Feasibility and evaluation of an emergency department‐based general practitioner streaming and treatment service

Rationale Offering a primary care service that can provide good quality primary care at emergency departments may reduce pressure on usual emergency department (ED) services. Aims and Objectives To evaluate the acceptability, satisfaction, and potential impacts of a co-located primary care service at an emergency department. Methods This is a prospective feasibility study and service evaluation comprising a narrative summary of activity, satisfaction, well-being, and safety, and comparisons of wait times for ED services by patient category (‘minor’, ‘majors’, ‘paediatric’ or ‘resus’) before and during the service operation. Patients and staff were asked using semistructured interview topic guides about service perception, well-being, representation within 48 h, safety concerns, and/or satisfaction. Wait times for patient categories in usual ED care service were in secondary care electronic records. Pathway changes were captured under primary care electronic records. Results Approximately 96% of general practitioner streaming and treatment (GPST) patients were seen within 1 h. There was a statistically significant reduction in ED patients with minor injuries or illnesses waiting >4 h for admission or discharge ‘breaches’ during the 3 months that GPST was operating compared with the previous 3 months (p ≤ 0.005). Wait times for other ED services did not significantly improve. A total of 769 walk-in patients received GPST consultation and 661 (86%) needed no further ED intervention. Fast discharge was a major determinant of patient satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in eligibility criteria and built environment design features. Conclusion Provision of GPST correlated with shorter waits for discharge from ED. Patient and staff experiences of GPST were positive

CARer-ADministration of as-needed subcutaneous medication for breakthrough symptoms in homebased dying patients (CARiAD):study protocol for a UK-based open randomised pilot trial

Legal framework. (DOCX 23 kb

Carer administration of as-needed sub-cutaneous medication for breakthrough symptoms in people dying at home: the CARiAD feasibility RCT

Background Most people who are dying want to be cared for at home, but only half of them achieve this. The likelihood of a home death often depends on the availability of able and willing lay carers. When people who are dying are unable to take oral medication, injectable medication is used. When top-up medication is required, a health-care professional travels to the dying person’s home, which may delay symptom relief. The administration of subcutaneous medication by lay carers, although not widespread UK practice, has proven to be key in achieving better symptom control for those dying at home in other countries. Objectives To determine if carer administration of as-needed subcutaneous medication for common breakthrough symptoms in people dying at home is feasible and acceptable in the UK, and if it would be feasible to test this intervention in a future definitive randomised controlled trial. Design We conducted a two-arm, parallel-group, individually randomised, open pilot trial of the intervention versus usual care, with a 1 : 1 allocation ratio, using convergent mixed methods. Setting Home-based care without 24/7 paid care provision, in three UK sites. Participants Participants were dyads of adult patients and carers: patients in the last weeks of their life who wished to die at home and lay carers who were willing to be trained to give subcutaneous medication. Strict risk assessment criteria needed to be met before approach, including known history of substance abuse or carer ability to be trained to competency. Intervention Intervention-group carers received training by local nurses using a manualised training package. Main outcome measures Quantitative data were collected at baseline and 6–8 weeks post bereavement and via carer diaries. Interviews with carers and health-care professionals explored attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The main outcomes of interest were feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures. Results In total, 40 out of 101 eligible dyads were recruited (39.6%), which met the feasibility criterion of recruiting > 30% of eligible dyads. The expected recruitment target (≈50 dyads) was not reached, as fewer than expected participants were identified. Although the overall retention rate was 55% (22/40), this was substantially unbalanced [30% (6/20) usual care and 80% (16/20) intervention]. The feasibility criterion of > 40% retention was, therefore, considered not met. A total of 12 carers (intervention, n = 10; usual care, n = 2) and 20 health-care professionals were interviewed. The intervention was considered acceptable, feasible and safe in the small study population. The context of the feasibility study was not ideal, as district nurses were seriously overstretched and unfamiliar with research methods. A disparity in readiness to consider the intervention was demonstrated between carers and health-care professionals. Findings showed that there were methodological and ethics issues pertaining to researching last days of life care. Conclusion The success of a future definitive trial is uncertain because of equivocal results in the progression criteria, particularly poor recruitment overall and a low retention rate in the usual-care group. Future work regarding the intervention should include understanding the context of UK areas where this has been adopted, ascertaining wider public views and exploring health-care professional views on burden and risk in the NHS context. There should be consideration of the need for national policy and of the most appropriate quantitative outcome measures to use. This will help to ascertain if there are unanswered questions to be studied in a trial. Trial registration Current Controlled Trials ISRCTN11211024. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 25. See the NIHR Journals Library website for further project information

An analytical framework for delirium research in palliative care settings: integrated epidemiologic, clinician-researcher, and knowledge user perspectives

peer-reviewedContext. Delirium often presents difficult management challenges in the context of goals of care in palliative care settings. Objectives. The aim was to formulate an analytical framework for further research on delirium in palliative care settings, prioritize the associated research questions, discuss the inherent methodological challenges associated with relevant studies, and outline the next steps in a program of delirium research.Methods. We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting, relevant literature searches, focused input of epidemiologic expertise, and a meeting participant and coauthor survey to formulate a conceptual research framework and prioritize research questions.Results. Our proposed framework incorporates three main groups of research questions: the first was predominantly epidemiologic, such as delirium occurrence rates, risk factor evaluation, screening, and diagnosis; the second covers pragmatic management questions; and the third relates to the development of predictive models for delirium outcomes. Based on aggregated survey responses to each research question or domain, the combined modal ratings of "very'' or "extremely'' important confirmed their priority.Conclusion. Using an analytical framework to represent the full clinical care pathway of delirium in palliative care settings, we identified multiple knowledge gaps in relation to the occurrence rates, assessment, management, and outcome prediction of delirium in this population. The knowledge synthesis generated from adequately powered, multicenter studies to answer the framework's research questions will inform decision making and policy development regarding delirium detection and management and thus help to achieve better outcomes for patients in palliative care settings. (C) 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.PUBLISHEDpeer-reviewe

'A clear understanding of our duty': Labour women in rural Scotland, 1919-1939

No abstract available

'A rough kind of feminism' : the formation of working class women's political identities, Clydeside, c1919-1936

Feminist historiography has generally focused on middle-class women and formal organisations taking the view the World War I heralded the decline of the feminist movement and thereby any forms of feminist activity in Britain. This thesis,by investigating Clydeside women's experiences between the wars, subverts that approach.It offers a wider interpretation of feminist aims,objectives, and activities by examining the premise that' sexual antagonism' can shape 'sexual solidarity', providing a conduct for the operation of 'a rough kind of feminism'. During the inter-war years attempts were made, through discourse,to reformulate traditional gender identities. The proposed vision of womanhood sought to re-situate females in the 'private sphere' as exulted progenitors and guardians of the race. Correspondingly, these women were to be provided for, and protected by the 'new man' who would love and respect his wife, whilst recognising that their roles,although different should be equal in status. A response to the potential liberation of women after World War 1 ,concerns over the quality and quantity of the British race and the ruptures wrought by war,this world view was to permeate society. Despite the persuasiveness of this discourse, however,these ideals were not generally compatible with the extra-discursive realities and imaginative boundaries of working-class life between the wars on Clydeside and more so those of men. The proposed 'new men' of the Clyde faced extreme social, economic, and political transformations which impeded their subjectification of the ideal.In turn, this contributed to the extreme gender antagonism faced by women in the worlds of work,politics, community, and play and in their relations with men. Women's responses were complex and contradictory. Although they were divided materially and ideologically, sexual antagonism provided a basis for coalition on specific issues which affected these women as a group. Working-class women countered their potential for powerlessness formally and informally in a variety of ways.They formed gender-specific work-cultures, they exploited the dominant gender discourse of this period,they used kin and community networks, they combined to take advantage of community organisations and they used defiance as strategies to challenge male domination. Whilst these same forces could also create class and gender divisions amongst women, nevertheless, sexual antagonism on Clydeside acted as a catalyst for behaviour identifiable as a' rough kind of feminism'.Feminist historiography has generally focused on middle-class women and formal organisations taking the view the World War I heralded the decline of the feminist movement and thereby any forms of feminist activity in Britain. This thesis,by investigating Clydeside women's experiences between the wars, subverts that approach.It offers a wider interpretation of feminist aims,objectives, and activities by examining the premise that' sexual antagonism' can shape 'sexual solidarity', providing a conduct for the operation of 'a rough kind of feminism'. During the inter-war years attempts were made, through discourse,to reformulate traditional gender identities. The proposed vision of womanhood sought to re-situate females in the 'private sphere' as exulted progenitors and guardians of the race. Correspondingly, these women were to be provided for, and protected by the 'new man' who would love and respect his wife, whilst recognising that their roles,although different should be equal in status. A response to the potential liberation of women after World War 1 ,concerns over the quality and quantity of the British race and the ruptures wrought by war,this world view was to permeate society. Despite the persuasiveness of this discourse, however,these ideals were not generally compatible with the extra-discursive realities and imaginative boundaries of working-class life between the wars on Clydeside and more so those of men. The proposed 'new men' of the Clyde faced extreme social, economic, and political transformations which impeded their subjectification of the ideal.In turn, this contributed to the extreme gender antagonism faced by women in the worlds of work,politics, community, and play and in their relations with men. Women's responses were complex and contradictory. Although they were divided materially and ideologically, sexual antagonism provided a basis for coalition on specific issues which affected these women as a group. Working-class women countered their potential for powerlessness formally and informally in a variety of ways.They formed gender-specific work-cultures, they exploited the dominant gender discourse of this period,they used kin and community networks, they combined to take advantage of community organisations and they used defiance as strategies to challenge male domination. Whilst these same forces could also create class and gender divisions amongst women, nevertheless, sexual antagonism on Clydeside acted as a catalyst for behaviour identifiable as a' rough kind of feminism'

Community psychology and parenting education Issues arising in a multi-agency practice

SIGLEAvailable from British Library Document Supply Centre-DSC:DXN026462 / BLDSC - British Library Document Supply CentreGBUnited Kingdo