Understanding and remedying the performance of doctors in training

Identifying and responding appropriately to doctors who are underperforming, whether they are in training or in clinical practice, is vital in a profession where high standards are a pre-requisite for ensuring high-quality care that is safe and effective and provides patients with a good experience

It’s scary, scary, scary …”: the lived experience of asthma.

The research presented here contributes to a developing sociological-phenomenological empirical corpus of literature by addressing the lived experience of asthma in non-élite sports participants and committed exercisers. Despite the prevalence of asthma and exercise-induced asthma/bronchoconstriction, there is a distinct lacuna in terms of qualitative research into living with asthma, and specifically in relation to participation in sports and physical cultures. Here we focus upon the aural dimension of asthma experiences, examining the role of ‘auditory attunement’ and ‘auditory work’ in sporting embodiment

Anxiety and depression: a model for assessment and therapy in primary care

Patients who feel anxious and depressed often turn to primary care for initial professional help. However, systematic service evaluations allege poor standards of diagnosis and treatment, resulting in disappointing clinical outcomes. All the same, special educational and quality improvement initiatives have not raised standards significantly. Why this should be so and possible remedies are suggested by this article, on the basis that the empirical evidence base for criticising primary care standards is weaker than commonly acknowledged. Systematic clinical trials are often premised by assumptions that are not relevant to primary care, they tend to select subject populations unrepresentative of those typically seen by general practitioners and results are often compromised by a series of methodological flaws. This article proposes an alternative conceptualisation of anxiety and depression apposite to primary care assessment and therapy. It draws on an emergent evidence base within psychobiology that recognises that these reactions have two adaptive functions. Firstly, they are responses evoked by actual personal adversity, secondly they have the function of prompting communication to self and to others of the need for practical remedial action to be taken independently, or with assistance, to improve the quality of the recovery environment. A table summarises the phased stages of anxiety and depression and lists their adaptive and communicative functions along with some phase-appropriate primary care interventions. This new model of assessment and therapy is offered to stimulate discussion and inspire future research that is appropriate for primary care service improvement

An evaluation of an educational intervention to reduce inappropriate cannulation and improve cannulation technique by paramedics

Background: Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique. Method: We used a non-randomised control group design, comparing two counties in the East Midlands (UK)as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a ‘‘model’’ arm using a predesigned checklist. Results: There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p,0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p,0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p,0.001). Conclusion: The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation

To cannulate or not to cannulate? Variation, appropriateness and potential for reduction in cannulation rates by ambulance staff

Background: Peripheral intravenous (IV) cannulation is a key intervention in the prehospital setting, but inappropriate use may cause unnecessary pain, distress or risk of infection. The aim of this study was to examine the rate and appropriateness of prehospital cannulation and the relative importance of factors associated with increased likelihood of cannulation. Design and setting: Cross-sectional survey of patients transported in Lincolnshire, East Midlands Ambulance Service. Methods: Retrospective non-identifiable data for September 2006 were extracted. Clinical conditions were classified according to whether they warranted, did not warrant or were uncertain as to the need for cannulation. Other potential indications for cannulation including IV drug administration, reduced consciousness, systolic hypotension, respiratory depression and haemorrhage were combined to determine whether cannulation was indicated. Other variables were investigated as predictors of cannulation. The method of analysis was agreed at the outset. Results: Paramedics cannulated 14.6% (1295/8866) of patients. IV drug administration, clinical indication, reduced conscious level, respiratory depression and hypotension were associated with greater likelihood of cannulation (p,0.001). Cannulation was more likely in older patients but was not associated with gender, haemorrhage or hypoglycaemia. Multivariate logistic regression showed IV drug administration as the strongest predictor of cannulation. Cannulation rates varied threefold by ambulance station (mean 13.4%, 5.8% to 19.0%). It was estimated that 202 (15.6%) of the cannulations performed could potentially have been avoided. Conclusion: Rates of cannulation were higher than previous studies with wide variations between ambulance stations. 15.6% of cannulations performed could have been avoided, thus reducing pain, distress and other potential complications such as thrombophlebitis, extravasation and infection. The generalisability of this study was limited by use of a single site, short duration and dependence on accurate retrospective data. The data demonstrating wide variations suggest that there may be scope for consideration of interventions to reduce cannulation rates

Evaluation of the Falls Response Partnership’s community first responder response to adults who have fallen in Lincolnshire

Background The Falls Response Partnership (FRP) is an innovative approach to ensuring a safe health and social care response to people who fall in Lincolnshire. It involves LIVES Lincolnshire First Responders being trained and supported to attend adults who fall and then either call for an ambulance or an ambulance is called on their behalf. This scheme was implemented from December 2018 and this report describes the interim evaluation of the service. We aimed to investigate the effect of LIVES responders allocated to and attending people who fell and the overall effect of the FRP. Method We accessed data from East Midlands Ambulance Service NHS Trust (EMAS) and LIVES to conduct the evaluation, comparing outcomes for adults who fell and called the ambulance, and who then received an ambulance response or a LIVES response. We have provided descriptive analyses based on these data and more detailed economic models and analyses comparing LIVES with ambulance responses in terms of outcomes and costs while adjusting for other factors likely to be associated with these. Results Between December 2018 and the end of June 2019 we ascertained that 445 patients were attended by LIVES through the FRP. Patients were seen on average in under 30 minutes and around 30 minutes was spent on average assessing and managing each patient. In just over half the cases (53%) ambulance backup was called. 62% of FRP patients were conveyed to hospital. Additional data on severity category, location and adjustment for inclusion and exclusion criteria were available for 183 unique cases of falls attended by CFRs of which 153 remained that were actually attended by the Bariatric Support Vehicles (BSVs) allocated to the FRP. Of the 153 cases FRP attended the scene, 95 (63%) eventually went to hospital. More severe cases increased the likelihood of an ambulance being called to attend. Costs of standard care and the LIVES responders attending have been estimated and are presented based on an economic model formed as a decision tree. The model suggests that the effectiveness and costeffectiveness of the FRP increases as transportation to hospital following FRP attendance decreases, as referral to the community falls service increases and with the duration of the intervention because of a reduction in recurrent falls. Cost effectiveness estimates are presented as incremental cost effectiveness ratios (ICERs). Conclusion Our preliminary results suggest that the FRP has the potential to be effective and cost-effective, for management of adult fallers who call the ambulance service and are attended by LIVES CFRs, as additional ambulance attendance and transportation decreases, referrals to community falls services increase and as the intervention continues over time, due to reduction in recurrent falls

The effect of specific learning difficulties on general practice written and clinical assessments

Background Substantial numbers of medical students and doctors have specific learning difficulties (SpLDs) and failure to accommodate their needs can disadvantage them academically. Evidence about how SpLDs affect performance during postgraduate general practice (GP) specialty training across the different licencing assessments is lacking. We aimed to investigate the performance of doctors with SpLDs across the range of licencing assessments. Methods We adopted the social model of disability as a conceptual framework arguing that problems of disability are societal and that barriers that restrict life choices for people with disabilities need to be addressed. We used a longitudinal design linking Multi-Specialty Assessment (MSRA) records from 2016 and 2017 with their Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA) and Workplace Based Assessment (WPBA) outcomes up to 2021. Multivariable logistic regression models accounting for prior attainment and demographics were used to determine the SpLD doctors' likelihood of passing licencing assessments. Results The sample included 2070 doctors, with 214 (10.34%) declaring a SpLD. Candidates declaring a SpLD were significantly less likely to pass the CSA (OR 0.43, 95% CI 0.26, 0.71, p = 0.001) but not the AKT (OR 0.96, 95% CI 0.44, 2.09, p = 0.913) or RCA (OR 0.81, 95% CI 0.35, 1.85, p = 0.615). Importantly, they were significantly more likely to have difficulties with WPBA (OR 0.28, 95% CI 0.20, 0.40, p < 0.001). When looking at licencing tests subdomains, doctors with SpLD performed significantly less well on the CSA Interpersonal Skills (B = −0.70, 95% CI −1.2, −0.19, p = 0.007) and the RCA Clinical Management Skills (B = −1.68, 95% CI −3.24, −0.13, p = 0.034). Conclusions Candidates with SpLDs encounter difficulties in multiple domains of the licencing tests and during their training. More adjustments tailored to their needs should be put in place for the applied clinical skills tests and during their training

Has there been a change in the knowledge of GP registrars between 2011 and 2016 as measured by performance on common items in the Applied Knowledge Test?

The aim of this study was to assess whether the absolute standard of candidates sitting the MRCGP Applied Knowledge Test (AKT) between 2011 and 2016 had changed. It is a descriptive study comparing the performance on marker questions of a reference group of UK graduates taking the AKT for the first time between 2011 and 2016. Using aggregated examination data, the performance of individual ‘marker’ questions was compared using Pearson’s chi-squared tests and trend-line analysis. Binary logistic regression was used to analyse changes in performance over the study period. Changes in performance of individual marker questions using Pearson’s chi-squared test showed statistically significant differences in 32 of the 49 questions included in the study. Trend line analysis showed a positive trend in 29 questions and a negative trend in the remaining 23. The magnitude of change was small. Logistic regression did not demonstrate any evidence for a change in the performance of the question set over the study period. However, candidates were more likely to get items on administration wrong compared with clinical medicine or research. There was no evidence of a change in performance of the question set as a whole

The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England

Background Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke. Methods We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts. Results We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations. Conclusions This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims

Machine learning for predictive modelling of ambulance calls

A novel machine learning approach is presented in this paper, based on extracting latent information and using it to assist decision making on ambulance attendance and conveyance to a hospital. The approach includes two steps: in the first, a forward model analyzes the clinical and, possibly, non-clinical factors (explanatory variables), predicting whether positive decisions (response variables) should be given to the ambulance call, or not; in the second, a backward model analyzes the latent variables extracted from the forward model to infer the decision making procedure. The forward model is implemented through a machine, or deep learning technique, whilst the backward model is implemented through unsupervised learning. An experimental study is presented, which illustrates the obtained results, by investigating emergency ambulance calls to people in nursing and residential care homes, over a one-year period, using an anonymized data set provided by East Midlands Ambulance Service in United Kingdom