How can quality be measured within a physician-led Community Emergency Medical service? A scoping review protocol.

BACKGROUND: Quality measurement as part of quality improvement in healthcare is integral for service delivery and development. This is particularly pertinent for health services that deliver care in ways that differ from traditional practice. Community Emergency Medicine (CEM) is a novel and evolving concept of care delivered by services in parts of the UK and Ireland. This scoping review aims to provide a broad overview of how quality may be measured within services delivering CEM. METHODS AND ANALYSIS: The methodology follows both the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). It is guided by recognised work of Arksey and O'Malley and the guidelines developed by the Joanna Briggs Institute. Several databases will be searched: MEDLINE, EMbase, EMcare, CINAHL, Scopus, the Cochrane Library and grey literature. Search terms have been developed by representatives within Community Emergency Medicine services. Two reviewers will independently screen eligible studies for final study selection. Results will be collected and analysed in descriptive and tabular form to illustrate the breadth of quality indicators that may be applicable to CEM services. This scoping review protocol has been registered with the Open Science Framework platform (osf.io/e7qxg). DISCUSSION: This is the first stage of a larger research study aimed at developing national quality indicators for CEM. The purpose of this scoping review is to provide a comprehensive review of quality indicators that could be used within CEM. The results will be mapped using a framework and identify gaps in the literature to help guide future-focused research.

Just-in-time interprofessional training: lessons from the NHS Nightingale London.

The Coronavirus 2019 (COVID-19) pandemic placed significant pressure on healthcare systems across the globe, with many clinicians redeployed in unfamiliar specialties or disciplines. In England, a just-in-time interprofessional training and education programme was rapidly established to upskill nearly 2,500 people who volunteered to work at the NHS Nightingale London Hospital. Of the 488 respondents in our evaluation, representing a 20% response rate, most felt confident and safe to start work in NHS Nightingale London. Key findings were: streaming of learners should be driven by predicted shared roles in the workplace and previous experience; in situ training to experience how teams work together in the real clinical setting was well received; and online learning should be focused on essential learning. A just-in-time interprofessional training programme can be effective in upskilling and redeploying healthcare staff in emergency situations, and can be useful for supporting staff redeployment or upskilling across the NHS more widely.

A Cross-Sectional Study of Serum Glutathione Peroxidase: An Antioxidative Marker in Chronic Periodontitis and Chronic Kidney Disease.

BACKGROUND AND AIM: Oxidative stress as an individual risk for periodontitis and chronic kidney disease (CKD) has been elaborated through various mechanical pathways, yet its role in association with both diseases remains unexplored. Thus, the current study aims in evaluating serum glutathione peroxidase, an oxidative stress marker in CKD patients with periodontitis, and compare it with the healthy controls. METHODOLOGY: One hundred and twenty subjects were divided into four groups as control (C=30 subjects), periodontitis and non-CKD patients (CP=30 patients), non-periodontitis and CKD patients (CKD=30 patients), and periodontitis and CKD patients (CKD+CP=30 patients). Demographic variables, periodontal parameters, such as plaque index (PI), gingival index (GI), probing pocket depth (PPD), percentage proportion of sites with probing pocket depth more than 5 mm, clinical attachment loss (CAL), percentage proportion of sites with clinical attachment loss more than 3 mm and serum stress marker, and glutathione peroxidase were compared between the groups and the results were statistically analyzed. RESULTS: The demographic variables did not differ significantly between the groups, except for age. The means PI, GI, PPD, percentage proportion of sites with probing pocket depth more than 5 mm, CAL, percentage proportion of sites with clinical attachment loss were higher in CKD+CP. The glutathione peroxidase was significantly higher in CP group (p=0.001) and significantly correlated with periodontal parameters. CONCLUSION: The oxidative stress marker glutathione peroxidase was higher in CP, followed by the CKD groups. This could pave a strong link of oxidative stress as a risk factor for chronic periodontitis, as well as chronic kidney disease.

Inside The O2: the NHS Nightingale Hospital London education center.

As part of the response to COVID-19 in the United Kingdom (UK) the NHS Nightingale Hospital London was rapidly established in March 2020. Set up in the ExCel, an international conference center, it aimed to address the anticipated shortfall of intensive care beds in London. Whilst this hospital garnered huge amounts of publicity in the UK, less widely discussed is the Nightingale Education Center. The education center was instrumental in ensuring that there were staff across all professions ready to work there and had interprofessional education at its core. In a period of under two months it inducted and upskilled over 2,500 people from multiple healthcare and non-healthcare professions. That is more than most hospitals would induct in a whole year. To complete interprofessional training on this scale the education center decamped from the ExCel to The O2, a 20,000 capacity arena, and remained there for six weeks beating the iconic artist Prince for the title of longest running residency. This report offers a reflection on the authors' time spent working in the Education Center as members of the 'Core Operations' team. The content of the article is based upon the authors' reflections, first-hand experiences and field observations. It offers a reflection upon the massive undertaking of setting up an education center in an entertainment venue, as well as the successes and challenges of working interprofessionally in this unique space and under pandemic conditions.

The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK.

In this paper, we describe the potential of simulation to improve hospital responses to the COVID-19 crisis. We provide tools which can be used to analyse the current needs of the situation, explain how simulation can help to improve responses to the crisis, what the key issues are with integrating simulation into organisations, and what to focus on when conducting simulations. We provide an overview of helpful resources and a collection of scenarios and support for centre-based and in situ simulations.

Validation evidence of the paediatric Objective Structured Assessment of Debriefing (OSAD) tool.

Introduction: Debriefing is essential to maximise the simulation-based learning experience, but until recently, there was little guidance on an effective paediatric debriefing. A debriefing assessment tool, Objective Structured Assessment of Debriefing (OSAD), has been developed to measure the quality of feedback in paediatric simulation debriefings. This study gathers and evaluates the validity evidence of OSAD with reference to the contemporary hypothesis-driven approach to validity. Methods: Expert input on the paediatric OSAD tool from 10 paediatric simulation facilitators provided validity evidence based on content and feasibility (phase 1). Evidence for internal structure validity was sought by examining reliability of scores from video ratings of 35 postsimulation debriefings; and evidence for validity based on relationship to other variables was sought by comparing results with trainee ratings of the same debriefings (phase 2). Results: Simulation experts' scores were significantly positive regarding the content of OSAD and its instructions. OSAD's feasibility was demonstrated with positive comments regarding clarity and application. Inter-rater reliability was demonstrated with intraclass correlations above 0.45 for 6 of the 7 dimensions of OSAD. The internal consistency of OSAD (Cronbach α) was 0.78. Pearson correlation of trainee total score with OSAD total score was 0.82 (p<0.001) demonstrating validity evidence based on relationships to other variables. Conclusion: The paediatric OSAD tool provides a structured approach to debriefing, which is evidence-based, has multiple sources of validity evidence and is relevant to end-users. OSAD may be used to improve the quality of debriefing after paediatric simulations.

'The Diamond': a structure for simulation debrief.

BACKGROUND: Despite debriefing being found to be the most important element in providing effective learning in simulation-based medical education reviews, there are only a few examples in the literature to help guide a debriefer. The diamond debriefing method is based on the technique of description, analysis and application, along with aspects of the advocacy-inquiry approach and of debriefing with good judgement. It is specifically designed to allow an exploration of the non-technical aspects of a simulated scenario. CONTEXT: The debrief diamond, a structured visual reminder of the debrief process, was developed through teaching simulation debriefing to hundreds of faculty members over several years. The diamond shape visually represents the idealised process of a debrief: opening out a facilitated discussion about the scenario, before bringing the learning back into sharp focus with specific learning points. Debriefing is the most important element in providing effective learning in simulation-based medical education reviews INNOVATION: The Diamond is a two-sided prompt sheet: the first contains the scaffolding, with a series of specifically constructed questions for each phase of the debrief; the second lays out the theory behind the questions and the process. IMPLICATION: The Diamond encourages a standardised approach to high-quality debriefing on non-technical skills. Feedback from learners and from debriefing faculty members has indicated that the Diamond is useful and valuable as a debriefing tool, benefiting both participants and faculty members. It can be used by junior and senior faculty members debriefing in pairs, allowing the junior faculty member to conduct the description phase, while the more experienced faculty member leads the later and more challenging phases. The Diamond gives an easy but pedagogically sound structure to follow and specific prompts to use in the moment.

Development of a tool to improve performance debriefing and learning: the paediatric Objective Structured Assessment of Debriefing (OSAD) tool.

BACKGROUND: Simulation is an important educational tool to improve medical training and patient safety. Debriefing after simulation is crucial to maximise learning and to translate the lessons learnt to improve real clinical performance, and thus to reduce medical error. Currently there are few tools to improve performance debriefing and learning after simulations of serious paediatric situations. PURPOSE: The purpose of this study was to develop a tool to guide and assess debriefings after simulations of serious paediatric situations, applying the current evidence base and user-based research. STUDY DESIGN: A literature review and semistructured interviews (performed in 2010) to identify important features of a paediatric simulation debriefing. Emergent theme analysis was used to identify key components of an effective debriefing which could be used as a tool for assessing debriefing effectiveness. RESULTS: The literature review identified 34 relevant studies. Interviews were carried out with 16 paediatricians, both debriefing facilitators and learners. In total, 307 features of a debriefing were identified. These were grouped into eight dimensions representing the key components of a paediatric debriefing: the facilitator's approach, learning environment, engagement of learners, reaction, descriptive reflection, analysis, diagnosis and application. These eight dimensions were used to create a tool, the Objective Structured Assessment of Debriefing (OSAD). Each dimension can be scored on a five-point Likert scale containing descriptions for scores 1, 3 and 5 to serve as anchors and aid scoring. CONCLUSIONS: The study identified the important features of a paediatric simulation debriefing, which were developed into the OSAD tool. OSAD offers a structured approach to paediatric simulation debriefing, and is based on evidence from published literature and views of simulation facilitators and learners. OSAD may be used as a guide or assessment tool to improve the quality of debriefing after paediatric simulation.

Short-term effects of nonsurgical periodontal treatment with and without use of diode laser (980 nm) on serum levels of reactive oxygen metabolites and clinical periodontal parameters in patients with chronic periodontitis: a randomized controlled trial.

OBJECTIVE: The aim of this study was to compare the clinical efficiency of a diode laser as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis patients, and also to evaluate the changes in the clinical parameters such as clinical attachment level in teeth with periodontal pockets and blood reactive oxygen metabolites. METHOD AND MATERIALS: A total of thirty patients (mean age 38.2 years) with chronic periodontitis were selected for this study. The patients were randomly assigned into two groups of 15 patients each, as the control group and test group. The control group received only conventional SRP and the test group received conventional SRP and diode laser (GaAlAs)-assisted pocket debridement. The clinical parameters (Plaque Index, bleeding on probing, probing pocket depth, and clinical attachment level) were recorded at baseline and day 60, and the serum levels of reactive oxygen metabolites were estimated at baseline, day 30, and day 60 for both the groups. RESULTS: When the groups were compared, there was statistically significant improvement in Plaque Index score, decrease in bleeding on probing and probing pocket depth, and gain in clinical attachment level (P < .001) in both the groups from baseline to day 60. There was significant reduction in reactive oxygen metabolites in both the groups from baseline to day 30 and day 60 (P < .001). However no statistically significant changes were present between the treatment groups from baseline to day 60 in terms of clinical parameters and blood reactive oxygen metabolites. CONCLUSION: From the results observed in this study it can be concluded that use of diode laser as an adjunct to SRP did not provide any significant difference compared to use of SRP alone in terms of clinical parameters and reactive oxygen metabolites.

A comparative clinical study of the efficacy of subepithelial connective tissue graft and acellular dermal matrix graft in root coverage: 6-month follow-up observation.

AIMS: The purpose of this study was to compare the clinical efficacy of subepithelial connective tissue graft and acellular dermal matrix graft associated with coronally repositioned flap in the treatment of Miller's class I and II gingival recession, 6 months postoperatively. SETTINGS AND DESIGN: Ten patients with bilateral Miller's class I or class II gingival recession were randomly divided into two groups using a split-mouth study design. MATERIALS AND METHODS: Group I (10 sites) was treated with subepithelial connective tissue graft along with coronally repositioned flap and Group II (10 sites) treated with acellular dermal matrix graft along with coronally repositioned flap. Clinical parameters like recession height and width, probing pocket depth, clinical attachment level, and width of keratinized gingiva were evaluated at baseline, 90(th) day, and 180(th) day for both groups. The percentage of root coverage was calculated based on the comparison of the recession height from 0 to 180(th) day in both Groups I and II. STATISTICAL ANALYSIS USED: Intragroup parameters at different time points were measured using the Wilcoxon signed rank test and Mann-Whitney U test was employed to analyze the differences between test and control groups. RESULTS: There was no statistically significant difference in recession height and width, gain in CAL, and increase in the width of keratinized gingiva between the two groups on the 180(th) day. Both procedures showed clinically and statistically significant root coverage (Group I 96%, Group II 89.1%) on the 180(th) day. CONCLUSIONS: The results indicate that coverage of denuded root with both subepithelial connective tissue autograft and acellular dermal matrix allograft are very predictable procedures, which were stable for 6 months postoperatively.

Efficacy of guided bone regeneration using composite bone graft and resorbable collagen membrane in Seibert's Class I ridge defects: radiological evaluation.

The purpose of the study was to evaluate radiologically the efficacy of guided bone regeneration using composite bone graft (autogenous bone graft and anorganic bovine bone graft [Bio-Oss]) along with resorbable collagen membrane (BioMend Extend) in the augmentation of Seibert's class I ridge defects in maxilla. Bone width was evaluated using computerized tomography at day 0 and at day 180 at 2 mm, 4 mm, and 6 mm from the crest. There was a statistically significant increase in bone width between day 0 and day 180 at 2 mm, 4 mm, and 6 mm from the crest. The results of the study demonstrated an increase in bone width of Seibert's class I ridge defects in the maxilla of the study patients.

Peri-implant esthetics assessment and management.

Providing an esthetic restoration in the anterior region of the mouth has been the basis of peri-implant esthetics. To achieve optimal esthetics, in implant supported restorations, various patient and tooth related factors have to be taken into consideration. Peri-implant plastic surgery has been adopted to improve the soft tissue and hard tissue profiles, during and after implant placement. The various factors and the procedures related to enhancement of peri-implant esthetics have been discussed in this review article.

Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team-working, communication and decision-making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programmes that aims to combine technical and non-technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants - South-East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non-technical skills (simulated operating theatres). OBJECTIVES: To establish the feasibility and acceptability of a centralized, simulation-based training-programme. Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills. MATERIALS AND METHODS: For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme. The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA], Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills. The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales. RESULTS: In total 33, three specialist registrars of different grades and five urological nurses participated in the present study. Construct-validity between junior and senior trainees was significant. Of the participants, 90% rated the training models as being realistic and easy to use. In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized. A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills. CONCLUSIONS: A centralized simulation programme that provides training in both technical and non-technical skills is feasible. It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.

Simulation training for improving the quality of care for older people: an independent evaluation of an innovative programme for inter-professional education.

INTRODUCTION: This paper describes the evaluation of a 2-day simulation training programme for staff designed to improve teamwork and inpatient care and compassion in an older persons' unit. OBJECTIVE: The programme was designed to improve inpatient care for older people by using mixed modality simulation exercises to enhance teamwork and empathetic and compassionate care. METHODS: Healthcare professionals took part in: (a) a 1-day human patient simulation course with six scenarios and (b) a 1-day ward-based simulation course involving five 1-h exercises with integrated debriefing. A mixed methods evaluation included observations of the programme, precourse and postcourse confidence rating scales and follow-up interviews with staff at 7-9 weeks post-training. RESULTS: Observations showed enjoyment of the course but some anxiety and apprehension about the simulation environment. Staff self-confidence improved after human patient simulation (t=9; df=56; p<0.001) and ward-based exercises (t=9.3; df=76; p<0.001). Thematic analysis of interview data showed learning in teamwork and patient care. Participants thought that simulation had been beneficial for team practices such as calling for help and verbalising concerns and for improved interaction with patients. Areas to address in future include widening participation across multi-disciplinary teams, enhancing post-training support and exploring further which aspects of the programme enhance compassion and care of older persons. CONCLUSIONS: The study demonstrated that simulation is an effective method for encouraging dignified care and compassion for older persons by teaching team skills and empathetic and sensitive communication with patients and relatives.

Simulation training for hyperacute stroke unit nurses.

National clinical guidelines have emphasized the need to identify acute stroke as a clinical priority for early assessment and treatment of patients on hyperacute stroke units. Nurses working on hyperacute stroke units require stroke specialist training and development of competencies in dealing with neurological emergencies and working in multidisciplinary teams. Educational theory suggests that experiential learning with colleagues in real-life settings may provide transferable results to the workplace with improved performance. Simulation training has been shown to deliver situational training without compromising patient safety and has been shown to improve both technical and non-technical skills (McGaghie et al, 2010). This article describes the role that simulation training may play for nurses working on hyperacute stroke units explaining the modalities available and the educational potential. The article also outlines the development of a pilot course involving directly relevant clinical scenarios for hyperacute stroke unit patient care and assesses the benefits of simulation training for hyperacute stroke unit nurses, in terms of clinical performance and non-clinical abilities including leadership and communication.

Dietary circumvention of acorn tannins by blue jays : Implications for oak demography.

Blue jays consume large quantities of acorns to fuel energy-demanding caching flights in the fall. Yet blue jays possess no known physiological adaptation to counter the negative effects of a high tannin diet on protein digestion. Dietary experiments were conducted to determine if blue jays could subsist on an acorn-only diet, and if they could not, to determine whether supplements of acorn weevil larvae (Curculio), present inside acorns, enabled them to maintain their mass. Comparative tannin assays also were conducted on Lepidobalanus (low tannin; white oak) and Erythrobalanus (high tannin; pin oak) acorns using radial diffusion assay. Captive jays consumed considerable acorn material, yet were unable to maintain mass on ad lib. acorn-only diets or on an acorn +1.5 g larvae/day supplement. There were no significant differences in mass loss between high and low tannin diets. In contrast, blue jays were able to stabilize mass on a diet of acorns +5.0 g larvae supplement/day. These results suggest that acorn weevil larvae, or perhaps other insects, counteract the effects of acorn tannins in the jay diet allowing jays to subsist largely on acorns during the fall caching season. Oak demographic processes may be partly regulated by a tri-trophic relationship among plant, insect and bird. Acorn weevil larvae, considered damaging to oak populations, may actually facilitate oak recruitment and population vagility in the long-term.