Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.</p

A comparison of the clinical effectiveness and cost of specialised individually-delivered parent training for preschool attention-deficit/hyperactivity disorder and a generic, group-based programme: a multi-centre, randomised controlled trial of the New Forest Parenting Programme versus Incredible Years

Objective: To compare the efficacy and cost of specialised individually-delivered parent training (PT) for preschool children with attention-deficit/ hyperactivity disorder (ADHD) against generic group-based PT and treatment as usual (TAU). Design: Multi-centre, three-arm parallel group randomised controlled trial. Research Setting: National Health Service Trusts. Participants: Preschool children (33-54 months) fulfilling ADHD research diagnostic criteria. Interventions: New Forest Parenting Programme (NFPP) – 12 week individual, home-delivered ADHD PT programme; Incredible Years (IY) – 12 week group-based, PT programme initially designed for children with behaviour problems. Main outcome measures: Primary outcome - Parent ratings of child’s ADHD symptoms (Swanson, Nolan & Pelham Questionnaire - SNAP-IV). Secondary outcomes - teacher ratings (SNAP-IV) and direct observations of ADHD symptoms and parent/teacher ratings of conduct problems. NFPP, IY and TAU outcomes were measured at baseline (T1) and post-treatment (T2). NFPP and IY outcomes only were measured 6 months post treatment (T3). Researchers, but not therapists or parents, were blind to treatment allocation. Analysis employed mixed effect regression models (multiple imputation). Intervention and other costs were estimated using standardized approaches. Results: NFPP and IY did not differ on parent-rated SNAP-IV, ADHD combined symptoms (mean difference -0.009 95%CI [-0.191, 0.173], p=0.921) or any other measure. Small, non-significant, benefits of NFPP over TAU were seen for parent-rated SNAP-IV, ADHD combined symptoms (-0.189 95%CI [-0.380, 0.003], p=0.053). NFPP significantly reduced parent-rated conduct-problems compared to TAU across scales (p-values.05). The cost per family of providing NFPP in the trial was significantly lower than IY (£1,591 versus £2,103). Conclusions: Although, there were no differences between NFPP and IY with regards clinical effectiveness, individually-delivered NFPP cost less. However, this difference may be reduced when implemented in routine clinical practice. Clinical decisions should take into account parental preferences between delivery approaches. Funding: National Institute of Health Research. Trial Registration: Trial name: COPPI Trial; ISRCTN39288126

Return to work following lower limb arthroplasty

Osteoarthritis causes significant problems in the working age population. Total hip and knee replacements are successful operations and consequently are increasingly offered at younger ages. Moreover, people are being encouraged to work to older ages so that these operations are increasingly likely to occur during a person’s working life with the recipient needing to return to work post-operatively. Currently, there is no evidence-based guidance for when and how people can expect to return to different types of work after surgery. The aims of this thesis were to identify factors which impact the time it takes to return to work, and explore the lived experiences of working-aged individuals undergoing lower limb arthroplasty.We used a mixed methodology approach: a systematic review; a prospective cohort study; and a qualitative study.In the systematic review, we found 23 studies suitable for inclusion. However, there was marked heterogeneity of how return to work was measured, ranging from mean or median times, or proportions of patients returning by a fixed time point. Consequently, lack of comparable data prevented data synthesis. However, we found that most people are able to return to work after lower limb arthroplasty. There was some evidence to suggest that earlier RTW was associated with: younger age at time of surgery; possibly male gender; higher levels of educational attainment; (possibly) returning to work that is less physically demanding; (possibly) being self-employed; some surgical techniques; unrestricted post-operative rehabilitation and not being off sick pre-operatively.Benefitting from an existing cohort study of outcomes after lower limb arthroplasty (COASt), we set up a new prospective cohort study (RTW-COASt). Our aim was to recruit people pre-operatively who wished to return to work after their operation and to follow their journey at several time points until 6 months post-operatively. We recruited 53 participants to the prospective cohort study, amongst whom 47 (89%) returned to work within 6 months of surgery. Median time to RTW was 60 days (IQR 44-74): 62 days (range 10-165) after hip arthroplasty; and 55.5 days (range 19-174) after knee arthroplasty. Six individuals (11%) returned to work within 30 days and 16 within 7 weeks. Factors associated with earlier time to return to work were: younger age; better score for EQ-5D usual activities pre-operatively; not needing to stand/walk at work for &gt; 2 hours day and; and expecting to be able to return to work within 7 weeks. There was no indication of harm after returning to work early, either within 30 days or 49 days of surgery.The lived experiences of RTW-COASt participants were then investigated through qualitative research. Everyone recruited to RTW-COASt was eligible for the qualitative study providing that they had reached the 6-month post-operative milestone. In total, 13 of RTW-COASt participants took part. We chose to use semi-structured interviews to explore what was important to them when deciding when to RTW. Four key themes were identified: trust that the replaced joint has healed; self-efficacy to achieve a successful RTW; the importance of appropriate healthcare support within a positive patient-healthcare professional partnership; and support from the workplace to which the patient needs to return. These themes were inter-related and reciprocal. In particular, we found that healthcare professionals can have an important influence directly and indirectly on timing of return to work, by enhancing confidence in the replaced joint, creating positive expectations about return to work, increasing the patient’s self-efficacy but also by being perceived as available if needed post-operatively. Employers too had an important role in supporting the return to work journey. More research is needed to understand why some people had the impression that they needed to be 100% healed before they could return to work.In conclusion, a large multi-site long term study is needed to address the important issues highlighted in this thesis. The routine collection of a standardised set of RTW variables is recommended in research and clinical settings. The impact of beliefs and expectations on RTW times warrants further investigation, and if confirmed, allows the potential for healthcare professionals to intervene and improve RTW outcomes for patients

Compassionate care intervention for hospital nursing teams caring for older people: a pilot cluster randomised controlled trial

OBJECTIVE: Compassionate care continues to be a focus for national and international attention, but the existing evidence base lacks the experimental methodology necessary to guide the selection of effective interventions for practice. This study aimed to evaluate the Creating Learning Environments for Compassionate Care (CLECC) intervention in improving compassionate care.SETTING: Ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n=4) or control (n=2). Intervention wards comprised two medicines for older people (MOP) wards and two medical/surgical wards. Control wards were both MOP’s.PARTICIPANTS: Data collected from 627 patients and 178 staff. Exclusion criteria: Reverse barrier nursed, critically ill, palliative or non-English speaking. All other patients and all nursing staff and HCAs were invited to participant, agency and bank staff were excluded.INTERVENTION: CLECC, a workplace intervention focused on developing sustainable leadership and work-team practices to support the delivery of compassionate care. Control: no educational activity.PRIMARY AND SECONDARY OUTCOME MEASURES: Primary- Quality of Interaction Schedule (QuIS) for observed staff-patient interactions. Secondary- patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy).RESULTS: Trial proceeded as per protocol, randomisation was acceptable. Some but not all blinding strategies were successful. QuIS observations achieved 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more total positive (78% versus 74%) and less total negative (8% versus 11%) QuIS ratings for intervention wards versus control wards. Sixty-three percent of intervention ward patients scored lowest (i.e. more negative) scores on PEECH connection subscale, versus 79% of control. This was not a statistically significant difference. No statistically significant differences in nursing empathy were observed.CONCLUSIONS: Use of experimental methods is feasible. The use of structured observation of staff-patient interaction quality is a promising outcome measure inclusive of hard to reach groups

Exploring the work of nurses who administer chemotherapy to children and young people

PURPOSE OF THE RESEARCH: To explore the knowledge, attitudes and beliefs of nurses who administer chemotherapy to children and young people. METHODS AND SAMPLE: A national postal survey of nurses working within the 21 cancer centres in the United Kingdom and Ireland. The questionnaire included 25-items addressing the attitudes, beliefs and concerns regarding nurses' roles, support mechanisms and educational preparation related to administration of chemotherapy. RESULTS: In total 286/507 (56%) questionnaires were returned. The majority of nurses worked in inpatient +/-outpatient (78%) settings and most gave chemotherapy on a daily basis (61%). The median time working in oncology was 10 [range 0.5-32] years and time administering chemotherapy was 8 [0.1-32] years. Aspects of administration that caused the most worry included treatment side-effects, extravasation, dealing with allergic/anaphylactic reactions and knowledge deficits in colleagues. There was no significant difference in worry according to level of nurse education but those with an oncology qualification had less Knowledge-related worry (p = 0.05). There was no difference in attitude according to level of education or having an oncology qualification. There were significant correlations between time qualified, time working in oncology and the number of years administering chemotherapy and the worry domains (ranging from r = -0.14 to r = -0.24, p < 0.05); and attitude to chemotherapy (ranging from r = 0.12 to r = 0.26, p < 0.001). CONCLUSION: As anticipated nurses new to chemotherapy administration were initially anxious about the role and they worried about making a drug error. Education and support from colleagues appears to have a positive effect on reducing worry and increasing competence

Clinical practice guidelines for the care of patients with a chronic subdural haematoma: multidisciplinary recommendations from presentation to recovery

Introduction A cSDH is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway. Methods Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care. Results We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across 8 major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery. Conclusions We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care