On doing ‘risk work’ in the context of successful outcomes:exploring how medication safety is brought into action through health professionals’ everyday working practices

Interest in risk has grown exponentially in healthcare, resulting in a plethora of policies and guidelines to manage risk at all levels across the healthcare system. However, the impact of risk on the nature and experiences of healthcare work remains a relatively neglected area of research on risk in healthcare. Building on the concept of ‘risk work’, in this article we examine how medication safety is brought into action through health professionals’ everyday working practices at the point of medication administration. Drawing on two closely related data sets, both generated in a large paediatric hospital providing secondary and tertiary care in England, we argue that medication-related risks are constructed and negotiated through situated social interactions. Frontline practitioners actively reconcile the logics of risk work and good-quality bedside patient care enabling them to get risk work done to successfully meet the formally established standards of quality and safety performance. ‘Risk work’ has the potential to make visible and explicit a range of risk-related practices that may not be acknowledged as such if they do not align with the established meanings of risk and the normative frameworks built around them. A focus on ‘risk work’ can bring in a new lens to the study of risk in healthcare with the potential to generate learning from how risk work gets done in the context of routine clinical practice and successful outcomes, rather than incidents and failures, in healthcare service provision

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background: Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research. Methods: We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically. Results: 79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact. Conclusions: Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation

Decision analytic model of the diagnostic pathways for patients with suspected non-alcoholic fatty liver disease using non-invasive transient elastography and multiparametric magnetic resonance imaging

OBJECTIVES: The mortality associated with liver disease continues to increase, despite the improvements implemented in the UK healthcare as does the prevalence of non-alcoholic fatty liver disease (NAFLD), given the escalating prevalence of obesity. The currently available methods to assess and monitor the stage of liver disease present several limitations. Recently, multiparametric MRI has been developed to address these limitations. The aim of this study is to develop a decision analytic model for patients with suspected NAFLD, to investigate the effect of adding multiparametric MRI to the diagnostic pathway. PERSPECTIVE: The model takes the perspective of the UK National Health Service (NHS) as the service provider. METHODS: A simple decision-tree model was developed to compare the costs associated with 3 diagnostic pathways for NAFLD that use non-invasive techniques. First, using transient elastography alone; second, using multiparametric MRI as an adjunct to transient elastography and third, multiparametric MRI alone. The model was built to capture these clinical pathways, and used to compare the expected diagnostic outcomes and costs associated with each. RESULTS: The use of multiparametric MRI as an adjunct to transient elastography, while increasing screening costs, is predicted to reduce the number of liver biopsies required by about 66%. Used as the sole diagnostic scan, there remains an expected 16% reduction in the number of biopsies required. There is a small drop in the overall diagnostic accuracy, as in the current model, liver biopsy is presumed to give a definitive diagnosis. CONCLUSIONS: The inclusion of multiparametric MRI, either as an adjunct to or replacement of transient elastography, in the diagnostic pathway of NAFLD may lead to cost savings for the NHS if the model presumptions hold. Further high-quality clinical evidence and cost data are required to test the model's predictions

Health professional perspectives on lifestyle behaviour change in the paediatric hospital setting : a qualitative study

BACKGROUND: Research exists examining the challenges of delivering lifestyle behaviour change initiatives in practice. However, at present much of this research has been conducted with primary care health professionals, or in acute adult hospital settings. The purpose of this study was to identify barriers and facilitators associated with implementing routine lifestyle behaviour change brief advice into practice in an acute children’s hospital. METHODS: Thirty-three health professionals (nurses, junior doctors, allied health professionals and clinical support staff) from inpatient and outpatient departments at a UK children’s hospital were interviewed about their attitudes and beliefs towards supporting lifestyle behaviour change in hospital patients and their families. Responses were analysed using thematic framework analysis. RESULTS: Health professionals identified a range of barriers and facilitators to supporting lifestyle behaviour change in a children’s hospital. These included (1) personal experience of effectiveness, (2) constraints associated with the hospital environment, (3) appropriateness of advice delivery given the patient’s condition and care pathway and (4) job role priorities, and (5) perceived benefits of the advice given. Delivery of lifestyle behaviour change advice was often seen as an educational activity, rather than a behaviour change activity. CONCLUSION: Factors underpinning the successful delivery of routine lifestyle behaviour change support must be understood if this is to be implemented effectively in paediatric acute settings. This study reveals key areas where paediatric health professionals may need further support and training to achieve successful implementation

A randomised controlled trial to compare two methods of constraint-induced movement therapy to improve functional ability in the affected upper limb in pre-school children with hemiplegic cerebral palsy::CATCH TRIAL

Objective: To determine the feasibility and short-term efficacy of caregiver-directed constraint-induced movement therapy to improve upper limb function in young children with hemiplegic cerebral palsy. Design: Randomized controlled trial with masked assessment. Setting: Community paediatric therapy services. Subjects: Pre-school children with hemiplegic cerebral palsy. Interventions: Caregiver-directed constraint-induced movement therapy administered using either 24-hour short-arm restraint device (prolonged) or intermittent holding restraint during therapy (manual). Main measures: Primary measures include Assisting Hand Assessment (AHA) at 10 weeks. Secondary measures include adverse events, Quality of Upper Extremity Skills Test and Pediatric Quality of Life Inventory. Feasibility measures include recruitment, retention, data completeness and adherence. Results: About 62/81 (72%) of eligible patients in 16 centres were randomized (prolonged restraint n = 30; manual restraint n = 32) with 97% retention at 10 weeks. The mean change at 10 weeks on the AHA logit-based 0–100 unit was 9.0 (95% confidence interval (CI): 5.7, 12.4; P &lt; 0.001) for prolonged restraint and 5.3 (95% CI: 1.3, 9.4; P = 0.01) for manual restraint with a mean group difference of 3.7 (95% CI: −1.5, 8.8; P = 0.156) (AHA smallest detectable difference = 5 units). No serious related adverse events were reported. There were no differences in secondary outcomes. More daily therapy was delivered with prolonged restraint (60 vs 30 minutes; P &lt; 0.001). AHA data were complete at baseline and 10 weeks. Conclusion: Caregiver-directed constraint-induced movement therapy is feasible and associated with improvement in upper limb function at 10 weeks. More therapy was delivered with prolonged than with manual restraint, warranting further testing of this intervention in a longer term trial. </jats:sec

Improving health, well-being and parenting skills in parents of children with medical complexity::a scoping review protocol

IntroductionLess than 1% of children have complex medical conditions but account for one-third of all child health spending. The impact of suboptimal management of this group of children can have a considerable effect on families as well as services. Some families appear to cope more easily than others do, but there are compelling reasons to suggest that effective interventions may improve family coping and ultimately outcomes. Hospitalisation of their child presents a unique set of pressures and challenges for parents, but also an opportunity to intervene. However, the evidence is not well described in relation to this group of families. The primary objective of this scoping review is to identify parent and family-based interventions available to improve parental health, well-being, functioning or skills in the context of a child’s medically complex hospital admission and hospital care.Methods and analysisNine bibliographic databases will be searched spanning medicine, nursing, psychology, education, social work and the grey literature using a combination of index terms and text words related to parents, childhood, chronic illness and interventions. Study eligibility will be assessed by two researchers against preset inclusion and exclusion criteria. Key information from each study will be extracted and charted including year of publication, condition, severity, geographical setting, key concepts and definitions, aims, study population and sample size, methodology/methods, interventions, outcomes and key findings. Directed qualitative content analysis will be used to make sense of narrative findings within the included studies. Results will be presented which summarise the scope of the literature and identify key findings, potential areas for evidence synthesis and research gaps.Ethics and disseminationEthical approval is not required. The results of this review will be disseminated through publication in a peer-reviewed journal and feedback to stakeholders during the development of a hospital-based intervention.</jats:sec

Adverse effects of extracorporeal carbon dioxide removal (ECCO2R) for acute respiratory failure: a systematic review protocol

Background The extracorporeal membrane carbon dioxide removal (ECCO2R) system is primarily designed for the purpose of removing CO2 from the body for patients with potentially reversible severe acute hypercapnic respiratory failure or being considered for lung transplantation. Systematic reviews have focused on the effectiveness of ECCO2R. To the author’s best knowledge, this is the first systematic review to focus on the adverse effects of this procedure. Methods We will conduct a systematic review of procedure-related adverse effects of ECCO2R systems. A high sensitivity search strategy will be employed in Cochrane Library, MEDLINE, EMBASE, Web of Science and product regulatory databases and ongoing trial registers to identify citations. Reference lists of relevant studies and grey literature will also be searched. Screening of the results will be performed by two reviewers independently using pre-defined inclusion and exclusion criteria. Clinical trials and observational studies will be included. Data will be extracted using a purposefully developed extraction form. Appropriateness for statistical pooling of the results will be determined and carried out if heterogeneity is low to moderate. The GRADE framework will be employed to grade the overall quality of the evidence. Discussion In the UK, the current access to the use of ECCO2R is possible only with special arrangements for clinical governance, consent and for audit or research. Current evidence on ECCO2R suggests that there are a number of well-recognised complications which vary greatly across studies. This systematic review will consolidate the existing knowledge on adverse effects resulting from the use of ECCO2R.</p

The effect of early postnatal discharge from hospital for women and infants: a systematic review protocol

BackgroundThe length of postnatal hospital stay has declined over the last 40 years. There is little evidence to support a policy of early discharge following birth, and there is some concern about whether early discharge of mothers and babies is safe. The Cochrane review on the effects of early discharge from hospital only included randomised controlled trials (RCTs) which are problematic in this area, and a systematic review including other study designs is required. The aim of this broader systematic review is to determine possible effects of a policy of early postnatal discharge on important maternal and infant health-related outcomes.Methods/designA systematic search of published literature will be conducted for randomised controlled trials, non-randomised controlled trials (NRCTs), controlled before-after studies (CBA), and interrupted time series studies (ITS) that report on the effect of a policy of early postnatal discharge from hospital. Databases including Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and Science Citation Index will be searched for relevant material. Reference lists of articles will also be searched in addition to searches to identify grey literature. Screening of identified articles and data extraction will be conducted in duplicate and independently. Methodological quality of the included studies will be assessed using the Effective Practice and Organisation of Care (EPOC) criteria for risk of bias tool. Discrepancies will be resolved by consensus or by consulting a third author. Meta-analysis using a random effects model will be used to combine data. Where significant heterogeneity is present, data will be combined in a narrative synthesis. The findings will be reported according to the preferred reporting items for systematic reviews (PRISMA) statement.DiscussionInformation on the effects of early postnatal discharge from hospital will be important for policy makers and clinicians providing maternity care. This review will also identify any gaps in the current literature on this topic and provide direction for future research in this area of study.Systematic review registrationPROSPERO CRD42015020545<br/

Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings: protocol for a systematic review of qualitative studies

ABSTRACTIntroduction: There is increasing evidence that electronic prescribing (ePrescribing) or Computerized Provider/Physician Order Entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitativeapproaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support (CDS).Methods and analysis: Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest, and SCOPUS. In addition, other sources will besearched for ongoing studies (ClinicalTrials.gov) and grey literature: HMIC, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by two reviewers. Qualitative studies, either standalone or in the context of mixed methods designs, reporting the perspectives of any actors involved in the implementation,management and use of ePrescribing/CPOE systems in hospital-based care settings will be included.Data extraction will be conducted by two reviewers using a piloted form. Quality appraisal will be based on criteria from the CASP and SRQR checklists. Studies will not be excluded based on quality assessment. A post-synthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method.Ethics and dissemination: The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.Systematic review registration: PROSPERO CRD42016035552.STRENGTHS AND LIMITATIONS OF THIS STUDY• Although a number of systematic reviews have been conducted to date on ePrescribing or CPOE systems, only a few have focused on hospital settings.• According to the scoping searches conducted by the authors, only two existing reviews included qualitative studies, of which, only one focused on providers’ perceptions in a hospital setting.• To the best of the knowledge of the authors, this is the first systematic review of qualitative evidence relating to the management and use/optimisation of ePrescribing systems in hospital settings, not limited to the implementation process, and including any reported perspectives (i.e. not only health professionals, but also managers, commissioners, patients and relatives/carers).• The review will not address perceptions and experiences related to non-hospital based settings