The meaning and importance of dignified care: findings from a survey of health and social care professionals.

BACKGROUND: There are well established national and local policies championing the need to provide dignity in care for older people. We have evidence as to what older people and their relatives understand by the term 'dignified care' but less insight into the perspectives of staff regarding their understanding of this key policy objective. METHODS: A survey of health and social care professionals across four NHS Trusts in England to investigate how dignified care for older people is understood and delivered. We received 192 questionnaires of the 650 distributed. RESULTS: Health and social care professionals described the meaning of dignified care in terms of their relationships with patients: 'respect' (47%), 'being treated as an individual' (40%), 'being involved in decision making' (26%) and 'privacy' (24%). 'Being treated as an individual' and 'maintaining privacy' were ranked as the most important components of dignified care. Physical caring tasks such as 'helping with washing, dressing and feeding' were rarely described as being part of dignified care and attributed much less importance than the relational components. CONCLUSION: Dignity in care is a concept with multiple meanings. Older people and their relatives focus upon the importance of providing physical care when describing what this means to them. Our participants focussed upon the relational aspects of care delivery rather than care itself. Proactive measures are therefore required to ensure that the physical aspects of care are met for all older people receiving care in NHS trusts.

Management of gastroenteritis over 10 years: changing culture and maintaining the change.

OBJECTIVE: To examine the impact of an implementation program on adherence to a guideline for the management of acute gastroenteritis. DESIGN: Using four retrospective audits over a 10-year period, the authors examined the change in practice and maintenance of that change following a targeted implementation program for the clinical guideline. SETTING: Tertiary children's hospital in South Wales. PARTICIPANTS: 447 children aged less than 5 years, admitted to hospital with acute gastroenteritis, comprising four cross-sectional samples (106 in 1999, 153 in 2002, 99 in 2004, 89 in 2009). MAIN OUTCOME MEASURES: Age of child, hydration status, method of rehydration and duration of admission, for each audit, with an implementation strategy delivered after the second audit. RESULTS: In 1999 and 2002, intravenous rehydration was used in 20% and 15% of cases, respectively. After the implementation program in 2004, compared to 1999, there was a significant decrease in the intravenous rehydration rate to 4% in 2004 (p<0.001); in 2009 the intravenous rehydration rate was maintained at a low level of 6% (p<0.001). CONCLUSION: It was only after the implementation program that a change in practice was achieved. Once change had been accepted, it was maintained even in the absence of targeted training. Audit does not improve clinical practice unless, in addition, there is a clear, succinct guideline with an implementation programme in place.

Standing secure amidst a falling world? Practitioner understandings of old age in responses to a case vignette.

The specialist knowledge and skills of health and social care practitioners working with older people are often unacknowledged. This paper examines an important aspect of specialist knowledge, the understandings of ageing and old age that underpin practice in a society where negative assumptions about old age and older people are widespread. These understandings were explored through analysis of data from 30 interviews with health and social care practitioners working with older people at risk of falling. The interviews centred on a case vignette and the analysis presented here focuses on respondents' perceptions of the scenario and of the reluctance of its subject, a 79-year-old woman, to seek help after a fall. The findings suggest that practitioners' understandings of older people are grounded in practice and personal experience, with little evidence of the use of theoretical or research-based knowledge of ageing and old age. This suggests that the potential for formal knowledge of ageing to support reflective and empowering practice with older people has yet to be fully exploited. The paper concludes with a discussion of the relevance to interprofessional practice of gerontological theory and research and suggestions for further research.

Triplex targeted genomic crosslinks enter separable deletion and base substitution pathways.

We have synthesized triple helix forming oligonucleotides (TFOs) that target a psoralen (pso) interstrand crosslink to a specific chromosomal site in mammalian cells. Mutagenesis of the targeted crosslinks results in base substitutions and deletions. Identification of the gene products involved in mutation formation is important for developing practical applications of pso-TFOs, and may be informative about the metabolism of other interstrand crosslinks. We have studied mutagenesis of a pso-TFO genomic crosslink in repair proficient and deficient cells. Deficiencies in non homologous end joining and mismatch repair do not influence mutation patterns. In contrast, the frequency of base substitutions is dependent on the activity of ERCC1/XPF and polymerase zeta, but independent of other nucleotide excision repair (NER) or transcription coupled repair (TCR) genes. In NER/TCR deficient cells the frequency of deletions rises, indicating that in wild-type cells NER/TCR functions divert pso-TFO crosslinks from processes that result in deletions. We conclude that targeted pso-TFO crosslinks can enter genetically distinct mutational routes that resolve to base substitutions or deletions.

Feasibility of using ambulatory electrocardiographic monitors following discharge after cardiac surgery.

Although ambulatory electrocardiographic (ECG) monitors are increasingly being used to detect arrhythmias in outpatient and home care settings, little is known about patients' reactions to these devices and their ability to use them correctly. This study determined the feasibility of this type of monitoring. It provides clinicians a research-based approach to patient care and teaching in the home.

Do Personal Medical Services contracts improve quality of care? A multi-method evaluation.

OBJECTIVES: To assess whether the new contractual arrangements of first-wave Personal Medical Services (PMS) practices in England improved their quality of care, compared with changes in care provided in a control sample of General Medical Services (GMS) practices. METHODS: Controlled 'before' (at or near 1 April 1998) and 'after' (at or near 31 March 2001) quantitative observational study in a sample of 23 PMS and 23 GMS practices. Quantitative data focused on access, chronic disease management, mental health care, primary care of older people, costs and patient evaluation using the General Practice Assessment Survey. Case studies were also undertaken in all PMS pilots, involving interviews with general practitioners, nurses, practice managers and Health Authority and Primary Care Group/Trust managers, documentation review, and analysis of site-specific data. RESULTS: There were improvements in quality of care in PMS sites in all areas of care evaluated, but improvements in care over and above those found in GMS sites (the 'PMS effect') were only statistically significant for angina care (P = 0.05) and elderly care (P = 0.04). Teamwork, shared culture, clear objectives and leadership were important catalysts for quality improvement in PMS sites. Improvements in PMS practices came at additional financial cost. There were concurrent improvements in GMS practices. No PMS site succeeded in meeting its aims without successfully introducing effective leadership and management, and changing relationships within the practice (e.g. equalising power between nurses and doctors). CONCLUSIONS: Small but steady improvements were observed in English primary care. PMS contracts facilitated quality improvements in specific areas over and above these broad improvements (the 'PMS effect') during the study period. New contractual arrangements for health care can be used to improve quality of care. However, the mechanisms that resulted in quality gains, while facilitated by the new contractual arrangements, were not specific or unique to the PMS experiment. Factors such as effective management, clear objectives and flexible professional relationships within practices are likely to be important in determining whether new contractual arrangements result in improved outcomes. The context within which care and services are provided is as important for quality innovations as specific contractual arrangements.

Incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation is the most common complication after cardiac surgery and a major cause of morbidity and increased cost of care. OBJECTIVES: To examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery. METHODS: A total of 302 patients were continuously monitored for atrial fibrillation with standard hardwire and telemetry devices during hospitalization after coronary artery bypass graft and/or valve surgery and with wearable cardiac event recorders for 2 weeks after discharge from the hospital. After discharge, patients recorded and transmitted their rhythm by telephone daily and whenever they had symptoms suggestive of atrial fibrillation. RESULTS: Of the 302 patients, 127 (42%) had atrial fibrillation; 41 had it after discharge, and for 10 it was their first episode. The first episode occurred at a mean of 2.9 days after surgery (SD, 3.1; range, day of surgery to 21 days after surgery). Although palpitations was the most common symptom (17%), most episodes of atrial fibrillation (69%) were not associated with symptoms. Independent predictors of atrial fibrillation were age 65 years or greater, history of intermittent atrial fibrillation, atrial pacing, male sex, white race, and not having hyperlipidemia. Independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation while hospitalized, valve surgery, and pulmonary hypertension. CONCLUSIONS: Atrial fibrillation is common after cardiac surgery and often occurs after discharge from the hospital and without accompanying symptoms. Outpatient monitoring may be warranted in patients with characteristics that place them at increased risk for atrial fibrillation.

Gene targeting by triple helix-forming oligonucleotides.

Effective gene targeting reagents would have widespread utility for genomic manipulation including transgenic cell and animal construction and for gene therapy. They would also be useful in basic research as probes of chromatin structure, and as tools for studying the repair and mutagenesis of targeted DNA damage. We are developing triple helix-forming oligonucleotides (TFOs) for gene targeting in living mammalian cells. Challenges to TFO bioactivity include the impediments to the biochemistry of triplex formation presented by the physiological environment and the charge repulsion between the duplex and the third strand. In addition, there are biological constraints to target access imposed by mammalian chromatin structure. Here we describe the oligonucleotide modification format that appears to support biological activity of TFOs. In addition we show that manipulation of the cell biology, specifically the cell cycle, has a dramatic influence on TFO bioactivity.