Evaluating multisite multiprofessional simulation training for a hyperacute stroke service using the behaviour change wheel

Background Stroke is a clinical priority requiring early specialist assessment and treatment. A London (UK) stroke strategy was introduced in 2010, with Hyper Acute Stroke Units (HASUs) providing specialist and high dependency care. To support increased numbers of specialist staff, innovative multisite multiprofessional simulation training under a standard protocol-based curriculum took place across London. This paper reports on an independent evaluation of the HASU training programme. The main aim was to evaluate mechanisms for behaviour change within the training design and delivery, and impact upon learners including potential transferability to the clinical environment. Methods The evaluation utilised the Behaviour Change Wheel framework. Procedures included: mapping training via the framework; examination of course material; direct and video-recorded observations of courses; pre-post course survey sheet; and follow up in-depth interviews with candidates and faculty. Results Patient management skills and trainee confidence were reportedly increased post-course (post-course median 6 [IQ range 5–6.33]; pre-course median 5 [IQ range 4.67–5.83]; z = 6.42, P <.001). Thematic analysis showed that facilitated ‘debrief’ was the key agent in supporting both clinical and non-clinical skills. Follow up interviews in practice showed some sustained effects such as enthusiasm for role, and a focus on situational awareness, prioritization and verbalising thoughts. Challenges in standardising a multi-centre course included provision for local context/identity. Conclusions Pan-London simulation training under the London Stroke Model had positive outcomes in terms of self-reported skills and motivation. These effects persisted to an extent in practice, where staff could recount applications of learning. The evaluation demonstrated that a multiple centre simulation programme congruent with clinical practice can provide valuable standard training opportunities that support patient care

Resilience engineering as a quality improvement method in healthcare

Current approaches to quality improvement rely on the identification of past problems through incident reporting and audits or the use of Lean principles to eliminate waste, to identify how to improve quality. In contrast, Resilience Engineering (RE) is based on insights from complexity science, and quality results from clinicians’ ability to adapt safely to difficult situations, such as a surge in patient numbers, missing equipment or difficult unforeseen physiological problems. Progress in applying these insights to improve quality has been slow, despite the theoretical developments. In this chapter we describe a study in the Emergency Department of a large hospital in which we used RE principles to identify opportunities for quality improvement interventions. In depth observational fieldwork and interviews with clinicians were used to gather data about the key challenges faced, the misalignments between demand and capacity, adaptations that were required, and the four resilience abilities: responding, monitoring, anticipating and learning. Data were transcribed and used to write extended resilience narratives describing the work system. The narratives were analysed thematically using a combined deductive/inductive approach. A structured process was then used to identify potential interventions to improve quality. We describe one intervention to improve monitoring of patient flow and organisational learning about patient flow interventions. The approach we describe is challenging and requires close collaboration with clinicians to ensure accurate results. We found that using RE principles to improve quality is feasible and results in a focus on strengthening processes and supporting the challenges that clinicians face in their daily work

Novel Characteristics of Valveless Pumping

This study investigates the occurrence of valveless pumping in a fluidfilled system consisting of two open tanks connected by an elastic tube. We show that directional flow can be achieved by introducing a periodic pinching applied at an asymmetrical location along the tube, and that the flow direction depends on the pumping frequency. We propose a relation between wave propagation velocity, tube length, and resonance frequencies associated with shifts in the pumping direction using numerical simulations. The eigenfrequencies of the system are estimated from the linearized system, and we show that these eigenfrequencies constitute the resonance frequencies and the horizontal slope frequencies of the system; 'horizontal slope frequency' being a new concept. A simple model is suggested, explaining the effect of the gravity driven part of the oscillation observed in response to the tank and tube diameter changes. Results are partly compared with experimental findings.Art. no. 22450

Three-dimensional numerical simulation of blood flow in mouse aortic arch around atherosclerotic plaques

Atherosclerosis is a progressive disease, involving the build-up of lipid streaks in artery walls, leading to plaques. Understanding the development of atherosclerosis and plaque vulnerability is critically important since plaque rupture can result in heart attack or stroke. Plaques can be divided into two distinct types: those likely to rupture (vulnerable) or less likely to rupture (stable). In the last decade, researchers have been interested in studying the influence of the mechanical effects (blood shear stress, pressure forces and structural stress) on the plaque formation, progression and rupture processes but no general agreement has been found. The purpose of the present work is to include more realistic conditions for the numerical calculations of the blood flow by implementing real geometries with plaques in the numerical model. Hemodynamical parameters are studied in both diseased and healthy configurations. The healthy configuration is obtained by removing numerically the plaques from three dimensional geometries obtained by micro-computed tomography. A new hemodynamical parameter is also introduced to relate the location of plaques to the characteristics of the flow in the healthy configuration

Beyond 'find and fix': improving quality and safety through resilient healthcare systems

OBJECTIVE: The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions. DESIGN: Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance-anticipating, monitoring, responding and learning. SETTING: Accident and Emergency Department (ED) and the Older People's Unit (OPU) of a large teaching hospital in central London. PARTICIPANTS: ED-observations 104 h, and 14 staff interviews. OPU-observations 60 h, and 15 staff interviews. RESULTS: Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment. CONCLUSIONS: The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work

Erythrocyte hemolysis and hemoglobin oxidation promote ferric chloride-induced vascular injury,” The

Abstract The release of redox-active iron and heme into the blood-stream is toxic to the vasculature, contributing to the development of vascular diseases. How iron induces endothelial injury remains ill defined. To investigate this, we developed a novel ex vivo perfusion chamber that enables direct analysis of the effects of FeCl3 on the vasculature. We demonstrate that FeCl3 treatment of isolated mouse aorta, perfused with whole blood, was associated with endothelial denudation, collagen exposure, and occlusive thrombus formation. Strikingly exposing vessels to FeCl3 alone, in the absence of perfused blood, was associated with only minor vascular injury. Whole blood fractionation studies revealed that FeCl3-induced vascular injury was red blood cell (erythrocyte)-dependent, requiring erythrocyte hemolysis and hemoglobin oxidation for endothelial denudation

Local and global behaviour of nonlinear equations with natural growth terms

This paper concerns a study of the pointwise behaviour of positive solutions to certain quasi-linear elliptic equations with natural growth terms, under minimal regularity assumptions on the underlying coefficients. Our primary results consist of optimal pointwise estimates for positive solutions of such equations in terms of two local Wolff's potentials.Comment: In memory of Professor Nigel Kalto

“That’s not what you expect to do as a doctor, you know, you don’t expect your patients to die.” Death as a learning experience for undergraduate medical students

BACKGROUND: Experiencing the death of a patient can be one of the most challenging aspects of clinical medicine for medical students. Exploring what students' learn from this difficult experience may contribute to our understanding of how medical students become doctors, and provide insights into the role a medical school may play in this development. This research examined medical students' responses of being involved personally in the death of a patient. METHOD: Ten undergraduate medical students were followed through their three years of clinical medical education. A total of 53 individual semi-structured interviews were conducted. Grounded theory analysis was used to analyze the data. RESULTS: Students illustrated a variety of experiences from the death of a patient. Three main themes from the analysis were derived: (i) Students’ reactions to death and their means of coping. Experiencing the death of a patient led to students feeling emotionally diminished, a decrease in empathy to cope with the emotional pain and seeking encouragement through the comfort of colleagues; (ii) Changing perceptions about the role of the doctor, the practice of medicine, and personal identity. This involved a change in students’ perceptions from an heroic curing view of the doctor’s role to a role of caring, shaped their view of death as a part of life rather than something traumatic, and resulted in them perceiving a change in identity including dampening their emotions; (iii) Professional environment, roles and responsibilities. Students began to experience the professional environment of the hospital by witnessing the ordinariness of death, understanding their role in formalizing the death of a patient, and beginning to feel responsible for patients. CONCLUSIONS: Along with an integrative approach to facilitate students learning about death, we propose staff development targeting a working knowledge of the hidden curriculum. Knowledge of the hidden curriculum, along with the role staff play in exercising this influence, is vital in order to facilitate translating the distressing experiences students face into worthwhile learning experiences. Finally, we argue that student learning about death needs to include learning about the social organization and working life of clinical settings, an area currently omitted from many medical education curricula