Evaluation of junior doctors' retention of knowledge and skills after simulation training in shockable rhythm cardiac arrest in a low-resource setting in Nepal.

Aims: To test junior doctors' abilities to retain advanced life support psychomotor skills and theoretical knowledge in management of shockable rhythm cardiac arrest. Methods: A repeated measure pre-post study design was used with 43 junior doctors, recruited after notifying them with robust method of attraction through flyers, brochures, email and phone calls. Written and performance tests, initial pre-test, immediate post-training, 30-days post-training and 60-days post-training, using simulation-based scenarios with a low-fidelity manikin were used with recording performance of ALS. Instrumentation: Resuscitation Council UK ALS algorithms and guidelines1 were used in a simulated testing environment. Results: There was a highly significant improvement in knowledge immediately after training (p < 0.00), with a net gain of marks from a mean value of 63.2% before training to 87.7% after training by 24.5% (95% CI 19.4, 29.6).There was a gradual decline of retained knowledge with time from immediate post-training over, 30-days and 60-days post-training (p < 0.00). The simulation pre-training assessments and immediate post-training assessments results were statistically significant (p < .00). The mean difference was 44.1% (95% CI 50.11, 38.10). There was a statistically significant decline of the competency with time (p < .00). Unlike for the knowledge test, the drop was significant on the 30th day (p < .00) with a mean difference of -10.5% (95% CI -13.55, -7.40). Conclusion: The training of junior doctors in shockable rhythm cardiac arrest in a low resource setting, improved knowledge and skills in the participants after training. However, retention of knowledge declined at 30 days and more significantly after 60 days and retention of skill was declined more significantly at 30 days.

Upstreamist leaders: how risk factors for unscheduled return visits (URV) to the emergency department can inform integrated healthcare.

PURPOSE: This paper aims to report on research undertaken in an National Health Service (NHS) emergency department in the north of England, UK, to identify which patients, with which clinical conditions are returning to the emergency department with an unscheduled return visit (URV) within seven days. This paper analyses the data in relation to the newly introduced Integrated Care Boards (ICBs). The continued upward increase in demand for emergency care services requires a new type of "upstreamist", health system leader from the emergency department, who can report on URV data to influence the development of integrated care services to reduce further demand on the emergency department. DESIGN/METHODOLOGY/APPROACH: Patients were identified through the emergency department symphony data base and included patients with at least one return visit to emergency department (ED) within seven days. A sample of 1,000 index visits between 1 January 2019-31 October 2019 was chosen by simple random sampling technique through Excel. Out of 1,000, only 761 entries had complete data in all variables. A statistical analysis was undertaken using Poisson regression using NCSS statistical software. A review of the literature on integrated health care and its relationship with health systems leadership was undertaken to conceptualise a new type of "upstreamist" system leadership to advance the integration of health care. FINDINGS: Out of all 83 variables regressed with statistical analysis, only 12 variables were statistically significant on multi-variable regression. The most statistically important factor were patients presenting with gynaecological disorders, whose relative rate ratio (RR) for early-URV was 43% holding the other variables constant. Eye problems were also statistically highly significant (RR = 41%) however, clinically both accounted for just 1% and 2% of the URV, respectively. The URV data combined with "upstreamist" system leadership from the ED is required as a critical mechanism to identify gaps and inform a rationale for integrated care models to lessen further demand on emergency services in the ED. RESEARCH LIMITATIONS/IMPLICATIONS: At a time of significant pressure for emergency departments, there needs to be a move towards more collaborative health system leadership with support from statistical analyses of the URV rate, which will continue to provide critical information to influence the development of integrated health and care services. This study identifies areas for further research, particularly for mixed methods studies to ascertain why patients with specific complaints return to the emergency department and if alternative pathways could be developed. The success of the Esther model in Sweden gives hope that patient-centred service development could create meaningful integrated health and care services. PRACTICAL IMPLICATIONS: This research was a large-scale quantitative study drawing upon data from one hospital in the UK to identify risk factors for URV. This quality metric can generate important data to inform the development of integrated health and care services. Further research is required to review URV data for the whole of the NHS and with the new Integrated Health and Care Boards, there is a new impetus to push for this metric to provide robust data to prioritise the need to develop integrated services where there are gaps. ORIGINALITY/VALUE: To the best of the authors' knowledge, this is the first large-scale study of its kind to generate whole hospital data on risk factors for URVs to the emergency department. The URV is an important global quality metric and will continue to generate important data on those patients with specific complaints who return back to the emergency department. This is a critical time for the NHS and at the same time an important opportunity to develop "Esther" patient-centred approaches in the design of integrated health and care services.

Implementing the HEART score in an NHS emergency department: can identity leadership combined with quality improvement promote racial equality?

PURPOSE: The purpose of this paper is to report on the dynamics of "identity leadership" with a quality improvement project undertaken by an International Medical Graduate (IMG) from Sri Lanka, on a two year Medical Training Initiative (MTI) placement in the National Health Service (NHS) [Academy of Medical Royal Colleges (AoMRC), 2017]. A combined MTI rotation with an integrated Fellowship in Quality Improvement (Subedi et al., 2019) provided the driver to implement the HEART score (HS) in an NHS Emergency Department (ED) in the UK. The project was undertaken across ED, Acute Medicine and Cardiology at the hospital, with stakeholders emphasizing different and conflicting priorities to improve the pathway for chest pain patients. DESIGN/METHODOLOGY/APPROACH: A social identity approach to leadership provided a framework to understand the insider/outsider approach to leadership which helped RH to negotiate and navigate the conflicting priorities from each departments' perspective. A staff survey tool was undertaken to identify reasons for the lack of implementation of a clinical protocol for chest pain patients, specifically with reference to the use of the HS. A consensus was reached to develop and implement the pathway for multi-disciplinary use of the HS and a quality improvement methodology (with the use of plan do study act (PDSA) cycles) was used over a period of nine months. FINDINGS: The results demonstrated significant improvements in the reduction (60%) of waiting time by chronic chest pain patients in the ED. The use of the HS as a stratified risk assessment tool resulted in a more efficient and safe way to manage patients. There are specific leadership challenges faced by an MTI doctor when they arrive in the NHS, as the MTI doctor is considered an outsider to the NHS, with reduced influence. Drawing upon the Social Identity Theory of Leadership, NHS Trusts can introduce inclusion strategies to enable greater alignment in social identity with doctors from overseas. RESEARCH LIMITATIONS/IMPLICATIONS: More than one third of doctors (40%) in the English NHS are IMGs and identify as black and minority ethnic (GMC, 2019a) a trend that sees no sign of abating as the NHS continues its international medical workforce recruitment strategy for its survival (NHS England, 2019; Beech et al., 2019). IMGs can provide significant value to improving the NHS using skills developed from their own health-care system. This paper recommends a need for reciprocal learning from low to medium income countries by UK doctors to encourage the development of an inclusive global medical social identity. ORIGINALITY/VALUE: This quality improvement research combined with identity leadership provides new insights into how overseas doctors can successfully lead sustainable improvement across different departments within one hospital in the NHS.

Review DebrIeF: a collaborative distributed leadership approach to "hot debrief" after cardiac arrest in the emergency department - a quality improvement project.

PURPOSE: The purpose of this paper is to re-conceptualise the hot debrief process after cardiac arrest as a collaborative and distributed process across the multi-disciplinary team. There are multiple benefits to hot debriefs but there are also barriers to its implementation. Facilitating the hot debrief discussion usually falls within the remit of the physician; however, the American Heart Association suggests "a facilitator, typically a health-care professional, leads a discussion focused on identifying ways to improve performance". Empowering nurses through a distributed leadership approach supports the wider health-care team involvement and facilitation of the hot debrief process, while reducing the cognitive burden of the lead physician. DESIGN/METHODOLOGY/APPROACH: A mixed-method approach was taken to evaluate the experiences of staff in the Emergency Department (ED) to identify their experiences of hot debrief after cardiac arrest. There had been some staff dissatisfaction with the process with reports of negative experiences of unresolved issues after cardiac arrest. An audit identified zero hot debriefs occurring in 2019. A quality Improvement project (Model for Healthcare Improvement) used four plan do study act cycles from March 2020 to September 2021, using two questionnaires and semi-structured interviews to engage the team in the design and implementation of a hot debrief tool, using a distributed leadership approach. FINDINGS: The first survey (n = 78) provided a consensus to develop a hot debrief in the ED (84% in the ED; 85% in intensive care unit (ICU); and 92% from Acute Medicine). Three months after implementation of the hot debrief tool, 5 out of 12 cardiac arrests had a hot debrief, an increase of 42% in hot debriefs from a baseline of 0%. The hot debrief started to become embedded in the ED; however, six months on, there were still inconsistencies with implementation and barriers remained. Findings from the second survey (n = 58) suggest that doctors may not be convinced of the benefits of the hot debrief process, particularly its benefits to improve team performance and nurses appear more invested in hot debriefs when compared to doctors. RESEARCH LIMITATIONS/IMPLICATIONS: There are existing hot debrief tools; for example, STOP 5 and Take STOCK; however, creating a specific tool with QI methods, tailored to the specific ED context, is likely to produce higher levels of multi-disciplinary team engagement and result in distributed roles and responsibilities. Change is accepted when people are involved in the decisions that affect them and when they have the opportunity to influence that change. This approach is more likely to be achieved through distributed leadership rather than from more traditional top-down hierarchical leadership approaches. ORIGINALITY/VALUE: To the best of the authors' knowledge, this study is the first of its kind to integrate Royal College Quality Improvement requirements with a collaborative and distributed medical leadership approach, to steer a change project in the implementation of a hot debrief in the ED. EDs need to create a continuous quality improvement culture to support this integration of leadership and QI methods combined, to drive and sustain successful change in distributed leadership to support the implementation of clinical protocols across the multi-disciplinary team in the ED.