Barriers and impact of disclosure of HIV status to children at the National Hospital, Abuja Nigeria

Background: HIV infected children survive to adolescence because of anti retroviral therapy, however, only a small proportion know their diagnosis. Disclosure is critical to long-term disease management, yet little is known about if, how, and when disclosure takes place and the barriers associated with it, and its impact on children in resourcelimited settings. Objective: This study set out to determine the process of and barriers to HIV disclosure in children as well as the immediate impact of this on children and their caregivers. Methods: A cross-sectional study was done June-July 2016 using a structured questionnaire, convenience sampling and quantitative methods at the infectious disease clinics of National Hospital Abuja. A sample of 164 caregivers of HIV positive children aged 5 to 16 years receiving antiretroviral therapy for at least one year were enrolled. Results: Prevalence of full disclosure was 24.5%, partial 22.7% with overall prevalence of 47.2%. Main barrier to disclosure was child’s age and fear of informing others. The impact of disclosure on caregivers was relief in 45.5% but emotional and difficult for others. Immediate reactions by children were sadness; tearfulness and worry in 28.6%, some showed no reaction while others even expressed relief. On a longer term, disclosure had several effects. Main predictors of disclosure on regression were the child’s age and caregiver’s opinion on disclosure. Conclusion: The prevalence of full disclosure is low and several barriers affect disclosure. Caregiver’s and HCWs need empowerment and support with culturally appropriate skills and platforms to deal with the barriers, process and impact of disclosure

What does the ideal urgent and emergency care system look like? A qualitative study of service user perspectives

Background: Policies aimed at diverting care from EDs to alternative services have not been successful in reducing ED attendances and have contributed to confusion for service users when making care-seeking decisions. It is important that service users are at the heart of decision making to ensure new services meet the needs of those who will be accessing them. In this study, service users were encouraged to think freely about the desirable qualities of an ideal urgent and emergency care (UEC) system. Methods: From September to February 2019, an open inductive methodology was used to conduct focus groups with service users who had used UK UEC services within the previous year. Service users that had contact with NHS111, ambulance service, General Practice out-of-hours, minor injuries unit, walk-in centre or ED were purposively sampled and stratified into the following groups: (1) 18–45 years; (2)≥75 years; (3) adults with young children; (4) adults with long-term conditions. Focus groups were structured around experiences of accessing UEC services and perspectives of an ‘ideal’ UEC system. Results: 30 service users took part in the study, across four focus groups. The ideal UEC system centred around three themes: a simplified UEC system (easier to understand and a single-point of access); more ‘joined-up’ UEC services and better communication between health staff and patients. Conclusion: Desirable qualities of an ideal UEC system from a service user perspective related to simplifying access for example, through a single point of access system where health professionals decide the appropriate service required and improving continuity of care through better integration of UEC services. Service users value reassurance and communication from health professionals about care pathways and care choices, and this helps service users feel more in control of their healthcare journey

Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort

Objectives: It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (e.g. loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared to selective CT use for anticoagulated patients with a head injury. Design: Decision-analysis modelling of data from a multi-centre observational study. Setting: 33 Emergency Departments in England and Scotland. Participants: 3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning. Main outcome measures: Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared to observed practice based on guidelines recommending selective CT use. Results: Of the 1420/3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional quality-adjusted life years (QALYs) but would have incurred £193,149 additional treatment costs and £130,683 additional CT costs. The incremental cost-effectiveness ratio of £94,895/QALY gained for unselective compared to selective CT use is markedly above the threshold of £20-30,000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness. Conclusions: CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injur

AHEAD Study: an observational study of the management of anticoagulated patients who suffer head injury

OBJECTIVES: Management of anticoagulated patients after head injury is unclear due to lack of robust evidence. This study aimed to determine the adverse outcome rate in these patients and identify risk factors associated with poor outcome. DESIGN: Multicentre, observational study using routine patient records. SETTING: 33 emergency departments in England and Scotland. PARTICIPANTS: 3566 adults (aged ≥16 years) who had suffered blunt head injury and were currently taking warfarin. MAIN OUTCOME MEASURES: Primary outcome measure was rate of adverse outcome defined as death or neurosurgery following initial injury, clinically significant CT scan finding or reattendance with related complication within 10 weeks of initial hospital attendance. Secondary objectives included identifying risk factors for adverse outcome using univariable and multivariable analyses. RESULTS: Clinical data available for 3534/3566 patients (99.1%), median age 79 years; mean initial international normalised ratio (INR) 2.67 (SD 1.34); 81.2% Glasgow Coma Scale (GCS) 15: 59.8% received a CT scan with significant head injury-related finding in 5.4% (n=208); 0.5% underwent neurosurgery; 1.2% patients suffered a head injury-related death. Overall adverse outcome rate was 5.9% (95% CI 5.2% to 6.7%). Patients with GCS=15 and no associated symptoms had lowest risk of adverse outcome (risk 2.7%; 95% CI 2.1 to 3.6). Patients with GCS=15 multivariable analysis (using imputation) found risk of adverse outcome to increase when reporting at least one associated symptom: vomiting (relative risk (RR) 1.8; 95% CI 1.0 to 3.4), amnesia (RR 3.5; 95% CI 2.1 to 5.7), headache (RR 1.3; 95% CI 0.8 to 2.2), loss of consciousness (RR 1.75; 95% CI 1.0 to 3.0). INR measurement did not predict adverse outcome in patients with GCS=15 (RR 1.1; 95% CI 1.0 to 1.2). CONCLUSIONS: In alert warfarinised patients following head injury, the presence of symptoms is associated with greater risk of adverse outcome. Those with GCS=15 and no symptoms are a substantial group and have a low risk of adverse outcome. TRIAL REGISTRATION NUMBER: NCT02461498

The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies.

STUDY QUESTION: To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators. DESIGN: Systematic review. DATA SOURCES: Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies. REVIEW METHODS: Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data. DATA SYNTHESIS: Narrative synthesis and meta-analysis of homogenous data were performed. RESULTS: Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified. CONCLUSIONS: This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings

Creating a real-world linked research platform for analyzing the urgent and emergency care system

Background This article describes the development of a system-based data platform for research developed to provide a detailed picture of the characteristics of the Urgent and Emergency Care system in 1 region of the United Kingdom. Data Set Development CUREd is an integrated research data platform that describes the urgent and emergency care system in 1 region of the United Kingdom on almost 30 million patient contacts within the system. We describe regulatory approvals required, data acquisition, cleaning, and linkage. Data Set Analyses The data platform covers 2011 to 2017 for 14 acute National Health Service (NHS) Hospital Trusts, 1 ambulance service, the national telephone advice service (NHS 111), and 19 emergency departments. We describe 3 analyses undertaken: 1) Analyzing triage patterns from the NHS 111 telephone helpline using routine data linked to other urgent care services, we found that the current triage algorithms have high rates of misclassifying calls. 2) Applying an algorithm to consistently identify avoidable attendances for pediatric patients, we identified 21% of pediatric attendances to the emergency department as avoidable. 3) Using complex systems analysis to examine patterns of frequent attendance in urgent care, we found that frequent attendance is stable over time but varies by individual patient. This implies that frequent attendance is more likely to be a function of the system overall. Discussion We describe the processes necessary to produce research-ready data that link care across the components of the urgent and emergency care system. Making the use of routine data commonplace will require partnership between the collectors, owners, and guardians of the data and researchers and technical teams. Highlights -This article describes the development of a system-level data platform for research using routine patient-level data from the urgent and emergency care system in 1 region of the United Kingdom. -The article describes how the data were acquired, cleaned, and linked and the challenges faced when undertaking analysis with the data. -The data set has been used to understand patient use of the system, journeys once in the system, and outcomes following its use, for example, patterns of frequent use within urgent care and accuracy of referral decisions within the system

Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study

Background Advanced Clinical Practitioners (ACPs) are a new role that have been established to address gaps and support the existing medical workforce in an effort to help reduce increasing pressures on NHS services. ACPs have the potential to practice at a similar level to mid-grade medical staff, for example independently undertaking assessments, requesting and interpreting investigations, and diagnosing and discharging patients. These roles have been shown to improve both service outcomes and quality of patient care. However, there is currently no widespread formalised standard of training within the UK resulting in variations in the training experiences and clinical capabilities of ACPs. We sought to explore the training experiences of ACPs as well as their views on role identity and future development of the role. Methods Five online focus groups were conducted between March and May 2021 with trainee and qualified advanced clinical practitioners working in a range of healthcare settings, in the North of England. The focus groups aimed to explore the experiences of undertaking ACP training including supervision, gaining competence, role identity and career progression. Thematic analysis of the focus group transcripts was performed, informed by grounded theory principles. Results Fourteen advanced clinical practitioners participated. Analysis revealed that training was influenced by internal and external perceptions of the role, often acting as barriers, with structural aspects being significant contributory factors. Key themes identified (1) clinical training lacked structure and support, negatively impacting progress, (2) existing knowledge and experience acted as both an enabler and inhibitor, with implications for confidence, (3) the role and responsibilities are poorly understood by both advanced clinical practitioners and the wider medical profession and (4) advanced clinical practitioners recognised the value and importance of the role but felt changes were necessary, to provide security and sustainability. Conclusions Appropriate structure and support are crucial throughout the training process to enable staff to have a smooth transition to advanced level, ensuring they obtain the necessary confidence and competence. Structural changes and knowledge brokering are essential, particularly in relation to role clarity and its responsibilities, sufficient allocated time to learn and practice, role accreditation and continuous appropriate supervision

Outcomes of elective surgery undertaken in independent sector treatment centres and NHS providers in England: audit of patient outcomes in surgery.

OBJECTIVE: To compare characteristics of patients and outcomes after elective surgery in independent sector treatment centres (ISTCs) and NHS providers. DESIGN: Follow-up study with outcomes reported by patients three to six months after surgery. SETTING: 25 ISTCs and 72 NHS providers in England. Population Consecutive patients undergoing hip or knee replacement (5671 in ISTCs and 14,292 in NHS), inguinal hernia repair (640 and 2023, respectively), or surgery for varicose veins (248 and 1336, respectively). MAIN OUTCOMES: Symptoms and disability reported by patients (Oxford hip and knee scores on a 48 point scale; Aberdeen varicose vein questionnaire) and quality of life (EuroQol EQ-5D score). RESULTS: Patients in ISTCs were healthier than those in NHS providers, had less severe preoperative symptoms, and were more affluent, though the differences were small. With adjustment, patients undergoing joint replacements in NHS providers had poorer outcomes: difference of -1.7 (95% confidence interval -2.5 to -0.9) on the Oxford hip score and -0.9 (-1.6 to -0.2) on the Oxford knee score. They more often reported complications: odds ratio 1.3 (95% confidence interval 1.1 to 1.5) for hip and 1.4 (1.2 to 1.6) for knee. There were no significant differences in outcomes after surgery for hernia or varicose veins, except that NHS patients more often reported poor results after hernia repair (1.4, 1.0 to 1.9) and additional surgery after varicose vein surgery (2.8, 1.2 to 6.8). CONCLUSION: Patients undergoing surgery in ISTCs were slightly healthier and had less severe conditions than those undergoing surgery in NHS providers. Some outcomes were better in ISTCs, but differences were small compared with the impact ISTCs could have on the provision of elective services

Understanding the management of patients with head injury taking warfarin: who should we scan and when? Lessons from the AHEAD study

Anticoagulated patients represent an important and increasing proportion of the patients with head trauma attending the ED, but there is no international consensus for their appropriate investigation and management. International guidelines vary and are largely based on a small number of studies, which provide poor-quality evidence for the management of patients taking warfarin. This article provides an overview of the clinical research evidence for CT scanning head-injured patients taking warfarin and a discussion of interpretation of risk and acceptable risk. We aim to provide shop floor clinicians with an understanding of the limitations of the evidence in this field and the limitations of applying 'one-size-fits-all' guidelines to individual patients. There is good evidence for a more selective scanning approach to patients with head injuries taking warfarin than is currently recommended by most guidelines. Specifically, patients without any head injury-related symptoms and GCS score 15 have a reduced risk of adverse outcome and may not need to be scanned. We argue that there is evidence to support an individualised approach to decision to CT scan in mild head injuries on warfarin and that clinicians should feel able to discuss risks with patients and sometimes decide not to scan

Should children know their HIV status? Prevalence, caregiver's perspectives and barriers to disclosure at the National Hospital Abuja, Nigeria

Background: Nigeria ranks second globally with a HIV/AIDS prevalence of 3.2%. HIV infected children are surviving to adolescence because of anti-retroviral therapy, but many do not know why they need to take these medicines. Disclosure is critical to long-term disease management, yet, if, how and when caregivers and or health professionals disclose to children is not well known in resource-limited settings. The barriers to disclosure remain largely undocumented. Objectives: To determine the prevalence and age of HIV disclosure to children in Abuja, Nigeria and identify caregivers perspectives as well as barriers to disclosure. Methods: A cross-sectional study was done June-July 2016 using a structured questionnaire, convenience sampling and quantitative methods at the infectious disease clinics of National Hospital Abuja. A sample of 164 caregivers of HIV-positive children aged 5-16 years receiving antiretroviral therapy for at least 1 year were enrolled. Results: Prevalence of full disclosure was 24.5%, partial disclosure 22.7%, with overall prevalence of 47.2%. Mean age at full disclosure was 11.87 years. Bivariate analysis showed significant difference between disclosure and child's level of education (χ2 for trend 26.710, P < 0.001), support for disclosure (χ2 4.399, P = 0.036) and if caregiver held the opinion that children should have disclosure done (Pearson's χ2 30.174, P < 0.001). However, on logistic regression, only the age of the child (P < 0.001, 95% CI 1.176-1.499) and the caregiver's opinion (P = < 0.001, 95% CI 4.914-2.542) remained significant. Various barriers to disclosure were identified. Conclusion: The prevalence of full disclosure is low and several barriers prevent early disclosure. Caregiver's and HCWs need empowerment with culturally appropriate skills and platforms to increase disclosure rates, which may help improve adherence