Is there a role for patients and their relatives in monitoring, detecting and escalating clinical deterioration in hospital?

Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Yet, 11% of deaths in UK hospitals in 2005 were the result of patient deterioration going unrecognised or not being acted on (NPSA, 2007). The thesis aimed to investigate whether patients and relatives can aid health professionals in recognising clinical deterioration. A systematic review was conducted which identified interventions that allow patients and relatives to escalate patient deterioration. However, there is not strong evidence for the clinical effectiveness of these interventions, and a limited understanding of patient and relative ability to recognise patient deterioration. In study 1, health professionals generated potentially feasible and acceptable methods of involving patients and/or relatives in recognising deterioration in hospital. Recording patients’ views on changes in their wellness during routine observation was proposed. Focus groups were held in study 2 with healthcare assistants and patients to develop a questionnaire to capture patients’ and relatives’ ratings of patient wellness. Study 3 piloted approaches to routinely collecting patient wellness ratings using the questionnaire on in-patient wards. Where the researcher attended observation to record patients’ ratings, this was acceptable to most patients. However, there was limited uptake where patients and relatives were invited to complete the questionnaire themselves, and staff were invited to record patients’ wellness ratings during observation. It may be necessary to encourage and support staff to adopt this change in practice. In study 4, the use of behaviour change techniques to encourage staff to routinely record patient-reported wellness in practice were effective on wards showing high previous levels of engagement with the observation system. The clinical effectiveness of routinely recording patient-reported wellness was also explored. Significant associations between patient-reported wellness, and early warning score and vital sign measurements were found, and these were stronger in more acutely unwell patients. Evidence from the thesis suggests that routinely recording patient-reported wellness may be one feasible strategy that could aid health professionals in the early recognition of clinical deterioration

Surface chemistry modification of glass and gold for low density neural cell culture

Surface chemical modifications are presented for supporting primary neurons in culture. The initial substrates for culture were glass and gold. The surface modifications were based on self assembled monolayer (SAM) approaches. Glass surfaces were initially modified by silanisation with either 3-aminopropyltrimethoxysilane (APTMS) or 3-aminopropyldimethylethoxysilane (APDES), to present amino-terminated surfaces. Gold surfaces were initially modified by thiol SAMs of either 11-amino-1-undecanethiol (AUT) or a peptide fragment of laminin (PA22-2), to present an amino- or peptide-terminated surface respectively. The amine-terminated surfaces of both glass and gold were subject to further modification. A heterobifunctional linker, containing a polyethylene glycol (PEG) spacer, was used to couple the peptide PA22-2 to the amino-terminated surfaces. Surface modifications were characterised using WCA, XPS and ToF-SIMS. The heterobifunctional linker bound homogeneously across the AUT SAM surface, however the linker was not distributed evenly on either of the amino silanisations of glass. Primary neurons from dissociated embryonic rat hippocampi were cultured on the modified glass and gold surfaces. The cell viability was measured during a 3 week long culture using calcein and ethidium homodimer fluorescence. Neuronal cell cultures were viable on all the gold surface modifications. The only viable glass surface was a control surface of adsorbed poly-l-lysine (PLL) on glass. Cell viability on the AUT and the Peptide-PEG-AUT modified gold surfaces was equivalent to the PLL coated glass. Inclusion of the PEG linker reduced protein adsorption from the media to the peptide modified gold surface, allowing cells to recognise the peptide rather than an adsorbed protein layer and improving their viability. The presented gold surface modifications provide suitable substrates for neural cultures which can be used in existing applications for investigating neural activity, such as; multi-electrode arrays, micro-fluidics devices, and surface plasmon resonance

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review

Background: Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team (RRT). Objective: To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration. Search strategy: Following PRISMA guidelines, four electronic databases and two web search engines were searched to identify literature investigating patient and relative led escalation. Inclusion criteria: Articles investigating the implementation or use of systems involving patients and relatives in the detection of clinical patient deterioration and escalation of patient care to address any clinical or non-clinical outcomes were included. Articles' eligibility was validated by a second reviewer (20%). Data extraction: Data were extracted according to pre-defined criteria. Data synthesis: Narrative synthesis was applied to included studies. Main results: Nine empirical studies and 36 grey literature articles were included in the review. Limited studies were conducted to establish the clinical effectiveness of patient and relative led escalation. Instead, studies investigated the impact of this intervention on health-care staff and available resources. Although appropriate, this reflects the infancy of research in this area. Patients and relatives did not overwhelm resources by activating the RRT. However, they did activate it to address concerns unrelated to patient deterioration. Conclusions: Activating a RRT may not be the most appropriate or cost-effective method of resolving non-life-threatening concerns

Assessing the information and support needs of radical prostate cancer patients and acceptability of a group based treatment review: A questionnaire and qualitative interview study

Aims Current literature suggests the information and support needs of oncology patients undergoing radical radiotherapy to the prostate often remain unmet and can impact quality of life. We aimed to explore the effectiveness of delivery and opportunities for service improvement, including a group based treatment review. Methods: Sixty prostate patients completing radical radiotherapy (mean age 70, range 47-79) in a UK cancer-centre completed a self-designed questionnaire assessing information and support.. To explore views on a group-based-treatment-review, 11% took part in a semi-structured interview. Descriptive data were computed and interviews transcribed and analysed thematically. Results: Eighty-seven percent were satisfied with information and support when delivered by radiographers. However, 26% were only ‘sometimes’ able to complete bladder-filling, suggesting information regarding treatment delays would improve this. 49% preferred both Doctor and Urology nurse reviews whereas 26% preferred nurse only. 70% stated their ‘concerns were always addressed’ by a nurse and 49% by a Doctor. Interviews revealed that a group review was generally acceptable with peer support an influencing factor. Findings: Overall patients felt their needs were being met. Suggestions for improvement (more information on preparation, side effects and delays) will be implemented locally. Future work will explore the feasibility of group reviews in patients undergoing radical radiotherapy to the prostate

Ultrastable embedded surface plasmon confocal interferometry

As disease diagnosis becomes more sophisticated, there is a requirement to measure small numbers of molecules attached to, for instance, an antibody. This requires a sensor capable not only of high sensitivity but also the ability to make measurements over a highly localized region. In previous publications, we have shown how a modified confocal microscope allows one to make localized surface plasmon (SP) measurements on a scale far smaller than the surface plasmon propagation distance. The present implementation presents a new ultrastable interferometer system, which greatly improves the noise performance. Hitherto, we have used the central part of the back focal plane to form a reference beam with the reradiated surface plasmons. In the current system, we block the central part and use the spatial light modulator to deflect s-polarized light into the pinhole to form an interference signal with the surface plasmons, thus creating an ultrastable interferometer formed with two beams incident at very similar angles. We demonstrate the superior noise performance of the system in hostile environments and examine further adaptations of the system to further enhance noise performance

Surface chemistry modification of glass and gold for low density neural cell culture

Surface chemical modifications are presented for supporting primary neurons in culture. The initial substrates for culture were glass and gold. The surface modifications were based on self assembled monolayer (SAM) approaches. Glass surfaces were initially modified by silanisation with either 3-aminopropyltrimethoxysilane (APTMS) or 3-aminopropyldimethylethoxysilane (APDES), to present amino-terminated surfaces. Gold surfaces were initially modified by thiol SAMs of either 11-amino-1-undecanethiol (AUT) or a peptide fragment of laminin (PA22-2), to present an amino- or peptide-terminated surface respectively. The amine-terminated surfaces of both glass and gold were subject to further modification. A heterobifunctional linker, containing a polyethylene glycol (PEG) spacer, was used to couple the peptide PA22-2 to the amino-terminated surfaces. Surface modifications were characterised using WCA, XPS and ToF-SIMS. The heterobifunctional linker bound homogeneously across the AUT SAM surface, however the linker was not distributed evenly on either of the amino silanisations of glass. Primary neurons from dissociated embryonic rat hippocampi were cultured on the modified glass and gold surfaces. The cell viability was measured during a 3 week long culture using calcein and ethidium homodimer fluorescence. Neuronal cell cultures were viable on all the gold surface modifications. The only viable glass surface was a control surface of adsorbed poly-l-lysine (PLL) on glass. Cell viability on the AUT and the Peptide-PEG-AUT modified gold surfaces was equivalent to the PLL coated glass. Inclusion of the PEG linker reduced protein adsorption from the media to the peptide modified gold surface, allowing cells to recognise the peptide rather than an adsorbed protein layer and improving their viability. The presented gold surface modifications provide suitable substrates for neural cultures which can be used in existing applications for investigating neural activity, such as; multi-electrode arrays, micro-fluidics devices, and surface plasmon resonance

Sub-100 nm resolution microscopy based on proximity projection grating scheme

Structured illumination microscopy (SIM) has been widely used in life science imaging applications. The maximum resolution improvement of SIM, compared to conventional bright field system is a factor of 2. Here we present an approach to structured illumination microscopy using the proximity projection grating scheme (PPGS), which has the ability to further enhance the SIM resolution without invoking any nonlinearity response from the sample. With the PPGS-based SIM, sub-100 nm resolution has been obtained experimentally, and results corresponding to 2.4 times resolution improvement are presented. Furthermore, it will be shown that an improvement of greater than 3 times can be achieved

What do primary care staff think about patients accessing electronic health records? A focus group study

Background Patients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals. Methods A focus group study involving 19 clinical and non-clinical primary care staff. Primary care practices were purposively sampled based on practice size and the percentage of patients using online services. Data were analysed inductively using reflexive thematic analysis. Results Three themes were generated: (1) Information – what, why and when? (2) Changing behaviours and protecting relationships, and (3) Secure access and safeguarding. The emotional considerations and consequences for staff and patients featured prominently in the data as an overarching theme. Conclusions Primary care staff described being invested and supportive of patients accessing their electronic health records, and acknowledged the numerous potential benefits for safety. Uncertainty around the parameters of access, the information available and what this might look like in the future, processes for patients highlighting errors in records, relational issues, security and safeguarding and equitable access, were key areas warranting examination in future research

Can Routinely Collected, Patient-Reported Wellness Predict National Early Warning Scores? A Multilevel Modeling Approach

Objective: Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognize or respond to deterioration. The current study explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalized deteriorating patients. Methods: A prospective observation study design was used. Nurses on four inpatient wards were invited to participate and record patient-reported wellness during every routine observation (where possible) using an electronic observation system. Linear multilevel modeling was used to examine the relationship between patient-reported wellness, and national early warning scores (NEWS), and whether patient-reported wellness predicted subsequent NEWS. Results: A significant positive relationship was found between patient-reported wellness and NEWS recorded at the next observation while controlling for baseline NEWS (β = 0.180, P = 0.033). A significant positive relationship between patient-reported wellness and NEWS (β = 0.229, P = 0.005) recorded during an observation 24 hours later while controlling for baseline NEWS was also found. Patient-reported wellness added to the predictive model for subsequent NEWS. Conclusion: The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required

Rejection, acceptance and the spectrum between: understanding male attitudes and experiences towards conflict-related sexual violence in eastern Democratic Republic of Congo

Background: Female survivors of sexual violence in conflict experience not only physical and psychological sequelae from the event itself, but often many negative social outcomes, such as rejection and ostracisation from their families and community. Male relatives – whether husbands, fathers, brothers – play a key role in determining how the family and community respond to a survivor of sexual violence. Understanding these perspectives could help improve services for survivors of sexual violence, as well as their families and communities. Methods: This study draws on qualitative data gathered from focus groups of 68 men in the eastern region of Democratic Republic of Congo. Men were asked about their experiences as relatives of women who had experienced sexual violence. Results: Two dominant themes arose throughout the focus groups: factors driving rejection and pathways to acceptance. Factors driving rejection included: fear of sexually transmitted infections, social stigma directed toward the husbands themselves, and an understanding of marriage and fidelity that is incompatible with rape. Men also touched on their own trauma, including struggling with witnessing a rape that took place in public, or caring for a survivor with a child from rape. They noted that the economic burden of medical treatment for survivors was a salient factor in the decision to reject. Pathways to acceptance included factors such as the love of their spouse or relative, survivors’ potential to give continued financial contribution to the family, the need to keep the family together to care for children in the home, and pressure from people of importance in the community. Conclusion: This study provides unique insight into how male relatives respond to close family members who have experienced sexual violence. This is particularly critical since the reaction of a male relative after rape can be the most pivotal factor in promoting or impeding recovery for a survivor. These results emphasise the importance of services that focus not only on the survivor of violence herself, but also on key family members that can ideally help support her recovery. Electronic supplementary material The online version of this article (10.1186/s12905-017-0479-7) contains supplementary material, which is available to authorized users