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

Neonatal Intensive Care Unit Nurses Experiences Regarding Parent Decision Making For Extremely Low Birth Weight Infants

poster abstractNeonatal intensive care unit (NICU) nurses play an important role in caring for extremely low birth weight infants (ELBW) and these patients are at a much greater risk of abnormal development. The NICU is unique in that the infant’s parents are their primary advocates, but they lack the medical background to comprehend their child’s condition. Parents also experience high anxiety and stress; consequently, aspects of decision-making may be overlooked due to inadequate amounts of information. NICU nurses must provide accurate and consistent information and emotional support to ELBW infant parents to help with decision-making. The purpose of this study is to describe NICU nurses’ experiences in aiding parents in decision-making regarding their ELBW infant and to identify if a visual aid would be useful during this difficult process. This research is based on 2 of 3 components of the Ottawa Decision Support Framework (ODSF): the evaluation of the needs of the healthcare team necessary for decision making and the evaluation of the healthcare team when providing individualized aid to parents. Using a qualitative descriptive design, five English-speaking nurses with at least one year of experience in the NICU were interviewed. The nurses ranged from 28-55 years of age and had a bachelor’s or master’s degree in nursing. Prior to the semi-structured interview, consent to participate was acknowledged and eligibility and demographic forms were completed. All interviews were tape-recorded and transcribed, and they were qualitatively analyzed. Findings will be used to evaluate nurses’ experiences, including how prepared they felt in providing information and support to parents, and to determine whether visual aids were used or would be useful to help nurses’ communication and parents’ decision-making

Genetic Variants in Immune Related Genes as Predictors of Responsiveness to BCG Immunotherapy in Metastatic Melanoma Patients.

Adjuvant immunotherapy in melanoma patients improves clinical outcomes. However, success is unpredictable due to inherited heterogeneity of immune responses. Inherent immune genes associated with single nucleotide polymorphisms (SNPs) may influence anti-tumor immune responses. We assessed the predictive ability of 26 immune-gene SNPs genomic panels for a clinical response to adjuvant BCG (Bacillus Calmette-Guérin) immunotherapy, using melanoma patient cohorts derived from three phase III multicenter clinical trials: AJCC (American Joint Committee on Cancer) stage IV patients given adjuvant BCG (pilot cohort; n = 92), AJCC stage III patients given adjuvant BCG (verification cohort; n = 269), and AJCC stage III patients that are sentinel lymph node (SLN) positive receiving no immunotherapy (control cohort; n = 80). The SNP panel analysis demonstrated that the responder patient group had an improved disease-free survival (DFS) (hazard ratio [HR] 1.84, 95% CI 1.09-3.13, p = 0.021) in the pilot cohort. In the verification cohort, an improved overall survival (OS) (HR 1.67, 95% CI 1.07-2.67, p = 0.025) was observed. No significant differences of SNPs were observed in DFS or OS in the control patient cohort. This study demonstrates that SNP immune genes can be utilized as a predictive tool for identifying melanoma patients that are inherently responsive to BCG and potentially other immunotherapies in the future

Patient preferences in tinnitus outcomes and treatments:a qualitative study

In order to identify patient preferences in care for tinnitus an in depth grounded theory study was conducted. This consisted of interviews with 41 patients who had sought help for tinnitus across a range of locations and tinnitus services in England. Preferences for outcomes were for both the removal of the tinnitus and for improved coping and management of the tinnitus. Preferences for treatment were for individualized care, tailored information and for treatment to assist with psychological adjustment and auditory distraction. Adoption of treatments to manage tinnitus were based on a trial and error approach. Patients? preferences for individual treatments varied but were informed by the information they received. Information plays an important role in care for people with tinnitus. Patients hold individual preferences and require engagement in shared decision making

The Silk Road Health Project: How Mobility and Migration Status Influence HIV Risks among Male Migrant Workers in Central Asia

Objectives We examined whether mobility, migrant status, and risk environments are associated with sexually transmitted infections (STIs) and HIV risk behaviors (e.g. sex trading, multiple partners, and unprotected sex). Methods We used Respondent Driven Sampling (RDS) to recruit external male migrant market vendors from Kyrgyzstan, Uzbekistan, and Tajikistan as well internal migrant and non-migrant market vendors from Kazakhstan. We conducted multivariate logistic regressions to examine the effects of mobility combined with the interaction between mobility and migration status on STIs and sexual risk behaviors, when controlling for risk environment characteristics. Results Mobility was associated with increased risk for biologically-confirmed STIs, sex trading, and unprotected sex among non-migrants, but not among internal or external migrants. Condom use rates were low among all three groups, particularly external migrants. Risk environment factors of low-income status, debt, homelessness, and limited access to medical care were associated with unprotected sex among external migrants. Conclusion Study findings underscore the role mobility and risk environments play in shaping HIV/STI risks. They highlight the need to consider mobility in the context of migration status and other risk environment factors in developing effective prevention strategies for this population

Clinical Safety-in-Use Study of a New Tampon Design

Objective: To confirm the safety of a new experimental Tampax(®) tampon and applicator compared with that of a currently marketed Tampax(®) tampon and applicator using comprehensive gynecological and microbiological assessments. Methods: A 2-month, single-blind, randomized, crossover study was conducted in which each subject served as her own control. Safety was evaluated by comparing potential product-related irritation (using colposcopic examination and subject diary data), assessment of vaginal discharge, vaginal pH, and effects on selected microorganisms (yeast, Escherichia coli ,Staphylococcus aureus and group B streptococci) obtained by vaginal swab cultures after normal menstrual use in the experimental and control groups. Results: In total, 110 women completed the study. There were no significant differences between the groups that used either the experimental or control tampon with regard to prevalence or mean cell density for the selected microorganisms. No differences were observed in the incidence or severity of erythema, in abrasion or ulceration of the cervix, vagina, introitus, vulva or perineum, or in mean vaginal pH and discharge assessments. There were equivalent low incidences of reported symptoms such as discomfort during insertion, wear or removal, and a similar low incidence of burning, stinging or itching during use of either the control or experimental tampon. There was a more favorable overall product rating for the experimental tampon (p = 0.003). Conclusions: This approach provides a combination of gynecological, microbiological and self-reported (diary recall) methodologies in order to assess tampon safety during use more thoroughly than has previously been reported, and it supports a comparable safety profile for the experimental tampon and a currently marketed tampon

Molecular Characterization of Haemaphysalis Species and a Molecular Genetic Key for the Identification of Haemaphysalis of North America

Haemaphysalis longicornis (Acari: Ixodidae), the Asian longhorned tick, is native to East Asia, but has become established in Australia and New Zealand, and more recently in the United States. In North America, there are other native Haemaphysalis species that share similar morphological characteristics and can be difficult to identify if the specimen is damaged. The goal of this study was to develop a cost-effective and rapid molecular diagnostic assay to differentiate between exotic and native Haemaphysalis species to aid in ongoing surveillance of H. longicornis within the United States and help prevent misidentification. We demonstrated that restriction fragment length polymorphisms (RFLPs) targeting the 16S ribosomal RNA and the cytochrome c oxidase subunit I (COI) can be used to differentiate H. longicornis from the other Haemaphysalis species found in North America. Furthermore, we show that this RFLP assay can be applied to Haemaphysalis species endemic to other regions of the world for the rapid identification of damaged specimens. The work presented in this study can serve as the foundation for region specific PCR-RFLP keys for Haemaphysalis and other tick species and can be further applied to other morphometrically challenging taxa

Academic doctors' views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study

<p>Abstract</p> <p>Background</p> <p>There has been a marked increase in the use of complementary and alternative medicine (CAM) in the UK population in recent years. Surveys of doctors' perspectives on CAM have identified a variety of views and potential information needs. While these are useful for describing the proportions of doctors who hold particular attitudes towards CAM, they are less helpful for understanding why. In addition, while the views of non-academic doctors have begun to be studied, the perspective and rationales of academic doctors remains under-researched. It seems important to investigate the views of those with a research-orientation, given the emphasis on the need for more scientific evidence in recent debates on CAM.</p> <p>Methods</p> <p>This exploratory study used qualitative methods to explore academic doctors' views of CAM and the rationales they provided for their views. A purposeful sampling strategy was used to identify doctors with a dual clinical and academic role in the Bristol area, with an anticipated variety of views on CAM. Semi-structured interviews were conducted with nine doctors. The data were analysed thematically, drawing on the Framework Approach.</p> <p>Results</p> <p>The doctors expressed a spectrum of views on CAM, falling into three broad groups: the 'enthusiasts', the 'sceptics' and the 'undecided'. Scepticism or uncertainty about the value of CAM was prominent, except among those practising a form of CAM. A variety of rationales underpinned their perspectives on CAM, a key recurring rationale being their perspective on the scientific evidence base. The main themes arising included: the role of doctors' professional experiences of conventional medicine and CAM in shaping their attitudes towards CAM, doctor-patient communication about CAM and patient disclosure, whether there is a need for training and education in CAM for doctors, a hierarchy of acceptability of CAM and the nature of evidence; and the role of CAM within the NHS.</p> <p>Conclusion</p> <p>Despite the caution or scepticism towards CAM expressed by doctors in this study, more open doctor-patient communication about CAM may enable doctors' potential concerns about CAM to be addressed, or at least enhance their knowledge of what treatments or therapies their patients are using. Offering CAM to patients may serve to enhance patients' treatment choices and even increase doctors' fulfilment in their practice. However, given the recurring concerns about lack of scientific evidence expressed by the doctors in this study, perceptions of the evidence base may remain a significant barrier to greater integration of CAM within the NHS.</p