Recorded vignettes: a novel method for investigating documentation in the Electronic Healthcare Record (EHR)

Background: 360 million consultations documented annually in England1 Accurate descriptors required for secondary data functions: Computerised decision support; Financial reimbursement; Audit; Disease prevalence monitoring and research Coding is not explicitly taught within the GP curriculum How do you research how clinicians document? Previous studies: use real patients2/actors3 interacting with clinician studied; Lack standardisation; Expensive. Why Allergy? Growing clinical problem; 2014 NICE guidelines4: Poor clinical documentation is a major issue in allergy; EHR can’t distinguish between intolerance and allergy; Incorrect labelling of patients; Adverse impact on patient care? Little known about coding practices in non-incentivised condition such as allergy. Method: A novel method developed to standardize research of EHR use. Filmed 6 short vignettes (21-50 secs) Monologue of common allergic presentations as if in consultation with a doctor. Digital photographs were included to replicate rashes. Electronic distribution of study files Documented vignettes in their own EHR Returned screen-prints to the researcher for analysis - Codes, free text and EHR functions Questionnaire - Exploring decision-making and validation of method Initially piloted on 1 GP and 2 trainees leading to refinements. Results 7 GPs and 15 GP trainees were recruited All successfully completed Data was returned from 4 different EHRs SystmOne (6), EmisLV (2), EmisWeb (6) and Vision (8) Screen prints effectively captured data with minor technical difficulties reported by 2 participants The study took 1 - 2 hours to complete: longer than expected from the pilot study

‘Maiden, whom we never see’ : cultural representations of the ‘lady telephonist’ in Britain, c.1880-1930, and institutional responses

This article examines attitudes to the female telephone operator in the British press and a range of literary and cultural sources. Perceptions of female telephonists were rooted in both reactions to the increasingly visible employment of women in white-collar work and uncertain responses to the telephone as a new communication medium. Such perceptions of the female telephonist became stereotyped and static, though there were later some challenges to, and attempts to nuance, these. The General Post Office took over the service and implemented a number of changes, but ultimately the organisation and telephonists themselves had to co-exist with these stereotypes

Reducing the Use of Seclusion and Restraint in Segregated Special Education School Settings Through Implementation of the Collaborative Problem Solving Model

The intent of this study was to determine whether implementation of the Collaborative Problem Solving (CPS) model, that has proven successful in psychiatric settings, was equally effective in reducing restrictive practices in public school settings. Many peer-reviewed, published reports suggest that educators are poorly prepared to manage the extremely challenging behaviors of aggression and non-compliance, which are common in students classified with an emotional disturbance (ED). Too often educators rely on ineffective, potentially harmful interventions such as seclusion and restraint, which adversely impact students as well as staff. The nonrandom sample was comprised of students enrolled in two segregated special education schools located in large communities in northwestern Pennsylvania. The enrollment was 69 students in School A and 26 students in School B. The schools serve students, kindergarten through twelfth grade. All students were evaluated and classified as ED by their referring home school district as per Chapter 14 Regulations of the Pennsylvania Department of Education and received one-hundred percent of their special education program in this restrictive school-based environment. This study used a quasi-experimental, pre-test-post-test research design and used two separate existing electronic data sources to test for relationships between the implementation of the CPS model and identified variables (standardized measures of externalizing maladaptive behaviors, incidents of aggression, noncompliance, and disruption, as well as incidents and duration of seclusion and restraint). The analyses included frequency comparisons, a series of Wilcoxon Signed Rank Tests, a series of dependent samples T-tests, and two-way repeated measures analyses of variance. Implementation of the model reduced the incidents of aggression, noncompliance, and disruption, as well as incidents and duration of seclusion and restraint. However, only one of the schools in the study demonstrated a statistically significant reduction of aggression incidents and the use of restraint procedures. The results suggest that when implemented with fidelity, the research-based CPS model is a promising, preventative behavior approach for students classified with ED in a segregated special education school

The effects of oxygen and reactive oxygen species on antibiotic resistance and microbial communities in chronic wounds

Infection is one of the factors that may contribute to non-healing of chronic wounds; the presence of antibiotic resistant bacteria serves to exacerbate the problem due to limited treatment options. Bacteria utilise several mechanisms to survive exposure to antibiotics, including synthesis of deactivating enzymes, target modification or substitution, changes to membrane permeability, upregulation of efflux pumps and the formation of a biofilm. Quorum sensing is a density-dependent mechanism of bacterial cell to cell communication that can be instrumental in co-ordinating biofilm initiation. Hyperbaric oxygen therapy (HBOT) is an option offered to some patients with chronic wounds, including diabetic foot ulcers. Evidence suggests that HBOT can reduce the incidence of major amputation in these patients. As well as the direct toxicity of increased tissue oxygenation on anaerobic bacteria HBOT may also increase levels of reactive oxygen and nitrogen species in the wound environment. This study aimed to investigate the effects of hyperoxia and oxidative damage on three specific mechanisms of antibiotic resistance: the activity of penicillinase, an antibiotic deactivating enzyme synthesised by bacteria; the activity of quorum sensing signalling molecules (AHLs); and biofilms and their associated bacteria. It also analysed the population dynamics of, primarily, bacteria in diabetic foot ulcers during HBOT, by the use of molecular analysis tools such as PCRDGGE. The presence of fungal species was investigated in wounds prior to HBOT and in two wounds at two points during HBOT. This study found that hydrogen peroxide, hypochlorous acid and peroxynitrite reduced the activity of penicillinase in vitro. Hypochlorous acid reduced the activity of a range of AHLs in vitro but not in vivo. Oxygen concentration did not have any impact on biofilm mass, nor did it significantly affect the ability of an oxidant-generating enzyme to reduce live bacterial cells within a biofilm. The population dynamics of bacterial species identified in all the wounds were complex and did not undergo identifiable changes during HBOT. Fungal species were identified in all wounds prior to HBOT, though different profiles were observed in the two wounds investigated during HBOT. These results suggest that oxidants could play a role in the attenuation of antibiotic resistance in chronic wound bacteria. It is unclear whether HBOT alters the population dynamics of non-healing wound microfloraThe Diving Diseases Research Centr