Ensuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex ...healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management.
In a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis.
Fourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed.
Traditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Introduction‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are ...limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting.MethodsThe original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders.ResultsSix interrelated principles for healthcare were agreed. The foundation concept acknowledges that ‘most healthcare problems and solutions belong to the system’. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions—demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions.A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design.ConclusionsApplication of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.
OBJECTIVE—Leukocyte telomere length (LTL), a marker of cellular senescence, is inversely associated with cardiovascular events. However, whether LTL reflects plaque extent or unstable plaques, and ...the mechanisms underlying any association are unknown.
METHODS AND RESULTS—One hundred seventy patients with stable angina or acute coronary syndrome referred for percutaneous coronary intervention underwent 3-vessel virtual histology intravascular ultrasound; 30 372 mm of intravascular ultrasound pullback and 1096 plaques were analyzed. LTL was not associated with plaque volume but was associated with calcified thin-capped fibroatheroma (OR, 1.24; CI, 1.01–1.53; P=0.039) and total fibroatheroma numbers (OR, 1.19; CI, 1.02–1.39; P=0.027). Monocytes from coronary artery disease patients showed increased secretion of proinflammatory cytokines. To mimic leukocyte senescence, we disrupted telomeres and binding and expression of the telomeric protein protection of telomeres protein-1, inducing DNA damage. Telomere disruption increased monocyte secretion of monocyte chemoattractant protein-1, IL-6, and IL-1β and oxidative burst, similar to that seen in coronary artery disease patients, and lymphocyte secretion of IL-2 and reduced lymphocyte IL-10.
CONCLUSION—Shorter LTL is associated with high-risk plaque morphology on virtual histology intravascular ultrasound but not total 3-vessel plaque burden. Monocytes with disrupted telomeres show increased proinflammatory activity, which is also seen in coronary artery disease patients, suggesting that telomere shortening promotes high-risk plaque subtypes by increasing proinflammatory activity.
Previous studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnea syndrome (OSAS). Right to left shunting through a PFO may be encouraged by the ...respiratory physiology of OSAS, contributing to the disease pathophysiology. We assessed whether PFO closure would improve respiratory polygraphy parameters compared with baseline measurements in patients with OSAS.
Twenty-six patients with newly diagnosed OSAS and a moderate-large PFO (prevalence, 18% of 143 patients screened) were referred for PFO closure. The oxygen desaturation index (ODI), apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), 6-minute walk test (6MWT), and Sleep Apnea Quality of Life Index (SAQLI) results were compared in these patients at baseline (before continuous positive pressure ventilation CPAP) and at 6-month follow-up (after interrupting CPAP for 1 week).
All PFOs were safely sealed at 6 months, as confirmed by repeated transthoracic echocardiography. The ODI (44.8 interquartile range (IQR), 31.2-63.5) vs 42.3 IQR, 34.0-60.8; P = 0.89) and AHI (47.9 IQR, 31.5-65.2 vs 42.3 IQR, 32.1-63; P = 0.99) did not change after PFO closure nor did the 6MWT, although the ESS (13.0 IQR, 12.0-16.8 vs 6.0 IQR, 4.0-8.8; P < 0.001) and the SAQLI (3.4 IQR, 2.8-4.3 vs 4.4 IQR, 3.9-5.3; P < 0.001) did improve.
The prevalence of PFO in OSAS appears to be no higher than that in the general population. Although PFO closure is safe and effective, it did not improve respiratory polygraphy measures of OSAS severity. The improvement in the ESS and SAQLI likely reflect residual benefits from CPAP.
Les études antérieures ont démontré une prévalence plus élevée du foramen ovale perméable (FOP) chez les patients atteints du syndrome de l’apnée obstructive du sommeil (SAOS). Le shunt droite-gauche à travers un foramen ovale perméable peut être favorisé par la physiologie respiratoire du SAOS, ce qui contribue à la physiopathologie de la maladie. Nous avons évalué si la fermeture du FOP pouvait améliorer les paramètres de la polygraphie respiratoire en les comparant aux mesures initiales chez les patients atteints du SAOS.
Nous avons orienté 26 patients ayant récemment reçu un diagnostic de SAOS et de FOP de taille modérée ou grande (prévalence, 18 % des 143 patients dépistés) pour la fermeture du FOP. Nous avons comparé les résultats de l’indice de désaturation en oxygène (IDO), de l’indice d’apnées-hypopnées (IAH), de l’échelle de somnolence d’Epworth (ESE), du test de marche de 6 minutes (TM6) et du SAQLI (de l’anglais, Sleep Apnea Quality of Life Index) chez ces patients au début (avant la ventilation en pression positive permanente CPAP) et au suivi après 6 mois (après l’interruption du CPAP durant 1 semaine).
Tous les FOP s’étaient bien refermés après 6 mois, ce que la nouvelle échocardiographie transthoracique a permis de confirmer. Il n’y a pas eu de changement dans l’IDO (44,8 intervalle interquartile (IIQ), 31,2-63,5) vs 42,3 IIQ, 34,0-60,8 ; P = 0,89) et l’IAH (47,9 IIQ, 31,5-65,2 vs 42,3 IIQ, 32,1-63 ; P = 0,99) après la fermeture du FOP ni après le TM6 bien que l’ESE (13,0 IIQ, 12,0-16,8 vs 6,0 IIQ, 4,0-8,8 ; P < 0,001) et le SAQLI (3,4 IIQ, 2,8-4,3 vs 4,4 IIQ, 3,9-5,3 ; P < 0,001) s’étaient améliorés.
La prévalence du FOP lors du SAOS ne semble pas plus élevée que cela dans la population générale. Bien que la fermeture du FOP soit sûre et efficace, elle n’améliore pas les mesures de la gravité du SAOS à la polygraphie respiratoire. L’amélioration de l’ESE et du SAQLI reflète vraisemblablement les avantages résiduels de la CPAP.
Hypoxia in a Patient With Carcinoid Syndrome Rekhraj, Sushma, MBChB; McNab, Duncan C., MPhil; Shapiro, Leonard M., MD ...
Journal of the American College of Cardiology,
10/2013, Letnik:
62, Številka:
17
Journal Article
Recenzirano
Odprti dostop
Three-dimensional transesophageal echocardiography revealed shunting of the tricuspid regurgitation jet across a large patent foramen ovale (PFO) into the left atrium (D, white arrow, and E, left ...atrial view, PFO opening denoted by dotted line, Online Videos 6 and 7).
BackgroundInadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved ...standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context.MethodsA multimethod study was undertaken in Scottish GP involving: consensus building workshops with users and ‘experts’ to revise checklist content; regional testing of the modified checklist and follow-up usability evaluation survey of users. Quantitative data underwent descriptive statistical analyses and selected survey free-text comments are presented.ResultsA redesigned checklist tool consisting of eight themes (eg, medication safety) and 61 items (eg, out-of-date stock is appropriately disposed) was agreed by 53 users/experts with items reclassified as: mandatory (n=25), essential (n=24) and advisory (n=12). Totally 42/55 GPs tested the tool and submitted checklist data (76.4%). The mean aggregated results demonstrated 92.0% compliance with all 61 checklist items (range: 83.0%–98.0%) and 25/42 GP managers responded to the survey (59.5%) and reported high mean levels of agreement on the usefulness of the checklist (77.0%), ease of use (89.0%), learnability (94.0%) and satisfaction (78.4%).ConclusionsThe checklist was comprehensively redesigned as a practical safety monitoring and improvement tool for potential implementation in Scottish GP. Testing and evaluation demonstrated high levels of checklist content compliance and strong usability feedback, but some variation was evident indicating room for improvement in current safety-critical checking processes. The checklist should be of interest in similar GP settings internationally and to other areas of primary care practice.
BackgroundPatients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple ...healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community.AimTo explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England.MethodsWe applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie.ResultsThree themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs.ConclusionsThere are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.
BackgroundPharmacists’ completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare ...efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload.MethodsThis is a systematic literature review and meta-analysis of extracted data. Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Allied and Complementary Medicine Database (AMED),Education Resources Information Center (ERIC), Scopus, NHS Evidence and the Cochrane databases were searched using a combination of medical subject heading terms and free-text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using the Critical Appraisal Skills Programme. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively.ResultsFourteen studies were included, comprising five randomised controlled trials, six cohort studies and three pre–post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload.ConclusionsPharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge, but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload.
The Eustachian Ridge: Not an Innocent Bystander Kydd, Anna C., MD; McNab, Duncan, MD; Calvert, Patrick A., MD, PhD ...
JACC. Cardiovascular imaging,
10/2014, Letnik:
7, Številka:
10
Journal Article
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