Introduction of a Physiotherapy Associate Practitioner role on Critical Care: an innovative service improvement to enhance seven-day services and improve efficiency and quality of care

Introduction: Rehabilitation after Critical Illness (RaCI) and Enhanced Recovery after Surgery (ERAS) have been areas of increasing focus over the last decade. Physiotherapy is integral to the optimal delivery of both pathways. Historically, physiotherapy staffing on our ICU limited the ability to best deliver these services. To address this, we developed a non-qualified Physiotherapy Associate Practitioner (PAP) role within ICU to carry a caseload of elective surgical patients. This increased the mobilisation of ERAS patients, and also released a specialist critical care physiotherapist to coordinate a multi-disciplinary RaCI service. Aims: • Improve outcomes for surgical patients. • More therapeutic time to patients with complex needs. • More consistent physiotherapy service on the ICU, seven days a week. • A multidisciplinary team (MDT) RaCI service; weekly outreach rounds and monthly outpatient clinic. Method: 1.8 WTE Band 4 PAPs were recruited on a pilot basis. They both completed a comprehensive training and competency framework. Functional mobility outcome scores at discharge from ICU and weekend productivity statistics were collected for six months. This was compared with data from 6 months prior to the pilot commencing. The senior physiotherapist co-ordinated the RACI pathway, as per NICE CG83. This included involvement in each RaCI patient’s rehabilitation on ITU, ward follow up, and outpatient review. Data was also collected to evaluate RaCI Pathway delivery. Results: Table View larger version Conclusion: We have described an innovative service change within the ICU physiotherapy team. This has allowed implementation of an enhanced mobility service 7 days a week. It has also facilitated the development of a RaCI service, to address the complex needs of long-term ICU patients. The recruitment of PAPs represents a relatively small financial investment, but one that has facilitated a restructure of the physiotherapy team, allowing optimisation of resource allocation to different ICU patient groups. Given the current financial constraints on NHS services, this project represents a unique and practical approach to achieving NHS England’s recommendation for safe, sustainable staffing with “the right staff, with the right skills, in the right place, at the right time” (National Quality Board 2016)

Detecting Memory Impairment in Deaf People: A New Test of Verbal Learning and Memory in British Sign Language

Objective Most existing tests of memory and verbal learning in adults were created for spoken languages, and are unsuitable for assessing deaf people who rely on signed languages. In response to this need for sign language measures, the British Sign Language Verbal Learning and Memory Test (BSL-VLMT) was developed. It follows the format of the English language Hopkins Verbal Learning Test Revised, using standardized video-presentation with novel stimuli and instructions wholly in British Sign Language, and no English language requirement. Method Data were collected from 223 cognitively healthy deaf signers aged 50–89 and 12 deaf patients diagnosed with dementia. Normative data percentiles were derived for clinical use, and receiver-operating characteristic curves computed to explore the clinical potential and diagnostic sensitivity and specificity. Results The test showed good discrimination between the normative and clinical samples, providing preliminary evidence of clinical utility for identifying learning and memory impairment in older deaf signers with neurodegeneration. Conclusions This innovative video testing approach transforms the ability to accurately detect memory impairments in deaf people and avoids the problems of using interpreters, with international potential for adapting similar tests into other signed languages

Detecting cognitive impairment and dementia in Deaf people: The British Sign Language Cognitive Screening Test

To provide accurate diagnostic screening of deaf people who use signed communication, cognitive tests must be devised in signed languages with normative deaf samples. This article describes the development of the first screening test for the detection of cognitive impairment and dementia in deaf signers. The British Sign Language Cognitive Screening Test uses standardized video administration to screen cognition using signed, rather than spoken or written, instructions and a large norm-referenced sample of 226 deaf older people. Percentiles are provided for clinical comparison. The tests showed good reliability, content validity, and correlation with age, intellectual ability, and education. Clinical discrimination was shown between the normative sample and 14 deaf patients with dementia. This innovative testing approach transforms the ability to detect dementia in deaf people, avoids the difficulties of using an interpreter, and enables culturally and linguistically sensitive assessment of deaf signers, with international potential for adaptation into other signed languages

Community engagement to enhance trust between Gypsy/Travellers, and maternity, early years’ and child dental health services: protocol for a multimethod exploratory study

Gypsy/Travellers have poor health and experience discrimination alongside structural and cultural barriers when accessing health services and consequently may mistrust those services. Our study aims to investigate which approaches to community engagement are most likely to be effective at enhancing trust between Gypsy/Travellers and mainstream health services. Methods This multi-method 30-month study, commenced in June 2015, and comprises four stages. 1. Three related reviews: a) systematic review of Gypsy/Travellers’ access to health services; b) systematic review of reviews of how trust has been conceptualised within healthcare; c) realist synthesis of community engagement approaches to enhance trust and increase Gypsy/Travellers’ participation in health services. The reviews will consider any economic literature; 2. Online consultation with health and social care practitioners, and civil society organisations on existing engagement activities, including perceptions of barriers and good practice; 3. Four in-depth case studies of different Gypsy/Traveller communities, focusing on maternity, early years and child dental health services. The case studies include the views of 32–48 mothers of pre-school children, 32–40 healthcare providers and 8–12 informants from third sector organisations. 4. Two stakeholder workshops exploring whether policy options are realistic, sustainable and replicable. Case study data will be analysed thematically informed by the evaluative framework derived from the realist synthesis in stage one. The main outputs will be: a) an evaluative framework of Gypsy/Travellers’ engagement with health services; b) recommendations for policy and practice; c) evidence on which to base future implementation strategies including estimation of costs. Discussion Our novel multi-method study seeks to provide recommendations for policy and practice that have potential to improve uptake and delivery of health services, and to reduce lifetime health inequalities for Gypsy/Travellers. The findings may have wider resonance for other marginalised populations. Strengths and limitations of the study are discussed

Influence of Natural Organic Matter Fouling and Osmotic Backwash on Pressure Retarded Osmosis Energy Production from Natural Salinity Gradients

Pressure retarded osmosis (PRO) has the potential to produce clean, renewable energy from natural salinity gradients. However, membrane fouling can lead to diminished water flux productivity, thus reducing the extractable energy. This study investigates organic fouling and osmotic backwash cleaning in PRO and the resulting impact on projected power generation. Fabricated thin-film composite membranes were fouled with model river water containing natural organic matter. The water permeation carried foulants from the feed river water into the membrane porous support layer and caused severe water flux decline of ∼46%. Analysis of the water flux behavior revealed three phases in membrane support layer fouling. Initial foulants of the first fouling phase quickly adsorbed at the active-support layer interface and caused a significantly greater increase in hydraulic resistance than the subsequent second and third phase foulants. The water permeability of the fouled membranes was lowered by ∼39%, causing ∼26% decrease in projected power density. A brief, chemical-free osmotic backwash was demonstrated to be effective in removing foulants from the porous support layer, achieving ∼44% recovery in projected power density. The substantial performance recovery after cleaning was attributed to the partial restoration of the membrane water permeability. This study shows that membrane fouling detrimentally impacts energy production, and highlights the potential strategies to mitigate fouling in PRO power generation with natural salinity gradients

How is success achieved by individuals innovating for patient safety and quality in the NHS?

Background: Innovation in healthcare is said to be notoriously difficult to achieve and sustain yet simultaneously the health service is under intense pressure to innovate given the ever increasing demands placed upon it. Whilst many studies have looked at diffusion of innovation from an organisational perspective, few have sought to understand how individuals working in healthcare innovate successfully. We took a positive deviance approach to understand how innovations are achieved by individuals working in the NHS. Method: We conducted in depth interviews in 2015 with 15 individuals who had received a national award for being a successful UK innovator in healthcare. We invited only those people who were currently (or had recently) worked in the NHS and whose innovation focused on improving patient safety or quality. Thematic analysis was used. Findings: Four themes emerged from the data: personal determination, the ability to broker relationships and make connections, the ways in which innovators were able to navigate organisational culture to their advantage and their ability to use evidence to influence others. Determination, focus and persistence were important personal characteristics of innovators as were skills in being able to challenge the status quo. Innovators were able to connect sometimes disparate teams and people, being the broker between them in negotiating collaborative working. The culture of the organisation these participants resided in was important with some being able to use this (and the current patient safety agenda) to their advantage. Gathering robust data to demonstrate their innovation had a positive impact and was seen as essential to its progression. Conclusions: This paper reveals a number of factors which are important to the success of innovators in healthcare. We have uncovered that innovators have particular personal traits which encourage a propensity towards change and action. Yet, for fruitful innovation to take place, it is important for relational networks and organisational culture to be receptive to change

Four steps for the Earth: mainstreaming the post-2020 global biodiversity framework

The upcoming Convention on Biological Diversity (CBD) meeting, and adoption of the new Global Biodiversity Framework, represent an opportunity to transform humanity's relationship with nature. Restoring nature while meeting human needs requires a bold vision, including mainstreaming biodiversity conservation in society. We present a framework that could support this: the Mitigation and Conservation Hierarchy. This places the Mitigation Hierarchy for mitigating and compensating the biodiversity impacts of developments (1, avoid; 2, minimize; 3, restore; and 4, offset, toward a target such as "no net loss" of biodiversity) within a broader framing encompassing all conservation actions. We illustrate its application by national governments, sub-national levels (specifically the city of London, a fishery, and Indigenous groups), companies, and individuals. The Mitigation and Conservation Hierarchy supports the choice of actions to conserve and restore nature, and evaluation of the effectiveness of those actions, across sectors and scales. It can guide actions toward a sustainable future for people and nature, supporting the CBD's vision

Analysis of shared heritability in common disorders of the brain

ience, this issue p. eaap8757 Structured Abstract INTRODUCTION Brain disorders may exhibit shared symptoms and substantial epidemiological comorbidity, inciting debate about their etiologic overlap. However, detailed study of phenotypes with different ages of onset, severity, and presentation poses a considerable challenge. Recently developed heritability methods allow us to accurately measure correlation of genome-wide common variant risk between two phenotypes from pools of different individuals and assess how connected they, or at least their genetic risks, are on the genomic level. We used genome-wide association data for 265,218 patients and 784,643 control participants, as well as 17 phenotypes from a total of 1,191,588 individuals, to quantify the degree of overlap for genetic risk factors of 25 common brain disorders. RATIONALE Over the past century, the classification of brain disorders has evolved to reflect the medical and scientific communities' assessments of the presumed root causes of clinical phenomena such as behavioral change, loss of motor function, or alterations of consciousness. Directly observable phenomena (such as the presence of emboli, protein tangles, or unusual electrical activity patterns) generally define and separate neurological disorders from psychiatric disorders. Understanding the genetic underpinnings and categorical distinctions for brain disorders and related phenotypes may inform the search for their biological mechanisms. RESULTS Common variant risk for psychiatric disorders was shown to correlate significantly, especially among attention deficit hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder (MDD), and schizophrenia. By contrast, neurological disorders appear more distinct from one another and from the psychiatric disorders, except for migraine, which was significantly correlated to ADHD, MDD, and Tourette syndrome. We demonstrate that, in the general population, the personality trait neuroticism is significantly correlated with almost every psychiatric disorder and migraine. We also identify significant genetic sharing between disorders and early life cognitive measures (e.g., years of education and college attainment) in the general population, demonstrating positive correlation with several psychiatric disorders (e.g., anorexia nervosa and bipolar disorder) and negative correlation with several neurological phenotypes (e.g., Alzheimer's disease and ischemic stroke), even though the latter are considered to result from specific processes that occur later in life. Extensive simulations were also performed to inform how statistical power, diagnostic misclassification, and phenotypic heterogeneity influence genetic correlations. CONCLUSION The high degree of genetic correlation among many of the psychiatric disorders adds further evidence that their current clinical boundaries do not reflect distinct underlying pathogenic processes, at least on the genetic level. This suggests a deeply interconnected nature for psychiatric disorders, in contrast to neurological disorders, and underscores the need to refine psychiatric diagnostics. Genetically informed analyses may provide important "scaffolding" to support such restructuring of psychiatric nosology, which likely requires incorporating many levels of information. By contrast, we find limited evidence for widespread common genetic risk sharing among neurological disorders or across neurological and psychiatric disorders. We show that both psychiatric and neurological disorders have robust correlations with cognitive and personality measures. Further study is needed to evaluate whether overlapping genetic contributions to psychiatric pathology may influence treatment choices. Ultimately, such developments may pave the way toward reduced heterogeneity and improved diagnosis and treatment of psychiatric disorders

Genomic Relationships, Novel Loci, and Pleiotropic Mechanisms across Eight Psychiatric Disorders

Genetic influences on psychiatric disorders transcend diagnostic boundaries, suggesting substantial pleiotropy of contributing loci. However, the nature and mechanisms of these pleiotropic effects remain unclear. We performed analyses of 232,964 cases and 494,162 controls from genome-wide studies of anorexia nervosa, attention-deficit/hyper-activity disorder, autism spectrum disorder, bipolar disorder, major depression, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome. Genetic correlation analyses revealed a meaningful structure within the eight disorders, identifying three groups of inter-related disorders. Meta-analysis across these eight disorders detected 109 loci associated with at least two psychiatric disorders, including 23 loci with pleiotropic effects on four or more disorders and 11 loci with antagonistic effects on multiple disorders. The pleiotropic loci are located within genes that show heightened expression in the brain throughout the lifespan, beginning prenatally in the second trimester, and play prominent roles in neurodevelopmental processes. These findings have important implications for psychiatric nosology, drug development, and risk prediction.Peer reviewe