4,872 research outputs found

    Clinical dilemmas in acute neurological disorders

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    This thesis introduces the evolving landscape of acute neurology and the challenges it presents to clinicians in the emergency department (ED).In Chapter 2, the focus is on mild traumatic brain injury (mTBI) in patients on anticoagulation therapy. The study, involving 905 patients, reveals that delayed intracranial hemorrhage within 24 hours is very rare after a normal cranial CT, suggesting that routine hospitalization may be unnecessary.Chapter 3 delves into alcohol intoxication as a stroke mimic, especially in posterior circulation cases. The study, involving 974 patients, emphasizes considering measuring blood ethanol levels in patients with a possible stroke of the posterior circulation presenting after working hours. Nevertheless, elevated blood ethanol levels should not withhold clinicians from administering reperfusion therapy.Chapter 4 explores the association between low blood pressure and outcomes after acute ischemic stroke (AIS). Analyzing data from 2124 patients, the study finds that low systolic blood pressure is linked to increased in-hospital mortality and complications, urging clinicians to investigate potential underlying conditions.In Chapter 5, the focus shifts to AIS patients with active cancer undergoing endovascular treatment. The study, involving 2583 patients, indicates that despite technical success, those with active cancer experience significantly worse outcomes and an increased risk of recurrent stroke after EVT. Still, about a quarter of the patients regained functional independence, and the risk of other complications was not increased.This thesis collectively highlights the importance of nuanced decision-making in acute neurology, offering insights into specific clinical dilemmas and proposing considerations for optimized patient care

    Success Factors Facilitating Care During Escalation (the SUFFICE study)

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    Ede, J., Watkinson, P., Endacott, R., (2021) Protocol for a mixed methods exploratory study of success factors to escalation of care: the SUFFICE study. medRxiv 2021.11.01.21264875. Ede J, Petrinic T, Westgate V, Darbyshire J, Endacott R, Watkinson PJ. (2021) Human factors in escalating acute ward care: a qualitative evidence synthesis. BMJ Open Qual 10. Bedford, J. P., Ede, J. and Watkinson, P. J. (2021) ‘Triggers for new-onset atrial fibrillation in critically ill patients’, Intensive and Critical Care Nursing. Elsevier Ltd, 67, p. 103114. doi: 10.1016/j.iccn.2021.103114. Ede, J. et al. (2023) ‘Patient and public involvement and engagement (PPIE) in research: The Golden Thread’, Nursing in critical care, (April), pp. 16–19. doi: 10.1111/nicc.12921. Ede, J., Hutton, R., Watkinson, P., Kent, B. and Endacott, R. (2023) ‘Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done’, International Journal of Nursing Studies.BACKGROUND: In the United Kingdom, there continues to be preventable National Health Service (NHS) patient deaths. Contributory factors include inadequate recognition of deterioration, poor monitoring, or delayed escalation to a higher level of care. Strategies to improve care escalation, such as vital sign scoring systems and specialist teams who manage deterioration events, have shown variable impact on patient mortality. The need for greater care improvements has consistently been identified in NHS care reviews as well as patient stories. Furthermore, current research informing escalation improvements predominantly comes from examining failure to rescue events, neglecting what can be learned from rescue or successful escalation. AIM: The focus of this study was to address this knowledge gap by examining rescue and escalation events, and from this, to develop a Framework of Escalation Success Factors that can underpin a multi-faceted intervention to improve outcomes for deteriorating patients. METHODS: Escalation success factors, hospital and patient data were collected in a mixed methods, multi-site exploratory sequential study. Firstly, 151 ward care escalation events were observed to generate a theoretical understanding of the process. To identify escalation success factors, 390 care records were also reviewed from unwell ward patients in whom an Intensive Care Unit admission was avoided and compared to the records for patients who became unwell on the ward, admitted to an Intensive Care Unit, and died. Finally, thirty Applied Cognitive Task Analysis interviews were conducted with clinical experts (defined as greater than four years’ experience) including Ward Nurses (n= 7), Outreach Nurses (n= 5), Nurse Managers (n=5), Physiotherapists (n=4), Sepsis Nurses (n=3), Advanced Nurse Practitioners and Educators (n=2), Advance Clinical Practitioners (n=2), Nurse Consultant (n=1) and Doctor (n=1) to examine process of escalation in a Functional Resonance Analysis Model. RESULTS: In Phase 1, over half (n= 77, 51%) of the 151 escalation events observed were not initiated through an early warning score but other clinical concerns. The data demonstrated four escalation communication phenotypes (Informative, Outcome Focused, General Concern and Spontaneous Interaction) utilised by staff in different clinical contexts for different escalation purposes. In Phase 2, the 390 ward patient care record reviews (Survivors n=340, Non-survivors admitted to ICU n=50) identified that care and quality of escalation in the Non-survivor’s group was better overall than those that survived. Reviews also identified success factors present within deterioration events including Visibility, Monitoring, Adaptability, and Adjustments, not dissimilar to characteristics of high reliability organisations. Finally, Phase 3 interview data were dynamically modelled in a Functional Resonance Analysis Method. This illustrated differences in the number of escalation tasks contained in the early warning scoring system (n=8) compared to how escalation is successfully completed by clinical staff (n=24). Interview participants identified that 28% (9/32) of these tasks were cognitively difficult, also indicating how they overcome system complexity and challenges to successfully escalate. Interactions between escalation tasks were also examined, including Interdependence (how one affects another), Criticality (how many downstream tasks are initiated), Preconditions (what system factors need to be present), and Variability (factors which affect output reliability). This approach developed a system-focused understanding of escalation and signposted to process improvements. CONCLUSION: This research uniquely contributes to international evidence by presenting new elements to escalation of care processes. This includes indicating how frequently early warning scores trigger an escalation, the different ways in which escalation is communicated, that patient outcomes may inaccurately portray the quality of care delivered and examining the interaction between escalation tasks can identify areas of improvement. This is the first study to develop a preliminary Framework of Escalation Success Factors, which will be refined and used to underpin evidenced based care improvements. A key recommendation would be for organisations to use, when tested, the Framework of Escalation Success Factors to make system refinements that will promote successful escalation of care. PPI: This study has had Patient and Public Involvement and Engagement (PPIE) through a SUFFICE PPI Advisory Group

    Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

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    Background Multiple long-term conditions—the co-existence of two or more chronic health conditions in an individual—present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals. Methods We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings. Results Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care. Conclusions Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care

    The role of the peripheral system dysfunction in the pathogenesis of sepsis-associated encephalopathy

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    Sepsis is a condition that greatly impacts the brain, leading to neurological dysfunction and heightened mortality rates, making it one of the primary organs affected. Injury to the central nervous system can be attributed to dysfunction of various organs throughout the entire body and imbalances within the peripheral immune system. Furthermore, central nervous system injury can create a vicious circle with infection-induced peripheral immune disorders. We collate the pathogenesis of septic encephalopathy, which involves microglial activation, programmed cell death, mitochondrial dysfunction, endoplasmic reticulum stress, neurotransmitter imbalance, and blood–brain barrier disruption. We also spotlight the effects of intestinal flora and its metabolites, enterocyte-derived exosomes, cholinergic anti-inflammatory pathway, peripheral T cells and their cytokines on septic encephalopathy

    Abdominal aortic aneurysm treatment outcomes in the Netherlands

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    In this thesis, the nationwide trends in abdominal aortic aneurysm treatment outcomes and outcomes of subgroups such as octogenarians following abdominal aortic aneurysm repair are investigated using data from the Dutch Surgical Aneurysm Audit (DSAA). Moreover, the nationwide outcomes of complex EVAR are described, including a volume-outcome association, and new opportunities for feedback and outcome measurement are discussed

    Life on a scale:Deep brain stimulation in anorexia nervosa

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    Anorexia nervosa (AN) is a severe psychiatric disorder marked by low body weight, body image abnormalities, and anxiety and shows elevated rates of morbidity, comorbidity and mortality. Given the limited availability of evidence-based treatments, there is an urgent need to investigate new therapeutic options that are informed by the disorder’s underlying neurobiological mechanisms. This thesis represents the first study in the Netherlands and one of a limited number globally to evaluate the efficacy, safety, and tolerability of deep brain stimulation (DBS) in the treatment of AN. DBS has the advantage of being both reversible and adjustable. Beyond assessing the primary impact of DBS on body weight, psychological parameters, and quality of life, this research is novel in its comprehensive approach. We integrated evaluations of efficacy with critical examinations of the functional impact of DBS in AN, including fMRI, electroencephalography EEG, as well as endocrinological and metabolic assessments. Furthermore, this work situates AN within a broader theoretical framework, specifically focusing on its manifestation as a form of self-destructive behavior. Finally, we reflect on the practical, ethical and philosophical aspects of conducting an experimental, invasive procedure in a vulnerable patient group. This thesis deepens our understanding of the neurobiological underpinnings of AN and paves the way for future research and potential clinical applications of DBS in the management of severe and enduring AN

    Abdominal aortic aneurysm treatment outcomes in the Netherlands

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    In this thesis, the nationwide trends in abdominal aortic aneurysm treatment outcomes and outcomes of subgroups such as octogenarians following abdominal aortic aneurysm repair are investigated using data from the Dutch Surgical Aneurysm Audit (DSAA). Moreover, the nationwide outcomes of complex EVAR are described, including a volume-outcome association, and new opportunities for feedback and outcome measurement are discussed

    Adult Post-Cardiac Surgery Deep Sternal Wound Infections

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    ABSTRACT Purpose and rationale: Deep Sternal Wound Infections (DSWI) are associated with morbidity rates and mortality rates as high as 10% -15% as well as significantly increased hospital costs. The purpose of this project is to decrease current rates of DSWIs in adults undergoing cardiac surgery at a large medical institution. Synthesis of evidence: The literature shows a strong relationship between elevated HbA1C and DSWI. All articles reviewed for this proposal which implement a sternal vest intervention support its use to prevent DSWI. Practice change and implementation strategies: The strategy used to implement these evidence-based practice interventions includes four steps. These steps include creating awareness and interest, building knowledge and commitment, promoting action and adoption, and pursuing integration and sustained use. The Johns Hopkins Nursing Evidence-based Practice Model is implemented to guide this project proposal. Evaluation: Data on DSWI rates among cardiac surgical patients will continue to be monitored and provide data to compare to pre-implementation. Process screening indicators, evaluation surveys, and real-time feedback will be analyzed to measure success. Conclusions and implications for practice: Implementing an evidence-based intervention to address DSWI is proposed. Checking a patient’s HbA1C prior to surgery and referring them to endocrinology or their primary care provider for education if their HbA1C is above 8.0% is already a part of a different department project; for this reason, it was not further pursued. This DNP project’s focus is to implement a sternal support vest worn by high-risk patients as early as post-op day 0 (once in the ICU and stabilized) for at least six weeks postoperatively to protect and promote sternal healing, thus preventing an infection. This vest intervention will help to reduce DSWI rates within the department
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