bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cohort study investigating the relationship between cholesterol, cardiovascular risk score and the prescribing of statins in UK primary care: study protocol
Authors: Finnikin Samuel , Ryan Ronan , Marshall Tom 
Published: November 2016

IntroductionRisk scoring is an integral part of the prevention of cardiovascular disease (CVD) and should form the basis for the decision to offer medication to reduce cholesterol (statins). However, there is a suggestion in the literature that many patients are still initiated on statins based on raised cholesterol rather than a raised CVD risk. It is important, therefore, to investigate the role that lipid levels and CVD risks have in the decision to prescribe. This research will establish how cholesterol levels and CVD risk independently influence the prescribing of statins for the primary prevention of CVD in primary care.Methods and analysisThe Health Improvement Network (THIN) is a database of coded primary care electronic patient records from over 500 UK general practices. From this resource, a historical cohort will be created of patients without a diagnosis of CVD, not currently receiving a prescription for statins and who had a lipid profile measured. A post hoc QRISK2 score will be calculated for these patients and they will be followed up for 60 days to establish whether they were subsequently prescribed a statin. Primary analysis will consist of predictive modelling using multivariate logistic regression with potential predictors including cholesterol level, calculated QRISK2 score, sociodemographic characteristic and comorbidities. Descriptive statistics will be used to identify trends in prescribing and further secondary analysis will explore what other factors may have influenced the prescribing of statins and the degree of interprescriber variability.Ethics and disseminationThe THIN Data Collection Scheme was approved by the South-East Multicentre Research Ethics Committee in 2003. Individual studies using THIN require Scientific Review Committee approval. The original protocol for this study and a subsequent amendment have been approved (16THIN009A1). The results will be published in a peer review journal and presented at national and international conferences.
Evaluation of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care: a qualitative study
Authors: Roets-Merken Lieve M , Vernooij-Dassen Myrra J F J , Zuidema Sytse U , Dees Marianne K , Hermsen Pieter G J M , Kempen Gertrudis I J M , Graff Maud J L 
Published: November 2016

ObjectivesTo gain insights into the process of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors that contributed to these changes in their perceptions.DesignQualitative study alongside a cluster randomised controlled trial.Setting17 long-term care homes spread across the Netherlands.Participants34 licensed practical nurses supporting 54 dual sensory impaired older adults.InterventionA 5-month training programme designed to enable nurses to support the self-management of dual sensory impaired older adults in long-term care.Primary outcomesNurses’ perceptions on relevance and feasibility of the self-management programme collected from nurses’ semistructured coaching diaries over the 5-month training and intervention period, as well as from trainers’ reports.ResultsNurses’ initial negative perceptions on relevance and feasibility of the intervention changed to positive as nurses better understood the concept of autonomy. Through interactions with older adults and by self-evaluations of the effect of their behaviour, nurses discovered that their usual care conflicted with client autonomy. From that moment, nurses felt encouraged to adapt their behaviour to the older adults’ autonomy needs. However, nurses’ initial unfamiliarity with conversation techniques required a longer exploration period than planned. Once client autonomy was understood, nurses recommended expanding the intervention as a generic approach to all their clients, whether dual sensory impaired or not.ConclusionsLongitudinal data collection enabled exploration of nurses’ changes in perceptions when moving towards self-management support. The training programme stimulated nurses to go beyond ‘protocol thinking’, discovering client autonomy and exploring the need for their own behavioural adaptations. Educational programmes for practical nurses should offer more longitudinal coaching of autonomy supportive conversational skills. Intervention programming should acknowledge that change is a process rather than an event, and should include self-evaluations of professional behaviours over a period of time.Trial registration numberNCT01217502, Post-results.
Effect of support group peer facilitator training programmes on peer facilitator and support group member outcomes: a systematic review
Authors: Delisle Vanessa C , Gumuchian Stephanie T , Kloda Lorie A , Boruff Jill , El-Baalbaki Ghassan , Körner Annett , Malcarne Vanessa L , Thombs Brett D 
Published: November 2016

ObjectivePeer facilitators play an important role in determining the success of many support groups for patients with medical illnesses. However, many facilitators do not receive training for their role and report a number of challenges in fulfilling their responsibilities. The objective of this systematic review was to evaluate the effects of training and support programmes for peer facilitators of support groups for people with medical illnesses on (1) the competency and self-efficacy of group facilitators and (2) self-efficacy for disease management, health outcomes and satisfaction with support groups among group members.MethodsSearches included the CENTRAL, CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science databases from inception through 8 April 2016; reference list reviews; citation tracking of included articles; and trial registry reviews. Eligible studies were randomised controlled trials (RCTs) in any language that evaluated the effects of training programmes for peer facilitators compared with no training or alternative training formats on (1) competency or self-efficacy of peer facilitators, and (2) self-efficacy for disease management, health outcomes and satisfaction with groups of group members. The Cochrane Risk of Bias tool was used to assess risk of bias.ResultsThere were 9757 unique titles/abstracts and 2 full-text publications reviewed. 1 RCT met inclusion criteria. The study evaluated the confidence and self-efficacy of cancer support group facilitators randomised to 4 months access to a website and discussion forum (N=23; low resource) versus website, discussion forum and 2-day training workshop (N=29). There were no significant differences in facilitator confidence (Hedges' g=0.16, 95% CI −0.39 to 0.71) or self-efficacy (Hedges' g=0.31, 95% CI −0.24 to 0.86). Risk of bias was unclear or high for 4 of 6 domains.ConclusionsWell-designed and well-conducted, adequately powered trials of peer support group facilitator training programmes for patients with medical illnesses are needed.Trial registration numberCRD42014013601.
End-of-life experiences of mothers with advanced cancer: perspectives of widowed fathers
Authors: Park Eliza M , Deal Allison M , Yopp Justin M , Edwards Teresa P , Wilson Douglas J , Hanson Laura C , Rosenstein Donald L 
Published: November 2016

ObjectiveDespite the importance of parenting-related responsibilities for adult patients with terminal illnesses who have dependent children, little is known about the psychological concerns of dying parents and their families at the end of life (EOL). The aim of this study was to elicit widowed fathers’ perspectives on how parental status may have influenced the EOL experiences of mothers with advanced cancer.Subjects344 men identified themselves through an open-access educational website as widowed fathers who had lost a spouse to cancer and were raising dependent children.MethodsParticipants completed a web-based survey about their wife's EOL experience and cancer history, and their own depression (Center for Epidemiologic Studies Depression Scale, CES-D) and bereavement (Texas Revised Inventory of Grief, TRIG) symptoms. Descriptive statistics, Fisher's exact tests, and linear regression modelling were used to evaluate relationships between variables.ResultsAccording to fathers, 38% of mothers had not said goodbye to their children before death and 26% were not at all ‘at peace with dying.’ Ninety per cent of widowed fathers reported that their spouse was worried about the strain on their children at the EOL. Fathers who reported clearer prognostic communication between wife and physician had lower CES-D and TRIG scores.ConclusionsTo improve EOL care for seriously ill patients and their families, we must understand the concerns of parents with dependent children. These data underscore the importance of parenting-related worries in this population and the need for additional clinical and research programmes devoted to addressing these issues.
ROUTINE HIV TESTING IN AN INNER CITY EMERGENCY DEPARTMENT
Authors: Hunter LJ , Lojo Rial C , Larbalestier N , Paparello J 
Published: November 2016

Objectives & BackgroundThe National Institute of Clinical Excellence (NICE) and the Royal College of Emergency Medicine recommend that adults should be tested for HIV in endemic areas with a prevalence >0.2%. It is estimated that approximately 25% of those living with HIV are unaware of their diagnosis. Late diagnosis is associated with a ten-fold increased risk of death in the following year,1and increased risk of onwards HIV transmission. In July 2015 our Emergency Department commenced a pilot project to assess the feasibility of routine HIV testing within a busy inner city ED.MethodsPatients over the age of 16 had an HIV test performed if they required venepuncture during their emergency department attendance. Tests were ordered using a pre-configured blood order set including a pre-selected HIV test. Patients were informed of the intention to test all attendances and were able to opt out if desired. Positive or equivocal results were followed up by our HIV team.ResultsOver 36 weeks, 64% of ED attendances (19,569/30,461) were tested for HIV. Our prevalence was 0.9% (n=172) and of those 0.3% were not aware of their positive HIV status (n=68). Thirteen patients were not currently engaged in services, although aware of their diagnosis. Median age was 36(18–61). Patients who tested positive were predominantly male (84%) and Caucasian (59%) (37% BME, 4% Asian).50% of patients who tested positive self- identified as heterosexual, and 50% as MSM(men who have sex with men). A significant number (54%) of newly diagnosed patients had previously attended our emergency department prior to routine HIV testing. 23% of new diagnoses required an acute admission.ConclusionThe Emergency Department provides a suitable environment for opportunistic HIV testing in areas of high prevalence. We have maintained testing rates of >65% of our ED attendances, achieved early diagnosis and treatment engagement in patients who were unaware of their HIV status. In addition, we have identified a number of patients who had been lost to follow-up and have now re-engaged in care. Use of pre-configured blood order sets, regular staff education and feedback on results improves testing rates.
MANAGEMENT OF HEAD INJURY IN THE HOSPITAL SETTING
Authors: Carnachan A , Savage R , Waters E , Elwen F 
Published: November 2016

Objectives & Background700,000 people visit Accident and Emergency (A&E) with head injuries annually. NICE have clear guidance as to how these patients are managed in hospital, as outlined below:▸A standard head injury proforma must be used in all clinical departments.▸Indication for a CT head in 1 hour, or 8 hours.▸Observations must be performed every 30 minutes for 2 hours, every hour for 4 hours, then 2 hourly.▸On discharge, verbal and printed advice must be given.Guy's and St Thomas' Foundation Trust (GSTT) has developed a specific head injury proforma, which aims to implement these guidelines. Advice on the management of complex head injury cases is sought from neurosurgery at King's College Hospital.Our study aims to determine how well head injuries are managed at GSTT in accordance with NICE guidelines, to identify and implement service improvements where necessary.MethodsA search was performed on Symphony (A&E tracking system) for all codes to find adult (>18 years) head injury cases during the month of December 2015. Cases were investigated using paper notes, Symphony, e-noting, and EPR, and data was analysed using excel.Results251 head injury cases were seen in A&E in December 2015. The GSTT A&E head injury proforma was completed in only 9 cases.A CT head was performed in 47 cases, of which 5 revealed an abnormality. 32 patients had an indication for CT in 8 hours. 12 did not receive scan at all, the remaining 20 all received scans within 8 hours. There were 27 patients who required a CT in 1 hour; 15 of these were performed in 1 hour after being seen (average time 59 minutes). 3 were not performed.27 patients were admitted: 19 under medical teams, 3 under surgical teams, 5 under specific teams for other injuries. 1 patient was transferred to King's College Hospital. 5 patients were discussed with King's College Hospital, and in 4 cases advice was followed correctly.Only 13 out of 27 patients admitted had neurological observations recorded in e-noting.ConclusionAlthough a relatively small study, it has highlighted the need for further education and training of staff in regards to the head injury guidance that exists within the trust, specifically in regards to comprehensive documentation.There will be a focus on promoting the use of the head injury proforma in A&E, and making it readily available on all wards. With collaborative working with IT on e-noting, the plan is to ensure observations can be recorded and accessed quickly and easily.
IMPACT OF POINT OF CARE CRP TESTING ON THE MANAGEMENT OF PATIENTS WITH SUSPECTED COMMUNITY ACQUIRED PNEUMONIA IN THE ED
Authors: Robinson D , Till J 
Published: November 2016

Objectives & BackgroundThe World Health Organisation has identified antimicrobial resistance as “an increasingly serious threat to global public health that requires action across all government sectors and society”, and state that “health workers should only prescribe antibiotics when they are truly needed”.The Emergency Department (ED) at Bradford Royal Infirmary is a busy urban ED, with significant numbers of patients attending with lower respiratory tract infections, particularly in the winter months. NICE CG191 (Pneumonia in Adults, December 2014) recommends the use of point of care (POC) CRP testing to guide antibiotic therapy inprimary care. This study aims to evaluate the impact of POC CRP testing inED patientswith low risk Community Acquired Pneumonia (CAP).MethodsA before and after study was performed. We included adults (aged 16 years and above) presenting to the ED with suspected Lower Respiratory Tract Infection (LRTI) AND CURB-65 score 0–1. During the pre-intervention phase (November 2015–January 2016) patients were managed using the pre-existing ED CAP guideline. During the intervention phase (February–March 2016) patients meeting the inclusion criteria underwent POC CRP testing, and the results of this were used to guide antibiotic prescribing. Retrospective analysis of the ED documentation and hospital results systems was performed to determine antibiotic prescribing rates, return to the ED within 30 days, and subsequent new radiographic pneumonia within 30 days of ED presentation.Results143 patients were included (50 pre-intervention, 93 post-intervention). Baseline characteristics were similar in both study periods. Antibiotic prescribing rates were significantly lower in the POC CRP group (20% versus 70%, p<0.0001 Fisher's exact test). There was no significant difference in the proportion of patients returning to the ED within 30 days requiring further treatment for LRTI (2.2% POC CRP group versus 6% pre-intervention, p=0.34). No patients in either group developed new radiological pneumonia within 30 days of ED presentation.ConclusionThe introduction of POC CRP testing in ED patients with suspected CAP led to a significant reduction in antibiotic prescribing rates. This is consistent with evidence from primary care and NICE guidance, and we advocate the wider use of POC CRP testing in this group of patients in the ED.
A MULTI-MODAL APPROACH TO QUALITY IMPROVEMENT: REDUCING 'DOOR-TO-CT' TIME IN POTENITALLY THOMBOLYSABLE STROKE PATIENTS
Authors: Waterson F , Braithwaite I , Tuck I , Alcock R 
Published: November 2016

Objectives & BackgroundWith 1.9 million neurons lost every minute a stroke is untreated1, rapid assessment and management is a time critical medical emergency, and is reliant on robust Emergency Department (ED) systems. Rapid access to CT imaging is an immediate priority to allow exclusion of patients with haemorrhagic stroke, an absolute contraindication to thrombolysis. Our QI project aimed to reduce the time from arrival in ED to CT scan for patients presenting with potentially thrombolysable stroke.MethodsUsing a combination of live and simulated stroke scenarios, we process-mapped the care of potentially thrombolysable patients through the ED at Forth Valley Royal Hospital. We identified ‘unnecessary’ delays from non-value adding activity and following consultation with the Scottish Ambulance Service, Radiology & Neurology, created a new pre-alert procedure and streamlined protocol for this patient group which facilitated rapid assessment, stabilization and early access to CT imaging.We used a multi-modal approach to deliver change which included weekly clinical governance meetings, teaching for medical & nursing staff, in-situ simulation to educate and stress the system, regular safety brief announcements and the development of a ‘Stroke Awareness Week' at our hospital.ResultsDoor to CT time was reduced by 40%, from 30 minutes (median 23) to 18 minutes (median 13), comparing 4 month sample periods before and after changes. During our QI project, Door-to-Needle (DTN) time has reduced from a mean of 81 minutes (in 2015) to a mean of 64 minutes (2016YTD).ConclusionEarly thrombolysis has been shown to improve outcomes in patients with ischaemic stroke.2 Reducing ‘Door-to-CT' scan time in the ED is an important step in enabling a reduction in the overall DTN time. This can be achieved by stream-lining key processes in the patient journey through the ED. A multi-modal approach ensured this change was introduced safely and effectively whilst re-enforcing a core change to standard working practice. Further work on process mapping and the delivery of thrombolysis is the next obvious step in further reduction in DTN time.Figure 1Quality Improvement Run Chart 'Door-to-CT' time with change processes highlighted
THE DAY MY HEART SKIPPED A BEAT. SAFE, CONSISTENT AND EFFECTIVE MANAGEMENT OF ATRIAL FIBRILLATION IN THE EMERGENCY DEPARTMENT
Authors: Summerhayes R , Cartwright N , Quartermain A 
Published: November 2016

Objectives & BackgroundAtrial Fibrillation (AF) is a common presentation to the Emergency Department. However there is marked inconsistency in how patients are managed.Professor Mark Baker, NICE's Director of Clinical Practice:“AF increases the risk of strokes by up to five times. It's estimated that the condition causes around 12,500 strokes each year…. Unfortunately only half of those who should be getting these drugs (anticoagulants), are. This needs to change.”An audit of practice in December 2015 UHS ED revealed that only 10% had any documented stroke risk stratification.The aims of our Quality Improvement Project were:▸To provide a standardised, evidence based approach to the management of newly diagnosed AF in UHS ED.▸Reduce the admission rate of patients attending ED with AF.▸Improve patient safety by ensuring patients are appropriately risk stratified and anticoagulated.Methods▸ Review of literature and current guidelines. NICE 2014, ESC 2012, AHA 2014. We created a pragmatic and evidence based ‘Management of AF Pathway' agreed by ED/Cardiology/Pharmacy and Governance leads. The pathway went through several PDSA cycles.▸ We created process maps looking at the journey of patients with AF to identify delays in investigation, diagnosis and treatment. If patients with new AF are treated in a timely manner successful rate/rhytm control can be achieved in a greater proportion within 4 hrs and therefore discharged with follow up.▸ Clinician education and clear guidance with regard to risk stratification and anticoagulation.ResultsThe results of this QuIP are:▸ A locally agreed, evidence based approach to the management of newly diagnosed AF.Outcome 2 and 3 are represented by Run Charts demonstrating Discharge Rate over time and Risk Stratification/anticoagulation over time.▸ Admission rates fluctuated around 60%. There was no significant change after implementation of changes.▸ There was a huge change in numbers of patients risk stratified/anticoagulated. The initial rate was 10% increasing to 85% in the most recent data collected.ConclusionThe management of AF is complex. However it is possible to create and implement a locally agreed, evidence based guideline which is well received by both ED physicians and Cardiology. We have demonstrated a marked improvement in stroke risk stratification/anticoagulation and therefore impacted on patient safety.Figure 1
THE PARAMEDIC ULTRASOUND IN CARDIAC ARREST STUDY
Authors: Reed MJ , Gibson L , Black P , Dewar A , Clegg G , Short S 
Published: November 2016

Objectives & BackgroundThe Edinburgh 3RU paramedics have some advanced training in cardiac arrest (CA) managementThe PUCA study aimed to see whether pre-hospital paramedics can▸be trained to perform and [2] interpret pre-hospital ELS▸retain ELS performance and interpretation skills▸perform satisfactory pre-hospital ELS▸perform pre-hospital ELS without impacting CA careMethodsPhase 1 – Testing/purchasing a suitable ultrasound machinePhase 2 – Formal classroom based training: one-day training course with practical and moulage sessions.Phase 3 – Field based training.Phase 4 – Prospective observational study of pre-hospital paramedic ELS using saved ultrasound clips and wearable camera videos.ResultsDuring classroom based training, all paramedics could obtain parasternal (PS) and subxiphoid (SX) images.▸ 88% of attempts in both views were successful in the pulse check window.▸ Theoretical knowledge improved (mean pre vs post course score 54% vs 89%; p<0.001) and at 10 weeks was non-significantly reduced (82%; p=0.13) but less so than practical performance (75% SX success, 25% PS success).▸ By Sep 2015, 8 of 11 paramedics who attended initial training, had passed a triggered competency assessment and were practicing pre-hospital ELS independently.▸ Between 23rd June 2014 and 31st Jan 2016, seven 3RU paramedics attended 45 patients suffering out-of-hospital CA where resuscitation was attempted and the Venue 40 ultrasound machine was available and used.▸ 80% of first paramedic ELS attempts produced an adequate view which was excellent/good/satisfactory in 68%.▸ 44% of views were obtained within the pulse check window with a median time off the chest of 17 seconds (IQR 13–20).▸ A decision to perform ELS was communicated in 67% and the pulse check counted aloud in 60%.▸ A manual pulse check was seen to be performed in a quarter of patients and the monitor rhythm checked in 38%.▸ All decision changing scans involved a decision to stop resuscitation.ConclusionParamedics can perform focussed ELS in the classroom, integrate attempts into simulated CA scenarios and retain some of this knowledge.▸ They obtain good ELS views in the pre-hospital environment but with longer hands off the chest times.▸ The quality of life support may be reduced with less obvious pulse and monitor checking.▸ Paramedic pre-hospital ELS is more likely to be performed in patients where discontinuation of resuscitation is being considered.▸ Further training should focus on improving ELS situational awareness.