Excellence In Clinical Care Research Articles

Research as a Standard of Care in the PICU*

Excellence in clinical care coupled with basic and applied research reflects the maturation of a medical subspecialty, advances that field, and provides objective data for identifying best practices. PICUs are uniquely suited for conducting translational and clinical research. In addition, multiple investigations have reported that a majority of parents are interested in their children's participation in clinical research, even when the research offers no direct benefit to their child. However, such activity may generate ethical conflict with bedside care providers trying to acutely identify the best approach for an individual critically ill child. Ultimately, this conflict may diminish enthusiasm for the generation of scientific evidence that supports the application of evidence-based medicine into PICU clinical standard work. Accordingly this review endeavors to provide an overview of current state PICU clinical research strengths, liabilities, opportunities, and barriers and contrast this with an established pediatric hematology-oncology iterative research model that constitutes a learning healthcare system. Narrative review of medical literature published in English. Currently, most PICU therapy is not evidence based. Developing a learning healthcare system in the PICU integrates clinical research into usual practice and fosters a culture of evidence-based learning and continual care improvement. As PICU mortality has significantly decreased, identification and validation of patient-centered, clinically relevant research outcome measures other than mortality is essential for future clinical trial design. Because most pediatric critical illness may be classified as rare diseases, participation in research networks will facilitate iterative, collaborative, multiinstitutional investigations that over time identify the best practices to improve PICU outcomes. Despite real ethical challenges, critically ill children and their families should have the opportunity to participate in translational/clinical research whenever feasible.

Peter Henry Dickinson

In his time as a consultant at the Royal Victoria Infirmary, Newcastle upon Tyne, from 1958 to 1986, Peter Henry Dickinson was one of the major figures in vascular surgery...

Allan St John Dixon

In his time as a consultant in Bath from 1966 to 1986, Allan St John Dixon, one of the major figures in British rheumatology, helped raise the reputation of the...

G290 The development of a paediatric healthcare at home service

<h3>Aims</h3> The 2012 NHS mandate recommended reduction in the length of stay for inpatients, to improve the care of patients with both long term conditions and those with acute problems. Reference was also made to improving patients’ experience of care. In paediatrics, these visions are most easily realised within ambulatory paediatrics. In April 2014 a pioneering ambulatory care service was established at our hospital, with ‘Healthcare at Home’ (HAH). The first childrens’ service of its kind, it is a consultant led, nurse delivered model of acute paediatric care. The nurses visit children up to four times a day, to administer medication, perform observations and provide clinical review. The observations and notes are recorded electronically. A daily consultant-led virtual ward round is conducted with the HAH nurses, facilitated by review of the patient’s electronic health records. The initial goal was to enable early discharge from hospital, with future aspirations to facilitate admission avoidance with direct admission to HAH from the paediatric emergency department. <h3>Methods</h3> Activity data for the first 9 months has been analysed and patient experience feedback has been evaluated. <h3>Results</h3> 78 patients have been accepted onto the HAH service to date, giving 815 visits, and saving 389 bed days. 796/815 (97.7%) were for administration of IV medication, with 48% for medications needing to be administered more than once a day. Referrals are increasing, with the majority from the general paediatrics service (90.5%). Orthopaedics, gastroenterology and neurosurgery contribute the remainder. There have been 28 episodes of patients re-attending following transfer to HAH; 22/28 (78.6%) have been due to problems with intravenous access, and 6/28 (21.4%) for clinical review. No patients have required readmission to the hospital. Patient feedback has been excellent with 100% of questionnaire responders saying they would recommend HAH to their friends and relatives. <h3>Conclusion</h3> HAH is in its infancy but, thus far, has delivered exemplary clinical care. As stated in the NHS mandate, improving the experience of patients’ and their families is essential The development of a flexible and robust community nursing service, which provides excellent acute clinical care is a proven means of facilitating this.

Inherited and acquired immunodeficiencies underlying tuberculosis in childhood.

Tuberculosis (TB), caused by Mycobacterium tuberculosis (M.tb) and a few related mycobacteria, is a devastating disease, killing more than a million individuals per year worldwide. However, its pathogenesis remains largely elusive, as only a small proportion of infected individuals develop clinical disease either during primary infection or during reactivation from latency or secondary infection. Subacute, hematogenous, and extrapulmonary disease tends to be more frequent in infants, children, and teenagers than in adults. Life-threatening primary TB of childhood can result from known acquired or inherited immunodeficiencies, although the vast majority of cases remain unexplained. We review here the conditions conferring a predisposition to childhood clinical diseases caused by mycobacteria, including not only M.tb but also weakly virulent mycobacteria, such as BCG vaccines and environmental mycobacteria. Infections with weakly virulent mycobacteria are much rarer than TB, but the inherited and acquired immunodeficiencies underlying these infections are much better known. Their study has also provided genetic and immunological insights into childhood TB, as illustrated by the discovery of single-gene inborn errors of IFN-γ immunity underlying severe cases of TB. Novel findings are expected from ongoing and future human genetic studies of childhood TB in countries that combine a high proportion of consanguineous marriages, a high incidence of TB, and an excellent clinical care, such as Iran, Morocco, and Turkey.

A clinical governance framework for blood services.

The elements of clinical governance, which ensure excellence in clinical care, can be applied to blood services. In this survey, their application in a range of blood providers was gauged, with the aim of identifying best practice and producing a generalizable framework. The Medical Directors of members of the Alliance of Blood Operators surveyed how different elements of clinical governance operated within their organizations and developed recommendations applicable in the blood service environment. The recommendations that emerged highlighted the importance of an organization's culture, with the delivery of optimal clinical governance being a corporate responsibility. Senior management must agree and promote a set of values to ensure that the system operates with the patient and donor at its heart. All staff should understand how their role fits into the 'journey to the patient', and a culture of openness promoted. Thus, reporting of errors and risks should be actively sought and praised, with penalties applied for concealment. Systems should exist to collect, analyse and escalate clinical outcomes, safety data, clinical risk assessments, incident reports and complaints to inform organizational learning. Clinical governance principles from general health care can be applied within blood services to complement good manufacturing practice. This requires leadership, accountability, an open culture and a drive for continuous improvement and excellence in clinical care.

Evaluating a Brief, Video-Based Sexual Risk Reduction Intervention and Assessment Reactivity with STI Clinic Patients: Results from a Randomized Controlled Trial.

We report results from a randomized controlled trial designed to evaluate the efficacy of a video-based sexual risk reduction intervention and to measure assessment reactivity. Patients (N = 1010; 56 % male; 69 % African American) receiving care at a sexually transmitted infection (STI) clinic were assigned to one of four conditions formed by crossing assessment condition (i.e., sexual health vs. general health) with intervention condition (i.e., sexual risk reduction intervention vs. general health promotion). After completing their assigned baseline assessment, participants received their assigned intervention, and subsequently returned for follow-up assessments at 3, 6, 9, and 12 months. Participants in all conditions reduced their self-reported sexual risk behavior, and the incidence of new STIs declined from baseline through the follow-ups; however, there was no effect of intervention or assessment condition. We conclude that further risk reduction will require more intensive interventions, especially in STI clinics that already provide excellent clinical care.

Processus, procédures et critères d’évaluation conduisant à la mise sur la liste d’aptitude aux fonctions de Maître de conférences des universités – praticien hospitalier (MCU-PH) et de professeur des universités – praticien hospitalier (PU-PH) en anesthésie-réanimation

Since several decades, anesthesia care and intensive care, as well, are engaged in the way of excellence in clinical care and research. This requirement is also applied for the selection of professor and academic workers. The goals of this article are twice: first to diffuse this knowledge at the medical community and second to describe in details the long process leading to the final appointment.

The development of a specialty: an interview with Dr. Mark C. Rogers, a pioneering pediatric intensivist.

Dr. Mark C. Rogers (1942-), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long-term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.

An inspector calls

Purpose – The purpose of this paper is to summarise key concepts within clinical governance by reference to literature, and to present the topic of statutory clinical governance inspections of hospitals. Design/methodology/approach – Conceptual paper in form of extended editorial; rapid, non-systematic review of basic clinical governance literature from UK, Republic of Ireland and Australia. Findings – The Mid-Staffordshire Hospitals report (Francis, 2013) is evidence that, more than 15 years after its inception, clinical governance in the UK has not yet fulfilled its mission. This report has stimulated the subjection of all NHS provider institutions to a statutory inspection regime. Two different yet complementary, authoritative perspectives on clinical governance are identified and discussed. Whilst the inspection regimes methodology is under review, the object of inspection is not. The object of inspection could usefully be broadened to bring the arms length planning and funding bodies associated with provision under closer scrutiny for their obligation to engage constructively and collaboratively with providers in difficulty. Research limitations/implications – A more extensive, systematic study of international literature will provide a foundation for international comparison studies which will enable participants in clinical governance to learn from each other. Practical implications – The information contained in this brief review will assist practices of governance inspection and local self-governance. Originality/value – Other studies (e.g. Brennan and Flynn 2013) have garnered definitions of clinical governance from other health systems, which tend to emphasise accountability as the key concept. Inspired by Halligan (2006), the present contribution stresses leadership and empowerment alongside accountability (in the sense of enabling “every clinical team to put quality at the heart of their moment-to moment care of patients”. It implies that accountability to “create an environment in which excellence in clinical care will flourish” should lie not only with individual clinical departments and healthcare provider institutions but also with funding and planning bodies such as the Clinical Commissioning Groups, recently introduced in the UK. The latter are not subject to the same inspection regime as providers but could usefully be made more accountable to engage constructively and collaboratively with providers in difficulty (Colin-Thomé, 2013).

Defining Patient Experience

In recent years, perceptions of performance and quality of healthcare organizations have begun to move beyond examining the provision of excellent clinical care, alone, and to consider and embrace the patient experience as an important indicator. There is a need to determine the extent to which clear and formal definitions exist, have common overarching themes, and/or have unique, but important constructs that should be considered more widely. In this article, we provide a 14-year synthesis of existing li patient experience. A total of 18 sources (articles or organizational websites) were identified that provided a tangible, explicit definition of patient experience. A narrative synthesis according to constructs of the definitions provided. The objectives of the synthesis were to: (1) identify the key elements, constructs, and themes that were commonly and frequently cited in exis (2) summarize these findings into what might be considered a common shared definition, and (3) identify important constructs that may be missing from and may enhance existing definition(s). The overarching premise and promote a working definition of patient experience that is applicable and practical for research, quality improvement efforts, and general clinical practice. Our findings identified several concepts and recommendations to consider wit regard to the definition of patient experience. First, the patient experience reflects occurrences and events that happen independently and collectively across the continuum of care. Also, it is important to move beyond results from surveys, for example those that specifically capture concepts such as ‘patient satisfaction,’ because patient experience is more than satisfaction alone. Embedded within patient experience is a focus on individualized care and tailoring of services to meet patient needs and engage them as partners in their care. Next, the patient experience is strongly tied to patients’ expectations and whether they were positively realized (beyond clinical outcomes or health status). Finally, the patient experience is integrally tied to the principles and practice of patient continues to emerge as an important focus area across healthcare globally, the need for a standard consistent definition becomes even more evident, making it critical embraced part of the healthcare conversation.

Levantamento do Perfil Social, Demográfico e Econômico de Pacientes Atendidos na Clínica de Odontologia do Centro Universitário de Araraquara – Uniara

O conhecimento do perfil social, demográfico e econômico dos pacientes que recorrem aos serviços de saúde em uma Instituição de Ensino Superior – IES permite um planejamento de ações de educação e prevenção em saúde bucal das principais doenças que acometem esses indivíduos, assim como uma melhora no atendimento clínico de excelência prestado para a população que necessita de cuidados odontológicos. Com esse objetivo, o presente trabalho propôs avaliar o perfil social, demográfico e econômico dos pacientes que recorreram ao serviço odontológico oferecido pela Clínica do Curso de Graduação em Odontologia do Centro Universitário de Araraquara – UNIARA. Para isso, a amostra foi composta por conveniência e formada por indivíduos maiores de 13 anos, que procuraram atendimento ou que já estavam em tratamento no período de agosto a novembro de 2011 e março a junho de 2012, totalizando 198 indivíduos. Foi utilizado um questionário pré- codificado, com perguntas sobre os aspectos sociais e demográficos e também dados econômicos, de acordo com os Critérios de Classificação Econômica Brasil (CCEB 2011-base LSE 2009). Com base na metodologia utilizada, e os dados obtidos tabulados e expressos em números e porcentagens, conclui-se que a maior parte dos indivíduos é formada pelo gênero feminino (65,66%), pertencente à classe C (57,57%) e procurou atendimento odontológico pelo motivo de dor (35,86%). Dessa forma, este estudo resultou em dados relevantes que proporcionarão maior atenção à qualidade de planejamento dos atendimentos clínicos oferecidos à população que anualmente recorre ao Curso de Odontologia da Instituição de Ensino Superior estudada.

Encomium: Giovanni Neri—Polyhedral and down‐to‐earth mentor

Encomium: Giovanni Neri—Polyhedral and down‐to‐earth mentor

EPILEPSY, DEPRESSION AND ANXIETY DISORDERS: A COMPLEX RELATION WITH SIGNIFICANT THERAPEUTIC IMPLICATIONS FOR THE THREE CONDITIONS

Andres M. Kanner is a senior attending physician at the department of Neurology and Director of the Comprehensive Epilepsy Center at the University of Miami, Miller School of Medicine, which...

Anesthetizing children: little people, big problems!

At the time of graduation from residency, we possess the most knowledge of anesthesia than at any other time in our lives. Dr. S. Burwell, Dean of the Harvard Medical School, said in 1956: “Half of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is none of your teachers know which half ”. Our understanding of the etiology and pathogenesis of many of the “big problems” that children present may lead to better outcomes and better quality of care, and it is the quintessential proposition for the delivery of excellence in clinical care to these “little people”. In this lecture we review a number of contentious and controversial issues that face pediatric anesthesiologists on a daily basis and present practical, evidence based approaches to addressing them.

Advancing Neuroscience Research: America’s Next Great Challenge

Advancing Neuroscience Research: America’s Next Great Challenge

Restricting resident work hours

Inadequate sleep and long work hours are long-standing traditions in the medical profession, and work schedules are especially intense in resident physicians. However, it has been increasingly recognized that the extreme hours commonly worked by residents may have substantial occupational and patient safety consequences. Largely because of these concerns, new regulations related to resident work hours came into effect July 2011, in the United States. Residents in their first year of training are now restricted to a maximum shift length of 16 hrs, with residents in subsequent years restricted to a maximum of 24 hrs. The purpose of this review is to summarize the literature regarding resident work hours in the intensive care unit, focusing on the potential positive and negative impacts of work hour limits. The authors electronically searched MEDLINE, manually searched reference lists from retrieved articles, and reviewed their own personal databases for articles relevant to resident work hour limits. To function well, humans, including physicians, require adequate sleep. Resident work hour limits will likely reduce the incidence of fatigue-related medical errors and improve resident safety and quality of life. However, a reduction in work hours may not represent the panacea for patient safety given the potential for increased errors because of discontinuity. Furthermore, there may be other substantial negative impacts, including reduced clinical exposure, erosion of professionalism, and inadequate preparation for independent practice. Costs of implementation are likely to be substantial. Currently, there is fairly limited evidence available, and a more in-depth understanding of this complex topic is required to design a residency experience that will provide the next generation of physicians the best compromise between education, experience, and quality patient care. In the end, the primary goal of the postgraduate medical education system must be to ensure the creation of healthy physicians who can provide excellent clinical care in this complex interdisciplinary medical industry and who will have long fulfilling careers providing this outstanding care to their patients.

Using Improvement Science to Promote Evidence-Based Practice in a Childhood Cancer and Hematology Center

A major children's cancer and hematology center established a Quality Transformation (QT) Core to develop and monitor empirical outcomes that demonstrate excellence in clinical care. The QT Core, based on the Institute of Medicine's domains of quality health care, aims to ensure that care is safe, effective, patient centered, timely, efficient, and equitable. Specific goals for the first year of the QT Core were to develop a team of improvement science experts, engage faculty and staff in QT initiatives, promote accountability for excellence in clinical care, and establish specific metrics to evaluate process, structure, and outcomes for QT Core projects. The purpose of this article is to discuss the successful development of a quality transformation core within a pediatric subspecialty and demonstrate the principles of improvement science through an actual quality transformation project designed to implement an evidence-based guideline for procedural sedation for children with cancer. The QT Core within this subspecialty was founded on principles of successful transformation of patient care that includes motivation to change, leaders committed to quality, active engagement of staff in meaningful problem-solving initiatives, alignment with organization goals with resource allocation, and integration to bridge boundaries throughout an organization. These key principles are demonstrated through the discussion of the development of the QT Core and implementation of an evidence-based procedure sedation guideline. Pediatric and pediatric subspecialty groups can be on the forefront of national initiatives that promote quality health care, exemplified by the QT Core developed within the cancer and hematology center.

Research needs in allergy: an EAACI position paper, in collaboration with EFA

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the continuous process of urbanization and globalization. Therefore, there is an urgent need to prioritize and concert research efforts in the field of allergy, in order to achieve sustainable results on prevention, diagnosis and treatment of this most prevalent chronic disease of the 21st century.The European Academy of Allergy and Clinical Immunology (EAACI) is the leading professional organization in the field of allergy, promoting excellence in clinical care, education, training and basic and translational research, all with the ultimate goal of improving the health of allergic patients. The European Federation of Allergy and Airways Diseases Patients’ Associations (EFA) is a non-profit network of allergy, asthma and Chronic Obstructive Pulmonary Disorder (COPD) patients’ organizations. In support of their missions, the present EAACI Position Paper, in collaboration with EFA, highlights the most important research needs in the field of allergy to serve as key recommendations for future research funding at the national and European levels.Although allergies may involve almost every organ of the body and an array of diverse external factors act as triggers, there are several common themes that need to be prioritized in research efforts. As in many other chronic diseases, effective prevention, curative treatment and accurate, rapid diagnosis represent major unmet needs. Detailed phenotyping/endotyping stands out as widely required in order to arrange or re-categorize clinical syndromes into more coherent, uniform and treatment-responsive groups. Research efforts to unveil the basic pathophysiologic pathways and mechanisms, thus leading to the comprehension and resolution of the pathophysiologic complexity of allergies will allow for the design of novel patient-oriented diagnostic and treatment protocols. Several allergic diseases require well-controlled epidemiological description and surveillance, using disease registries, pharmacoeconomic evaluation, as well as large biobanks. Additionally, there is a need for extensive studies to bring promising new biotechnological innovations, such as biological agents, vaccines of modified allergen molecules and engineered components for allergy diagnosis, closer to clinical practice. Finally, particular attention should be paid to the difficult-to-manage, precarious and costly severe disease forms and/or exacerbations. Nonetheless, currently arising treatments, mainly in the fields of immunotherapy and biologicals, hold great promise for targeted and causal management of allergic conditions. Active involvement of all stakeholders, including Patient Organizations and policy makers are necessary to achieve the aims emphasized herein.

The effects of early rehabilitation in patients with surgically treated colorectal cancer

Colorectal cancer is one of the most common cancer. Caught early, it is often curable. The important role in functional recovery of these patients, have enhanced recovery after surgery (ERAS) clinical care protocol and early rehabilitation. The goal of this research is the objective evaluation of the effects of early rehabilitation in patients after surgical treatment of colorectal cancer, respecting their functional recovery and quality of life, before and after rehabilitation. Tis study was made as experimental, randomized, controlled clinical trial, opened type.The examination included 58 patients (39 males and 19 females), age from 36 to 85 years, average 63.3, with surgically treated colorectal cancer. All patients had appropriate early multimodal accelerated rehabilitation program.The mean value of this program was 7,24 days. As observing parameter was used short form, 36 items health related questionnaire (SF-36), with two summary measures-Physical component summary (PCS) and Mental component summary (MCS), for the evaluation of quality of life, before and after treatment. For the statistical analysis of the aquired data, before and after therapy, was used Student's t-test. Afer therapy, the quality of life of patients was significantly improved, physical health (p< 0.01), as well as mental health (p<0,01). SF36 score after rehabilitation, show important improvement of quality of life in early treated patients. These results show exellent therapeutic possibilities of enhaced recovery clinical care protocol and early rehabilitation procedures. Acording to the results of this study, it can be concluded that early rehabilitation accelerated program is very effective in treatment of patients with surgically treated colorectal cancer.