Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice

© 2015 Swinglehurst and Greenhalgh; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Additional file 1: Box 1. Field notes on summarising (Clover Surgery). Box 2. Extract of document prepared for GPs by summarisers at Clover Surgery. Box 3. Fieldnotes on coding incoming post, Clover (original notes edited for brevity).This work was funded by a research grant from the UK Medical Research Council (Healthcare Electronic Records in Organisations 07/133) and a National Institute of Health Research doctoral fellowship award for DS (RDA/03/07/076). The funders were not involved in the selection or analysis of data nor did they make any contribution to the content of the final manuscript

The effectiveness of strategies to change organisational culture to improve healthcare performance: a systematic review

<p>Abstract</p> <p>Background</p> <p>Organisational culture is an anthropological metaphor used to inform research and consultancy and to explain organisational environments. In recent years, increasing emphasis has been placed on the need to change organisational culture in order to improve healthcare performance. However, the precise function of organisational culture in healthcare policy often remains underspecified and the desirability and feasibility of strategies to be adopted have been called into question. The objective of this review was to determine the effectiveness of strategies to change organisational culture in order to improve healthcare performance.</p> <p>Methods</p> <p>We searched the following electronic databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Sociological Abstracts, Web of Knowledge, PsycINFO, Business and Management, EThOS, Index to Theses, Intute, HMIC, SIGLE, and Scopus until October 2009. The Database of Abstracts of Reviews of Effectiveness (DARE) was searched for related reviews. We also searched the reference lists of all papers and relevant reviews identified, and we contacted experts in the field for advice on further potential studies. We considered randomised controlled trials (RCTs) or well designed quasi-experimental studies (controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series (ITS) analyses). Studies could be set in any type of healthcare organisation in which strategies to change organisational culture in order to improve healthcare performance were applied. Our main outcomes were objective measures of professional performance and patient outcome.</p> <p>Results</p> <p>The search strategy yielded 4,239 records. After the full text assessment, two CBA studies were included in the review. They both assessed the impact of interventions aimed at changing organisational culture, but one evaluated the impact on work-related and personal outcomes while the other measured clinical outcomes. Both were at high risk of bias. Both reported positive results.</p> <p>Conclusions</p> <p>Current available evidence does not identify any effective, generalisable strategies to change organisational culture. Healthcare organisations considering implementing interventions aimed at changing culture should seriously consider conducting an evaluation (using a robust design, <it>e.g.</it>, ITS) to strengthen the evidence about this topic.</p

Sequential or alternating administration of docetaxel (Taxotere®) combined with FEC in metastatic breast cancer: a randomised phase II trial

The aim of this study, using a Fleming single-stage design, was to explore the efficacy and safety of Taxotere® 100 mg m−2 docetaxel and FEC 75 cyclophosphamide 500 mg m−2, fluorouracil 500 mg m−2 and epirubicin 75 mg m−2, in alternating and sequential schedules for the first-line treatment of metastatic breast cancer. One hundred and thirty-six women were randomly allocated, to one of three treatment regimens: DTX 100 plus FEC 75, alternated for eight courses (ALT); four courses of DTX 100 followed by four courses of FEC 75 (SEQ T); or four courses of FEC 75 followed by four courses of DTX 100 (SEQ F). One hundred and thirty-one women were evaluable for tumour response. Although the treatment outcome was equivalent in the two sequential arms and the alternating regimen (P=0.110, not significant), the response rate was less encouraging in the SEQ F arm (52.3%) than in the other two arms (71.1% for ALT and 70.5% for SEQ T), in which docetaxel was administered first. Time to progression was similar in the ALT, SEQ T and SEQ F arms (9.5, 9.3 and 10.4 months respectively). Grade 3–4 neutropenia was observed in nearly all patients; febrile neutropenia occurred in 9% (ALT), 16% (SEQ T) and 2% (SEQ F) of patients. Few patients (⩽9%) developed grade 3–4 non-haematological toxicities. Relative dose intensity was 97–99% for all regimens. All treatment regimens were active and well tolerated

Effects of genotype on the response of Populus tremuloides michx. To ozone and nitrogen deposition

Elevated O 3 concentrations and N deposition levels co -occur in much of eastern United States. However, very little is known about their combined effects on tree growth. The effects of three O 3 treatments: charcoal-filtered air, non-filtered air and O 3 , added at the rate of 80 ppb for 6 hr d −1 3 d per week), four N deposition levels (0, 10, 20 and 40 kg ha −1 yr −1 ), and their interactions on growth of two Populus tremuloides clones in open-top chambers at two sites 600 km apart in Michigan were examined. Our results revealed a highly significant fertilization effect of the N treatments, even at the 10 kg ha −1 yr −1 rate. Ozone alone induced foliar injury, but not significant growth reductions. There was an indication that O 3 decreased growth at the O N level, but this decrease was reversed in all N treatments by the N fertilization effect. Further study is needed to more fully understand the combined effects of N deposition and O 3 .Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/43906/1/11270_2004_Article_BF00480254.pd

Learning physical examination skills outside timetabled training sessions: what happens and why?

Lack of published studies on students’ practice behaviour of physical examination skills outside timetabled training sessions inspired this study into what activities medical students undertake to improve their skills and factors influencing this. Six focus groups of a total of 52 students from Years 1–3 using a pre-established interview guide. Interviews were recorded, transcribed and analyzed using qualitative methods. The interview guide was based on questionnaire results; overall response rate for Years 1–3 was 90% (n = 875). Students report a variety of activities to improve their physical examination skills. On average, students devote 20% of self-study time to skill training with Year 1 students practising significantly more than Year 3 students. Practice patterns shift from just-in-time learning to a longitudinal selfdirected approach. Factors influencing this change are assessment methods and simulated/real patients. Learning resources used include textbooks, examination guidelines, scientific articles, the Internet, videos/DVDs and scoring forms from previous OSCEs. Practising skills on fellow students happens at university rooms or at home. Also family and friends were mentioned to help. Simulated/real patients stimulated students to practise of physical examination skills, initially causing confusion and anxiety about skill performance but leading to increased feelings of competence. Difficult or enjoyable skills stimulate students to practise. The strategies students adopt to master physical examination skills outside timetabled training sessions are self-directed. OSCE assessment does have influence, but learning takes place also when there is no upcoming assessment. Simulated and real patients provide strong incentives to work on skills. Early patient contacts make students feel more prepared for clinical practice

Gene deletion of P-Selectin and ICAM-1 does not inhibit neutrophil infiltration into peritoneal cavity following cecal ligation-puncture

BACKGROUND: Neutrophil infiltration is one of the critical cellular components of an inflammatory response during peritonitis. The adhesion molecules, P-selectin and intercellular adhesion molecule (ICAM)-1, mediate neutrophil-endothelial cell interactions and the subsequent neutrophil transendothelial migration during the inflammatory response. Despite very strong preclinical data, recent clinical trials failed to show a protective effect of anti-adhesion therapy, suggesting that the length of injury might be a critical factor in neutrophil infiltration. Therefore, the objective of this study was to determine the role of P-selectin and ICAM-1 in neutrophil infiltration into the peritoneal cavity during early and late phases of peritonitis. METHODS: Peritonitis was induced in both male wild-type and P-selectin/ICAM-1 double deficient (P/I null) mice by cecal ligation-puncture (CLP). Peripheral blood and peritoneal lavage were collected at 6 and 24 hours after CLP. The total leukocyte and neutrophil contents were determined, and neutrophils were identified with the aid of in situ immunohistochemical staining. Comparisons between groups were made by applying ANOVA and student t-test analysis. RESULTS: CLP induced a severe inflammatory response associated with a significant leukopenia in both wild-type and P/I null mice. Additionally, CLP caused a significant neutrophil infiltration into the peritoneal cavity that was detected in both groups of mice. However, neutrophil infiltration in the P/I null mice at 6 hours of CLP was significantly lower than the corresponding wild-type mice, which reached a similar magnitude at 24 hours of CLP. In contrast, in peritonitis induced by intraperitoneal inoculation of 2% glycogen, no significant difference in neutrophil infiltration was observed between the P/I null and wild-type mice at 6 hours of peritonitis. CONCLUSIONS: The data suggest that alternative adhesion pathway(s) independent of P-selectin and ICAM-1 can participate in neutrophil migration during peritonitis and that the mode of stimuli and duration of the injury modulate the neutrophil infiltration

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability