Applying social network analysis to the examination of interruptions in healthcare

Examinations of interruptions in healthcare often focus on a single clinical discipline, and solutions are targeted accordingly. This approach does not take into account the inter-disciplinary dependencies and other sociotechnical aspects that make up the healthcare work system, and suggested solutions may not meet the needs of all stakeholders. In this article a sociotechnical systems perspective is used to uncover the interdependencies between 16 unique work roles that result in interruptions in an intensive care unit (ICU). By applying social network analysis techniques to data collected using the Dual Perspectives Method, we identified targeted systems-based interventions that may reduce unnecessary interruptions while avoiding unintended consequences that impose additional burden on ICU staff. The rich insights gained into the interruptive communication patterns in the ICU work system stand in contrast to findings that would have otherwise been obtained by focusing only on a single clinical discipline or a single perspective

A 10-year analysis of organ donor referrals to a South African tertiary public sector hospital

Background. South Africa (SA) has one of the lowest deceased organ donor rates in the world (1.4 donors per million population), with thousands of patients awaiting solid-organ transplantation. In order to improve access to transplantation we have to clearly define the reasons for the low deceased donation rate, specific to the population we serve.Objectives. Review of actual donor statistics highlights our successes, yet is not able to contextualise the factors responsible for the unsuccessful conversion of referred organ donors to actual organ donors. In an attempt to identify key factors preventing referred donors from becoming actual donors, we analysed the donor referral patterns at our institution over a 10-year period.Methods. This was a retrospective descriptive study of consecutive deceased donor referrals at Groote Schuur Hospital, Cape Town, SA (from January 2007 to December 2016), utilising a regional donor referral registry. Qualitative and quantitative data were collected and presented as descriptive statistics and temporal trends.Results. Over the 10-year study period, 861 possible organ donors were referred, with a steady increase in the number of referrals over time. Of the referrals, 514 (59.7%) were eligible for donation of at least one solid organ. Of the 508 families that were approached for consent to donation, 342 declined consent for a variety of reasons, resulting in a consent rate of 32.7%. Ultimately, at least one solid organ was obtained from 159 of the 166 consented donors. Despite the increasing number of possible and eligible donors, a statistically significant decline in consent rate was observed over time (ptrend=0.023). Furthermore, increasing trends in medical (as opposed to trauma) (ptrend<0.001) and extended criteria (as opposed to standard criteria) donor referrals (ptrend<0.001) were observed over the 10-year study period.Conclusions. Donor referral patterns have changed over time, with a notable increase in medical and extended criteria donors. Despite the increase in possible and eligible donors, the consent rate has declined. Further qualitative and quantitative research studies are required to understand and address this trend.

Factors influencing consent rates of deceased organ donation in Western Cape Province, South Africa

Background. South Africa (SA) has very low and unchanging organ donation rates. A key point in the pathway of organ donation is obtaining informed consent from the family, which is necessary before organ donation can proceed. There is no published SA research on the consent rate and factors that influence this.Objectives. To describe the number of requests for consent and factors influencing this process in the SA context.Methods. A prospective descriptive study was performed of all requests to families for organ donation in Western Cape Province, SA, by Groote Schuur Hospital (state sector), Red Cross War Memorial Children’s Hospital (state sector) and Netcare (private sector) transplant co-ordinators from 1 May 2017 to 1 May 2018 to describe factors influencing consent rates.Results. The 6 co-ordinators (3 state sector and 3 private sector) recorded data of 83 consecutive families approached in 16 hospitals over the 1-year period. Consent to organ donation was granted for 23 family requests (n=18 (state sector); n=5 (private sector)). The number of families approached was greater in the state sector (n=74) than in the private sector (n=9). The overall consent rate was 27.7% (24.3% (state sector); 55.5% (private sector)). The majority of referrals came from trauma and emergency units (n=55; 66.3%) and very few from intensive care units (n=25; 30.1%). Immediate fluid resuscitation was required in 56 (67.5%) potential donors. The majority of families (n=74; 89.2%) were receptive to the organ donation request, independent of their ultimate decision regarding donation. The main reason given for refusing to consent was that it was against their religion (n=21) or culture (n=18).Conclusions. This study showed that the number of families approached for consent to organ donation were low in the Western Cape (lower in the private sector), with a low consent rate (lower in the state sector). Donor management by clinical teams needs to be ongoing and active during the consent process. Consent discussions (and public awareness initiatives) need to be sensitive to and deal with religious and cultural reservations about organ donation

Two sides to every story: The Dual Perspectives Method for examining interruptions in healthcare

Interruptions are widely considered a problem in healthcare. Results from observation and experimental studies have guided extensive mitigation efforts, but the effectiveness of interventions remains mixed. We have built on current theories and methods for studying interruptions to develop a novel observational approach – the Dual Perspectives Method – for examining interruptions from the perspectives of the different work functions in an Intensive Care Unit (ICU). We detail the method and provide representative examples of the insights it offers, such as why interruptions happen, the role they play, and the consequences of preserving them or eliminating them. We anticipate that the Dual Perspectives Method will help us to arrive at a better basis on which to draw conclusions about interruptions, and will lead to the development of appropriate and sustainable interventions to ensure the effective and safe functioning of the work system under examination

Liver transplantation at Red Cross War Memorial Children's Hospital

The liver transplant programme for infants and children at Red Cross War Memorial Children's Hospital is the only established paediatric service in sub-Saharan Africa. Referrals for liver transplant assessment come from  most provinces within Smith Africa as well as neighbouring countries. Patients and methods. Since 1987, 81 children (range 6 months - 14 years) have had 84liver transplants with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (48), metabolic (7), fulminant hepatic failure (10), redo transplants (3) and other (16). Four combined liver/kidney transplants have been performed. Fifty-three were reduced-size transplants with donor/recipient weight ratios  ranging from 2:1 to 11:1 and .32 children weighed less than 10 kg.Results. Sixty patients (74%) survived 3 months -14 years post transplant. Overall cumulative 1- and 5-year patient survival figures are 79% and 70% respectively. However, with the introduction of prophylactic intravenous ganciclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the 1-year patient survival is 90% and the projected 5-year  paediatric survival is> 80%. Early(< 1 month) postliver- transplantmortality was low. Causes include primary malfunction (1), inferior vena cava   thrombosis (1), bleeding oesophageal ulcer (1), sepsis (1) and cerebral oedema (1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths), Epstein--Barr virus (EBV)related post-transplantation lymphoproliferative disease (12 patients, 7 deaths) and cytomegalovirus (CMV) disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in 3 patients was complicated by chronic rejection (1) and TB-drug-induced subfulminant liver failure (1).Conclusion. Despite limited resources, a successful paediatric programme has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors because of infection with HBV and human immunodeficiency virus (HIV) leads to significant waiting-list mortality and infrequent transplantation

Study protocol: a double blind randomised control trial of high volume image guided injections in achilles and patellar tendinopathy in a young active population

Background: Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). Methods: RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. Inclusion criteria: male, 18–55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. Discussion: Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment

Liver transplantation at Red Cross War Memorial Children's Hospital

No Abstract. South African Medical Journal Vol. 96(9) (Part 2) 2006: 960-96

Developing mHealth Apps with researchers: multi-stakeholder design considerations

The authors have been involved with developing a number of mHealth smartphone Apps for use in health or wellness research in collaboration with researchers, clinicians and patient groups for clinical areas including Sickle Cell Disease, Attention Deficit Hyperactivity Disorder, asthma and infertility treatment. In these types of applications, end-users self-report their symptoms and quality of life or conduct psychometric tests. Physiological data may also be captured using sensors that are internal or external to the device. Following a discussion of the multiple stakeholders that are typically involved in small scale research projects involving end-user data collection, four Apps are used as case studies to explore the issue of non-functional requirements