Development of a Patient Reported Experience Measure (PREM) for use in the ambulance service

Background NHS health policy emphasises the crucial role of patient experience as a core component of high quality care, alongside effectiveness and safety. Patient Reported Experience Measures (PREMs) measure patients’ experiences with their healthcare. They are increasingly being seen as valuable for assessing patient outcomes and differences in quality between health care providers. Previous patient surveys to assess ambulance service care have not been implemented routinely or in a standardised way. This research forms part of a doctoral study to develop a PREM for use in UK ambulance services. Methods The study comprised three subsections: 1. A secondary analysis of interview data exploring patients’ experiences of their prehospital care. 2. Development of questionnaire items based on those themes emerging from the secondary analysis. 3. Semi-structured interviews with service users that explore their opinions of the questionnaire items and whether the PREM includes all aspects of the ambulance service experience that should be encompassed. Results The secondary data analysis revealed specific ‘processes of importance’ to service users accessing ambulance care i.e. ‘timeliness’ and parallel ‘experiential components of care’ i.e. ‘reassurance’ that either enhanced or reduced the perception that the ‘processes of care’ were undertaken to a high standard. The key themes formed the foundation for generating the 53 item questionnaire. The interview stage is on-going and the data obtained are being used to amend the questionnaire items. Conclusions The construction of the PREM has incorporated the views of patients that the measure is ultimately designed for, and conforms to the concept of patient-centred care—the theoretical foundation of the research. Once completed, the PREM will enable ambulance trusts to measure differences in patient experiences, between and within organisations. This can result in positive changes to patient experience through the introduction of feedback, training and education to prehospital clinicians

Differences in delivery of prehospital ambulance care comparing non-white versus white patients with suspected cardiac chest pain: cross-sectional study

Introduction Quality implies equitable care irrespective of ethnicity. There have been few previous studies investigating quality of prehospital cardiac care by ethnicity. We aimed to investigate whether prehospital care for suspected cardiac pain varied by ethnicity. Methods We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with chest pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data (ethnicity, age, sex, deprivation), clinical measurements (blood pressure, respiratory rate, pain assessment, temperature, blood glucose, oxygen saturation), drugs (aspirin, nitroglycerin, Entonox, morphine) and outcomes such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-white with white patients. Results There were 7046 patients with suspected cardiac chest pain, with 4825 who had ethnicity recorded including 4661 (96.6%) white, 164 (3.4%) non-white (2221 patients had missing data for ethnicity). Non-white patients were similar in sex (p=0.63) and socioeconomic group (p=0.07) but significantly younger in age (p<0.001) than white patients. After correcting for age, sex, socioeconomic status and whether transported to hospital, non-white patients were similar to white patients in recording of blood pressure, pain score or electrocardiogram but significantly more likely to have temperature (77.4 vs.69.8%), blood glucose (78.7 vs. 69.4%), and oxygen saturation (85.4 vs. 80.7%) recorded. There were no differences in aspirin, nitroglycerin, Entonox or morphine treatment but non-white patients were less likely than white patients to be transported to hospital (93.3 vs. 94.4, p=0.02). Conclusion We found differences in prehospital ambulance care for non-white compared with white patients with cardiac pain that could be due to recording bias, varying clinical condition or provider management. Further analysis should involve larger and more complete datasets to explore ethnic differences in greater detail

Modified Early Warning Scores (MEWS) to support ambulance clinicians’ decisions to transport or treat at home

Introduction Modified Early Warning Scores (MEWS), calculated from patients’ vital signs, are used in hospital to identify patients who may benefit from admission or intensive care: higher MEWS indicates greater clinical risk. We aimed to evaluate MEWS to support paramedics’ decisions to transport patients to hospital or treat and leave them at home. Methods We used an interrupted time series design. We trained 19 volunteer paramedics to use MEWS to support decisions to transport or treat and leave at home. We used linear regression to evaluate differences in weekly transportation rates (percentage of patients attended and transported to hospital) and revisit rates (percentage of patients attended, treated at home and subsequently revisited within 7 days), comparing trends in rates 17 weeks prior (pre-MEWS) and 17 weeks post implementation of MEWS. Auto-calculated scores retrospectively applied to all data provided pre-MEWS and were compared with paramedic calculated scores post-MEWS. Results Of the 4140 patients attended, 2208 were excluded owing to missing values (n=1897), recording errors (n=21) or excluded clinical complaints (n=290). From the remaining data (n=1932) there were no significant differences in transportation rates (pre=55±6%; post=63±11%) by catering for the existing increasing trends where the confidence intervals of the regression slopes overlap (pre=0.15; 95%CI -0.51 to 0.80 vs. post=0.54; -0.58 to 1.65). Similarly, there were no significant difference in revisit rates (pre=4±4%; post=2±4%) catering for the similar trends (pre=-0.13; -0.53 to 0.27 vs. post=0.08; -0.33 to 0.49). Paramedic scores were incorrect 39% of the time (n=622). Conclusion MEWS had a minimal effect on transportation or revisit rates. Scores were frequently not calculated or recorded, or incorrectly calculated. Opportunities for ongoing training, clinical support and feedback were limited. A larger study, ensuring adequate ongoing support, is recommended before implementing MEWS on a wider scale

‘I can use things, but I can't make anything’: a qualitative exploration of team networks in the development and implementation of a new undergraduate e-compendium

In higher education, undergraduate teaching materials are increasingly becoming available online. There is a need to understand the complex processes that happen during their production and how social networks between different groups impact on their development. This paper draws on qualitative interviews and participant drawings of their social networks to understand the dynamics of creating a new e-compendium for a four-year online undergraduate nursing programme in Norway. Twenty staff interviews were undertaken to explore views of the e-compendium, the development process and the perceived networks that were formed during this course. Interview data were thematically analysed along with networks drawings. The findings showed three main institutional stakeholder groups emerging: the ‘management team’, ‘design team’ and ‘lecturers’. Analysis of social networks revealed variability of relations both within and between groups. The pedagogical designer, who was part of the design team, was central to communicating with and co-ordinating staff at all levels. The least well connected were the lecturers. To them, the e-compendium challenged and even threatened previously well-established notions of pedagogy. Future development of e-compendiums should account for the perceived lack of time and existing workload of lecturers so they may be involved with the development process

How should we measure psychological resilience in sport performers?

Psychological resilience is important in sport because athletes must constantly withstand a wide range of pressures to attain and sustain high performance. To advance psychologists’ understanding of this area, there exists an urgent need to develop a sport-specific measure of resilience. The purpose of this paper is to review psychometric issues in resilience research and to discuss the implications for sport psychology. Drawing on the wider general psychology literature to inform the discussion, the narrative is divided into three main sections relating to resilience and its assessment: adversity, positive adaptation, and protective factors. The first section reviews the different ways that adversity has been measured and considers the potential problems of using items with varying degrees of controllability and risk. The second section discusses the different approaches to assessing positive adaptation and examines the issue of circularity pervasive in resilience research. The final section explores the various issues related to the assessment of protective factors drawing directly from current measures of resilience in other psychology sub-disciplines. The commentary concludes with key recommendations for sport psychology researchers seeking to develop a measure of psychological resilience in athletes

The electro-structural behaviour of yarn-like carbon nanotube fibres immersed in organic liquids.

Yarn-like carbon nanotube (CNT) fibres are a hierarchically-structured material with a variety of promising applications such as high performance composites, sensors and actuators, smart textiles, and energy storage and transmission. However, in order to fully realize these possibilities, a more detailed understanding of their interactions with the environment is required. In this work, we describe a simplified representation of the hierarchical structure of the fibres from which several mathematical models are constructed to explain electro-structural interactions of fibres with organic liquids. A balance between the elastic and surface energies of the CNT bundle network in different media allows the determination of the maximum lengths that open junctions can sustain before collapsing to minimize the surface energy. This characteristic length correlates well with the increase of fibre resistance upon immersion in organic liquids. We also study the effect of charge accumulation in open interbundle junctions and derive expressions to describe experimental data on the non-ohmic electrical behaviour of fibres immersed in polar liquids. Our analyses suggest that the non-ohmic behaviour is caused by progressively shorter junctions collapsing as the voltage is increased. Since our models are not based on any property unique to carbon nanotubes, they should also be useful to describe other hierarchical structures

Systematic review: the barriers and facilitators for minority ethnic groups in accessing urgent and prehospital care

Introduction Research addressing inequalities has focused predominantly on primary and community care; few initiatives relate to the prehospital environment. We aimed to identify in the literature barriers or facilitators experienced by patients from black and minority ethnic (BME) communities in accessing prehospital care and to explore the causes and consequences of any differences in delivery. Methods We conducted a systematic literature review and narrative synthesis. Electronic and journal hand searches from 2003 through 2013 identified relevant evaluative studies (systematic reviews, randomised controlled trials, quasi-experimental, case and observational studies). A researcher extracted data to determine characteristics, results and quality, each checked by a second reviewer. The main outcome measures were delays in patient calls, mortality rates and 30-days survival post discharge. Results Eighteen studies met criteria for the review: two concerned services in England and Wales and 15 were United States based. Reported barriers to accessing care were generic (and well-known) given the heterogeneity of BME groups: difficulties in communication where English was the patient’s second language; new migrants’ lack of knowledge of the health care system leading to inappropriate emergency calls; and cultural assumptions among clinical staff resulting in inappropriate diagnoses and treatment. There were limited reported facilitators to improvement, such as the need for translation services and staff education, but the latter were poorly described or developed. Where outcomes were discussed, there was evidence for race-related disparity in mortality and survival rates. This could reflect differences in condition severity, delays between onset and initiation of calls, or the scope of response and assistance. Conclusion The paucity of literature and difficulties of transferring findings from US to UK context identified an important research gap. Further studies should be undertaken to investigate UK differences in prehospital care and outcomes for BME groups, followed by qualitative approaches to understand barriers and enablers to equitable access

Mechanical properties of carbon nanotube fibres: St Venant's principle at the limit and the role of imperfections

Carbon nanotube (CNT) fibres, especially if perfect in terms of purity and alignment, are of extreme anisotropy. With their high axial strength but ready slippage between the CNTs, there is utmost difficulty in transferring the force applied uniformly. Finite element analysis is used to predict the stress distribution in CNT fibres loaded by grips attached to their surface, along with the resulting tensile stress-strain curves. This study demonstrates that in accordance with St Venant’s principle very considerable length-to-diameter ratios (~ 103) are required before the stress becomes uniform across the fibre, even at low strains. It is proposed that lack of perfect orientation and presence of carbonaceous material between bundles greatly enhances the stress transfer, thus increasing the load it can carry before failing by shear. It is suggested that a very high strength batch of fibres previously observed experimentally had an unusually high concentration of internal particles, meaning that the pressure exerted by the grips would assist stress transfer between the layers. We conclude, that the strength of CNT fibres depends on the specific testing geometries and that imperfections, whether by virtue of less-than-perfect orientation or of embedded impurities, are actually major positive contributors to the observed strength.The authors are grateful to USN ONR GLOBAL for the provision of funding under award number N62909-14-1-N200. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Office of Naval Research.This is the accepted manuscript. The final version is available at http://www.sciencedirect.com/science/article/pii/S0008622315004728

A Short Chain NAD(H)-Dependent Alcohol Dehydrogenase (HpSCADH) from Helicobacter Pylori: a Role in Growth under Neutral and Acidic Conditions.

Toxic aldehydes produced by alcohol dehydrogenases have been implicated in the pathogenesis of Helicobacter pylori-related damage to the gastric mucosa. Despite this, the enzymes that might be responsible for producing such aldehydes have not been fully described. It was, therefore, of considerable interest to characterize the alcohol oxidizing enzymes in this pathogen. Previous work in this laboratory characterized two such H. pylori enzymes that had broad specificity for a range of aromatic alcohol substrates. An enzyme with broad specificity for aliphatic alcohols is likely to be required in order that H. pylori can metabolize the wide range of substrates encountered in the gastric mucosa. In this study we describe HpSCADH, an alcohol dehydrogenase from H. pylori 26695 with broad specificity for aliphatic alcohols. HpSCADH was classified in the cD1e subfamily of classical short chain alcohol dehydrogenases. The enzyme was a monomer of approximately 29 kDa with a preference for NAD+ as cofactor. Pyrazole was found to be a competitive inhibitor of HpSCADH. The physiological role of this enzyme was explored by construction of an HpSCADH isogenic mutant. AtpH 7.0 the mutant showed reduced growth which became more pronounced when the pH was lowered to 5.0. When pyrazole was added to wild type H. pylori cells it caused growth profiles to be reduced to those of the isogenic mutant suggesting that HpSCADH inhibition alone was responsible for growth reduction. Taken together, the data relating to the alcohol metabolizing enzymes of this pathogen indicate that they play an important role in H. pylori growth and adaptation to acidic environments. The therapeutic potential of targeting H. pylori alcohol dehydrogenases is discusse