Conducting a team-based multi-sited focused ethnography in primary care.

Focused ethnography is an applied and pragmatic form of ethnography that explores a specific social phenomenon as it occurs in everyday life. Based on the literature a problem-focused research question is formulated before the data collection. The data generation process targets key informants and situations so that relevant results on the pre-defined topic can be obtained within a relatively short time-span. As part of a theory based evaluation of alternative forms of consultation (such as video, phone and email) in primary care we used the focused ethnographic method in a multisite study in general practice across the UK. To date there is a gap in the literature on using focused ethnography in healthcare research.The aim of the paper is to build on the various methodological approaches in health services research by presenting the challenges and benefits we encountered whilst conducing a focused ethnography in British primary care. Our considerations are clustered under three headings: constructing a shared understanding, dividing the tasks within the team, and the functioning of the focused ethnographers within the broader multi-disciplinary team.As a result of using this approach we experienced several advantages, like the ability to collect focused data in several settings simultaneously within in a short time-span. Also, the sharing of experiences and interpretations between the researchers contributed to a more holistic understanding of the research topic. However, mechanisms need to be in place to facilitate and synthesise the observations, guide the analysis, and to ensure that all researchers feel engaged. Reflection, trust and flexibility among the team members were crucial to successfully adopt a team focused ethnographic approach. When used for policy focussed applied healthcare research a team-based multi-sited focused ethnography can uncover practices and understandings that would not be apparent through surveys or interviews alone. If conducted with care, it can provide timely findings within the fast moving context of healthcare policy and research.

A hidden history: A survey of the teaching of eugenics in health, social care and pedagogical education and training courses in Europe.

Knowledge and understanding of how eugenics has historically affected the lives of people with intellectual disabilities is vital if professionals are to mount an effective defence against its contemporary influences. An online survey of European providers of health, social care and pedagogical education and training courses was undertaken to find out how the history of eugenics is taught to those wishing to work in services for people with intellectual disabilities. Two hundred and six educational providers were contacted with a response rate of 35.9% (n = 74). Findings showed that the majority of educational providers recognize the importance of including the history of eugenics in their courses, although fewer feel confident that it is sufficiently well covered to prepare future professionals for their role as protector. Course content differs on both the emphasis given to the different components of this history, time dedicated to its delivery and the extent to which it is used to inform legal and ethical debate. Specific recommendations for developing the way in which this subject area is taught are outlined.

The guinea-pig tracheal potential difference as an in vivo model for the study of epithelial sodium channel function in the airways.

BACKGROUND AND PURPOSE: The epithelial sodium channel (ENaC) is a key regulator of airway mucosal hydration and mucus clearance. Negative regulation of airway ENaC function is predicted to be of clinical benefit in the cystic fibrosis lung. The aim of this study was to develop a small animal model to enable the direct assessment of airway ENaC function in vivo. EXPERIMENTAL APPROACH: Tracheal potential difference (TPD) was utilized as a measure of airway epithelial ion transport in the guinea-pig. ENaC activity in the trachea was established with a dose-response assessment to a panel of well-characterized direct and indirect pharmacological modulators of ENaC function, delivered by intra-tracheal (i.t.) instillation. KEY RESULTS: The TPD in anaesthetized guinea-pigs was attenuated by the direct ENaC blockers: amiloride, benzamil and CF552 with ED(50) values of 16, 14 and 0.2 microg kg(-1) (i.t.), respectively. 5-(N-Ethyl-N-isopropyl) amiloride, a structurally related compound but devoid of activity on ENaC, was without effect on the TPD. Intra-tracheal dosing of the Kunitz-type serine protease inhibitors aprotinin and placental bikunin, which have previously been demonstrated to inhibit proteolytic activation of ENaC, likewise potently attenuated TPD in guinea-pigs, whereas alpha(1)-antitrypsin and soya bean trypsin inhibitor were without effect. CONCLUSIONS AND IMPLICATIONS: The pharmacological sensitivity of the TPD to amiloride analogues and also to serine protease inhibitors are both consistent with that of ENaC activity in the guinea-pig trachea. The guinea-pig TPD therefore represents a suitable in vivo model of human airway epithelial ion transport.

Maternal depression, child behavior, and injury.

BACKGROUND: Few data exist on the effect of maternal depression on child injury outcomes and mediators of this relationship. OBJECTIVE: To examine the relationship between mothers' depressive symptoms and medically attended injuries in their children and the potential mediating role of child behavior. DESIGN/METHODS: A cohort of mother-child dyads from the National Longitudinal Study of Youth followed from 1992 to 1994. The primary exposure variable was maternal depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale in 1992. Child behavior was assessed by the Behavior Problems Index externalizing subscale. Logistic regression was used to examine the relationship between depressive symptoms, child behavior, and injury reported in the prior year in 1994. RESULTS: 94 medically attended injuries were reported in the 1106 children (8.5%); two-thirds were sustained in the home environment. Maternal depressive symptoms significantly increased the risk of child injury; injury risk increased 4% for every 1-point increase in depressive symptoms (adjusted OR 1.04, 95% CI 1.01 to 1.08, p=0.02). Increasing maternal depressive symptoms also increased the risk of externalizing behavior problems (adjusted OR 1.06, 95% CI 1.03 to 1.09), but externalizing behavior problems did not significantly mediate the relationship between maternal symptoms and child injury. CONCLUSIONS: Increasing depressive symptoms in mothers was associated with an increased risk of child injury. Child behavior did not significantly mediate the association between maternal depressive symptoms and child injury in this cohort. Greater recognition, referral, and treatment of depressive symptoms in mothers may have effects on child behavior and injury risk.

Predictors of cost of liver transplantation in children: a single center study.

OBJECTIVE: Efforts to decrease the cost of orthotopic liver transplantation (OLT) must address the impact of specific interventions on clinical outcome. We hypothesized that an intervention designed to decrease the length of hospitalization would reduce costs without jeopardizing clinical outcome. We further sought to identify predictors of length of stay and cost for hospitalization after liver transplantation. METHODS: The study group included 47 children who underwent OLT from September 1996 to April 1999, and the control group included 36 children who underwent OLT from March 1994 to August 1996. The intervention was a transition to home program in which patients were discharged to a family living center when they met established clinical criteria and their families met predefined educational goals. We analyzed patients who survived 3 months after OLT. RESULTS: For the intervention group, the mean length of stay, total costs, and surgical costs were 29%, 36%, and 34% lower, respectively. Organ type, height z score, race, hepatic artery thrombosis, early allograft rejection, and participation in the transition to home program predicted length of stay and total costs. CONCLUSION: An early discharge program based on defined criteria can be used to decrease length of stay and cost after OLT without jeopardizing clinical outcome.

The challenge of evidence-based practice for learning disabilities.

There is an ever-increasing pressure on professionals within both health and social care settings to demonstrate evidence-based practice. The main aim of this article is to consider as problematic the challenge of evidence-based practice for both health and social care professionals, with particular reference to those working in the field of learning disabilities. The article addresses a number of issues, including the nature of evidence, the different types of evidence that professionals have at their disposal, and issues of reliability and validity concerning the kinds of approaches used to obtain such evidence. The challenges of implementing evidence into practice are also discussed in relation to ideology, organizational implications, and educational issues.

Continuous measurement of core body temperature in preterm infants.

We tested a transcutaneous core temperature sensor using a method that relies on the principle of zero heat flow. We tested the hypothesis that transcutaneous and rectal temperatures would track within 0.3 degrees C of each other for >90% of the time. A thermistor was placed between the infant's abdomen or back and the incubator's or radiant warmer's mattress, or within the axilla, attached to the skin with a foam adhesive disk insulator. Thirty preterm infants were either placed on their abdomens or backs in a convective incubator or under a radiant warmer, and continuous transcutaneous and rectal temperatures were measured for 1 hour. There were no significant differences between abdominal and core temperatures or between axillary and core temperatures measured in double-walled convective incubators or in radiant warmers. The rectal-abdominal temperature difference was significantly less than the rectal-axillary difference (p < 0.02) in convective incubators, but not when the infant was placed prone under radiant warmers (p = 0.27). Transcutaneous thermometry is reliable for monitoring core body temperature as indicated by rectal temperature in stable preterm infants in a convective incubator.

Sustaining the implementation of an evidence-based guideline for bronchiolitis.

OBJECTIVE: To describe the changes occurring over a 3-year period after implementation of an evidence-based clinical practice guideline for the care of infants with bronchiolitis. DESIGN: Before and after study. SETTING: Children's Hospital Medical Center, Cincinnati, Ohio. PATIENTS: Infants 1 year or younger admitted to the hospital with a first-time episode of typical bronchiolitis. INTERVENTION: The guideline was implemented January 15, 1997. Data on all patients discharged from the hospital with bronchiolitis, from January 15 through March 27, in 1997, 1998, and 1999, were stratified by year and compared with data on similar patients discharged from the hospital in the same periods in the years 1993 through 1996. MAIN OUTCOME MEASURES: Patient volumes, length of stay for admissions, and use of specific laboratory and therapeutic resources ancillary to bed occupancy. RESULTS: After implementation of the guideline, admissions decreased 30% and mean length of stay decreased 17% (P<.001). Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients (P<.001); 14% fewer chest x-ray films were ordered (P<.001). There were significant reductions in the use of all respiratory therapies, with a 17% decrease in the use of at least 1 beta(2)-agonist inhalation therapy (P<.001). In addition, 28% fewer repeated inhalations were administered (P<.001); mean costs for all resources ancillary to bed occupancy fell 41% (P<.001); and mean costs for respiratory care services fell 72% (P<.001). CONCLUSIONS: An evidence-based clinical practice guideline for the care of patients encountered in major pediatric care facility has been successfully sustained beyond the initial year of its introduction to practitioners in southwest Ohio.

Differential markers for regionalization.

OBJECTIVE: To examine the site of delivery for very low birth weight (VLBW) infants and infants with major congenital malformations (MCM) within an established system of perinatal regionalization. STUDY DESIGN: A retrospective study of site of delivery for VLBW infants and infants born with MCM (tracheoesophageal fistula/esophageal atresia, diaphragmatic hernia, or gastroschisis/omphalocele) from 1990 through 1995 in Ohio. RESULTS: A total of 59.8% of VLBW infants and 36.1% of MCM infants were born in a level III hospital. There was a significant trend toward a decrease in VLBW infants (p < 0.01) and an increase in MCM infants (p < 0.05) born in a level III hospital between 1990 and 1995. There were significant regional variations among the six perinatal regions in Ohio in the proportion of both VLBW and MCM infants born in a tertiary center. CONCLUSION: Using the traditional marker of VLBW to assess regionalization in one state, we found significant variation in site of delivery among the perinatal regions and over the time course of the study. The delivery of infants with MCM at level III centers may be an alternative measure of regionalization.

Prenatal care and infant emergency department use.

OBJECTIVE: To determine the relationship between mothers' use of prenatal care and pediatric emergency department (ED) use by their infants in the first 3 months of life. METHODS: This is a retrospective, cohort-control study of well, full-term infants who use a children's hospital ED. Using logistic regression, the likelihood of an emergency visit in the first 3 months of life was compared between infants of women with fewer than two prenatal visits and infants of women with two or more prenatal visits. Covariates were maternal age, race, substance abuse history, parity, infant birth weight, insurance status, and distance from the ED. RESULTS: The odds of an ED visit before age 3 months by infants of mothers with less than two prenatal visits was 29% lower than the comparison group. ED use was increased by proximity, Medicaid or no health insurance and younger maternal age. Seventy percent (70%) of visits by both cohorts were classified as unjustified. The odds of making an unjustified ED visit were increased by younger maternal age and proximity to the emergency department. CONCLUSIONS: Women with poor prenatal care are less likely to seek ED care for their young infants. Although suboptimal prenatal care is associated with negative health outcomes, it is not known whether fewer infant ED visits are similarly deleterious.

Evaluation of an evidence-based guideline for bronchiolitis.

OBJECTIVE: To describe the effect of implementing an evidence-based clinical practice guideline for the inpatient care of infants with bronchiolitis at the Children's Hospital Medical Center in Cincinnati, Ohio. METHODOLOGY: A multidisciplinary team generated the guideline for infants < or = 1 year old who were admitted to the hospital with a first-time episode of typical bronchiolitis. The guideline was implemented January 15, 1997, and data on all patients admitted with bronchiolitis from that date through March 27, 1997, were compared with data on similar patients admitted in the same periods in the years 1993 through 1996. Data were extracted from hospital charts and clinical and financial databases. They included LOS and use and costs of resources ancillary to bed occupancy. RESULTS: After implementation of the guideline, admissions decreased 29% and mean LOS decreased 17%. Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients. Twenty percent fewer chest radiographs were ordered. There were significant reductions in the use of all respiratory therapies, with a 30% decrease in the use of at least 1 beta-agonist inhalation therapy. In addition, 51% fewer repeated inhalations were administered. Mean costs for all resources ancillary to bed occupancy decreased 37%. Mean costs for respiratory care services decreased 77%. CONCLUSIONS: An evidence-based clinical practice guideline for managing bronchiolitis was highly successful in modifying care during its first year of implementation.guideline, bronchiolitis, evidence-based medicine, pediatrics, outcome research.

Health system factors contributing to breastfeeding success.

OBJECTIVE: To identify and characterize health care system factors that contribute to successful breastfeeding in the early postpartum period. STUDY DESIGN: A prospective 8-week cohort study of 522 women at five area hospitals who had a vaginal delivery of a healthy, full-term single child and who intended to breastfeed. Mothers and infants had free access to each other for breastfeeding during the hospital stay. Data were obtained through chart review and surveys. In-person postpartum interviews in the hospital and 4- and 8-week telephone interviews were used to determine participants' perceptions of breastfeeding support by hospital personnel, home visit nurses, and family and friends. The hospital in-person interview with each mother was conducted before discharge to confirm maternal interest and intent to breastfeed. Questions were asked regarding breastfeeding information and support provided by medical and nursing personnel. Mothers were asked to rate the quality of information, as well as the degree of support they received for breastfeeding. Mothers also were asked to rate their hospital breastfeeding experience. A second interview was conducted by telephone 4 weeks after birth. The focus of this interview was to ascertain the rating of their breastfeeding experience, the quality of their interactions with health care professionals, and whether supplemental formula was being provided to the infant. If supplemental formula was being provided, the mothers were asked to quantify the volume and frequency of supplementation. A final telephone interview was conducted when the infants were 8 weeks of age. This interview determined the continuance or cessation of breastfeeding and information about formula supplementation, as in the 4-week interview. Mothers were given a journal and asked to note all telephone calls, clinic visits, and home nurse visits that related to breastfeeding issues and concerns. Demographic data examined included maternal age, marital status, highest level of education reached, race, employment, insurance coverage, and length of stay in the hospital. Pregnancy characteristics included prenatal care, parity, and gravity. Infant characteristics included gestational age and birth weight. Other factors examined included maternal rating of the support received from the infant's father for the decision to breastfeed, the time the infant spent in the mother's hospital room, and whether the infant was breastfed in the delivery room. RESULTS: The women were mostly white (90%), educated (82% had some college education), married, older (mean maternal age of 29.3 years), and insured (92% commercial). The primary outcome of interest was success at breastfeeding. Success was determined based on each mother's initial estimate of the planned duration of breastfeeding. Of the participants, 76% breastfed successfully for at least as long as they had initially planned. Seventeen percent of the mothers had stopped breastfeeding at the time of the 4-week interview, and 29% had stopped by the 8-week interview. Of the infants' fathers, 97% were reported by the mothers to be supportive of the decision to breastfeed. Once discharged, 98% of mothers expected to have help with the household chores. Eighty percent rated their hospital breastfeeding experience as good or very good. However, only 56% rated hospital breastfeeding support as good or very good, and only 44% spoke with a lactation consultant while in the hospital. Of those who spoke with the lactation consultant, 85% felt more confident afterward. Hospital nurses talked with 82% of women, and 97% of these found this helpful. Seventy-four percent reported receiving a home nursing visit after discharge, and of these, 82% found it helpful. Successful mothers were significantly more likely to report that the visiting nurse watched them breastfeed and asked how it was going. Mothers were more likely to call or visit family and friends with concerns about breastfeeding than

Safety of early discharge for Medicaid newborns.

CONTEXT: Neonates are being discharged from the hospital more rapidly, but the risks associated with this practice, especially for low-income populations, are unclear. OBJECTIVE: To determine the impact of decreasing postnatal length of stay on rehospitalization rates in the immediate postdischarge period for Medicaid neonates. DESIGN AND SETTING: Retrospective, population-based cohort study using Ohio Medicaid claims data linked to vital statistics files from July 1, 1991, to June 15, 1995. PARTICIPANTS: A total of 102 678 full-term neonates born to mothers receiving Medicaid for at least 30 days after birth. MAIN OUTCOME MEASURES: Rehospitalization rates within 7 and 14 days of discharge, postdischarge health care use, and regional variations in length of stay and rehospitalization. RESULTS: The proportion of neonates who were discharged following a short stay (less than 1 day after vaginal delivery, less than 2 days after cesarean birth) increased 185%, from 21% to 59.8% (P<.001) and the mean (SD) length of stay decreased 27%, from 2.2 (1.0) to 1.6 (0.9) days (P<.001), over the course of the study. The proportion of neonates who received a primary care visit within 14 days of birth increased 117% (P = .001). Rehospitalization rates within 7 and 14 days of discharge decreased by 23%, from 1.3% to 1.0% (P=.01), and by 19%, from 2.1% to 1.7% (P=.03), respectively. Short stay across the 6 regions of the state varied significantly over time (P<.001). Factors significantly associated with increased likelihood of rehospitalization within both 7 and 14 days of discharge were white race, shorter gestation, primiparity, earlier year of birth, lower 5-minute Apgar score, vaginal delivery, married mother, and region of the state. CONCLUSION: Our data suggest that reductions in length of stay for full-term Medicaid newborns in Ohio have not resulted in an increase in rehospitalization rates in the immediate postnatal period.

Outcomes and resource utilization for newborns with major congenital malformations: the initial NICU admission.

HYPOTHESIS: Newborns with major congenital malformations (MCM) have contributed to a significant proportion of resource utilization in a regional referral neonatal intensive care unit (NICU). SETTING: The Children's Hospital Medical Center NICU, Cincinnati, OH. SUBJECTS: Newborns with and without MCM admitted from August 1, 1993 through July 31, 1994. Total patients studied were 572; 147 with and 385 without MCM. No intervention was performed in this observational study. STATISTICS: Statistics were t test, chi-squared, and rank sum analysis. RESULTS: MCM accounted for 27.6% of NICU referrals, 32.4% of total NICU days, and 39.6% of NICU costs. Both median cost per patient and length of stay were significantly (p < 0.01) higher for patients with MCM than those without MCM. Surgery was more frequent in MCM than non-MCM cases. Thirty-three percent of the newborns with MCM received ongoing medical support at discharge. CONCLUSION: Patients with MCM remain as one of the largest and costliest groups hospitalized in a referral NICU.

Changes in skin blood flow over the foot with warming of the contralateral heel.

Vasospasm in one leg is a common complication of umbilical artery catheterization in preterm infants. It is a common practice to wrap the contralateral leg in a warm washcloth. The rationale for this intervention is to induce reflex vasodilatation of the affected extremity, thereby avoiding the necessity to remove or replace the catheter. This study tested the hypothesis that heating the contralateral extremity in preterm infants would increase peripheral blood flow to the contralateral foot. Ten stable preterm infants who had had no umbilical catheter inserted for at least 2 weeks were studied. Skin perfusion was measured using the laser Doppler method in the distal leg after heating of the opposite foot to 40.5 degrees C. Blood flow to the skin of the contralateral foot was measured before and after warming the ipsilateral one. The skin blood flow measured with and without heat application to the contralateral foot was not significantly different. Direct heat does not induce contralateral reflex vasodilatation in the foot of preterm infants.