Development, implementation and evaluation of the digital transformation of renal services in Wales: the journey from local to national.

BACKGROUND: Treatment for people with kidney disease is often associated with complicated combinations of medicines. Logistical challenges with traditiona paper-based prescribing means that these patients are particularly susceptible to medication-relation errors and harm. AIM: To improve the quality of care that people with kidney disease receive across Wales through a Value-Based digital transformation programme. SETTING: Renal units within the National Welsh Renal Clinical Network (WRCN). DEVELOPMENT: A novel Electronic Prescribing & Medicines Administration (EPMA) system, integrated into a patient care record and linked to a patient portal was developed in South West Wales (SWW) region of the WRCN, enabled by the Welsh Government (WG) Efficiency Through Technology Fund. National upscale was enabled through the WG Transformation Fund. IMPLEMENTATION: EPMA was designed and rolled out initially in SWW region of the WRCN (2018). A dedicated delivery team used the blueprint to finalise and implement a strategy for successful national roll-out eventually across all Wales (completed 2021). EVALUATION: A multi-factorial approach was employed, as both the technology itself and the healthcare system within which it would be introduced, were complex. Continuous cycles of action research involving informal and formal qualitative interviews with service-users ensured that EPMA was accessible and optimally engaging to all target stakeholders (patients and staff). Results confirmed that EPMA was successful in improving the quality of care that people with kidney disease receive across Wales, contributed to Value-Based outcomes, and put people who deliver and access care at the heart of transformation. CONCLUSION: Key findings of this study align directly with the national design principles to drive change and transformation, put forward by the WG in their plan for Health and Social Care: prevention and early intervention; safety; independence; voice; seamless care.

Views, experience and adherence among pregnant women with gestational diabetes participating in a weight loss study (WELLBABE).

AIMS: To investigate the views and experience of pregnant women newly diagnosed with gestational diabetes mellitus participating in a 1200 kcal/day diet to achieve moderate weight loss (the WELLBABE study), and to explore barriers to and facilitators of adherence. METHODS: Twelve participants engaged in semi-structured interviews after completion of the 4-week diet. An interview schedule was devised using open-ended questions guided by the Theoretical Domains Framework. Transcript responses were analysed thematically. RESULTS: Participants were anxious about their diagnosis of gestational diabetes, but concerns related to dieting in pregnancy were allayed by reassurance from the research team. Participants expected health benefits, improved knowledge and support from enrolling on the study. The participants' primary motivator to diet adherence was their baby's wellbeing. Other facilitatory factors included improving their own health and reducing any future risk of diabetes. Trying to provide reliable results and receiving extra care also facilitated adherence. Partners, friends and family were an important source of social support and no barrier caused by concern about weight loss in pregnancy was encountered. Observed and experienced physical changes and feedback from the research team positively reinforced adherence. The main barrier was that learning new skills was initially time-consuming. CONCLUSIONS: Weight loss was acceptable to women with gestational diabetes provided with clear information about likely benefit. A randomized controlled trial of this intervention is now required, employing clear information and feedback of glycaemic benefit to facilitate efficacy.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education.

BACKGROUND: Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. AIM: To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. METHODS: A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017. FINDINGS: A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals. CONCLUSION: Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Lesbian and bisexual women's likelihood of becoming pregnant: a systematic review and meta-analysis.

BACKGROUND: Few data exist regarding pregnancy in lesbian and bisexual (LB) women. OBJECTIVES: To determine the likelihood of LB women becoming pregnant, naturally or assisted, in comparison with heterosexual women SEARCH STRATEGY: Systematic review of papers published 1 January 2000 to 23 June 2015. SELECTION CRITERIA: Studies contained details of pregnancy rates among LB women compared with heterosexual women. No restriction on study design. DATA COLLECTION AND ANALYSIS: Inclusion decisions, data extraction and quality assessment were conducted in duplicate. Meta-analyses were carried out, with subgroups as appropriate. MAIN RESULTS: Of 6859 papers identified, 104 full-text articles were requested, 30 papers (28 studies) were included. The odds ratio (OR) of ever being pregnant was 0.19 (95% CI 0.18-0.21) in lesbian women and 1.22 (95% CI 1.15-1.29) in bisexual women compared with heterosexual women. In the general population, the odds ratio for pregnancy was nine-fold lower among lesbian women and over two-fold lower among bisexual women (0.12 [95% CI 0.12-0.13] and 0.50 [95% CI 0.45-0.55], respectively). Odds ratios for pregnancy were higher for both LB adolescents (1.37 [95% CI 1.18-1.59] and 1.98 [95% CI 1.85, 2.13], respectively). There were inconsistent results regarding abortion rates. Lower rates of previous pregnancies were found in lesbian women undergoing artificial insemination (OR 0.17 [95% CI 0.11-0.26]) but there were higher assisted reproduction success rates compared with heterosexual women (OR 1.56 [95% CI 1.24-1.96]). CONCLUSIONS: Heterosexuality must not be assumed in adolescents, as LB adolescents are at greater risk of unwanted pregnancies and terminations. Clinicians should provide appropriate information to all women, without assumptions about LB patients' desire for, or rejection of, fertility and childbearing. TWEETABLE ABSTRACT: Review of likelihood of LB women becoming pregnant: LB teenagers at greater risk of unwanted pregnancies.

Mechanism of insulin resistance in normal pregnancy.

Normal pregnancy is associated with insulin resistance although the mechanism is not understood. Increased intramyocellular lipid is closely associated with the insulin resistance of type 2 diabetes and obesity, and the aim of this study was to determine whether this was so for the physiological insulin resistance of pregnancy. Eleven primiparous healthy pregnant women (age: 27-39 years, body mass index 24.0±3.1 kg/m2) and no personal or family history of diabetes underwent magnetic resonance studies to quantify intramyocellular lipid, plasma lipid fractions, and insulin sensitivity. The meal-related insulin sensitivity index was considerably lower in pregnancy (45.6±9.9 vs. 193.0±26.1; 10(-4) dl/kg/min per pmol/l, p=0.0002). Fasting plasma triglyceride levels were elevated 3-fold during pregnancy (2.3±0.2 vs. 0.8±0.1 mmol/l, p<0.01) and the low-density density lipoprotein fraction, responsible for fatty acid delivery to muscle and other tissues, was 6-fold elevated (0.75±0.43 vs. 0.12±0.09 mmol/l; p=0.001). However, mean intramyocellular lipid concentrations of the soleus muscle were not different during pregnancy (20.0±2.3 vs. 19.1±3.2 mmol/l, p=0.64). The pregnancy effect on muscle insulin resistance is distinct from that underlying type 2 diabetes.

Are coagulation studies on blood sampled from arterial lines valid?

Coagulation tests were performed on two venous blood samples and two blood samples from arterial lines taken from 79 patients on an intensive care unit. For the first arterial sample the discard volume was 4.5 ml and for the second arterial sample the discard volume was 16 ml. From each pair of venous samples a mean venous coagulation value was calculated. There were statistically significant differences between arterial and venous results and between the two arterial samples for activated partial thromboplastin time and thrombin time assays but not for prothrombin time, reptilase time and fibrinogen assays. However, these differences were sufficiently small to be of little clinical significance. The bias for the difference in activated partial thromboplastin time values between the first arterial sample and the venous sample was +1.24 s (limits of agreement: -4.39 to +6.87 s) and between the second arterial sample and the venous sample the bias was +0.89 s (limits of agreement: -3.25 to +5.03 s). Only 3.8% of first arterial samples and 1.3% of second arterial samples produced activated partial thromboplastin time values that were more than 10% longer than the corresponding venous values. No heparin was detectable in these arterial samples using a heparin assay (< 0.02 iu.ml-1). The differences between arterial and venous activated partial thromboplastin times were slightly but not significantly greater in subgroups of patients with moderately or severely deranged coagulation compared with a group with normal coagulation. We conclude that samples from arterial lines provide valid activated partial thromboplastin time results using a discard volume of either 4.5 ml or 16 ml.

Integrating electronic conferencing to enhance problem solving in nursing.

The authors describe how a computer-mediated conference was integrated into a baccalaureate nursing program clinical course. They discuss methods used in implementing the conference, including a technical review of the software and hardware, and methods of implementing and monitoring the conference with students. Examples of discussion items, student and faculty responses to posted items, and responses to use of the computer-mediated conference are included. Results and recommendations from this experience will be useful to other schools integrating computer-mediated conference technology into the nursing school curriculum.

Design and development of an expert system for student use in a school of nursing.

Use of the expert system as a tool for clinical decision support for students and practitioners of nursing is a subject of much discussion and developmental activity. A prototype of a nursing expert system was designed for use in a simulated laboratory environment to provide nursing students with decision support in identifying and managing common postoperative complications. Formative evaluation of the system with associate and baccalaureate nursing students elicited positive response and formed the basis for ongoing program refinement. The practicing nurse of the future must understand expert system use in order to consider the implications and potential of such a clinical tool in nursing practice.

Employer evaluations of nurse graduates: a critical program assessment element.

Accountability in higher education dictates implementation of a comprehensive evaluation plan. Employer evaluation of graduates is an important component of program evaluation and contributes a different view that is rarely reported in the literature. The purpose of this study was to establish a database by surveying employers of baccalaureate-prepared nurses, postgraduation, over a five-year period. Employer surveys measured perceptions of graduates' functioning. Findings indicated that graduates function above expected levels for leadership skills, nursing skills, communication skills, and professionalism. Systematic program evaluation by employers is recommended at one and five years after graduation. A tool for employer evaluation of baccalaureate graduates is discussed.

Integrating HIV/AIDS policies and curricular content into baccalaureate nursing programs.

A model used by one school of nursing to implement HIV/AIDS policies, sequenced instructional opportunities, and a research-based evaluation process is described. In the evaluation phase, a study was undertaken to measure students' retention of HIV/AIDS knowledge and their application of universal precautions (U.P.). Findings revealed that 59% of junior baccalaureate nursing students and 75% of seniors retained knowledge about HIV/AIDS and U.P. Seniors indicated that in their role as nursing student or technician/extern, supplies and equipment were readily available and that they had sufficient time to implement U.P. However, only 64% admitted to following correct procedures, even though 96% acknowledged feeling confident in their ability to do so. Knowledge about HIV/AIDS and consistent application of U.P. protects nursing students, prevents legal problems, and promotes the quality of patient care.

A participatory learning module: asepsis and universal precautions.

Mastery of medical and surgical asepsis principles is mandatory for nurses in today's health care environment. The authors report on the development, implementation, and evaluation of a multimedia asepsis module incorporating universal precautions. Practical application of the content, using graphics, medical supplies, and video, occurs in the four-station participatory learning module. Student evaluations of this learning module are positive.

Team management: an alternative to acting directorship.

A sudden absence of leadership due to unexpected illness, death, or resignation can seriously weaken an organization. Orderly administrative transition was believed to be necessary by those confronting a sudden leadership void. A team management administrative approach was proposed in response to an urgent and complex problem. Results of an evaluation of the team at the end of 1 year of leadership are presented. Team management is documented as a viable alternative to a one person acting director in an academic setting.

Posology: the battle against dosage calculation errors.

The authors explored math and dosage calculation deficiencies in a sample of 223 baccalaureate, associate, and diploma programs representing the geographic United States. The dissemination of results serves to inform nurse educators of the potential for graduating math deficient student nurses and to recommend measures for resolution of the identified problem.

Prophylactic immunization against experimental leishmaniasis. VI. Comparison of protective and disease-promoting T cells.

In previous studies, we reported that mice immunized i.v. with lethally irradiated Leishmania major promastigotes developed substantial resistance to a subsequent L. major infection. However, such protection could be totally suppressed by prior s.c. injection with the same antigens. Both the protective immunity and the inhibition of its induction could be adoptively transferred with specific Lyt-2- T cells. Here, we present evidence showing that protection and disease promotion resulting from i.v. or s.c. immunization, respectively, are mediated by functionally distinct subsets of T cells. In a series of titration experiments, it was found that freshly isolated T cells derived from prophylactically i.v. immunized BALB/c mice were either protective (greater than 10(7) cells/recipient) or ineffective (less than 10(7) cells/recipient). No exacerbation of disease was observed at any dose. Conversely, T cells from mice immunized s.c. either accelerated disease development and inhibited protective immunization (greater than 10(7) cells/recipient) or had no effect (less than 10(7) cells/recipient). No protection was observed at any dose tested. In mixed transfer experiments, increasing numbers of T cells from s.c. immunized donors progressively inhibited the protective effect of T cells from i.v. immunized donors. Supernatant of T cell cultures from protectively immunized donors contained substantial macrophage-activating factor whereas such activity was not detectable in the supernatant of T cell culture from s.c. immunized donors. Analysis by flow cytometry showed that the spleen and lymph nodes of normal, i.v., or s.c. immunized BALB/c mice contained similar ratios of L3T4+ cells and Lyt-2+ cells.