Determining optimal outcome measures in a trial investigating no routine gastric residual volume measurement in critically ill children

Background Choosing trial outcome measures is important. When outcomes are not clinically relevant or important to parents/patients, trial evidence is less likely to be implemented into practice. This study aimed to determine optimal outcome measures for a trial of no routine gastric residual volume measurement in critically ill children. Methods: A mixed methods approach: a focused literature review, parent and clinician interviews, a modified two-round Delphi and a stakeholder consensus meeting. Results: The review generated 13 outcomes. 14 Pediatric Intensive Care Unit (PICU) parents proposed 3 additional outcomes, these 16 were then rated by 28 clinicians in Delphi round 1. Six further outcomes were proposed, and 22 outcomes were rated in the second round. No items were voted ‘consensus out’. The 18 ‘no-consensus’ items were voted in a face-to-face meeting by 30 participants. The final 12 outcome measures were: Time to reach energy targets; ventilator associated pneumonia; vomiting; time enteral feeds withheld per 24 hour; necrotizing enterocolitis; length of invasive ventilation; PICU length of stay; mortality; change in weight and markers of feed intolerance: parenteral nutrition administered; feed formula altered and changing to post-pyloric feeds all secondary to feed intolerance. Conclusion: We have identified 12 outcomes for a trial of no gastric residual volume measurement through a multi-stage process, seeking views of parents and clinicians. Clinical Relevancy statement: Twelve relevant outcomes have been identified for a trial of no routine gastric residual volume measurement in critically ill children

Know your pulse awareness campaign: involving pharmacists for greater outreach

Poster presented at the 10th PCNE Working Conference, 1-4 February 2017, Bled, Sloveniainfo:eu-repo/semantics/publishedVersio

An inclusive approach to raising standards in general practice: working with a 'community of practice' in Western Australia

<p>Abstract</p> <p>Background</p> <p>In this study we explored the challenges to establishing a community of practice (CoP) to address standards in general practice. We focused on the issue of improving referral letters which are the main form of communication between general practitioners (GPs) and specialists. There is evidence to suggest that the information relayed to specialists at the time of referral could be improved.</p> <p>Methods</p> <p>We aimed to develop a community of practice consisting of GPs in Western Australia to improve the quality of referral letters to six specialty clinics. Three phases included: establishing the CoP, monitoring the progress of the CoP and sustaining and managing the CoP. The CoP's activity centred on referral letters to each of six selected specialties. A local measure for the quality of the referral letters was developed from a survey of participants about specific items of history and weighted for their perceived importance in the referral letter. Referral letters by participants written before and after the benchmarking exercise were scored for quality based on the standards set by the CoP. Feedback to participants regarding the 'quality' of their individual referrals was provided by a nominated member of the CoP, including a comparison of before and after scores.</p> <p>Results</p> <p>15 GPs were recruited. Only five GPs submitted referral letters both before and after benchmarking. The five GPs that participated in both study phases submitted a total of 102 referral letters (53 before and 49 after). There was a 26 point (95% CI 11–41) improvement in the average scores of the second set of letters after taking clustering by speciality into account, indicating the quality of referral letters improved substantially after feedback.</p> <p>Conclusion</p> <p>There are many challenges to forming a CoP to focus on improving a specific issue in general practice. However we were able to demonstrate that those practitioners who participated in all aspects of the project substantially improved the quality of their referral letters. For recruitment it was important to work with a champion for the project from within the practice. The project took several months to complete therefore some GPs became disengaged. Some were very disappointed by their performance when compared to colleagues. This reaction may be an important motivation to change, however it needs to be sensitively handled if participants are not to become disillusioned or disheartened.</p

Negotiated reorienting: a grounded theory of nurses’ end-of-life decision-making in the intensive care unit

Background Intensive care units (ICUs) focus on treatment for those who are critically ill and interventions to prolong life. Ethical issues arise when decisions have to be made regarding the withdrawal and withholding of life-sustaining treatment and the shift to comfort and palliative care. These issues are particularly challenging for nurses when there are varying degrees of uncertainty regarding prognosis. Little is known about nurses’ end-of-life (EoL) decision-making practice across cultures. Objectives To understand nurses’ EoL decision-making practices in ICUs in different cultural contexts. Design We collected and analysed qualitative data using Grounded Theory. Settings Interviews were conducted with experienced ICU nurses in university or hospital premises in five countries: Brazil, England, Germany, Ireland and Palestine. Participants Semi-structured interviews were conducted with 51 nurses (10 in Brazil, 9 in

Measuring the impact and costs of a universal group based parenting programme : protocol and implementation of a trial

Background Sub-optimal parenting is a common risk factor for a wide range of negative health, social and educational outcomes. Most parenting programmes have been developed in the USA in the context of delinquency prevention for targeted or indicated groups and the main theoretical underpinning for these programmes is behaviour management. The Family Links Nurturing Programme (FLNP) focuses on family relationships as well as behaviour management and is offered on a universal basis. As a result it may be better placed to improve health and educational outcomes. Developed in the UK voluntary sector, FLNP is popular with practitioners, has impressed policy makers throughout the UK, has been found to be effective in before/after and qualitative studies, but lacks a randomised controlled trial (RCT) evidence base. Methods/Design A multi-centre, investigator blind, randomised controlled trial of the FLNP with a target sample of 288 south Wales families who have a child aged 2-4 yrs living in or near to Flying Start/Sure Start areas. Changes in parenting, parent child relations and parent and child wellbeing are assessed with validated measures immediately and at 6 months post intervention. Economic components include cost consequences and cost utility analyses based on parental ranking of states of quality of life. Attendance and completion rates and fidelity to the FLNP course delivery are assessed. A nested qualitative study will assess reasons for participation and non-participation and the perceived value of the programme to families. By the end of May 2010, 287 families have been recruited into the trial across four areas of south Wales. Recruitment has not met the planned timescales with barriers including professional anxiety about families entering the control arm of the trial, family concern about video and audio recording, programme facilitator concern about the recording of FLNP sessions for fidelity purposes and delays due to the new UK research governance procedures. Discussion Whilst there are strong theoretical arguments to support universal provision of parenting programmes, few universal programmes have been subjected to randomised controlled trials. In this paper we describe a RCT protocol with quantitative and qualitative outcome measures and an economic evaluation designed to provide clear evidence with regard to effectiveness and costs. We describe challenges implementing the protocol and how we are addressing these

Effect of Contemporary Bariatric Surgical Procedures on Type 2 Diabetes Remission. A Population-Based Matched Cohort Study.

OBJECTIVE: The objective of the study is to evaluate the effect of gastric banding, gastric bypass and sleeve gastrectomy on medium to long-term diabetes control in obese participants with type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS: Matched cohort study using primary care electronic health records from the UK Clinical Practice Research Datalink. Obese participants with type 2 diabetes who received bariatric surgery from 2002 to 2014 were compared with matched control participants who did not receive BS. Remission was defined for each year of follow-up as HbA1c <6.5 % and no antidiabetic drugs prescribed. RESULTS: There were 826 obese participants with T2DM who received bariatric surgery including adjustable gastric banding (LAGB) 220; gastric bypass (GBP) 449; or sleeve gastrectomy (SG) 153; with four procedures undefined. Mean HbA1c declined from 8.0 % before BS to 6.5 % in the second postoperative year; proportion with HbA1c <6.5 % (<48 mmol/mol) increased from 17 to 47 %. The proportion of patients in remission was 30 % in the second year, being 20 % for LAGB, 34 % for GBP and 38 % for SG. The adjusted relative rate of remission over the first six postoperative years was 5.97 (4.86 to 7.33, P < 0.001) overall; for LAGB 3.32 (2.27 to 4.86); GBP 7.16 (5.64 to 9.08); and SG 6.82 (5.05 to 9.19). Rates of remission were maintained into the sixth year of follow-up. CONCLUSIONS: Remission of diabetes may continue for up to 6 years after bariatric surgical procedures. Diabetes outcomes are generally more favourable after gastric bypass or sleeve gastrectomy than LAGB

Exposure to traumatic perinatal experiences and posttraumatic stress symptoms in midwives: Prevalence and association with burnout

Background: Midwives provide care in a context where life threatening or stressful events can occur. Little is known about their experiences of traumatic events or the implications for psychological health of this workforce. Objectives: To investigate midwives’ experiences of traumatic perinatal events encountered whilst providing care to women, and to consider potential implications. Design: A national postal survey of UK midwives was conducted. Participants: 421 midwives with experience of a perinatal event involving a perceived risk to the mother or baby which elicited feelings of fear, helplessness or horror (in the midwife) completed scales assessing posttraumatic stress symptoms, worldview beliefs and burnout. Results: 33% of midwives within this sample were experiencing symptoms commensurate with clinical posttraumatic stress disorder. Empathy and previous trauma exposure (personal and whilst providing care to women) were associated with more severe posttraumatic stress responses. However, predictive utility was limited, indicating a need to consider additional aspects increasing vulnerability. Symptoms of posttraumatic stress were associated with negative worldview beliefs and two domains of burnout. Conclusions: Midwives may experience aspects of their work as traumatic and, as a consequence, experience posttraumatic stress symptomatology at clinical levels. This holds important implications for both midwives’ personal and professional wellbeing and the wellbeing of the workforce, in addition to other maternity professionals with similar roles and responsibilities. Organisational strategies are required to prepare midwives for such exposure, support midwives following traumatic perinatal events and provide effective intervention for those with significant symptoms

A pilot validation of a modified Illness Perceptions Questionnaire designed to predict response to cognitive therapy for psychosis

Background and objectives: Clinical responsiveness to cognitive behavioural therapy for psychosis (CBTp) varies. Recent research has demonstrated that illness perceptions predict active engagement in therapy, and, thereby, better outcomes. In this study, we aimed to investigate the psychometric properties of a modification of the Illness Perceptions Questionnaire (M-IPQ) designed to predict response following CBTp. Methods: Fifty-six participants with persistent, distressing delusions completed the M-IPQ; forty before a brief CBT intervention targeting persecutory ideation and sixteen before and after a control condition. Additional predictors of outcome (delusional conviction, symptom severity and belief inflexibility) were assessed at baseline. Outcomes were assessed at baseline and at follow-up four to eight weeks later. Results: The M-IPQ comprised two factors measuring problem duration and therapy-specific perceptions of Cure/Control. Associated subscales, formed by summing the relevant items for each factor, were reliable in their structure. The Cure/Control subscale was also reliable over time; showed convergent validity with other predictors of outcome; predicted therapy outcomes; and differentially predicted treatment effects. Limitations: We measured outcome without an associated measure of engagement, in a small sample. Findings are consistent with hypothesis and existing research, but require replication in a larger, purposively recruited sample. Conclusions: The Cure/Control subscale of the M-IPQ shows promise as a predictor of response to therapy. Specifically targeting these illness perceptions in the early stages of cognitive behavioural therapy may improve engagement and, consequently, outcomes