Training needs for staff providing remote services in general practice: a mixed-methods study.

BACKGROUND: Contemporary general practice includes many kinds of remote encounter. The rise in telephone, video and online modalities for triage and clinical care requires clinicians and support staff to be trained, both individually and as teams, but evidence-based competencies have not previously been produced for general practice. AIM: To identify training needs, core competencies, and learning methods for staff providing remote encounters. DESIGN AND SETTING: Mixed-methods study in UK general practice. METHOD: Data were collated from longitudinal ethnographic case studies of 12 general practices; a multi-stakeholder workshop; interviews with policymakers, training providers, and trainees; published research; and grey literature (such as training materials and surveys). Data were coded thematically and analysed using theories of individual and team learning. RESULTS: Learning to provide remote services occurred in the context of high workload, understaffing, and complex workflows. Low confidence and perceived unmet training needs were common. Training priorities for novice clinicians included basic technological skills, triage, ethics (for privacy and consent), and communication and clinical skills. Established clinicians' training priorities include advanced communication skills (for example, maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, coordinating multi-professional care in a distributed environment, and training others. Much existing training is didactic and technology focused. While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements were usually acquired through experience, informal discussions, and on-the-job methods such as shadowing. Whole-team training was valued but rarely available. A draft set of competencies is offered based on the findings. CONCLUSION: The knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective, and organisationally embedded. The vital role of non-didactic training, for example, joint clinical sessions, case-based discussions, and in-person, whole-team, on-the-job training, needs to be recognised.

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis.

BACKGROUND: Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. SETTING AND SAMPLE: UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. METHODS: Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts. RESULTS: Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. CONCLUSION: While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age.

Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and 'tinkering' by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving-to a greater or lesser extent-continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity-of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.

The impact of remote care approaches on continuity in primary care: a mixed-studies systematic review.

BACKGROUND: The value of continuity in primary care has been demonstrated for multiple positive outcomes. However, little is known about how the expansion of remote and digital care models in primary care have impacted continuity. AIM: To explore the impact of the expansion of remote and digital care models on continuity in primary care. DESIGN AND SETTING: A systematic review of continuity in primary care. METHOD: A keyword search of Embase, MEDLINE, and CINAHL databases was used along with snowball sampling to identify relevant English-language qualitative and quantitative studies from any country between 2000 and 2022, which explored remote or digital approaches in primary care and continuity. Relevant data were extracted, analysed using GRADE-CERQual, and narratively synthesised. RESULTS: Fifteen studies were included in the review. The specific impact of remote approaches on continuity was rarely overtly addressed. Some patients expressed a preference for relational continuity depending on circumstance, problem, and context; others prioritised access. Clinicians valued continuity, with some viewing remote consultations more suitable where there was high episodic or relational continuity. With lower continuity, patients and clinicians considered remote consultations harder, higher risk, and poorer quality. Some evidence suggested that remote approaches and/or their implementation risked worsening inequalities and causing harm by reducing continuity where it was valuable. However, if deployed strategically and flexibly, remote approaches could improve continuity. CONCLUSION: While the value of continuity in primary care has previously been well demonstrated, the dearth of evidence around continuity in a remote and digital context is troubling. Further research is, therefore, needed to explore the links between the shift to remote care, continuity and equity, using real-world evaluation frameworks to ascertain when and for whom continuity adds most value, and how this can be enabled or maintained.

Remote care in UK general practice: baseline data on 11 case studies.

Background: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs. Methods: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data. Results: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts. Conclusions: General practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

We describe early results from the Remote by Default 2 study, which is following 11 UK general practices for two years as they introduce various kinds of remote appointment booking and clinical consultations. We have been using interviews and ethnography (watching real-world activities), and analysing documents (such as practice reports and websites) to prepare case studies of the 11 practices, which vary widely in size, ethos, geographical location, practice population and digital maturity. Our initial interviews identified the following cross-cutting themes, which showed both commonalities and differences across the 11 practices: - The 'digital front door' (patients gaining access using digital portals), which was used to a greater or lesser extent in all practices; some found these systems frustrating and inefficient.- Quality and safety. Staff were concerned about the risk of missing an important diagnosis when consulting remotely, and felt that digitisation could threaten continuity of care.- Digital inclusion. All practices were keen to ensure that patients who lacked digital devices or skills were not disadvantaged; this goal was achieved in different ways (and to different degrees) in different settings.- Staff support and training. Some practices are finding current workload unsustainable due to (among other things) rising patient demand, unfilled staff posts, a post-pandemic backlog of unmet need, and task-shifting from secondary care. Digitisation appears to have increased workload in most practices.- Technologies and infrastructure. The IT infrastructure in each practice had grown in a particular way over time, and was in this sense 'path-dependent' (hence, not easily changed). In conclusion, different practices are responding to the 'disruptive innovation' of digital technologies in very different ways, reflecting their different practice populations, settings and priorities. We plan to follow the above themes over time and explore additional themes including the experience and role of patients.

Protocol: Remote care as the 'new normal'? Multi-site case study in UK general practice.

Background: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices' varied experiences over time as they seek to establish remote forms of accessing and delivering care. Methods: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). Results anticipated: We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). Conclusion: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

The pandemic required general practices to introduce remote (phone, video and email) consultations. That policy undoubtedly saved lives at the time but there are also clear benefits of face-to-face consultations in some circumstances, and the exact role of remote care still needs to be worked out. Despite best efforts, remote care tends to worsen health inequities (people who were poor or less well educated are less able to access and navigate the system and secure the type of appointment they need or prefer). Workstream 1: We will look at 11 GP surgeries across England, Scotland and Wales. We have selected a variety of sites: urban and rural, serving a range of different communities. Each surgery has a different approach to technology. A researcher from our team will work alongside surgery staff to learn what methods and technologies each practice uses to deliver care. They will gather information (mostly qualitative) about how different technological solutions are playing out over time. Workstream 2: Many people experience barriers to accessing care when it is done through technology. This could be because they lack understanding of how to do it, don't have the right equipment, can't afford data, or other reasons. We will ask patients about their experiences and work with them and staff to develop ideas about how to overcome barriers. Workstream 3: We will take what we have learnt in Workstreams 1 and 2 to make suggestions to inform national stakeholders and to influence policymakers. Patients and members of the public helped shape the research design. They continue to help guide our research by reading our reports, giving us their opinions and advising on how best to share our research so everyone can benefit from what we have learnt. Our governance panel is chaired by a member of the public.

Evaluation of albendazole efficiency and complications in patients with pulmonary hydatid cyst.

OBJECTIVES: This study investigated the efficacy and complications of albendazole use after surgery in patients with pulmonary hydatid cysts. METHODS: One hundred fifty-three consecutive patients who met the study criteria out of 215 patients who received prophylaxis with albendazole after surgery for isolated pulmonary hydatid cysts in our clinic between January 2011 and December 2020 were analysed retrospectively. RESULTS: Eighty-six out of 153 (56.2%) of cases were male and 67 (43.8%) were female. The average age was 24.6 ± 17.4 (between 3 and 71 years), 76 of them (49.7%) were 18 years old and younger, while 77 (50.3%) were adults. All cases were approached transthoracically and a total of 170 operations were performed on the 153 cases. Fever, weakness and dizziness were reported in only one patient who was given albendazole treatment. A partial increase in liver enzymes was observed in 16 cases (10.5%) after albendazole treatment. Mild leukopoenia and neutropenia were observed in only one of the cases. In 1 case, a second operation was performed 30 months later due to recurrence. Albendazole treatment was not required to be discontinued in any of the cases. Mortality was not observed in any of the cases. Factors such as mean age, cyst size and hospitalization period did not have a statistically significant effect on any changes in liver enzymes tests following albendazole therapy (P > 0.05). CONCLUSIONS: Albendazole treatment can safely be used for postoperative prophylaxis in patients with pulmonary hydatid cysts in a controlled manner without causing serious complications. SUBJ COLLECTION: 152.

Direct and indirect evidence of efficacy and safety of rapid exercise tests for exertional desaturation in Covid-19: a rapid systematic review.

BACKGROUND: Even when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of different rapid tests for exertional desaturation and draw on this evidence base to provide guidance in the context of acute Covid-19. MAIN RESEARCH QUESTIONS: 1. What exercise tests have been used to assess exertional hypoxia at home or in an ambulatory setting in the context of Covid-19 and to what extent have they been validated? 2. What exercise tests have been used to assess exertional hypoxia in other lung conditions, to what extent have they been validated and what is the applicability of these studies to acute Covid-19? METHOD: AMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. A protocol for the review was published on the Medrxiv database. RESULTS: Of 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-min sit-to-stand test [1MSTST] with reference to the 6-min walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%) and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). Heterogeneity of study design precluded meta-analysis. DISCUSSION: Exertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. A stronger evidence base exists for the diagnostic accuracy of the 1MSTST in chronic long-term pulmonary disease; the relative intensity of this test may raise safety concerns in remote consultations or unstable patients. The less strenuous 40-step walk test should be urgently evaluated.

Severe sepsis in women with group B Streptococcus in pregnancy: an exploratory UK national case-control study.

OBJECTIVE: To estimate the incidence of severe maternal sepsis due to group B Streptococcus (GBS) in the UK, and to investigate the associated outcomes for mother and infant. DESIGN: National case-control study. SETTING: All UK consultant-led maternity units. PARTICIPANTS: 30 women with confirmed or suspected severe GBS sepsis, and 757 control women. MAIN OUTCOME MEASURES: Disease incidence, additional maternal morbidity, critical care admission, length of stay, infant infection, mortality. RESULTS: The incidences of confirmed and presumed severe maternal GBS sepsis were 1.00 and 2.75 per 100,000 maternities, respectively, giving an overall incidence of 3.75 per 100,000. Compared with controls, severe GBS sepsis was associated with higher odds of additional maternal morbidity (OR 12.35, 95% CI 3.96 to 35.0), requiring level 2 (OR 39.3, 95% CI 16.0 to 99.3) or level 3 (OR 182, 95% CI 21.0 to 8701) care and longer hospital stay (median stay in cases and controls was 7 days (range 3-29 days) and 2 days (range 0-16 days), respectively, p<0.001). None of the women died. Severe maternal GBS sepsis was associated with higher odds of infant sepsis (OR 32.7, 95% CI 8.99 to 119.0); 79% of infants, however, did not develop sepsis. There were no associated stillbirths or neonatal deaths. CONCLUSIONS: Severe maternal GBS sepsis is a rare occurrence in the UK. It is associated with adverse maternal and neonatal outcomes.

Unicompartment compartment syndrome following laparascopic colonic resection.

We report the case of a 43-year-old man who developed anterior compartment syndrome following laparoscopic colorectal surgery in the lithotomy position. This was initially masked by postoperative epidural usage and ultimately diagnosed 2 days postoperatively. The patient underwent decompression by four compartment fasciotomy and two follow-up re-explorations of the affected lower limb. This case is unique for two reasons: only the anterior compartment of the lower limb was affected--which is rare in itself--and there was a delay in presentation secondary to postoperative epidural usage.

Management of reproductive health in Cowden syndrome complicated by endometrial polyps and breast cancer.

BACKGROUND: Cowden syndrome is an autosomal-dominant condition associated with mutations in the tumor suppressor gene PTEN. Gynecologic malignancies are common with a 5-10% risk of endometrial cancer and 25-50% risk of breast cancer. CASE: A 37-year-old woman with a history of breast cancer, other neoplasms, and multiple skin lesions was diagnosed with Cowden syndrome after a germline PTEN mutation was identified. The endometrium had high glucose uptake on positron emission tomography scan and was irregularly thickened on ultrasonography; biopsy revealed endometrial polyps and simple hyperplasia. Fifteen months later, hysteroscopy again confirmed numerous benign endometrial polyps. CONCLUSION: Recurrent, multiple endometrial polyps portend a high risk of endometrial cancer in women with Cowden syndrome. Monitoring for malignancy and consideration of hysterectomy after childbearing is completed is warranted.

Cardiac arrhythmia: a simple conceptual framework.

This review presents a simple trigger-substrate model of arrhythmogenesis and its application to the generation of reentrant ventricular arrhythmias. We demonstrate its broad applicability to the understanding of arrhythmic phenomena in a wide range of both hereditary and acquired arrhythmic disorders.

Alternans in genetically modified langendorff-perfused murine hearts modeling catecholaminergic polymorphic ventricular tachycardia.

The relationship between alternans and arrhythmogenicity was studied in genetically modified murine hearts modeling catecholaminergic polymorphic ventricular tachycardia (CPVT) during Langendorff perfusion, before and after treatment with catecholamines and a ß-adrenergic antagonist. Heterozygous (RyR2(p/s)) and homozygous (RyR2(s/s)) RyR2-P2328S hearts, and wild-type (WT) controls, were studied before and after treatment with epinephrine (100 nM and 1 µM) and propranolol (100 nM). Monophasic action potential recordings demonstrated significantly greater incidences of arrhythmia in RyR2(p/s) and RyR2(s/s) hearts as compared to WTs. Arrhythmogenicity in RyR2(s/s) hearts was associated with alternans, particularly at short baseline cycle lengths. Both phenomena were significantly accentuated by treatment with epinephrine and significantly diminished by treatment with propranolol, in full agreement with clinical expectations. These changes took place, however, despite an absence of changes in mean action potential durations, ventricular effective refractory periods or restitution curve characteristics. Furthermore pooled data from all hearts in which arrhythmia occurred demonstrated significantly greater alternans magnitudes, but similar restitution curve slopes, to hearts that did not demonstrate arrhythmia. These findings thus further validate the RyR2-P2328S murine heart as a model for human CPVT, confirming an alternans phenotype in common with murine genetic models of the Brugada syndrome and the congenital long-QT syndrome type 3. In contrast to these latter similarities, however, this report demonstrates the dissociation of alternans from changes in the properties of restitution curves for the first time in a murine model of a human arrhythmic syndrome.

Activation of purinergic receptors by ATP induces ventricular tachycardia by membrane depolarization and modifications of Ca2+ homeostasis.

Cardiac myocytes are continuously exposed to extracellular nucleotides secreted by the myocytes themselves, nerve terminals, or platelets and other blood cells during coronary perfusion, and the concentrations of such extracellular nucleotides are known to increase during cardiac ischemia and hypoxia. The effects of the extracellular nucleotides ATP, ADP, UTP, and adenosine on ventricular arrhythmogenic properties were explored in 36 Langendorff-perfused mouse hearts using monophasic action potential recording. Extracellular nucleotides induced arrhythmic phenomena in form of ectopic activity and ventricular tachycardia in a potency order of ATP (n=7) > ADP (n=5) > UTP (n=3) approximately adenosine (n=3). The purinergic receptor antagonists suramin and pyridoxal phosphate-6-azo(benzene-2,4-disulphonic acid) reduced the incidence of ATP-triggered arrhythmias. In isolated ventricular myocytes, ATP induced sustained increases in diastolic Ca2+ and triggered multiple Ca2+ waves, which were inhibited by suramin but not by the L-type Ca2+ channel antagonist nifedipine. In whole-cell patch clamp experiments, extracellular ATP induced two distinct types of inward currents, which were inhibited by suramin and PPADS, suggesting activation of P2X receptors. ATP also induced delayed after-depolarizations and ectopic action potentials in current clamped ventricular myocytes. In conclusion, extracellular ATP activates purinergic receptors and induces arrhythmic activity through modifications of Ca2+ homeostasis and an activation of depolarizing membrane currents.