Guidelines for the emergency department management of traumatic brain injury : an impact assessment and development of a prognostic model to inform hospital admission decisions

Background1.4 million patients attend English and Welsh Emergency Departments (ED) annually following head injury. 95% attend with a high level of consciousness, of whom 1% have life-threatening traumatic brain injuries (TBI), whilst 7% have TBI on CT imaging.National guidelines were introduced in England and Scotland to improve TBI outcomes and reduce hospital admissions. The impact of these guidelines has not been rigorously assessed. They recommend patients with injuries on CT imaging be admitted to hospital in case they deteriorate. Accurate prediction of deterioration could identify patients safe for discharge from the ED.AimsAssess the impact of national guidelines on deaths and admissions.Develop a prediction model for deterioration in patients with injuries identified by CT imaging.MethodsInterrupted time series analyses using national data for England and Scotland were conducted to evaluate guideline impact.A systematic review was completed to identify candidate prognostic factors for deterioration. Multivariable logistic regression was used to develop prognostic models using these factors in an English multi-centre retrospective cohort of patients.ResultsGuideline impact varied by age group. Associated reductions in hospital admissions and mortality were found in those aged 16-64. In older patients, an increase in TBI mortality was observed, which was unaffected by guideline introduction.A prognostic model and decision rule was developed, using data from a cohort of 1699 patients. It achieved a sensitivity of 99.5% (95% CI: 98.1% to 99.9%) and specificity of 7.4% (95% CI: 6% to 9.1%) to a measure of deterioration encompassing need for admission.ConclusionThis first national evaluation of head injury guidelines to use quasi-experimental methods suggests guideline impact varied by age. This first empirically derived prediction model to inform admission decisions suggests a small proportion of patients could be safely discharged from the ED. External validation is required before clinical use

Putting participation into practice

Background: The aim of the article is to share the findings of participatory action research performed to develop a mutual participatory doctor-patient relationship model, and to apply this model in a rural cross-cultural primary care setting. Method: Participatory action research was performed with four patient groups. Four patients with incurable illnesses formed groups with their family members and significant others. Seven monthly meetings with each group were audio recorded. The question asked at each meeting was “How can the group work together to achieve the best possible health outcome for the patient?” The recorded interviews were transcribed and translated from the local vernacular (Tsonga) into English. Themes were identified from the transcripts, field notes and a reflective diary. A list of combined themes was compiled and a model was constructed to depict the themes and their interrelatedness. The model was interpreted and conclusions were drawn. Results: To apply a mutual participatory model in a rural cross-cultural practice, the physician is required to operate from certain basic tenets. The patients have to participate actively to benefit optimally, and basic interviewing techniques are helpful to facilitate mutual participation. Conclusions: It is not easy to implement a mutual participatory model in a disadvantaged, rural practice, but it is possible. We need a paradigm shift in health care, from “helping” patients (which may nurture dependence), towards facilitating the personal growth and development of patients (to nurture self-reliance). For full text, click here:SA Family Pract 2004;46(5): 29-3

Delayed presentation to the Emergency Department following a head injury : current care and the risks of intra-cranial pathology

Background: Head injury is a common reason for Emergency Department attendance. The clinical dilemma is differentiating between patients who have mild/minor head injuries into those that can be discharged following clinical review and those that require a CT head scan to rule out neurosurgical pathology. Clinical decision rule research to aid this risk assessment has been conducted almost exclusively on patients presenting within twenty-four hours of injury. Delayed presentation head injury patients may be a distinct sub-population with a different risk profile. Methods: Three studies were undertaken. A systematic review was conducted to identify and assess existing evidence regarding the risk assessment in delayed presentation head injury patients. A survey of emergency physicians using clinical vignettes was used to assess variation in the investigation of this patient group. Lastly, six months of audit data were analysed to assess the size of the population of delayed presentation head injury patients, and the use and sensitivity of existing NICE guidelines in their risk assessment.Results: Few existing studies of poor methodological quality were found. A large degree of variation in clinical practice was identified in the investigation of this group. Head injury patients presenting after twenty-four hours of injury were found to account for 15.5% of CT head scans for the investigation of adult head trauma. In patients presenting after twenty-four hours of injury 30% of identified intra-cranial injuries were in patients without a NICE indication for a CT head scan compared to only 2.2% of intra-cranial injuries in patients presenting within twenty-four hours of their injury.Conclusions: Head injury patients presenting more than twenty-four hours after injury represent a significant clinical sub-population. A different approach to that recommended in the current NICE guidelines may be required in the risk assessment of this group

Vrugbaarheid van vleisbeeste op die soutpan beesplaas

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Mutual participation in the health worker-patient relationship

The importance of a mutual participatory model in medical care and decision making is supported by literature that now shows a link between patient participation and an improved health outcome. Illness (and the sick role) constitutes a state of diminished autonomy and mutual participation may help patients to regain control. Patients who participate most frequently are under 65 but above 30 years old, are better educated, have a higher income and profession and a higher socioeconomic status. Patients are keener to participate in decision making when more serious illnesses are present and when they have had prior experiences with a serious illness. They participate more fully if they feel that they are well enough, have enough knowledge and are allowed to participate. Patients are able to participate to a greater extent when they see themselves as experts in experiencing the illness. It is therefore important to encourage active participation by those patients who are less likely to participate. It is important for health workers to have at least the following personal values and skills, which will enable them to encourage and foster active participation: humility, the ability to relinquish the role of the expert, an awareness of their position of power and the ability to value even the poor are needed to set the scene for participation. It is important that health workers acknowledge the patients' right to self-determination and autonomy. Empathic listening, unconditional positive regard, sensitivity for the patients and their values and an ability to tolerate ambiguity create an atmosphere conducive to mutual participation. When health workers become aware of differences in opinion or in the balance of power, this should be acknowledged and discussed and a mutual understanding should be negotiated. Health workers have the potential to manipulate “mutual decision making” with the information they give. It is therefore essential to be open and honest about biases and opinions. Key Words: mutual participation, health worker-patient relationship, decision making, partnerships. For full text, click here: SA Fam Pract 2004;46(4):30-3

Verband tussen reproduksie, produksie en gedrag by Angorabokooie

No Abstrac

Caring, learning, improving quality and doing research: Different faces of the same process

The aim of this article is to describe the similarities between the consultation process, the quality improvement (QI) process, action- and problem-based learning and participatory action research (PAR). We feel this understanding adds value to our work in enabling personal development as practitioners, fostering teamwork and demystifying the different concepts. Learning to understand the different processes becomes easier, as they have a lot in common. All four of these spiral processes follow a number of steps. They start with building a relationship/team with a patient, students, co-workers or co-researchers. The next step is identifying the problem. The present situation, as well as the required state (setting standards), is identified. An intervention can then be planned, with a follow-up evaluation to see if the situation has improved. The spiral may continue with a follow-up plan. As authors we believe that we can conclude from this that health workers, teachers, managers and researchers can learn from each other and work together more readily if they understand that they share a common action process.SA Fam Pract 2004;46(7): 26-2

The perceptions of rural women doctors about their work

Background: Recruitment and retention of medical staff are important issues in rural health. The aim of this study was to describe and understand the perceptions of women doctors working in rural hospitals in South Africa about their work. Methods: This was a descriptive study, using a qualitative methodology. Free attitude interviews were conducted with 14 women doctors. Themes were identified and tested against the data and comments from the research diary. Results: The main theme was balance. A rural woman doctor has to juggle different issues, including running the household and responsibilities at work. Other themes that were identified included the reason for working at a rural hospital, attitudes to rural life, opportunities for personal and professional growth, the feeling of being needed in a rural hospital, advantages and disadvantages for children and family, the impact of relationships on the rural woman doctor, issues regarding the environment and security, and that the proximity of home and work gives a rural woman doctor far more connection with her family. Conclusions: Some of the themes identified in this study agreed with international research, e.g. the importance of a job for the spouse, family considerations including the choice to specialise, and balancing responsibilities at home and work. The advantage of accommodation close to the hospital is a them that has not been documented before. Based on the findings, recommendations are made to attract women doctors to rural areas. Keywords: women doctors, rural, qualitative, accommodation For full text, click here: SA Fam Pract 2004;46(3):27-3

The perceptions of rural women doctors about their work

Background: Recruitment and retention of medical staff are important issues in rural health. The aim of this study was to describe and understand the perceptions of women doctors working in rural hospitals in South Africa about their work. Methods: This was a descriptive study, using a qualitative methodology. Free attitude interviews were conducted with 14 women doctors. Themes were identified and tested against the data and comments from the research diary. Results: The main theme was balance. A rural woman doctor has to juggle different issues, including running the household and responsibilities at work. Other themes that were identified included the reason for working at a rural hospital, attitudes to rural life, opportunities for personal and professional growth, the feeling of being needed in a rural hospital, advantages and disadvantages for children and family, the impact of relationships on the rural woman doctor, issues regarding the environment and security, and that the proximity of home and work gives a rural woman doctor far more connection with her family. Conclusions: Some of the themes identified in this study agreed with international research, e.g. the importance of a job for the spouse, family considerations influencing the choice to specialise, and balancing responsibilities at home and work. The advantage of accommodation close to the hospital is a theme that has not been documented before. Based on the findings, recommendations are made to attract women doctors to rural areas

What helps volunteers to continue with their work?

Aim: The aim of the study was to understand what volunteers perceived to be the factors helping them to continue working as volunteers, thereby assisting project leaders to improve the recruitment procedures, as well as quality of service, in the future. Methodology: A focus group interview was held with the 14 most active volunteers in order to understand their perceptions about their work and their ability to continue their work as volunteers. The recorded interview was transcribed, translated and analysed. Findings: The volunteers feel that their work consists of various forms of support to patients. They see themselves as mediators (advocates) for the patients within the health care services. They have difficulties with some patients, who have high expectations of them. They also feel deeply about the difficulties experienced by many patients, particularly poverty. They are strongly motivated by their desire to help their own community. This is reinforced when they are thanked by patients whose health has improved as a result of the assistance they provided. They feel that, as people, they have gained knowledge and confidence. The support from the project coordinators/fieldworkers is very important to them. Conclusions: The findings above represent what would be motivational in general: internal motivation, the ability to see the importance of your work, positive feedback, a plan to deal with difficulties and support from senior colleagues. It is therefore important to ensure such support and cooperation at various levels. Keywords: Home-based care, volunteers, AIDS, motivation. For full text, click here: SA Fam Pract 2004;46(1) :25-2