Paul Sullivan

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015–July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7–98.9%) and specialist input (51.6–90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.

This paper describes the implementation of Behavioral Activation (BA) as the core psychotherapy treatment within a broader clinician-led effort to establish a care pathway for adolescent depression in an academic medical center that served public and private hospital systems. This quality improvement effort required a standardized yet flexible approach to psychotherapy to be used by clinicians with a range of experience and training backgrounds while serving diverse clinical populations in child psychiatry and pediatric clinics. This paper highlights implementation of BA in treating adolescent depression across these varying systems. In particular, the paper emphasizes the application of BA as a principle-driven, treatment that enables flexibility across settings while remaining rooted in scientific evidence. The paper also reviews lessons learned from this effort that may support efforts to implement BA in other clinical settings and systems.

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required. A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context. In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

Background: Although most health care is high quality, many patients and members of staff can recall episodes of a lack of empathy, respect or effective communication from health-care staff. In extreme form, this contributes to high-profile organisational failures. Reflective learning is a universally promoted technique for stimulating insight, constructive self-appraisal and empathy; however, its efficacy tends to be assumed rather than proven. The Patient Experience And Reflective Learning (PEARL) project has used patient and staff experience to co-design a novel reflective learning framework that is based on theories of behaviour and learning. Objective: To create a toolkit to help health-care staff obtain meaningful feedback to stimulate effective reflective learning that will promote optimal patient-, family- and colleague-focused behaviours. Design: A 3-year developmental mixed-methods study with four interlinked workstreams and 12 facilitated co-design meetings. The Capability, Opportunity, Motivation – Behaviour framework was used to describe factors influencing the behaviour of reflection. Setting: This took place at five acute medical units and three intensive care units in three urban acute hospital trusts in England. Participants: Patients and relatives, medical and nursing staff, managers and researchers took part. Data sources: Two anonymous surveys, one for patients and one for staff, were developed from existing UK-validated instruments, administered locally and analysed centrally. Ethnographers undertook interviews and observed clinical care and reflective learning activities in the workplace, as well as in the co-design meetings, and fed back their observations in plenary workshops. Main outcome measures: Preliminary instruments were rated by participants for effectiveness and feasibility to derive a final set of tools. These are presented in an attractively designed toolbox with multiple sections, including the theoretical background of reflection, mini guides for obtaining meaningful feedback and for reflecting effectively, guides for reflecting ‘in-action’ during daily activities, and a set of resources. Results: Local project teams (physicians, nurses, patients, relatives and managers) chaired by a non-executive director found the quarterly reports of feedback from the patient and staff surveys insightful and impactful. Patient satisfaction with care was higher for intensive care units than for acute medical units, which reflects contextual differences, but in both settings quality of communication was the main driver of satisfaction. Ethnographers identified many additional forms of experiential feedback. Those that generated an emotional response were particularly effective as a stimulus for reflection. These sources of data were used to supplement individual participant experiences in the nine local co-design meetings and four workshops to identify barriers to and facilitators of effective reflection, focusing on capability, opportunity and motivation. A logic model was developed combining the Capability, Opportunity, Motivation – Behaviour framework for reflection and theories of learning to link patient and staff experience to changes in downstream behaviours. Participants proposed practical tools and activities to enhance reflection ‘in-action’ and ‘on-action’. These tools were developed iteratively by the local and central project teams. Limitations: Paper-based surveys were burdensome to administer and analyse. Conclusions: Patients and health-care staff collaborated to produce a novel reflective learning toolkit. Future work: The toolkit requires evaluating in a cluster randomised controlled trial. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 32. See the NIHR Journals Library website for further project information.

Purpose: To describe the outcome of a series of patients who underwent pneumatic retinopexy (PR) for recurrent retinal detachment after scleral buckling and vitrectomy. Methods: This is a retrospective review of 42 consecutive cases who underwent secondary PR after either scleral buckling (n = 22) or vitrectomy (n = 20) between 1995 and 2011. Fisher's exact and nonparametric tests were used for comparison. Results: Hundred percent of patients in the scleral buckle group and 90% of the vitrectomy group were repaired with 1 PR procedure (P = 0.67). The two patients in the vitrectomy group failed because of presumed new breaks and proliferative vitreoretinopathy. The median time between the primary procedure and PR was 8.5 days for the scleral buckle group (interquartile range, 5–55 days) and 31.5 days for the vitrectomy group (interquartile range, 21–52 days) (P = 0.003). Postoperative median visual acuity improved by more than 2 logMAR lines in both the scleral buckle group (P = 0.0008) and the vitrectomy group (P = 0.007), with no difference between groups (P = 0.19). The overall complication rate in our patients was 16%, including transient intraocular pressure rise and development of tears requiring further indirect laser retinopexy within 3 months. None of the patients had vitreous hemorrhage, subretinal gas, or endophthalmitis. Conclusion: Rescue PR seems to be a safe and effective method of treating recurrent retinal detachment after both unsuccessful scleral buckling and vitrectomy.

Background/aims: To investigate the effect of hydroxypropylmethylcellulose (HPMC) on the physical interaction (contact angle) between silicone oil and a silicone intraocular lens (IOL). Methods: In vitro experiments were performed, to determine the effect of HPMC (0.5%, 1% or 2%), with or without an additional simple mechanical manoeuvre, on the contact angle of silicone oil at the surface of both silicone and acrylic (control) IOLs. A balanced salt solution chamber was used. The study group comprised 21 silicone and nine acrylic IOLs. Results: The median contact angle of silicone oil on silicone IOL was 99°. The addition of HPMC 2% alone did not significantly alter the contact angle. HPMC 2% combined with an additional single mechanical manoeuvre increased the contact angle to 180° (greater non-wetting), with complete separation of silicone oil from silicone IOL within 1 min. The manoeuvre alone, or in conjunction with a lower concentration of HPMC (0.5 or 1%), was ineffective in increasing the contact angle. Conclusion: We present a novel, non-toxic technique of using hydroxypropylmethylcellulose 2% combined with a simple mechanical manoeuvre, for the removal of adherent silicone oil droplets from silicone intraocular lenses.