A realist analysis of hospital patient safety in Wales:Applied learning for alternative contexts from a multisite case study

Background: Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms. Objectives: This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes. Design: We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+ patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction. Setting: Welsh Government and NHS Wales. Participants: Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety. Main outcome measures: Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+ patient safety programme in Welsh NHS hospitals. Results: An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme. Conclusions: Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Anterior cervical disc replacement for degenerative disc disease

Purpose. To review the outcomes of anterior cervical disc replacement using the Prestige LP system for degenerative disc disease. Methods. Medical records of 12 men and 23 women aged 26 to 66 (mean, 46) years who underwent 48 anterior cervical disc replacements using the Prestige LP system by a single spine surgeon were reviewed. 22 patients underwent one-level disc replacement at C5-C6 (n=13) and C6-C7 (n=9), and 13 patients underwent 2-level disc replacement at C5-C6 and C6-C7 (n=11), C4-C5 and C5-C6 (n=1), and C6-C7 and C7-T1 (n=1). Neck Disability Index (NDI) score, visual analogue scale (VAS) for pain in the neck and arm, and physical and mental component scores of the Short Form 36 were evaluated at week 6 and months 6, 12, 24, 36, and 48. Results. The NDI score, VAS score for neck and arm pain, and physical and mental component scores of the Short Form 36 improved significantly after surgery (p< 0.001). 80% of patients were satisfied with the treatment. One patient developed a neck haematoma on day 1 and underwent surgical evacuation. Another patient developed Horner\u27s syndrome and achieved partial recovery at 6 weeks and complete recovery at 6 months. No patient had implant-related complications or reoperation. Conclusion. The Prestige LP cervical disc implant was safe for one-and 2-level cervical disc replacement

Occipitocervical fusion – an epidemiological drift experienced in an irish tertiary spinal referral center: twenty-year follow-up study

Background: Occipitocervical disease is common in the elderly population, and is on the rise due to an increasingly aging population. Methods: We retrospectively reviewed all patients who underwent occipitocervical fusion in our institution over a 20 year period (1996-2016) at a tertiary spinal referral centre. Patients were divided in 2 groups. Group A included all patient who underwent OCF in the first decade between 1996 and 2005. Group B was all patients who underwent OCF in the second decade between 2006 and 2016. Results: A total of 23 patients underwent occipitocervical fusion between 1996 until 2016 at our institution. Instability secondary to Rheumatoid arthritis was the leading factor in group A, responsible for 43 percent of cases. In group B, trauma was the leading burden accounting for 44 percent of the cases. In contrast to Group A however, only 19 % of OCFs occurred secondary to RA in group B. Our fusion rate was 96 percent with a survival rate of 67 percent. Conclusion: We noticed a clear epidemiological drift in the cervical spine pathologies requiring OCF during the first and second decade of study period with an increase in prevalence of pathological fractures secondary to metastatic disease. In addition, a drop in rheumatoid cervical disease requiring OCF has been noted

Occipitocervical fusion – an epidemiological drift experienced in an irish tertiary spinal referral center: twenty-year follow-up study

Background: Occipitocervical disease is common in the elderly population, and is on the rise due to an increasingly aging population. Methods: We retrospectively reviewed all patients who underwent occipitocervical fusion in our institution over a 20 year period (1996-2016) at a tertiary spinal referral centre. Patients were divided in 2 groups. Group A included all patient who underwent OCF in the first decade between 1996 and 2005. Group B was all patients who underwent OCF in the second decade between 2006 and 2016. Results: A total of 23 patients underwent occipitocervical fusion between 1996 until 2016 at our institution. Instability secondary to Rheumatoid arthritis was the leading factor in group A, responsible for 43 percent of cases. In group B, trauma was the leading burden accounting for 44 percent of the cases. In contrast to Group A however, only 19 % of OCFs occurred secondary to RA in group B. Our fusion rate was 96 percent with a survival rate of 67 percent. Conclusion: We noticed a clear epidemiological drift in the cervical spine pathologies requiring OCF during the first and second decade of study period with an increase in prevalence of pathological fractures secondary to metastatic disease. In addition, a drop in rheumatoid cervical disease requiring OCF has been noted

Comparison of thermal spread with the use of an ultrasonic osteotomy device: Sonopet ultrasonic aspirator versus misonix bonescalpel in spinal surgery

Background: The development of high speed rotating burrs has greatly advanced spinal surgery in recent years. However, they produce unwanted frictional heat and temperature elevation during the burring process. We compare the misonix bone scalpel (MBS) and the Sonopet ultrasonic aspirator to assess which would be the safer device in terms of the risk of thermal injury following laminectomy. Methods: We describe an experimental nonrandomized study comparing two ultrasonic osteotomy devices. We use the device tip temperature and temperature of inner cortex of the lamina, following laminectomy, as the primary outcome. Our secondary outcome is to assess which device is associated with a lower risk of osteonecrosis and potential thermal injury to surrounding dura and nerves. Results: The average device tip temperature for the Sonopet ultrasonic aspirator following the process of laminectomy was 36.8 with a maximum temperature of 41.8°C. The average device tip temperature for the MBS following laminectomy was 48.6 with a maximum temperature of 85.3°C. Conclusion: Our results have demonstrated the safety of the Sonopet ultrasonic aspirator with the Nakagawa serrated knife with temperatures below the threshold for osteonecrosis and thermal neural injury. However, the MBS has shown to occasionally reach high temperatures above the threshold of potential thermal injury to surrounding nerves and dura for a very short period of time. We advise to withdraw and re-insert the ultrasonic tip repeatedly to re-establish adequate cooling and lubrication. Further studies should be carried out using cadaveric bone at body temperature to simulate more accurate results