Understanding Patterns of Emergency Services Use and Hospital Admissions for Patients of the NHS Case Management Programme

As a result of perceived insufficient non-acute care provision, the Government is making efforts to extend primary care hours to reduce the inappropriate utilisation of 999 and A&E services (NHS England, 2013c, 2014b; Kings Fund, 2017). The case management programme was implemented to reduce acute care use in the ageing and multimorbid demographic who are high-intensity service users (DOH, 2005a). However, case management typically has restricted hours of service delivery, which could place unnecessary burden on emergency and acute services during the out-ofhours period. The aim of this study was to understand the patterns of case-managed patients’ use of 999 emergency services and presentations at A&E, and hospital admissions, as well as to explore what factors were perceived as influencing patterns of service interaction. Within a pragmatic paradigm, a sequential explanatory mixed methods study was deployed, delivered in five studies. Two cross-sectional observational studies analysed 999 callout (n=2,930, study one) and A&E attendance and hospital admission data (n=16,495, study two). Descriptive statistics were applied, and inferential statistics conducted according to data type. Key stakeholders were interviewed (patients n=19, study three, carers n=19, study four) and three focus groups conducted (case managers n=18, study five). Transcripts were analysed via an analysis spiral using both deductive and inductive approaches (Creswell, 2007). Using a pluralistic framework and previously unexploited flagged patient-level quantitative datasets produced a novel understanding of when, why and how casemanaged patients interact with services. Despite no out-of-hours emergency service burden within studies one and two, twenty-four-hour case management service provision may be required to align with acute services. Quantitative data highlighted that integration and digital interoperability across systems are required to aid admission avoidance and to improve patient experience. Qualitative investigation revealed service contact was seen in places where several parts of the system were seen to be under strain. Person-centred care and shared decision making may also need to be improved when conveyance and admission decisions are made. Case management as a model for admission prevention to manage the ageing and multimorbid population was valued in studies three to five. The inclusion of elderly and housebound participants brought the lived experience of older people to the forefront, highlighting the negative impact of the media in delaying service interactions. This research could be used to inform policy and service-level decisions at the macro- and meso-levels of healthcare. A conceptual model of the factors that contribute to service interaction presents a holistic infographic guide for case management admission prevention

Non-market Valuation Biases Due to Aboriginal Cultural Characteristics in Northern Saskatchewan: The Values Structures Component

Current non-market valuation techniques have been developed based on assumptions about values held within the Eurocentred culture. Contentions between cultures over natural resources are hypothesized to occur because of differences in held values resulting in different values being assigned to the resources in question. This study measured the held values of an Aboriginal band in Northern Saskatchewan as the first dimension of a non-market valuation study of natural resources. These held value structures are presented noting differences by age and gender and in comparison with the local Non-Aboriginal community and another Aboriginal group in northern Alberta.Resource /Energy Economics and Policy,

A forced lateralisation test for dairy cows and its relation to their behaviour

Dairy cows’ emotional state can sometimes be inferred from their behaviour, for example previous studies have suggested that those passing a novel person to the right are more likely to be anxious than those passing to the left. We undertook two studies of cow behaviour as they passed a novel person, to validate these behaviours as emotional indicators, in addition to determining correlations to other indices of emotional state. Cows passing to the right were more likely to have a raised or tucked tail, sniff the ground, walk slowly and a faster exit when put in a crush, compared with those passing to the left, which had their ears held forwards. From a principal component analysis, it was determined that cows passing on the right side were also most likely to pass without turning their head towards the person, pass singly and defecate whilst passing. However, those passing to the left side were most likely to turn to look at the person and pass in pairs. Cows with high milk yields were more likely to pass on the right side. Measurements of side of passage were repeatable between experiments but those of ear position were not. It is concluded that side of passage past a person correlates with other behavioural indicators of the cow’s emotional state, with those passing to the right (i.e. left eye/right brain hemisphere) apparently more anxious. Evidence was also provided that high yielding cows are more anxious, as assessed by right side passage. With further validation, side of passage past a person could be developed as a simple measure of emotional state in dairy cows that can be conducted under field conditions.Higher Education Ministry of the EgyptianGovernment Universities Federation for Animal Welfar

Understanding the distribution of A&E attendances and hospital admissions for the case managed population: A single case cross sectional study

Aim To describe the characteristics of case-managed patients presenting at accident and emergency (A & E) and to explore the distribution of their attendances and admissions. Background Recently, the UK Government announced extended-hours primary care provision in an effort to reduce the growing utilization of A & E. No evidence is available to understand the use of acute services by this high-risk patient group. Method A cross-sectional design utilising routinely collected anonymsed A & E attendance and hospital admission data from 2010 to 2015. Results The case-managed population is typically 70 years and older and most often arrive at A & E via emergency services and during the night (00:00–08:59). A large proportion are subsequently admitted having a statistically significant A & E conversion rate. No variables were predictive of admission. Conclusion The high level of A&E conversion could indicate case-managed patients are presenting appropriately with acute clinical need. However, inadequate provision in primary-care could drive decisions for admitting vulnerable patients

Risk factors associated with heel pressure ulcer development in adult population: A systematic literature review

Aims The main aim of this systematic literature review was to identify risk factors for development of heel pressure ulcers and quantify their effect. Background Pressure ulcers remain one of the key patient safety challenges across all health care settings and heels are the second most common site for developing pressure ulcers after the sacrum. Design Quantitative systematic review. Methods Data sources: Electronic databases were searched for studies published between 1809 to March 2020 using keywords, Medical Subject Headings, and other index terms, as well as combinations of these terms and appropriate synonyms. Study eligibility criteria: Previous systematic literature reviews, cohort, case control and cross-sectional studies investigating risk factors for developing heel pressure ulcers. Only articles published in English were reviewed with no restrictions on date of publication. Participants: patients aged 18 years and above in any care setting. Study selection, data extraction, risk of bias and quality assessment were completed by two independent reviewers. Disagreements were resolved by discussion. Results Eleven studies met the eligibility criteria and several potential risk factors were identified. However, eligible studies were mainly moderate to low quality except for three high quality studies. Conclusions There is a paucity of high quality evidence to identify risk factors associated with heel pressure ulcer development. Immobility, diabetes, vascular disease, impaired nutrition, perfusion issues, mechanical ventilation, surgery, and Braden subscales were identified as potential risk factors for developing heel pressure ulcers however, further well-designed studies are required to elucidate these factors. Other risk factors may also exist and require further investigation

UK multisite evaluation of the impact of clinical educators in EDs from a learner’s perspective

Background: In England, demand for emergency care is increasing while there is also a staffing shortage. The Royal College of Emergency Medicine (RCEM) suggested that appointment of senior doctors as clinical educators (CEs) would enable support and development of learners in EDs and improve retention and well-being. This study aimed to evaluate the impact of CEs in ED on learners. Methods: CEs were placed in 54 NHS Acute Trust EDs for a pilot beginning July 2018 and ending October 2020. Learners from multiple disciplines working at 54 NHS Acute Trust EDs where CEs were deployed were invited to complete an online survey designed to identify the impact of CEs in July of 2019, as part of an interim service evaluation. Results: Respondents numbered 493 from 49 of 54 study sites, including 286 (58%) medical (non-consultant) and 72 (14.6%) all other nursing, allied health professionals. 9 out of 10 learners reported having experienced a change to their learning as a result of the deployment of CEs in their department. 49.9% (246/493) reported that CEs had a positive impact on their well-being. 95% (340/358) reported an improved accessibility to undertaking clinical based assessments. 78% (281/358) perceived that access to CEs increased likelihood of passing assessments. Of those responding, 80.9% (399/493) reported they would remain/return to the same ED with a CE, and 92.5% (456/493) responded that they would prefer to go to a Trust with a CE. Conclusions: According to survey respondents, deployment of CEs across NHS Trusts has resulted in improvement and increased accessibility of learning and assessment opportunities for learners within ED. The impact of CEs on well-being is uncertain with half reporting improvement and the remaining half unsure. Further evaluation within the project will continue to explore the service benefit and workforce impact of the CEED intervention

A video-feedback parenting intervention to prevent enduring behaviour problems in at-risk children aged 12-36 months: the Healthy Start, Happy Start RCT.

BACKGROUND: Behaviour problems emerge early in childhood and place children at risk for later psychopathology. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of a parenting intervention to prevent enduring behaviour problems in young children. DESIGN: A pragmatic, assessor-blinded, multisite, two-arm, parallel-group randomised controlled trial. SETTING: Health visiting services in six NHS trusts in England. PARTICIPANTS: A total of 300 at-risk children aged 12-36 months and their parents/caregivers. INTERVENTIONS: Families were allocated in a 1 : 1 ratio to six sessions of Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) plus usual care or usual care alone. MAIN OUTCOME MEASURES: The primary outcome was the Preschool Parental Account of Children's Symptoms, which is a structured interview of behaviour symptoms. Secondary outcomes included caregiver-reported total problems on the Child Behaviour Checklist and the Strengths and Difficulties Questionnaire. The intervention effect was estimated using linear regression. Health and social care service use was recorded using the Child and Adolescent Service Use Schedule and cost-effectiveness was explored using the Preschool Parental Account of Children's Symptoms. RESULTS: In total, 300 families were randomised: 151 to VIPP-SD plus usual care and 149 to usual care alone. Follow-up data were available for 286 (VIPP-SD, n = 140; usual care, n = 146) participants and 282 (VIPP-SD, n = 140; usual care, n = 142) participants at 5 and 24 months, respectively. At the post-treatment (primary outcome) follow-up, a group difference of 2.03 on Preschool Parental Account of Children's Symptoms (95% confidence interval 0.06 to 4.01; p = 0.04) indicated a positive treatment effect on behaviour problems (Cohen's d = 0.20, 95% confidence interval 0.01 to 0.40). The effect was strongest for children's conduct [1.61, 95% confidence interval 0.44 to 2.78; p = 0.007 (d = 0.30, 95% confidence interval 0.08 to 0.51)] versus attention deficit hyperactivity disorder symptoms [0.29, 95% confidence interval -1.06 to 1.65; p = 0.67 (d = 0.05, 95% confidence interval -0.17 to 0.27)]. The Child Behaviour Checklist [3.24, 95% confidence interval -0.06 to 6.54; p = 0.05 (d = 0.15, 95% confidence interval 0.00 to 0.31)] and the Strengths and Difficulties Questionnaire [0.93, 95% confidence interval -0.03 to 1.9; p = 0.06 (d = 0.18, 95% confidence interval -0.01 to 0.36)] demonstrated similar positive treatment effects to those found for the Preschool Parental Account of Children's Symptoms. At 24 months, the group difference on the Preschool Parental Account of Children's Symptoms was 1.73 [95% confidence interval -0.24 to 3.71; p = 0.08 (d = 0.17, 95% confidence interval -0.02 to 0.37)]; the effect remained strongest for conduct [1.07, 95% confidence interval -0.06 to 2.20; p = 0.06 (d = 0.20, 95% confidence interval -0.01 to 0.42)] versus attention deficit hyperactivity disorder symptoms [0.62, 95% confidence interval -0.60 to 1.84; p = 0.32 (d = 0.10, 95% confidence interval -0.10 to 0.30)], with little evidence of an effect on the Child Behaviour Checklist and the Strengths and Difficulties Questionnaire. The primary economic analysis showed better outcomes in the VIPP-SD group at 24 months, but also higher costs than the usual-care group (adjusted mean difference £1450, 95% confidence interval £619 to £2281). No treatment- or trial-related adverse events were reported. The probability of VIPP-SD being cost-effective compared with usual care at the 24-month follow-up increased as willingness to pay for improvements on the Preschool Parental Account of Children's Symptoms increased, with VIPP-SD having the higher probability of being cost-effective at willingness-to-pay values above £800 per 1-point improvement on the Preschool Parental Account of Children's Symptoms. LIMITATIONS: The proportion of participants with graduate-level qualifications was higher than among the general public. CONCLUSIONS: VIPP-SD is effective in reducing behaviour problems in young children when delivered by health visiting teams. Most of the effect of VIPP-SD appears to be retained over 24 months. However, we can be less certain about its value for money. TRIAL REGISTRATION: Current Controlled Trials ISRCTN58327365. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 29. See the NIHR Journals Library website for further project information.NIHR HTA programm

Evolution of long-term vaccine-induced and hybrid immunity in healthcare workers after different COVID-19 vaccine regimens

BACKGROUND: Both infection and vaccination, alone or in combination, generate antibody and T cell responses against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the maintenance of such responses-and hence protection from disease-requires careful characterization. In a large prospective study of UK healthcare workers (HCWs) (Protective Immunity from T Cells in Healthcare Workers [PITCH], within the larger SARS-CoV-2 Immunity and Reinfection Evaluation [SIREN] study), we previously observed that prior infection strongly affected subsequent cellular and humoral immunity induced after long and short dosing intervals of BNT162b2 (Pfizer/BioNTech) vaccination. METHODS: Here, we report longer follow-up of 684 HCWs in this cohort over 6-9 months following two doses of BNT162b2 or AZD1222 (Oxford/AstraZeneca) vaccination and up to 6 months following a subsequent mRNA booster vaccination. FINDINGS: We make three observations: first, the dynamics of humoral and cellular responses differ; binding and neutralizing antibodies declined, whereas T and memory B cell responses were maintained after the second vaccine dose. Second, vaccine boosting restored immunoglobulin (Ig) G levels; broadened neutralizing activity against variants of concern, including Omicron BA.1, BA.2, and BA.5; and boosted T cell responses above the 6-month level after dose 2. Third, prior infection maintained its impact driving larger and broader T cell responses compared with never-infected people, a feature maintained until 6 months after the third dose. CONCLUSIONS: Broadly cross-reactive T cell responses are well maintained over time-especially in those with combined vaccine and infection-induced immunity ("hybrid" immunity)-and may contribute to continued protection against severe disease

Antibody escape of SARS-CoV-2 Omicron BA.4 and BA.5 from vaccine and BA.1 serum

The Omicron lineage of SARS-CoV-2, first described in November 2021, spread rapidly to become globally dominant and has split into a number of sub-lineages. BA.1 dominated the initial wave but has been replaced by BA.2 in many countries. Recent sequencing from South Africa’s Gauteng region uncovered two new sub-lineages, BA.4 and BA.5 which are taking over locally, driving a new wave. BA.4 and BA.5 contain identical spike sequences and, although closely related to BA.2, contain further mutations in the receptor binding domain of spike. Here, we study the neutralization of BA.4/5 using a range of vaccine and naturally immune serum and panels of monoclonal antibodies. BA.4/5 shows reduced neutralization by serum from triple AstraZeneca or Pfizer vaccinated individuals compared to BA.1 and BA.2. Furthermore, using serum from BA.1 vaccine breakthrough infections there are likewise, significant reductions in the neutralization of BA.4/5, raising the possibility of repeat Omicron infections