Experiences of Multidisciplinary Working: Perspectives from the Wessex Ghana Stroke Partnership.

INTRODUCTION: Substantial gaps remain in our understanding of stroke in Africa as well as in stroke care, practice and policy on the continent. The effective organization of preventative, therapeutic and rehabilitative stroke services continue to be challenging in many African countries. METHODOLOGY: In this article we define the nature, function and benefits of effective multidisciplinary team (MDT) working. The experiences and perspectives of members of the MDT were collated by focus group discussions as well as individual and country specific contributions. RESULTS: The experiences and perspectives of multidisciplinary team members from the United Kingdom and Ghana implementing these practices at the first stroke unit in Korle Bu Teaching Hospital, Accra, with a transparent discussion of successes and challenges faced throughout development of the service, is presented. MDT working has improved outcomes for patients and families who use the services, including encouraging better shared treatment planning and compliance. More stroke rehabilitation services are provided than previously, including greater self-management education and better secondary prevention care. CONCLUSION: It is hoped that this article will provide an inspirational model for others working to provide stroke care in low-resource settings in Africa and worldwide.

INTRODUCTION: Des lacunes substantielles subsistent dans notre compréhension de l'accident vasculaire cérébral en Afrique ainsi que dans les pratiques et politiques sur le continent. L'organisation efficace des services de prévention, de traitement et de réadaptation des AVC reste un défi dans de nombreux pays africains. MÉTHODOLOGIE: Dans cet article, nous définissons la nature, la fonction et les avantages d'une équipe multidisciplinaire efficace (PCT).Les expériences et les points de vue des membres de la PCT ont été recueillis par des discussions de groupes de réflexion ainsi que contributions individuelles et spécifiques à chaque pays. RÉSULTATS: Les expériences et les perspectives des membres d'équipes multidisciplinaires du Royaume-Uni et du Ghana, qui ont mis en œuvre ces pratiques dans la première unité d'AVC du de l'hôpital universitaire Korle Bu, à Accra, avec une discussion transparente des succès et des défis rencontrés tout au long du développement du service, sont présentées. Le travail de la PCT a amélioré les résultats pour les patients et les familles qui utilisent les services, notamment en encourageant un meilleur partage du traitement, l'organisation et la complaisance. Davantage de services de réadaptation après un AVC sont fournis plus qu'auparavant, y compris une meilleure éducation à l'autogestion et de meilleurs soins de prévention secondaire. CONCLUSION: Nous espérons que cet article constituera un modèle inspirant pour d'autres personnes travaillant à la prise en charge d'AVC dans des contextes à faibles ressources en Afrique et dans le monde. Mots clés: Unité de expériences, multidisciplinaire, Ghana, partenariat.

Risk factors for persistent disability in children with obstetric brachial plexus palsy.

OBJECTIVE: Obstetric brachial plexus palsy (OBPP) at birth, is a serious neurologic injury that may lead to a long lasting disability. We aimed to examine the occurrence and risk factors associated with disability lasting >1 year. STUDY DESIGN: A retrospective cohort study conducted between 1993 and 2012 included individuals with diagnosis of OBPP at birth. Affected individual's motor function was evaluated by a direct physical exam based on a muscle grading system of the limb, shoulder, elbow and hand. When not feasible a telephone questionnaire was used. Participants reported on activities of daily living, disability duration and any type of intervention. Stepwise logistic regression model was used to identify demographic and obstetric risk factors for disability lasting >1 year. RESULTS: Of all 83 806 deliveries during this period, 144 OBPP cases were identified (1.7/1000). Of the 91 (63.2%) individuals located 42 (46.2%) were evaluated by a physical exam and 49 (53.8%) answered a telephone questionnaire. In 12 (13.2%) disability lasted >1 year. Significant predictors for disability lasting >1 year included birthweight >4 kg (P=0.02; odds ratio (OR) 6.17; 95% confidence interval (CI) 1.33-28.65) and younger maternal age (P=0.02; OR 0.84; 95% CI: 0.73-0.97). OBPP decreased 16% per 1 year increase in maternal age. CONCLUSIONS: OBPP is a transient injury in most cases. Birthweight over 4 kg and younger maternal age maybe associated with disability lasting >1 year.

Cervical ripening with the balloon catheter and the risk of subsequent preterm birth.

OBJECTIVE: To examine the risk of subsequent preterm birth after cervical ripening using a balloon catheter. STUDY DESIGN: A retrospective study was held at a university teaching hospital between January 2007 and June 2013. The study group included women who underwent cervical ripening using a balloon (single or double) catheter in the previous pregnancy followed by a subsequent singleton delivery (balloon catheter group). Two control groups were included. The first was similar to the study group except that ripening was achieved in the previous pregnancy with vaginal prostaglandin E2 (PGE2 group). The second control group had a previous pregnancy that resulted in spontaneous onset of labor at term (unexposed group). The primary outcome was the incidence of spontaneous preterm birth (before 37 weeks) in the index pregnancy. RESULT: Overall, 558 women were included; each group consisted of 186 women. The incidence of spontaneous preterm birth in the index pregnancy did not differ between the groups (0.5, 1.6 and 2.7% in the balloon catheter, PGE2 and in the unexposed groups, respectively, P=0.31). Among the balloon catheter group, 58 (31.2%) women had the ripening performed with a single-balloon catheter and 128 (68.8%) women with a double-balloon catheter. The rate of the spontaneous preterm birth in the index pregnancy did not differ between the two groups (P=1.0). CONCLUSION: Cervical ripening with a balloon catheter does not increase the rate of subsequent spontaneous preterm birth.

Hospital costs of out-of-hospital cardiac arrest patients treated in intensive care; a single centre evaluation using the national tariff-based system.

OBJECTIVES: There is a scarcity of literature reporting hospital costs for treating out of hospital cardiac arrest (OOHCA) survivors, especially within the UK. This is essential for assessment of cost-effectiveness of interventions necessary to allow just allocation of resources within the National Health Service. We set out primarily to calculate costs stratified against hospital survival and neurological outcomes. Secondarily, we estimated cost effectiveness based on estimates of survival and utility from previous studies to calculate costs per quality adjusted life year (QALY). SETTING: We performed a single centre (London) retrospective review of in-hospital costs of patients admitted to the intensive care unit (ICU) following return of spontaneous circulation (ROSC) after OOHCA over 18 months from January 2011 (following widespread introduction of targeted temperature management and primary percutaneous intervention). PARTICIPANTS: Of 69 successive patients admitted over an 18-month period, survival and cerebral performance category (CPC) outcomes were obtained from review of databases and clinical notes. The Trust finance department supplied ICU and hospital costs using the Payment by Results UK system. RESULTS: Of those patients with ROSC admitted to ICU, survival to hospital discharge (any CPC) was 33/69 (48%) with 26/33 survivors in CPC 1-2 at hospital discharge. Cost per survivor to hospital discharge (including total cost of survivors and non-survivors) was £50,000, cost per CPC 1-2 survivor was £65,000. Cost and length of stay of CPC 1-2 patients was considerably lower than CPC 3-4 patients. The majority of the costs (69%) related to intensive care. Estimated cost per CPC 1-2 survivor per QALY was £16,000. CONCLUSIONS: The costs of in-hospital patient care for ICU admissions following ROSC after OOHCA are considerable but within a reasonable threshold when assessed from a QALY perspective.

Are there modifiable risk factors that may predict the occurrence of brachial plexus injury?

OBJECTIVE: To identify risk factors, particularly modifiable, associated with brachial plexus injury. STUDY DESIGN: A retrospective case-control study conducted at a single hospital between the years 1993 and 2012. All neonates who were diagnosed of brachial plexus injury were included. A control group matched at a ratio of 1:2 was randomly selected. Demographic and obstetric data were obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. All medical files were manually checked and validated. A stepwise logistic regression model was performed to identify independent predictors for brachial plexus injury before delivery among those found significant in the univariate analysis. RESULTS: Of all 83 806 deliveries that took place during this period, 144 cases of brachial plexus injury were identified (1.7/1000 deliveries). Overall, 142 cases and 286 controls had available data. Among the study group, 41 (28.9%) had documented shoulder dystocia compared with 1 (0.4%) among the controls (P<0.0001). Logistic regression analysis revealed that maternal age above 35 years (P=0.01; odds ratio (OR) 2.7; 95% confidence interval (CI) 1.3 to 5.7), estimated fetal weight before delivery (P<0.0001; OR 2.5; 95% CI 1.7 to 3.8, for each 500 g increase), vaginal birth after cesarean (P=0.02; OR 3.3; 95% CI 1.2 to 8.8) and vacuum extraction (P=0.02; OR 3.6; 95% CI 1.2 to 10.3) were all found to be independent predictors for developing brachial plexus injury. When stratifying the analysis according to parity, vacuum delivery was found to be an independent risk factor only among primiparous women (OR 6.0; 95% CI 1.7 to 21.6). CONCLUSIONS: The findings suggest that very few factors contributing to brachial plexus injury are modifiable. For that reason, it remains an unpredictable and probably an unavoidable event.

Development and implementation of an information management and information technology strategy for improving healthcare services: a case study.

PeaceHealth is a multistate, not-for-profit integrated delivery network that owns and operates five acute care hospitals, one critical access hospital, and twenty-five outpatient clinics. PeaceHealth employs approximately two hundred physicians and seventy allied health professionals; it has relationships with one thousand affiliated physicians. In 1990, PeaceHealth developed a set of strategic priorities for delivering seamless care across the continuum, and creating partnerships between caregivers and patient-consumers. A major component of these strategies was development and implementation of the technology, knowledge, organizational, and community infrastructures that would support delivering and using high-quality, timely information when and where it is needed for effective clinical, operational, and financial decision making. Executing this strategy has resulted in implementation of standard enterprisewide information systems, including a computer-based patient record system in inpatient and outpatient settings, tactical and strategic decision support systems, a well-developed intranet and access to the Internet, and a knowledgeable workforce that have enabled PeaceHealth to support and improve its services and business by bringing interactive information directly to patients, caregivers, managers, directors, and executives. This case study discusses the drivers behind the development of this strategy, specific components of the information management and information technology infrastructure, examples of the impact they have had on patients, caregivers, and the organization, and lessons learned.

Multiple intracranial aneurysms as delayed complications of an atrial myxoma: case report.

OBJECTIVE AND IMPORTANCE: Atrial myxomas are rare cardiac tumors that may cause neurological complications; however, delayed neurological events after total tumor resection are rare. In this report, we present a patient who developed transient cerebral ischemic attacks and was found to have multiple intracranial aneurysms 5 years after successful resection of her atrial myxoma. At the time of myxoma resection, there were no neurological symptoms; at the time of presentation with transient ischemic attacks, there was no evidence of atrial recurrence. CLINICAL PRESENTATION: A 32-year-old woman presented with five episodes of right arm and face paresthesia, each lasting 15 to 20 minutes, 5 years after successful resection of her atrial myxoma. Clopidogrel bisulfate therapy was initiated, with resolution of her symptoms. Angiography revealed multiple, peripherally located, fusiform cerebral aneurysms. INTERVENTION: A left frontal craniotomy for resection and biopsy of one of the aneurysms was performed, to establish the diagnosis. Pathological analysis of the biopsied aneurysm provided evidence of direct atrial myxoma invasion and occlusion of the cerebral blood vessel. CONCLUSION: Neurological symptoms may accompany or lead to the diagnosis of atrial myxoma. Rarely, as in this case, myxomatous aneurysms may develop years after definitive treatment of the primary tumor. Patients who have undergone successful resection of a left atrial myxoma may be at risk for delayed cerebral ischemia associated with aneurysm development, and this phenomenon must be considered for patients with neurological symptoms who present even years after myxoma removal. The natural history, pathophysiological features, and treatment dilemma of these aneurysms are discussed.

A retrospective study into the effects of operator experience on the accuracy of ultrasound in the diagnosis of gastric neoplasia in dogs.

The accuracy of three diagnostic techniques in two separate time periods was examined. In the first time period, 18 dogs were referred to the University of Bristol with signs suggestive of gastric neoplasia. Of these 18 dogs, 7 had a positive diagnosis of gastric neoplasia from histopathology samples (38% prevalence). The sensitivity of ultrasound was found to be 42.9% with a specificity of 63.6%. A year later the study was repeated with 40 cases referred for investigation. Of these 40 dogs, 16 had a positive histopathologic diagnosis of gastric neoplasia (40% prevalence). At this time the sensitivity of ultrasound had increased to 81.3 % and the specificity had increased to 70.8 %. The increase in sensitivity was attributed to an increase in operator experience in the performance of the ultrasound examination. This improvement in sensitivity and experience resulted in a greater accuracy at detecting the presence of gastric neoplasia.

InstantCath from Hollister: pre-lubricated self-catheterization.

Over the centuries a variety of substances have been used to make a hollow tube to pass through the urethra to empty a poorly functioning bladder. The ancient Greeks used dried water reeds from the riverbank. The Romans and the Egyptians experimented with gold and silver. Following the industrial revolution stainless steel was used and catheters are still manufactured today using stainless steel. PVC and plastic catheters became popular in the 1970s and various hydrophilic coatings have been added to provide self-lubrication of the catheter when it comes into contact with water. The most recent development in the clean, intermittent self-catheterization (CISC) range is the Hollister InstantCath which is a self-lubricating catheter that does not require any water. It has shown itself to be well received by patients and is a welcome addition to the choice available to healthcare professionals and their patients when instigating CISC as therapy.

Developing a model of collaborative research: the complexities and challenges of implementation.

While the benefits of collaborative research have been well documented, fewer publications exist regarding the complex, problematic issues involved in these undertakings. This paper offers an integrated collaborative research model to depict the complexities and challenges of initiation and implementation of a 2 1/2 year joint research project between a community hospital and a university school of nursing in Southern Ontario, Canada. A sampling of the experiences of the researchers are analyzed to clarify the dynamic and often competing issues and interactions involved in encouraging hospital-wide research involvement during periods of organizational growth and change. The model reflects the simultaneous interaction of organizational, change and collaborative processes while maintaining the rigor of the research (RCT), and ensuring minimal disruption to the service agency. Quantitative outcomes of this collaboration are presented through an analysis of participant involvement on multiple organizational levels. Recommendations for future collaborative research, including design and methodological issues and collaborative and change strategies are offered. The complexity of balancing the necessary trade-offs required of successful collaborative research are highlighted and will be useful to those considering and planning future collaborations.

Prevalence of auditory hallucinations in nurses in mental health.

Seventy-nine nurses and student nurses working in the mental health field were asked to complete a questionnaire that asked about the prevalence of their experience of events that might be considered as examples of auditory hallucinations. Eighty-four per cent of the 55 nurses who returned the questionnaire described having experiences that might be described as auditory hallucinations. This level of prevalence is broadly consistent with other studies, and the difference between voices considered to indicate 'schizophrenia' and voices perceived as normal or unimportant is discussed. The relevance of these findings for the process of diagnosis and for the attitudes of nurses working in the mental health field towards voices reported by clients is highlighted.

The efficacy and effectiveness of process consultation in improving staff morale and absenteeism.

OBJECTIVES: The purpose of this randomized controlled trial was to test the efficacy and effectiveness of process consultation consisting of a series of nurse manager-consultant problem-solving meetings for leadership development that would lead to their staff's improved morale, quality of care, and reduced absenteeism. METHODS: Thirteen consenting clinical inpatient units were stratified for four variables known to affect outcome and were then randomly assigned to treatment and control conditions. The nurse managers from the seven experimental units were paired with outside nurse consultants from the McMaster University School of Nursing (Hamilton, Ontario, Canada) in a cooperative form of retraining in problem-solving through process consultation. Morale was determined through measures of perceptions of the work environment, an attitude scale concerning work (alienation), a personality measure (hardiness), and one of each scale for work satisfaction and for sources of satisfaction and dissatisfaction. Demographic data and information regarding family life responsibilities were collected as well. Assessment of quality of care was determined by the frequency and type of incident reports and by patients' perception of their satisfaction. A ratio of absence hours to total paid hours of work was used to compare experimental and control units' absenteeism rates. RESULTS: Experimental subjects reported a statistically significant improvement in the characteristics of their work setting and in the quality of working relationships. The consultation process facilitated a perceived change in the organizational context of the experimental hospital units with less centralization of authority and more clarity about expectation. These organizational changes were accompanied by improved working relationships and less alienation from work. There was no statistically significant difference in absenteeism. However, a subanalysis of the units by "dose" of the intervention identified those who benefited from the effects of the consultation. Subjects whose nurse managers participated more actively in the consultation process accounted for the changes in working relationships and perceived organizational changes. The "low-dose" experimental subjects were more like the control subjects, with the exception of absenteeism, for which they had higher rates. CONCLUSIONS: The findings of this study suggest that process consultation can alter the staff's perceptions of the characteristics of the work setting, can reverse negative attitudes (alienation), and can create a more positive and supportive working environment (improved working relationship). However, the results suggest the need to target this type of intervention to managers who have the personal resources to engage in self-evaluation and personal development and thus to participate in the consultative process.

Life-long education: problem-based learning. Part 1.

In the first of two articles, the authors describe how nurses in the urology department at Battle Hospital overcame several obstacles and developed a new learning module which could eventually be used by all nurses whatever their experience. The second article will discuss how the module has developed and will be published shortly.

Solving the problem of life-long learning. Part 2.

In their first article, the authors made the case for the use of problem-based learning as a vehicle for post-registration clinical nursing courses. In this second article, they describe how they implemented this approach in the clinical area and the impact on the professional development of the course participants.

Foreign investment and migration: analytics and extensions of the basic model.

"This paper provides a unified approach to the basic model of international factor mobility. The use of new graphical techniques complements the algebraic exposition to underscore the persistence of the Ramaswami effect which pushes an active, home country toward a near 'buy-out' of the foreign country's internationally mobile factors of production. By generalizing the Ramaswami function, which identifies the gains associated with moving to near buy-out, we are able to explore the forces at work that mitigate such a strategy and lead to situations in which only a partial buy-out, or even no acquisition of foreign factors is optimal. These features are developed in a context in which (i) technologies differ between countries or (ii) there exists a third, immobile factor of production."