal parents, neonatologists and neonatal nurses: a communication tool for parents comprising individualised, written, daily infant updates for parents, derived from EPR data. The intervention will be provided to parents over 6 weeks. Plan-Do-Study-Act cycles will inform the tool’s iterative development and improvement. The tool’s impact will be measured using a validated parent survey, staff survey, data completeness measures and interviews.Analysis Primary outcome: parent satisfaction ‘with communication of clinical information and involvement in care’. Secondary outcomes: parent–staff interactions, staff workload, data completeness. Baseline survey data will be obtained from clinical service evaluation preceding the intervention. Baseline data completeness will be derived from the NNRD. During the intervention, surveys will be administered biweekly and data completeness assessed daily. We will analyse outcomes using run charts and partially paired statistical tests. Parent and staff interviews will explore information exchange and the communication tool’s impact.Discussion This study will evaluate the impact of a parent co-designed intervention on communication with parents in neonatal care and
Soong JTY, Kaubryte J, Liew D, et al., 2019, Dr Foster global frailty score: an international retrospective observational study developing and validating a risk prediction model for hospitalised older persons from administrative data sets, BMJ Open, Vol: 9, ISSN: 2044-6055
OBJECTIVES: This study aimed to examine the prevalence of frailty coding within the Dr Foster Global Comparators (GC) international database. We then aimed to develop and validate a risk prediction model, based on frailty syndromes, for key outcomes using the GC data set. DESIGN: A retrospective cohort analysis of data from patients over 75 years of age from the GC international administrative data. A risk prediction model was developed from the initial analysis based on seven frailty syndrome groups and their relationship to outcome metrics. A weighting was then created for each syndrome group and summated to create the Dr Foster Global Frailty Score. Performance of the score for predictive capacity was compared with an established prognostic comorbidity model (Elixhauser) and tested on another administrative database Hospital Episode Statistics (2011-2015), for external validation. SETTING: 34 hospitals from nine countries across Europe, Australia, the UK and USA. RESULTS: Of 6.7 million patient records in the GC database, 1.4 million (20%) were from patients aged 75 years or more. There was marked variation in coding of frailty syndromes between countries and hospitals. Frailty syndromes were coded in 2% to 24% of patient spells. Falls and fractures was the most common syndrome coded (24%). The Dr Foster Global Frailty Score was significantly associated with in-hospital mortality, 30-day non-elective readmission and long length of hospital stay. The score had significant predictive capacity beyond that of other known predictors of poor outcome in older persons, such as comorbidity and chronological age. The score's predictive capacity was higher in the elective group compared with non-elective, and may reflect improved performance in lower acuity states. CONCLUSIONS: Frailty syndromes can be coded in international secondary care administrative data sets. The Dr Foster Global Frailty Score significantly predicts key outcomes. This methodology may be feasibly utili
Honeyford K, Bell D, Chowdhury F, et al., 2019, Unscheduled hospital contacts after inpatient discharge: A national observational study of COPD and heart failure patients in England, PLoS ONE, Vol: 14, ISSN: 1932-6203
IntroductionReadmissions are a recognised challenge for providers of healthcare and incur financial penalties in a growing number of countries. However, the scale of unscheduled hospital contacts including attendances at emergency departments that do not result in admission is not well known. In addition, little is known about the route to readmission for patients recently discharged from an emergency hospital stay.MethodsThis is an observational study of national hospital administration data for England. In this retrospective cohort study, we tracked patients for 30 days after discharge from an emergency admission for heart failure (HF) or chronic obstructive pulmonary disorder (COPD).ResultsThe majority of patients (COPD:79%; HF:75%) had no unscheduled contact with secondary health care within 30 days of discharge. Of those who did have unscheduled contact, the most common first unscheduled contact was emergency department (ED) attendance (COPD:16%; HF:18%). A further 5% of COPD patients and 4% of HF patients were admitted for an emergency inpatient stay, but not through the ED. A small percentage of patients (COPD:<1%, HF:2%) died without any known contact with secondary care. ED conversion rates at first attendance for both COPD and HF were high: 75% and 79% respectively. A quarter of patients who were not admitted during this first ED attendance attended the ED again within the 30-day follow-up period, and around half (COPD:56%; HF:63%) of these were admitted at this point.Patients who live alone, had an index admission which included an overnight stay and were comorbid had higher odds of being admitted through the ED than via other routes.ConclusionWhile the majority of patients did not have unscheduled contact with secondary care in the 30 days after index discharge, many patients attended the ED, often multiple times, and many were admitted to hospital, not always via the ED. More frail patients were more likely to be admitted through the ED, suggesting a
McNicholas C, Lennox L, Woodcock T, et al., 2019, Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed methods study, BMJ Quality and Safety, Vol: 28, Pages: 356-365, ISSN: 2044-5415
BackgroundThough widely recommended as an effective approach to quality improvement (QI), the Plan-Do-Study-Act (PDSA) cycle method can be challenging to use and low fidelity of published accounts of the method has been reported. There is little evidence of the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use. Data collected from 39 frontline improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this overtime.MethodsThe fidelity of 421 PDSA cycles was reviewed using a pre-defined framework, and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews.ResultsAlthough modest, statistically significant improvements in PDSA fidelity occurred, however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use, and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.ConclusionsThis study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.
Reed JE, Howe C, Doyle C, et al., 2019, Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence): simple rules to guide practice and research., Int J Qual Health Care, Vol: 31, Pages: 238-244
BACKGROUND: Evidence translation and improvement research indicate that healthcare contexts are complex systems, characterized by uncertainty and surprise, which often defy orchestrated intervention attempts. This article reflects on the implications of complexity on attempts to translate evidence, and on a newly published framework for Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence). DISCUSSION: SHIFT-Evidence positions the challenge of evidence translation within the complex and evolving context of healthcare, and recognizes the wider issues practitioners routinely face. It is empirically grounded, and designed to be comprehensive, practically relevant and actionable. SHIFT-evidence is summarized by three principles designed to be intuitive and memorable: 'act scientifically and pragmatically'; 'embrace complexity'; and 'engage and empower'. Common challenges and strategies to overcome them are summarized in 12 'simple rules' that provide actionable guidance. CONCLUSION: SHIFT-Evidence provides a practical tool to guide practice and research of evidence translation and improvement within complex dynamic healthcare settings. Implications are that improvement initiatives and research study designs need to take into account the unique initial conditions in each local setting; conduct needs to respond to unpredictable effects and address dependent problems; and evaluation needs to be sensitive to evolving priorities and the emergent range of activities required to achieve improvement.
Sunkersing D, Martin F, Reed J, et al., 2019, What do care home managers believe constitutes an ‘assessment for frailty’ of care home residents in North-West London? A survey, BMC Geriatrics, Vol: 19, ISSN: 1471-2318
BackgroundFrail individuals are at risk of significant clinical deterioration if their frailty is not identified and managed appropriately. Research suggests that any interaction between an older person and a health or social care professional should include an assessment for frailty. Many older care home residents are frail when admitted, but we have little knowledge of whether or how this is assessed. The aim of this paper is to understand and establish the characteristics of the reported ‘assessments for frailty’ used in care homes with nursing (nursing homes) across North-West London. This will help understand what an ‘assessment for frailty’ of care home residents mean in practice in North-West London.MethodsTelephone contact was made with every Care Quality Commission (CQC) (independent regulator of health and adult social care in England) regulated nursing home across North-West London [n = 87]. An online survey was sent to all that expressed interest [n = 73]. The survey was developed through conversations with healthcare professionals, based on literature and tested with academics and clinicians. Survey responses were analysed using descriptive statistics. The Mann-Whitney U test was used for statistical analyses.Results24/73 nursing homes completed the survey (33%). Differences in the characteristics of reported ‘assessments for frailty’ across nursing homes were evident. Variation in high level domains assessed (physical, social, mental and environmental) was observed. Nurses were the most common professional group completing assessments for frailty, with documentation and storage being predominantly paper based. A statistically significant difference between the number of assessments used in corporate chain owned nursing homes (3.9) versus independently owned nursing homes (2.1) was observed (U = 21, p = .005).ConclusionsGreat variation existed in the characterist
Soong J, Bell D, Poots AJ, 2018, The challenges of using the Hospital Frailty Risk Score, LANCET, Vol: 392, Pages: 2692-2692, ISSN: 0140-6736
Bottle A, Honeyford K, Chowdhury F, et al., 2018, Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study, Health Services and Delivery Research, Vol: 6, Pages: 1-60, ISSN: 2050-4349
<jats:sec id="abs1-1"><jats:title>Background</jats:title><jats:p>Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.</jats:p></jats:sec><jats:sec id="abs1-2"><jats:title>Objectives</jats:title><jats:p>To model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.</jats:p></jats:sec><jats:sec id="abs1-3"><jats:title>Design</jats:title><jats:p>Observational study.</jats:p></jats:sec><jats:sec id="abs1-4"><jats:title>Setting</jats:title><jats:p>English NHS.</jats:p></jats:sec><jats:sec id="abs1-5"><jats:title>Participants</jats:title><jats:p>All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.</jats:p></jats:sec><jats:sec id="abs1-6"><jats:title>Interventions</jats:title><jats:p>None.</jats:p></jats:sec><jats:sec id="abs1-7"><jats:title>Main outcome measures</jats:title><jats:p>One-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.</jats:p></jats:sec><jats:sec id="abs1-8"><jats:title>Data sources</jats:title><jats:p>Patient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.</jat
Reed JE, Howe C, Doyle C, et al., 2018, Simple rules for evidence translation in complex systems: a qualitative study, BMC Medicine, Vol: 16, ISSN: 1741-7015
BackgroundEnsuring patients benefit from the latest medical and technical advances remains a major challenge, with rational-linear and reductionist approaches to translating evidence into practice proving inefficient and ineffective. Complexity thinking, which emphasises interconnectedness and unpredictability, offers insights to inform evidence translation theories and strategies. Drawing on detailed insights into complex micro-systems, this research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems.MethodsUsing analytical auto-ethnography, including documentary analysis and literature review, we assimilated learning from 5 years of observation of 22 evidence translation projects (UK). We used a grounded theory approach to develop substantive theory and a conceptual framework. Results were interpreted using complexity theory and ‘simple rules’ were identified reflecting the practical strategies that enhanced project progress.ResultsThe framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) positions the challenge of evidence translation within the dynamic context of the health system. SHIFT-Evidence is summarised by three strategic principles, namely (1) ‘act scientifically and pragmatically’ – knowledge of existing evidence needs to be combined with knowledge of the unique initial conditions of a system, and interventions need to adapt as the complex system responds and learning emerges about unpredictable effects; (2) ‘embrace complexity’ – evidence-based interventions only work if related practices and processes of care within the complex system are functional, and evidence-translation efforts need to identify and address any problems with usual care, recognising that this typically includes a range of interdependent parts of the system; and (3) ‘engage and empower&r
Soong JTY, Poots AJ, Rolph G, et al., 2017, Frailty Syndromes Coded within Secondary User Service(SUS) Data Predict Inpatient Mortality and Long Length of Stay, Society for Acute Medicine Autumn Conference, Publisher: Rila Publications Ltd, Pages: 131-132, ISSN: 1747-4884
Lennox L, Doyle C, Reed J, et al., 2017, What makes a sustainability tool valuable, practical, and useful in real world healthcare practice? A mixed methods study on the development of the Long Term Success Tool in Northwest London, BMJ Open, Vol: 7, ISSN: 2044-6055
Objectives Although improvement initiatives show benefits to patient care, they often fail to sustain. Models and frameworks exist to address this challenge, but issues with design, clarity and usability have been barriers to use in healthcare settings. This work aimed to collaborate with stakeholders to develop a sustainability tool relevant to people in healthcare settings and practical for use in improvement initiatives.Design Tool development was conducted in six stages. A scoping literature review, group discussions and a stakeholder engagement event explored literature findings and their resonance with stakeholders in healthcare settings. Interviews, small-scale trialling and piloting explored the design and tested the practicality of the tool in improvement initiatives.Setting National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL).Participants CLAHRC NWL improvement initiative teams and staff.Results The iterative design process and engagement of stakeholders informed the articulation of the sustainability factors identified from the literature and guided tool design for practical application. Key iterations of factors and tool design are discussed. From the development process, the Long Term Success Tool (LTST) has been designed. The Tool supports those implementing improvements to reflect on 12 sustainability factors to identify risks to increase chances of achieving sustainability over time. The Tool is designed to provide a platform for improvement teams to share their own views on sustainability as well as learn about the different views held within their team to prompt discussion and actions.Conclusion The development of the LTST has reinforced the importance of working with stakeholders to design strategies which respond to their needs and preferences and can practically be implemented in real-world settings. Further research is required to study the use and effectivenes
Chowdhury FS, Elkin S, Bell D, et al., 2017, HOW MANY HOSPITAL WEBSITES PROVIDE INFORMATION TO ATTRACT PATIENTS TO ATTEND CARDIAC/PULMONARY REHABILITATION ACROSS ENGLAND?, Publisher: OXFORD UNIV PRESS, Pages: 7-8, ISSN: 1353-4505
Poots A, Reed J, Woodcock T, et al., 2017, How to attribute causality in quality improvement: lessons from epidemiology, BMJ Quality & Safety, Vol: 26, Pages: 933-937, ISSN: 2044-5423
Quality improvement and implementation (QI&I) initiatives face critical challenges in an era of evidence-based, value-driven patient care. Whether front-line staff, large organisations or government bodies design and run QI&I, there is increasing need to demonstrate impact to justify investment of time and resources in implementing and scaling up an intervention.Decisions about sustaining, scaling up and spreading an initiative can be informed by evidence of causation and the estimated attributable effect of an intervention on observed outcomes. Achieving this in healthcare can be challenging, where interventions often are multimodal and applied in complex systems.1 Where there is weak evidence of causation, credibility in the effectiveness of the intervention is reduced with a resultant reduced desire to replicate. The greater confidence of a causal relationship between QI&I interventions and observed results, the greater our confidence that improvement will result when the intervention occurs in different settings.Guidance exists for design, conduct, evaluation and reporting of QI&I initiatives;2–4; the Standards for QUality Improvement Reporting Excellence (SQUIRE) and the Standards for Reporting Implementation Studies (STARI) guidelines were developed specifically for reporting QI&I initiatives.5 6 However, much of this guidance is targeted at larger formal evaluations, and may require levels of resource or expertise not available to all QI&I initiatives. This paper proposes QI&I initiatives, regardless of scope and resources, can be enhanced by applying epidemiological principles, adapted from those promulgated by Austin Bradford Hill.7
Honeyford CE, Bell D, Aylin P, et al., 2017, The relation between length of stay, a&e attendance and readmission for heart failure patients, Heart, Vol: 103, Pages: A3-A3, ISSN: 1355-6037
Russell JA, Lee T, Singer J, et al., 2017, The Septic Shock 3.0 Definition and Trials: A Vasopressin and Septic Shock Trial Experience., Crit Care Med, Vol: 45, Pages: 940-948
OBJECTIVES: The Septic Shock 3.0 definition could alter treatment comparisons in randomized controlled trials in septic shock. Our first hypothesis was that the vasopressin versus norepinephrine comparison and 28-day mortality of patients with Septic Shock 3.0 definition (lactate > 2 mmol/L) differ from vasopressin versus norepinephrine and mortality in Vasopressin and Septic Shock Trial. Our second hypothesis was that there are differences in plasma cytokine levels in Vasopressin and Septic Shock Trial for lactate less than or equal to 2 versus greater than 2 mmol/L. DESIGN: Retrospective analysis of randomized controlled trial. SETTING: Multicenter ICUs. METHODS: We compared vasopressin-to-norepinephrine group 28- and 90-day mortality in Vasopressin and Septic Shock Trial in lactate subgroups. We measured 39 cytokines to compare patients with lactate less than or equal to 2 versus greater than 2 mmol/L. PATIENTS: Patients with septic shock with lactate greater than 2 mmol/L or less than or equal to 2 mmol/L, randomized to vasopressin or norepinephrine. INTERVENTIONS: Concealed vasopressin (0.03 U/min.) or norepinephrine infusions. MEASUREMENTS AND MAIN RESULTS: The Septic Shock 3.0 definition would have decreased sample size by about half. The 28- and 90-day mortality rates were 10-12 % higher than the original Vasopressin and Septic Shock Trial mortality. There was a significantly (p = 0.028) lower mortality with vasopressin versus norepinephrine in lactate less than or equal to 2 mmol/L but no difference between treatment groups in lactate greater than 2 mmol/L. Nearly all cytokine levels were significantly higher in patients with lactate greater than 2 versus less than or equal to 2 mmol/L. CONCLUSIONS: The Septic Shock 3.0 definition decreased sample size by half and increased 28-day mortality rates by about 10%. Vasopressin lowered mortality versus norepinephrine if lactate was less than or equal to 2 mmol/L. Patients had higher plasma cytokines in lactate
Green SA, Bell D, Mays N, 2017, Identification of factors that support successful implementation of care bundles in the acute medical setting: a qualitative study, BMC Health Services Research, Vol: 17, ISSN: 1472-6963
BackgroundClinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice. Many guidelines are relevant to the diagnosis and management of the acutely unwell patient during the first 24–48 h of admission. Care bundles are comprised of a small number of evidence-based interventions that when implemented together aim to achieve better outcomes than when implemented individually. Care bundles that are explicitly developed from guidelines to provide a set of related evidence-based actions have been shown to improve the care of many conditions in emergency, acute and critical care settings. This study aimed to review the implementation of two distinct care bundles in the acute medical setting and identify the factors that supported successful implementation.MethodsTwo initiatives that had used a systematic approach to quality improvement to successfully implement care bundles within the acute medical setting were selected as case studies. Contemporaneous data generated during the initiatives included the review reports, review minutes and audio recordings of the review meetings at different time points. Data were subject to deductive analysis using three domains of the Consolidated Framework for Implementation Research to identify factors that were important in the implementation of the care bundles.ResultsSeveral factors were identified that directly influenced the implementation of the care bundles. Firstly, the availability of resources to support initiatives, which included training to develop quality improvement skills within the team and building capacity within the organisation more generally. Secondly, the perceived sustainability of changes by stakeholders influenced the embedding new care processes into existing clinical systems, maximising their chance of being sustained. Thirdly, senior leadership support was seen as critical not just in supporting im
Sullivan PJ, Bell D, 2017, An investigation of the degree of organisational influence on patient experience scores in Acute Medical Admission Units in all acute hospitals in England using multilevel hierarchical regression modelling, BMJ Open, Vol: 7, ISSN: 2044-6055
Objectives: Previous studies found that hospital and specialty have limited influence on patient experience scores, and patient level factors are more important. This could be due to heterogeneity of experience delivery across sub-units within organisations. We aimed to determine whether organisation level factors have greater impact if scores for the same sub-specialty microsystem are analysed in each hospital. Setting: Acute medical admission units in all NHS Acute Trusts in England. Participants: We analysed patient experience data from the English Adult In-Patient Survey which is administered to 850 patients annually in each acute NHS Trusts in England. We selected all 8753 patients who returned the survey and who were emergency medical admissions and stayed in their admission unit for 1-2 nights, so as to isolate the experience delivered during the acute admission process. Primary and secondary outcome measures: We used multilevel logistic regression to determine the apportioned influence of host organisation and of organisation level factors (size and teaching status), and patient level factors, (demographics, presence of long term conditions and disabilities). We selected ‘being treated with respect and dignity’ and ‘pain control’ as primary outcome parameters. Other Picker Domain question scores were analysed as secondary parameters. Results: The proportion of overall variance attributable at organisational level was small; 0.5% (NS) for respect and dignity, 0.4% (NS) for pain control. Longstanding conditions, and consequent disabilities were associated with low scores. Other item scores also showed that most influence was from patient level factors. Conclusion: “Conclusion: When a single microsystem, the acute medical admission process, is isolated, variance in experience scores is mainly explainable by patient level factors with limited organisational level influence. This has implications for use of generic
Szymanski T, Reed J, Ehlers HL, et al., 2016, COST-EFFECTIVENESS ANALYSIS OF COMPREHENSIVE MEDICATION REVIEW (CMR) FOR PATIENTS ACUTELY ADMITTED TO HOSPITAL, 19th European ISPOR konference, Publisher: ELSEVIER SCIENCE INC, Pages: A612-A612, ISSN: 1098-3015
Soong JTY, Poots AJ, BELL D, 2016, Finding consensus on Frailty Assessment in Acute Care through Delphi method, BMJ Open, Vol: 6, ISSN: 2044-6055
Objective: We seek to address gaps in knowledge and agreement around optimal frailty assessment in the acute medical care setting. Frailty is a common term describing older persons who are at increased risk of developing multi-morbidity, disability, institutionalisation, and death. Consensus has not been reached on the practical implementation of this concept to assess clinically and manage older persons in the acute care setting.Design: Modified Delphi, via electronic questionnaire. Questions included ranking items that bestrecognise frailty, optimal timing, location, and contextual elements of a successful tool. Intra-Class Correlation Coefficients for overall levels of agreement; with consensus and stability tested by two-way ANOVA with absolute agreement and Fisher's Exact Test.Participants: A panel of national experts (academics, front-line clinicians, and specialist charities) were invited to electronic correspondence.Results: Variables reflecting accumulated deficit and high resource utilisation were perceived by participants as the most useful indicators of frailty in the acute care setting. The Acute Medical Unitand Care of the older Persons Ward were perceived as optimum settings for frailty assessment. "Clinically meaningful and relevant", "simple (easy to use)" and "Accessible by multidisciplinary team" were perceived as characteristics of a successful frailty assessment tool in the acute caresetting. No agreement was reached on optimal timing, number of variables, and organisational structures.Conclusions: This study is a first step in developing consensus for a clinically relevant frailty assessment model for the acute care setting, providing content validation, and illuminating contextual requirements. Testing on clinical datasets is a research priority.
Evans E, Smith SM, Bell D, 2016, Resilience in Chronic Obstructive Pulmonary Disease and Chronic Heart Failure, Chronic Obstructive Pulmonary Disease: Open Access, Vol: 1
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