Early Supported Discharge/Hospital At Home For Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Review and Meta-Analysis.

A systematic review and meta-analysis was performed to assess the safety, efficacy and cost of Early Supported Discharge (ESD) and Hospital at Home (HAH) compared to Usual Care (UC) for patients with acute exacerbation of COPD (AECOPD). The structure of ESD/HAH schemes was reviewed, and analyses performed assuming return to hospital during the acute period (prior to discharge from home treatment) was, and was not, considered a readmission. The pre-defined search strategy completed in November 2014 included electronic databases (Medline, Embase, Amed, BNI, Cinahl and HMIC), libraries, current trials registers, national organisations, key respiratory journals, key author contact and grey literature. Randomised controlled trials (RCTs) comparing ESD/HAH to UC in patients admitted with AECOPD, or attending the emergency department and triaged for admission, were included. Outcome measures were mortality, all-cause readmissions to 6 months and cost. Eight RCTs were identified; seven reported mortality and readmissions. The structure of ESD/HAH schemes, particularly selection criteria applied and level of support provided, varied considerably. Compared to UC, ESD/HAH showed a trend towards lower mortality (RRMH = 0.66; 95% CI 0.40-1.09, p = 0.10). If return to hospital during the acute period was not considered a readmission, ESD/HAH was associated with fewer readmissions (RRMH = 0.74, 95% CI: 0.60-0.90, p = 0.003), but if considered a readmission, the benefit was lost (RRMH = 0.84; 95% CI 0.69-1.01, p = 0.07). Costs were lower for ESD/HAH than UC. ESD/HAH is safe in selected patients with an AECOPD. Further research is required to define optimal criteria to guide patient selection and models of care.

Deconstructing dementia and delirium hospital practice: using cultural historical activity theory to inform education approaches.

Older patients with dementia and delirium receive suboptimal hospital care. Policy calls for more effective education to address this though there is little consensus on what this entails. The purpose of this clarification study is to explore how practice gaps are constructed in relation to managing the confused hospitalised older patient. The intent is to inform educational processes in the work-place beyond traditional approaches such as training. Adopting grounded theory as a research method and working within a social constructionist paradigm we explored the practice gaps of 15 healthcare professionals by interview and conducted five focus groups with patients, carers and Liaison mental health professionals. Data were thematically analysed by constant comparison and theoretical sampling was undertaken until saturation reached. Categories were identified and pragmatic concepts developed grounded within the data. Findings were then further analysed using cultural historical activity theory as a deductive lens. Practice gaps in relation to managing the confused older patient are determined by factors operating at individual (knowledge and skill gaps, personal philosophy, task based practice), team (leadership, time and ward environmental factors) and organisational (power relationships, dominance of medical model, fragmentation of care services) levels. Conceptually, practice appeared to be influenced by socio-cultural ward factors and compounded by a failure to join up existing "patient" knowledge amongst professionals. Applying cultural historical activity theory to further illuminate the findings, the central object is defined as learning about the patient and the mediating artifacts are the care relationships. The overarching medical dominance emerges as an important cultural historical factor at play and staff rules and divisions of labour are exposed. Lastly key contradictions and tensions in the system that work against learning about the patient are identified. Cultural historical activity theory can be used to advance understanding of practice gaps in order to develop a broader transformative approach to dementia and delirium practice and education. Structural changes at an individual, team and systems level resulting from this novel understanding of practice complexity are proposed. Contradictions can be used as foci for expansive learning. Lastly, interprofessional education (formal and informal) is advocated to further knotwork and improve the care of the older confused patient.

Learning about the patient: an innovative interprofessional dementia and delirium education programme.

BACKGROUND: Patients with confusion (delirium and dementia) in the general hospital environment are more likely to have negative health outcomes compared with other patients. Poor team and individual practice is partly responsible for this, and a training gap has been described. We report an innovative interprofessional teaching intervention that is founded on robust medical education research findings, and has the potential to improve staff practice. INNOVATION: A 2-day programme is described that seeks to address previously identified learning needs in relation to managing the confused older patient. The programme is underpinned theoretically by learning from patients and carers, action learning and matching of teaching methods to aims (e.g. by the use of mindmaps to differentiate between dementia, delirium and depression). The programme has been implemented in Northumbria, England. Patients with confusion in the general hospital environment are more likely to have negative health outcomes RESULTS: In total 48 health care professionals, representing 12 different professional groups, attended three courses. Findings suggest that the programme significantly increases confidence across six core domains towards managing the confused older patient (p < 0.001, Mann-Whitney U-test). Furthermore, the course addresses negative attitudes and empowers staff to introduce relevant practice change. IMPLICATIONS: These results are pertinent given the findings of the Francis Inquiry, which identified significant care deficits within a culture of failing to practice in a patient-centred manner. As the core material focuses on learning about the patient, rather than the disease process, this programme may help address these gaps. Arguably our findings are of relevance to other innovators seeking to teach effectively in the hospital setting and improve patient care.

Developing a long-term condition's information service in collaboration with third sector organisations.

BACKGROUND: People with long-term conditions need to be signposted to high quality information and advice to understand and manage their condition. Information seeking tools combined with third sector information could help address their information needs. OBJECTIVE: To describe the development and implementation of an information service for people living with long-term conditions at one NHS acute trust in the Northeast of England. METHODS: An information service was trialled using bespoke information models for three long-term conditions in collaboration with third sector organisations. These guided people to relevant, timely and reliable information. Both clinician and service user questionnaires were used to evaluate satisfaction with the service. RESULTS: Appropriately designed information models can be used interchangeably across all services. Between 75% and 91% of users agreed that they were satisfied with various aspects of the service. Generally, users received relevant, understandable and high quality information at the right time. Nearly all health professionals (94-100%) felt the service was accessible, provided high quality information and did not significantly impact on their consultation time. CONCLUSION: The developed information service was well received by service users and health professionals. Specifically, the use of information prescriptions and menus facilitated access to information for people with long-term conditions.

Reconceptualizing models of delirium education: findings of a Grounded Theory study.

BACKGROUND: Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients. METHODS: Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached. RESULTS: Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patient's fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patient's fear. DISCUSSION: These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.

The validity and reliability of a Direct Observation of Procedural Skills assessment tool: assessing colonoscopic skills of senior endoscopists.

BACKGROUND: Practitioners increasingly need to be able to evidence the quality of their care and their clinical competence for purposes of recredentialing and relicensing. Although this may be accomplished by audit and performance data, detailed and robust assessments of competence may be valuable in certain circumstances. OBJECTIVE: To develop and evaluate a detailed assessment of performance of colonoscopy. DESIGN: Evaluation of a Direct Observation of Procedural Skills (DOPS) method developed by an expert group of colonoscopists and clinical educationalists. SETTING: English National Health Service National Bowel Cancer Screening Programme (BCSP). SUBJECTS AND METHODS: Aspirant colonoscopists wishing to participate in the BCSP were assessed by using the DOPS. Reliability was estimated by using generalizability theory (G), and the candidates' and assessors' perspectives on validity were evaluated by questionnaire. INTERVENTIONS: Grading of performance by 2 assessors over 2 consecutive real cases. MAIN OUTCOME MEASUREMENTS: DOPS grades, global expert evaluation, performance data, evaluation questionnaire scores. RESULTS: The assessment had high relative reliability: G = 0.81. The DOPS grades correlated highly with a global expert assessment. The candidates and assessors believed that the DOPS was a valid assessment of competence. LIMITATIONS: Not guaranteed to assess therapeutic skills; evaluation questionnaire influenced by result of assessment. CONCLUSIONS: This is the first evaluation of a DOPS assessment on independent practitioners. It performs well, with good levels of reliability and validity, and is sufficient to be used in a high-stakes assessment. Similar approaches should be considered for assessment of competence in other areas of clinical practice for relicensing or recredentialing.

Developing effective educational approaches for Liaison Old Age Psychiatry teams: a literature review of the learning needs of hospital staff in relation to managing the confused older patient.

BACKGROUND: Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams. METHODS: A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatrick's system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes. RESULTS: 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories. CONCLUSIONS: The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Developing an information prescription service.

BACKGROUND: Availability and accessibility of high-quality information is inconsistent nationally and improving information is central to Department of Health policy. This article outlines an information prescription (IP) pilot. AIM AND METHOD: Using a quality-improvement cycle, feedback was gathered from stakeholders to develop an IP service for people with Parkinson's disease and their relatives/carers. RESULTS AND DISCUSSION: Generally, service users were satisfied with the information and felt it enabled them to better understand, manage and be in control of their condition. Despite initial concerns, health staff identified benefits to themselves and patients. Barriers to implementing IPs were discussed.

The relationship between birthweight, weight gain in infancy, and educational attainment in childhood.

Previous studies have examined the relationship between low weight gain (failure to thrive) in infancy and later cognitive ability, but no study to date appears to have examined the relationship between weight gain in infancy across the 'normal' range and later cognitive ability. We report results for a large prospective birth cohort of the relationship between weight gain in infancy and educational attainment at age 10. Routinely recorded weights from child health clinic records for an annual birth cohort of 3418 children born with gestation >36 weeks were collected, as well as gestation in weeks, birthweight and the postcode, for which the Townsend Deprivation Score was identified. At 10 years of age, those attending schools within the Newcastle Education Authority were given a picture vocabulary and a non-verbal ability test, and tests of educational attainment in maths and reading. These were successfully linked to the infant weight data for 2294 (63%) of the children, and complete growth data were available for 1724 (47%) of the children who had completed at least one educational test. There was a significant positive relationship between weight gain in infancy and picture vocabulary, adjusted for economic deprivation, gestational age and birthweight, but not with any of the other outcomes. There was a statistically significant association between birthweight and all four outcomes, which was positive up to about one SD above average birthweight, and negative above. In this population, the association between early growth and cognitive outcomes is stronger for growth before birth, postnatal weight gain having a relatively minor impact.

Development of a series of patient information leaflets for constipation using a range of cognitive interview techniques: LIFELAX.

BACKGROUND: The aim of the LIFELAX randomised controlled trial (diet and lifestyle vs. laxatives in the management of chronic constipation) is to develop and evaluate a cost effective intervention to promote diet and lifestyle in the treatment and management of chronic constipation for older people in Primary Care. Constipation affects the quality of life in around 20% of older people in the community. In the 65 years plus population, a significant proportion of men and women both living in institutions (81% and 75% respectively) and free living (30% and 37% respectively) use laxatives. Approximately 42 million pounds is spent each year on prescribed laxatives in England in addition to laxatives purchased over the counter. Although bowel problems are often multifactorial, diet and lifestyle have an extremely important role in their management. This paper describes one aspect of the main study, the development and piloting of the Patient information leaflets (PILs). METHODS: Following review of the literature and interviews with practitioners and patients, 8 PILs were designed on: constipation, activity, bowel health, fruit and vegetables, fibre, fluid, alternative therapies and laxatives. To check the patient's understanding of terms used in the PILS and the clarity and accessibility of the information understanding, cognitive interviews (CI) were used with nine patients (selected from 3 GP surgeries), aged > or = 55 years, who had received > or = 3 prescriptions of laxatives over 12 months. Interviews were recorded and transcribed. RESULTS: Changes made following the CI process included the lay-out, words used (e.g. 'exercise' was changed to 'activity', 'gut motility' changed to 'bowel movement') and descriptions and examples were adapted to be more appropriate for the target population. CONCLUSION: Pilot testing with CIs resulted in improvements in the PILs, which emphasises the need to pilot PILs with the target population before use. The techniques employed are relatively inexpensive and could be routinely used when preparing literature for research or clinical use including those intended for use with healthcare professionals and patients.

Describing clinical teachers' characteristics and behaviours using critical incidents and repertory grids.

CONTEXT: Completion of a rating questionnaire is the method used most frequently to evaluate a teacher's performance. Questionnaires that largely assess 'high-inference' teaching characteristics, such as 'enthusiasm' and 'friendliness', require the observer to make a judgement about the teacher but do not describe what the teacher actually did and so have limited use in providing feedback. Measures of 'low-inference' teaching behaviours (i.e. those that are concrete and observable), such as frequency, amount or types of verbal interaction, do not demonstrate how these are linked to good teaching. OBJECTIVES: To describe high-inference teacher characteristics and define the associated low-inference behaviours. METHODS: A purposive sample of consultants, postgraduate and undergraduate students, nurse lecture practitioners and patients were selected for semistructured interviews using repertory grids and critical incidents to elicit preferred characteristics and behaviours of clinical teachers. Interviews were audiotaped, transcribed and then content-analysed using a framework to pair teachers' characteristics and their behaviours. RESULTS: We identified a variety of preferred high-inference characteristics and their associated observable and recordable low-inference behaviours. DISCUSSION: We carried out a study that included all participants in clinical teaching and found that participants differed in their preferred characteristics and behaviours. It is important for future research to look at behaviours interdependently, rather than alone, and to take into account the evidence that participants tend to infer characteristics rather than think in terms of behaviours. This information will be used to inform the development of a formative tool for evaluating clinical teaching.

Safety on elective: a survey on safety advice and adverse events during electives.

The risk of students contracting HIV on electives has received much coverage. Few data exist, however, on risks of other adverse events. Medical schools gave comprehensive advice on infectious disease but little on personal safety. There were no reported parenteral infections or deaths from infection, despite cases of malaria and one needle-stick injury. Accidents were responsible for six deaths and three serious injuries from just nine medical schools. A further student committed suicide after return to the UK. Personal violence and events related to the political situation of the elected country were also reported. This paper is based on a retrospective survey of elective convenors from UK medical schools examining advice given and adverse events. Accidents appear to pose significant risk to medical students on elective and there appears to be a lack of advice on personal safety issues. Further research should examine behaviours that put students at risk of accidents, and strategies that could prevent such events.

Effects of changes in hemoglobin level on quality of life and cognitive function in inflammatory bowel disease patients.

BACKGROUND: Anemia commonly complicates inflammatory bowel disease (IBD). In patients with chronic renal failure, the treatment of anemia with iron+/-erythropoietin improves both quality of life (QOL) and cognitive function (CF). The same drugs are effective in treating severe anemia in IBD, but there is no evidence to direct the treatment of mild anemia. Concern exists that the use of iron may exacerbate inflammation in patients with IBD. The present study examined the association between changes in hemoglobin (Hb) in a population of IBD patients and changes in QOL and CF independent of change in disease activity (DA). Subsidiary aims were to assess whether the use of iron was associated with worsening DA. METHODS: A cohort of 50 patients with IBD (29 Crohn's disease and 21 ulcerative colitis) took part. Iron replacement was given to 21 patients with low Hb. Measures of QOL, CF, DA, and Hb were recorded at baseline and at 6 months. RESULTS: The iron-treated group had lower Hb and higher DA scores compared with the non-iron-treated group at baseline. In a hierarchical regression model, changes in DA accounted for 13% (P=0.17) and changes in Hb accounted for 18% (P=0.005) of the variance in change in SF-36 and 12% (P=0.23) and 17% (P=0.009) in the Inflammatory Bowel Disease Questionnaire. In this pilot study, although no associations were identified between changes in Hb or DA and CF, increases in Hb improved QOL scores in IBD patients independent of changes in DA. We found no similar effect with CF, but again, the sample size was small. We found no evidence that iron therapy causes worsening of DA. CONCLUSIONS: Treatment of IBD-associated anemia with iron may lead to improvement in patients' QOL.

Illness perceptions in people with acute bacterial gastro-enteritis.

Functional gastro-intestinal disorders (FGID) like irritable bowel syndrome (IBS) are common and can develop after gastro-enteritis. Illness representations may be important influences on the development of post-infectious FGIDs. Here, we studied both the relationship between prior chronic symptoms (FGIDs) and illness perception during an acute illness (bacterial gastro-enteritis) as well as the relationship between illness perception during an acute illness (bacterial gastro-enteritis) and the subsequent development of chronic abdominal symptoms. Two hundred and seventeen people with recent gastro-enteritis completed a questionnaire asking about gut symptoms consistent with a diagnosis of IBS, functional dyspepsia or functional diarrhoea and the Illness Perception Questionnaire. Those without a prior FGID were followed up and completed a similar gut questionnaire at six months. People with a prior FGID had significantly more symptoms and scored significantly higher on the timeline and consequence scores than those without. People who developed a FGID had a non-significantly higher number of symptoms and higher consequence and timeline scores than those who did not. Neither comparative group differed in the control/cure scores or causation scores. The implications of the findings are discussed.