Patients’ and emergency clinicians’ perceptions of improving pre-hospital pain management: a qualitative study

Background: The authors aimed to investigate patients' and practitioners' views and experiences of pre-hospital pain management to inform improvements in care and a patient-centred approach to treatment. Methods: This was a qualitative study involving a single emergency medical system. Data were gathered through focus groups and semi-structured interviews. Participants were purposively sampled from patients transported by ambulance to hospital with a painful condition during the past 6 months, ambulance service and emergency department (ED) clinicians. Interviews were audiotaped, transcribed and thematic analysis was conducted. Results: 55 participants were interviewed: 17 patients, 25 ambulance clinicians and 13 ED clinicians. Key themes included: (1) consider beliefs of patients and staff in pain management; (2) widen pain assessment strategies; (3) optimise non-drug treatment; (4) increase drug treatment options; and (5) enhance communication and coordination along the pre-hospital pain management pathway. Patients and staff expected pain to be relieved in the ambulance; however, refusal of or inadequate analgesia were common. Pain was commonly assessed using a verbal score, but practitioners' views of severity were sometimes discordant with this. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Pre-hospital pain management could be improved by addressing practitioner and patient barriers, increasing available drugs and developing multi-organisational pain management protocols supported by training for staff. Conclusions: Pain is often poorly managed and undertreated in the pre-hospital environment. The authors' findings may be used to inform guidance, education and policy to improve the pre-hospital pain management pathway

Identifying barriers and facilitators to improve prehospital care of asthma

Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. Problem: In 2008/09 there were nearly 80,000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. Assessment of problem and analysis of its causes: National benchmarking of ambulance clinical performance indicators for asthma, with performance analysed and compared using funnel plots, revealed important unexplained variations in care across ambulance services. Despite gradual improvements in care quality poor levels of prehospital assessment of asthma persist, particularly in recording of peak expiratory flow rates (PEFR: mean 42%, range 8-50% recorded) and saturation of peripheral oxygen (SpO2: mean 90%, range 66-100% recorded). Intervention: We aimed to collect data about ambulance clinicians’ perceptions and beliefs around asthma management, the barriers and facilitators to implementing current guidelines and what measures would improve prehospital care and pathways for asthma. Study design: We used a phenomenological qualitative approach focusing on participants’ lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on of barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Strategy for change: A number of preliminary themes were identified: 1. perceptions and beliefs of paramedics on the management of asthma, 2. barriers and facilitators to following asthma guidelines, 3 measures to improve prehospital asthma care and pathways. Measurement of improvement: Ambulance clinicians believed that asthma guidelines were usually followed with the exception of PEFR recording. They felt the guidelines were more suitable for the hospital environment, and that they were confusing or not always practical in the prehospital environment. Pre-treatment objective assessments were not seen as a priority where airway or breathing difficulty was apparent and where these were not thought to affect patient outcome. Oxygen measurement was more likely to be carried out where equipment was readily to hand. Peak flow measurement was believed by some to be detrimental to patients in respiratory distress and sometimes difficult to obtain. Reasons for not carrying out objective assessment were not always recorded. Ambulance guidelines and training were seen as barriers to pre-treatment assessment as the emphasis is on correcting breathing difficulties before carrying out other assessments. Development of better pathways and co-operation between health agencies was advocated. Effects of changes: Our findings will inform system interventions to address current deficiencies in care. Improvements will be measured using control charts. Lessons learnt: Important barriers to improving care are often not evident without involving front line clinicians, gathering information from them in order to understand the issues affecting care delivery from their perspective. Perceptions and beliefs held by ambulance clinicians for asthma management need to be addressed in order to change practice. Ambulance training and guidelines need to reinforce the reasons for taking objective assessments, reinforcing the place of pre-treatment assessment in the overall patient journey and highlighting the dangers of overreliance on non-objective assessment. Message for others: Detailed analysis of barriers and facilitators is an important precursor to real, sustained and systematic improvements in care

Effect of lead and cadmium on germination and seedling growth of Leucaena leucocephala

A study was conducted to determine the effect of different concentrations of lead and cadmium on seed germination and seedling growth of Leucaena leucocephala. Seed were grown under laboratory conditions at 25, 50, 75 and 100 ppm of metal ions of lead and cadmium. Both lead and cadmium treatments showed toxic effectson various growth indices of L. leucocephala. Increasing the concentration of lead to 75 ppm, significantly (

Pеngaruh Budaya Pеrusahaan dan Lingkungan Kеrja Tеrhadap Kinеrja Karyawan (Studi pada Karyawan dan Agеn PT Prudеntial Lifе Assurancе Cabang Kеdiri)

This study is conductеd in ordеr to analyzе and еxaminе thе impact bеtwееn thе variablеs of this study. Thе impacts studiеd on this study covеr thе impacts of company's culturе to еmployее's pеrformancе and thе impacts of working еnvironmеnt to еmployее's pеrformancе. In this study, thе writеr usеd an еxplanatory rеsеarch with a quantitativе approach of study, data collеction tеchniquеs usеd simplе random sampling. Thе data of this study arе 55 еmployее and agеnt of PT. Prudеntial Lifе Assurancе Kеdiri Branch. In collеcting thе data, thе writеr usеd quеstionnairе and rеcording as hеr mеans. Thе writеr usеd dеscriptivе analysis and infеrеntial analysis which consist of uji f and uji t in analyzing thе data of this study. Thе findings of this study shows that Company's Culturе and Working Еnvironmеnt arе simultanеously affеct thе Еmployее's Pеrformancе within significant scorе as much p=0.000 (p<0.05) and Fhitung scorе as much 36,082. Company's Culturе variablе partially affеcts Еmployее's Pеrformancе with significant scorе as much p=0.012 (p<0.05) and thitung scorе as much 2.596. Working Еnvironmеnt variablе is also partially affеcts Еmployее's Pеrformancе significantly with significant scorе p=0.000 (p<0.05) and thitung scorе as much 5.183. Kеywords: Company's Culturе, Working Еnvironmеnt, Еmployее's Pеrformancе АBSTRАK Pеnеlitian ini bеrtujuan untuk mеnganalisis dan mеnguji pеngaruh antara variabеl-variabеl yang ditеliti dalam pеnеlitian ini. Pеngaruh yang diuji tеrsеbut antara lain, pеngaruh budaya pеrusahaan tеrhadap kinеrja karyawan, dan pеngaruh lingkungan kеrja tеrhadap kinеrja karyawan. Jеnis pеnеlitian yang digunakan dalam pеnеlitian ini adalah еxplanatory rеsеarch dеngan mеnggunakan pеndеkatan kuantitatif, tеknik pеngambilan data yang digunakan simplе random sampling. Sampеl yang diambil sеbanyak 55 karyawan dan agеn PT. Prudеntial Lifе Assurancе Cabang Kеdiri. Mеtodе pеngumpulan data yang digunakan adalah kuеsionеr dan dokumеntasi. Analisis yang digunakan dalam pеnеlitian ini analisis diskriptif dan analisis infеrеnsial yang tеrdiri dari uji f dan uji t. Hasil pеnеlitian ini mеnunjukkan variabеl Budaya Pеrusahaan dan Lingkungan Kеrja sеcara simultan bеrpеngaruh sеcara signifikan tеrhadap variabеl Kinеrja Karyawan, dеngan nilai signifikansi p=0.000 (p<0.05) dan nilai Fhitung sеbеsar 36,082. Variabеl Budaya Pеrusahaan sеcara parsial bеrpеngaruh sеcara signifikan tеrhadap variabеl Kinеrja Karyawan, dеngan nilai signifikansi p=0.012 (p<0.05) dan nilai thitung sеbеsar 2.596. Variabеl Lingkungan Kеrja sеcara parsial bеrpеngaruh sеcara signifikan tеrhadap variabеl Kinеrja Karyawan, dеngan nilai signifikansi p=0.000 (p<0.05) dan nilai thitung sеbеsar 5.183. Kаtа Kunci: Budaya Pеrusahaan, Lingkungan Kеrja, Kinеrja Karyawa

Characteristics and costs of individuals experiencing severe hypoglycaemia requiring emergency ambulance assistance in the community

Background and aims: Hypoglycaemia causes considerable a burden to individuals the healthcare providers. The aim of this study was to examine clinical characteristics of individuals requiring emergency medical assistance by ambulance services for an episode of severe hypoglycaemia and to estimate provider costs of hypoglycaemia. Materials and methods: Routinely collected information was retrieved for all episodes of severe hypoglycaemia attended to by the emergency ambulance services for a population of 367,051 people, including 75,603 people with diabetes, in Nottinghamshire and Derbyshire, UK, between 01/11/10 to 28/02/11. A total of 90,435 emergency calls were received in the study period, of which 523 (0.6%) were recorded as severe hypoglycaemia. The time to response, on-site treatment and hospitalisation were recorded along with standard clinical and blood glucose (BG) measures. Ambulance services costs were calculated. Results: The mean (SD) [proportion <= 3.2 mmol/L] pre and post-treatment BG levels were 1.9 (0.9) mmol/L [92%] and 6.5 (3.1) mmol/L [3%] respectively, 74% were under insulin treatment, 28% had nocturnal hypoglycaemia, and 153 (32%) individuals were transported to hospital. Lower pre-treatment BG (p<0.01) and Glasgow Coma Scale scores (p=0.05) were observed in insulin treated individuals in comparison to non-insulin treated individuals. No significant differences in individual characteristics were observed for other clinical measurements: post-treatment blood glucose (p=0.39), systolic blood pressure (p=0.28), diastolic blood pressure (p=0.64) and heart rate (p=0.93). Non insulin treatment was an independent predictor of transportation to hospital (p<0.01). Median time from allocation of call to departure of scene by ambulance services was 39 and 59 minutes for those transported and not transported to hospital respectively, translating to costs of £92 and £139 respectively. The median time from allocation to handing over patients to emergency staff was 75 minutes, equating to a cost of £176. Conclusion: The majority of cases of severe hypoglycaemia are successfully treated at the scene by the emergency ambulance services. Insulin treated and non insulin treated individuals do not differ by clinical characteristics, however non insulin treated individuals were more likely to be transported to hospital. Further studies are needed into the effect of prehospital ambulance care by treatment type on subsequent outcomes

Qualitative interview study of patients', ambulance practitioners' and emergency department clinicians' perceptions of prehospital pain management

Introduction Pre-hospital pain management is increasingly important with most patients (80%) presenting to UK ambulance services in pain and 20% of patients reporting inadequate pain relief. Improving prehospital pain management is important for service quality. Our aim was to investigate perceptions of pain management from patients, ambulance and emergency care staff. Methods Qualitative data were gathered through focus group (5) and interviews (28). Participants were purposively sampled from patients recently transported to hospital in pain, ambulance staff and emergency department clinicians. Interviews were audiotaped and transcribed using thematic analysis to iteratively develop themes supported by data analysis software, MAXQDA. Results Themes emerging from the data included: (a) expectations and beliefs (b) assessment methods (c) drug treatment (d) non-drug treatment and (f) improvement strategies for pain. Patients and staff expected pain to be relieved in the ambulance; instances of refusal of or inadequate analgesia were not uncommon because patients were concerned about drug side effects or, did not want to be transported. Pain was commonly assessed using a verbal pain score; clinical observation was often discordant with subjective experience. Communication difficulties, non-cooperation or influence of alcohol or drugs were found as barriers to pain assessment. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Suggestions to improve prehospital pain management included addressing barriers, modifying the available drugs and developing agreed multi-organisational pain management protocols supported by training for staff. Discussion Patients and practitioners expected pain to be relieved in the ambulance. Suggestions to improve prehospital pain management included addressing identified barriers, modifying the available drugs, using non-drug measures and developing agreed multi-organisational pain management protocols supported by appropriate training for staff. Our findings will inform development of protocols and quality improvement programmes along the pathway of prehospital pain management

Pengaruh Budaya Perusahaan Terhadap Motivasi Kerja Serta Dampaknya Terhadap Kinerja Karyawan (Studi Pada PT. Syngenta Seed Indonesia, Pasuruan Site)

This research is aimed to explain the impacts of company culture that affected by home country culture on motivation, impacts of company culture on employee performance, and impacts of motivation on employee performance. This research is quantitative research with the method of explanatory research, and used questionnaire method. The populations are employees of PT. Syngenta Seed Indonesia, Pasuruan Site. This research was analyzed by using descriptive and path analysis. The results shows that company culture that affected by home country culture has significant positive effect on motivation. Company culture has significant positive effect on employee performance. Motivation has significant positive effect on employee performance. So that, company culture also has significant positive indirect effect on employee performance through motivation variable. It means that the more home country culture adapted to company culture, the more motivation and employee performance in multinational company will increase

Pengaruh Intellectual Capital Dan Organizational Value Terhadap Kinerja Perusahaan (Studi Pada Karyawan PT Semen Indonesia (Persero) Tbk)

The kind of this research is explanatory research and by using simple random sampling. Data collection by distributing questionnaire to 102 respondents which is the employee of PT Semen Indonesia (Persero) Tbk. Data analysis in this research used descriptive statistical analysis and using multiple linear regression analysis by SPSS Program v 23.0.0. Based on analysis data, it can be described that each result of respondents about Intellectual Capital score average in 4,03. In Organiztional Value shows average 4,00. Then, for variable of Company's Performance have average 3,87. Result of multiple linier regression that simultaneously and partially variable of Intellectual Capital and Organizational Value have significant influence on Company's Performance. This result of simultaneous test indicates that F-significance 0,000 &lt; 0,05. The regression coefficient obtained in this study of 0,546 which means that the variable of Intellectual Capital and Organizational Value have influence of 54,6% towards Company's Performance, while the remaining 45,4% are effected by other variable unobserved in this research. Intellectual Capital has significant influence on Company's Performance (Y) which has t significance for 0,021 &lt; α = 0,005. Organizational Value has significant influence on Company's Performance which has t significance for 0,000 &lt; α = 0,005

An Exploration of Strategic Alliance in the Improvement of Airlines' Performance (a Case Study of PT Garuda Indonesia)

The purpose of this research is to explore the improvement of company's performance while comply the high qualified SkyTeam membership requirements. This research also explores the networking impact that company able to obtain, and improvement of integrated ground service that SkyTeam offers to passenger. Research method that used in this research is qualitative method with case study approach. Data sources in this research are primary data, by doing interview with Alliance and Partnership Management and Ground Service Unit from PT Garuda Indonesia, and secondary data from company's documents, and news update which is related to the research theme. The result shows that joining Garuda Indonesia to SkyTeam improve company's performance in terms of passenger service system, quality of safety, human capital skills, brand recognition, and knowledge transfer process. Further, SkyTeam provide new potential market for Garuda Indonesia to Greater China, America, Europe, and Middle East. The integrated ground service that SkyTeam offers also increase the customer satisfaction index for Garuda Indonesia service. Besides that, Garuda Indonesia also faces some obstacles to adjust the high modern passenger service system, ground service officer which lack of SkyTeam product knowledge, and implementation of SkyTransfer which adjust the airport infrastructure and facility