The introduction of the new Symptom Specific Obstetric Triage System (SOTS) in an acute care trust: an examination of the views and experiences of midwives

BACKGROUND A need to develop a standardised triage system to prioritise clinical urgency of women when attending a maternity triage department has been identified. This study explores the views and experiences of midwives involved in the implementation of such a system. METHOD Focus groups and questionnaires were used to investigate midwives’ views and experiences of the implementation of the Symptom Specific Obstetric Triage System (SOTS). Thematic analysis of the focus group data was undertaken and descriptive statistics from the questionnaire responses were collated. RESULTS Focus groups were held with midwives (N=12) and questionnaires were sent to all midwives (N=79): response rate =67%. These demonstrated midwives felt the new system had been introduced well and helped them manage and organise the department. They felt patient safety had improved and the system allowed them to use their clinical judgment. It also highlighted issues that needed to be changed. CONCLUSION Implications for the future use of SOTS and implementation in other trusts include: changes are required to the documentation and pain score but the SOTS was useful for some for managing the department and the workload and still allowed the use of clinical judgment for most midwives. Clinicians are excellent at problem solving and their views and experiences are valuable in service improvement initiatives

The design and implementation of an obstetric triage system for unscheduled pregnancy related attendances: a mixed methods evaluation

Abstract Background No standardised system of triage exists in Maternity Care and local audit identified this to be problematic. We designed, implemented and evaluated an Obstetric Triage System in a large UK maternity unit. This includes a standard clinical triage assessment by a midwife, within 15 min of attendance, leading to assignment to a category of clinical urgency (on a 4-category scale). This guides timing of subsequent standardised immediate care for the eight most common reasons for attendance. A training programme was integral to the introduction. Methods A mixed methods evaluation was conducted. A structured audit of 994 sets of maternity notes before and after implementation identified the number of women seen within 15 min of attendance. Secondary measures reviewed included time to subsequent care and attendance. An inter-operator reliability study using scenarios was completed by midwives. A focus group and two questionnaire studies were undertaken to explore midwives’ views of the system and to evaluate the training. In addition a national postal survey of practice in UK maternity units was undertaken in 2015. Results The structured audit of 974/992 (98%) of notes demonstrated an increase in the number of women seen within 15 min of attendance from 39% before implementation to 54% afterwards (RR (95% CI) 1.4 (1.2, 1.7) p = <0.0001). Excellent inter-operator reliability (ICC 0.961 (95% CI 0.91–0.99)) was demonstrated with breakdown showing consistently good rates. Thematic analysis of focus group data (n = 12) informed the development of the questionnaire which was sent to all appropriate midwives. The response rate was 53/79 (67%) and the midwives reported that the new system helped them manage the department and improved safety. The National Survey (response rate 85/135 [63%]) demonstrated wide variation in where women are seen and staffing models in place. The majority of units 69/85 (81%) did not use a triage system based on clinical assessment to prioritise care. Conclusions This obstetric triage system has excellent inter- operator reliability and appears to be a reliable way of assessing the clinical priority of women as well as improving organisation of the department. Our survey has demonstrated the widespread need for implementation of such a system

Additional file 1: of The design and implementation of an obstetric triage system for unscheduled pregnancy related attendances: a mixed methods evaluation

Baseline characteristics of women who attended Triage (DOCX 190 kb

Caracterización de biomarcadores en la recurrencia post-quirúrgica de la enfermedad de Crohn: valor predictivo e implicación patogénica

A pesar de un conocimiento cada vez mayor sobre la patogenia de la enfermedad de Crohn (EC) y el desarrollo de esquemas de tratamiento más potentes que incluyen los fármacos biológicos, las tasas de cirugía en estos pacientes siguen siendo elevadas. Así, un 50-60% de los pacientes con EC requieren de una resección intestinal en los primeros 10 años tras el diagnóstico, y un 25% de éstos acabarán requiriendo de una segunda cirugía dentro de los 5 años siguientes. Dado que la cirugía no supone un tratamiento curativo, la reaparición de lesiones tras la resección de todo el tramo intestinal afecto (fenómeno conocido como recurrencia post-quirúrgica) es muy frecuente en estos pacientes, a pesar incluso de la intervención terapéutica. Entre los tratamientos empleados para prevenir la recurrencia de la EC se incluyen la mesalazina, los inmunomoduladores tiopurínicos y en la actualidad los fármacos biológicos o anti-TNF. En los últimos años, diferentes estudios han confirmado la eficacia del tratamiento biológico en la prevención de la recurrencia, especialmente en pacientes de alto riesgo, con una tendencia actual a su introducción precoz tras la cirugía. Sin embargo, estos tratamientos implican una tasa nada desdeñable de efectos adversos, además de un elevado coste por paciente. Por otro lado, no está claramente establecido qué pacientes se benefician de un tratamiento más intensivo tras la cirugía ni la duración de mantenimiento del mismo. Por todo ello, surge la necesidad de desarrollar nuevas herramientas y estrategias que permitan identificar el riesgo de una recurrencia precoz tras la cirugía y optimizar el manejo clínico de estos pacientes. En el momento actual, la ileocolonoscopia continúa siendo el gold estándar para el seguimiento y diagnóstico de la recurrencia, a pesar de suponer una técnica invasiva, costosa, no exenta de riesgos y en general mal tolerada por los pacientes. Esto es así porque hasta el momento no disponemos de buenos marcadores predictores de recurrencia tras la cirugía, y porque la utilidad de la valoración clínica y analítica para el diagnóstico de la recurrencia es limitada. Por este motivo, existe especial interés en el empleo de biomarcadores no invasivos y de fácil obtención, que sirvan para monitorizar a estos pacientes tras la cirugía y permitan detectar precozmente el desarrollo de recurrencia. En este sentido, entre los marcadores fecales, la calprotectina ha mostrado previamente gran utilidad clínica en diferentes escenarios de la enfermedad y, aunque su papel en el contexto post-quirúrgico no ha sido evaluado en profundidad en series amplias de carácter prospectivo, la evidencia disponible sugiere también su utilidad como marcador de recurrencia, aunque quedan aspectos por definir con claridad para su aplicación en la práctica. La existencia de otros posibles biomarcadores en sangre periférica tampoco ha sido explorada en este escenario de la EC. Por otro lado, el escenario clínico de la recurrencia supone una condición patogénica de novo, por lo que los pacientes con EC intervenidos constituyen el mejor modelo natural in vivo para poder estudiar e identificar los posibles mecanismos patogénicos implicados en la reaparición de la enfermedad. Con todo ello, el objetivo de la presente tesis doctoral se centra en la caracterización prospectiva de marcadores no invasivos, a partir de muestras biológicas de fácil obtención (sangre periférica y heces), que dispongan de capacidad predictiva de recurrencia en el contexto post-quirúrgico de la EC, y permitan identificar y monitorizar los cambios que acontecen en el desarrollo de la inflamación de novo. Igualmente, se pretende conocer el perfil de la respuesta inmune que dirige este proceso y los posibles elementos epigenéticos reguladores, así como su implicación patogénica en la génesis de la recurrencia. Finalmente, se plantea el desarrollo de una herramienta de predicción (índice predictivo combinado) empleando los biomarcadores identificados, con potencial aplicación en la práctica clínica para un mejor manejo de estos pacientes.Despite increasing awareness of the pathogenesis of Crohn's disease (CD) and the development of more potent therapeutic regimens including biological drugs, surgery rates in these patients remain high. Thus, 50-60% of patients with CD require bowel resection in the first 10 years after diagnosis, and 25% of these patients will require a second surgery within the next 5 years. Since surgery is not curative, the appearance of new intestinal lesions after resection is very frequent in these patients despite the therapeutic intervention. This phenomenon is known as post-operative recurrence. Treatments used to prevent recurrence of CD after surgery include mesalazine, thiopurines, and nowadays, biological or anti-TNF drugs. In recent years, several studies have confirmed the efficacy of biological treatment in the prevention of recurrence, especially in high-risk patients, with a current trend towards their early introduction after surgery. However, these drugs imply a not insignificant rate of adverse effects, in addition to a high cost per patient. On the other hand, it is not clearly established which patients benefit from a more intensive treatment after surgery or the duration of maintenance of the same. Therefore, the need arises to develop new tools and strategies to identify the risk of an early recurrence and to optimize the clinical management of these patients. Currently, ileocolonoscopy continues to be the gold standard for the follow-up and diagnosis of recurrence, despite being an invasive technique, expensive, non-risk-free and generally poorly tolerated by patients. This is because we do not have good predictive markers of recurrence after surgery until now, and because the usefulness of clinical and analytical assessment for the diagnosis of recurrence is limited. For this reason, there is a special interest in the use of non-invasive and easily obtained biomarkers, which serve to monitor these patients after surgery and allow early detection of post-operative recurrence. In this sense, fecal markers such as calprotectin have previously shown great clinical utility in different scenarios of the disease. In the post-surgical context, available evidence also suggests its potential utility as a marker of recurrence, although some aspects for its application in clinical practice remain to be clearly defined. Other possible biomarkers in peripheral blood have also not been explored in this EC scenario. On the other hand, post-operative recurrence supposes a new pathogenic condition, so that the CD patients underwent surgery are the best natural model in vivo to study and identify the pathogenic mechanisms involved in the reappearance of the disease. The aim of the present study is the prospective characterization of non-invasive markers in peripheral blood and feces, which have a predictive capacity for post-operative recurrence in CD, to identify and monitor the changes that occur in the development of the novo inflammation. Likewise, we intend to know the profile of the immune response that leads this process and possible regulatory epigenetic elements, as well as its pathogenic implication in the genesis of recurrence. Finally, we propose the development of a predictive tool (predictive combined index) using the identified biomarkers, with potential application in clinical practice for a better management of these patients