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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, The Lancet, Vol: 392, Pages: 2692-2692, ISSN: 0140-6736
Bell D, Deighan M, Gillen P, et al., 2018, Quality governance – a call to arms, Journal of the Royal College of Physicians of Edinburgh, Vol: 48, Pages: 195-197, ISSN: 1478-2715
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 and Social Care Delivery Research, Vol: 6, Pages: 1-84, ISSN: 2755-0060
Background: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplannedhospital activity, but our understanding of what drives this is incomplete.Objectives: To model patient, primary care and hospital factors associated with readmission and mortalityfor patients with HF and COPD, to assess the statistical performance of post-discharge emergencydepartment (ED) attendance compared with readmission metrics and to compare all the results for thetwo conditions.Design: Observational study.Setting: English NHS.Participants: All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.Interventions: None.Main outcome measures: One-year mortality and 30-day emergency readmission following the patient’sfirst unplanned admission (‘index admission’) for HF or COPD.Data sources: Patient-level data from Hospital Episodes Statistics were combined with publicly availablepractice- and hospital-level data on performance, patient and staff experience and rehabilitationprogramme website information.Results: One-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factorspredicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long)index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS andcomorbidities also predicted readmission. Of the practice and hospital factors we considered, only moredoctors per 10 beds [odds ratio (OR) 0.95 per doctor; p < 0.001] was significant for both cohorts for mortality,with staff recommending to friends and family (OR 0.80 per unit increase; p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP; p = 0.004) important for COPD. For readmission,only hospital size [OR per 100 beds = 2.16, 95% confidence interval (
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?, ISQua 34th International Conference, Publisher: Oxford University 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
Bell D, Paterson A, McAlister G, 2017, Prevention through Learning: working together to drive high-quality care., J R Coll Physicians Edinb, Vol: 47, Pages: 120-123
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
Walesby KE, Lyall MJ, Mackay TW, et al., 2016, Valuing our trainees: the future of medicine in the UK, JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, Vol: 46, Pages: 146-149, ISSN: 1478-2715
Delogu V, Nolan CM, Canavan JL, et al., 2016, The effect of co-existent chronic heart failure (CHF) on lower limb muscle function in COPD: Propensity matched analysis, Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Fletcher E, Nolan CM, Canavan JL, et al., 2016, COPD and co-existent chronic heart failure (CHF): Response to pulmonary rehabilitation (PR), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Leach R, Moore K, Bell D, 2016, Oxford Desk Reference: Acute Medicine, Publisher: Oxford University Press, ISBN: 9780191007156
Edited by three experts in acute medicine, this book should never be far from the acute medicine clinician's side.
COKER RJ, DESMOND N, POZNANSKY M, et al., 2016, EXPERIENCE OF HIV-DISEASE IN A LONDON DISTRICT-GENERAL-HOSPITAL, INTERNATIONAL JOURNAL OF STD & AIDS, Vol: 6, Pages: 47-49, ISSN: 0956-4624
Marvin V, Kuo S, Poots A, et al., 2016, Applying Quality Improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital, BMJ Open, Vol: 6, ISSN: 2044-6055
Objectives: Reliable reconciliation of medicines at admission and dischargefrom hospital is key to reducing unintentional prescribing discrepancies attransitions of health care. We introduced a team approach to the reconciliationprocess at an acute hospital with the aim of improving the provision ofinformation and documentation of reliable medication lists to enable clear,timely communications on discharge.Setting: An acute 400 bedded teaching hospital in London UK.Participants: The effects of change were measured in a simple randomsample of ten adult patients a week on the Acute Admissions Unit over 18months.Interventions: Quality Improvement methods were used throughout.Interventions included education and training of staff involved at ward leveland in the pharmacy department, introduction of medication documentationtemplates for electronic prescribing and for communicating information onmedicines in discharge summaries co-designed with patient representatives.Results: Statistical Process Control analysis showed reliable documentation(complete, verified and intentional changes clarified) of current medication on49.2% of patients’ discharge summaries. This appears to have improved (to85.2%) according to a post-study audit the year after the project end.Pharmacist involvement in discharge reconciliation significantly increased,and improvements in the numbers of medicines prescribed in error or omittedfrom the discharge prescription are demonstrated. Variation in weeklymeasures is seen throughout but particularly at periods of changeover of newdoctors and introduction of new systems.Conclusion: New processes led to a sustained increase in reconciledmedications and thereby an improvement in the number of patientsdischarged from hospital with unintentional discrepancies (errors oromissions) on their discharge prescription.The initiatives were pharmacist-led but involved close working and sharedunderstanding about roles and responsibilities between doctors, nurses
Bottle RA, Goudie R, Bell D, et al., 2016, Use of hospital services by age and comorbidity after an index heart failure admission in England: an observational study, BMJ Open, Vol: 6, ISSN: 2044-6055
Objectives: To describe hospital inpatient, emergency department (ED) and outpatient department (OPD) activity for patients in the year following their first emergency admission for heart failure (HF). To assess the proportion receiving specialist assessment within two weeks of hospital discharge, as now recommended by guidelines.Design: Observational study of national administrative data.Setting: all acute NHS hospitals in England.Participants: 82,241 patients with an index emergency admission between April 2009 and March 2011 with a primary diagnosis of HF.Main outcome measures: cardiology OPD appointment within two weeks and within a year of discharge from the index admission; emergency department (ED) and inpatient use within a yearResults: 15.1% died during the admission. Of the 69,848 survivors, 19.7% were readmitted within 30 days and half within a year, the majority for non-HF diagnoses. 6.7% returned to the ED within a week of discharge, of whom the majority (77.6%) were admitted. The two most common OPD specialties during the year were cardiology (24.7% of the total appointments) and anticoagulant services (12.5%). Although half of all patients had a cardiology appointment within a year, the proportion within the recommended two weeks of discharge was just 6.8% overall and varied by age, from 2.4% in those aged 90+ to 19.6% in those aged 18-45 (p<0.0001); appointments in other specialties made up only some of the shortfall. More comorbidity at any age was associated with higher rates of cardiology OPD follow-up. Conclusion: patients with HF are high users of hospital services. Post-discharge cardiology OPD follow-up rates fell well below current NICE guidelines, particularly for the elderly and those with less comorbidity.
Dunn S, Jones M, Woodcock T, et al., 2016, Consistent services throughout the week for acute medical care., Journal of the Royal College of Physicians of Edinburgh, Vol: 46, Pages: 77-80, ISSN: 1478-2715
Man WD, Chowdhury F, Taylor RS, et al., 2016, Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure, Chronic Respiratory Disease, Vol: 13, Pages: 229-239, ISSN: 1479-9731
The study aimed to gain consensus on key priorities for developing breathlessness rehabilitation services for patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). Seventy-four invited stakeholders attended a 1-day conference to review the evidence base for exercise-based rehabilitation in COPD and CHF. In addition, 47 recorded their views on a series of statements regarding breathlessness rehabilitation tailored to the needs of both patient groups. A total of 75% of stakeholders supported symptom-based rather than disease-based rehabilitation for breathlessness with 89% believing that such services would be attractive for healthcare commissioners. A total of 87% thought patients with CHF could be exercised using COPD training principles and vice versa. A total of 81% felt community-based exercise training was safe for patients with severe CHF or COPD, but only 23% viewed manual-delivered rehabilitation an effective alternative to supervised exercise training. Although there was strong consensus that exercise training was a core component of rehabilitation in CHF and COPD populations, only 36% thought that this was the ‘most important’ component, highlighting the need for psychological and other non-exercise interventions for breathlessness. Patients with COPD and CHF face similar problems of breathlessness and disability on a background of multi-morbidity. Existing pulmonary and cardiac rehabilitation services should seek synergies to provide sufficient flexibility to accommodate all patients with COPD and CHF. Development of new services could consider adopting a patient-focused rather than disease-based approach. Exercise training is a core component, but rehabilitation should include other interventions to address dyspnoea, psychological and education needs of patients and needs of carers.
Kaebnick GE, 2016, Open Questions., Hastings Cent Rep, Vol: 46, ISSN: 0093-0334
Mouncey PR, Osborn TM, Power GS, et al., 2015, Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock, Health Technology Assessment, Vol: 19, ISSN: 1366-5278
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