Extra Appointments Research Articles

Between delivering chronic care and answering patients' burdens: Understanding HIV specialist nurses' experiences in the age of treatment.

To understand the experiences of HIV nurses in the context of ambivalence between biomedical treatment advancements and the continuing burden for people living with HIV and negative representations of HIV. An interpretative phenomenological study was conducted using in-depth interviews. Twenty-one interviews with nurses were conducted between November 2021 and March 2022. A thematic analysis was performed. Six themes related to the nurses' experiences emerged. Despite effective treatment for most people with HIV, nurses identify patient populations that require additional care. Nurses are flexible in making extra appointments to accommodate complex issues in these patients. Nurses develop a unique relationship with their patients based on trust and empathy, linked to patient's experiences with stigma and discrimination for people with HIV. Nurses perceive their tasks as becoming increasingly complex. There is explicit awareness about the changes in HIV care from acute to chronic care and how this affects nurses' tasks. Nurses continue to differentiate HIV from other chronic conditions. Biomedical advancements change the organization of HIV care while public health concerns remain and patient population has particular needs due to negative social representations of HIV. Nurses navigate these issues in their everyday care. A potential re-evaluation of the role of nurses in providing chronic HIV care. Our study addresses the roles of HIV nurses as care is shifting towards chronic care models. The unique relationship between nurses and patients is key in understanding the importance of nurses in the care trajectory. These findings impact the institutional role of nurses in HIV treatment centres and the institutional organization of HIV care. The COREQ guideline was used. Amsterdam UMC (AMC) staff, the national organization of HIV Nurses and patient organizations contributed to the study design.

179 Improving respiratory screening and NIV assessment in motor neuron disease

Motor neurone disease (MND) commonly causes death from respiratory muscle weakness. Non-invasive ventilation (NIV) is currently the most life-prolonging treatment, and its inclusion in NICE guidelines has increased respiratory function testing, respiratory referrals and usage. Earlier referral to respiratory services results in more hospital appointments before NIV initiation. We aimed to assess whether patients were receiving NICE-compliant respiratory screening and calculate the NIV uptake rate of those referred. We also sought to measure the effect of NIV on survival. We retrospectively examined 194 patient records from the SRFT MND care centre between 1st January and 31st December 2016. A Kaplan-Meier analysis was used to calculate survival. All appropriate patients received NICE-compliant respiratory screening, with 27% patients referred for NIV. Of those referred 33% were started on NIV at initial assessment, and 12% during follow up. Non-invasive ventilation increased survival by 265 days. The result of NICE-compli- ant practice is a low rate of NIV uptake, burdening patients and services with extra appointments. NIV significantly increases life expectancy and patients must receive it as soon as it is indicated. We plan to incorporate NIV assessment by respiratory physicians within the MND clinic to complement the screening process and reduce unnecessary referrals.daniel.rice-wilson@nhs.net

Psychological Complaints at Psychological Emergency Service Associated with Referral to Extended Screening in a Psychology School Clinic

The Psychological Emergency Service (PES) at psychology school clinics is an unscheduled and free psychological service to meet urgent demands. From this service, some patients whose complaints require more time for clinical work are referred to the Extended Screening (ES), a modality composed of six extra appointments. This study aims to analyze the sociodemographic profile of patients seen on PES in a Brazilian Psychology School Clinic, and to identify the demands that motivated referral to the ES, for better qualification of the care offered. This is a descriptive analysis research, carried out based on data from the medical records of 46 patients who went through the PES and were referred to the ES at the institution, between the years 2019 and 2021. Sociodemographic data were collected and, from the session reports, a content analysis of the thematic analysis modality was performed to identify the complaints. The participants’ age ranged from 18 to 65 years, with a mean of 32.28 years (sd = 10.95). There was a predominance of female participants (71.74%), that completed High School (39.14%) and had an income from one to two Brazilian minimum wages (32.61%). The most frequent complaints were depressive symptoms (56.52%) and difficulties in interpersonal relationships (32.61%). The results obtained, besides allowing the survey of the social and demographic profile of the clientele of the PES at the Psychology School Clinic, and demonstrating its social relevance by providing free psychological care, also show to be of great importance for the definition of more accurate criteria for referral to the ES of patients seen on PES.

Investigation and comparison of patient experiences with removable functional appliances.

To compare patients' experiences with the Invisalign Teen with Mandibular Advancement® (ITMA) and Twin Block (TB) appliances, both initially and after several months of wear. Sixty-eight patients completed an anonymous survey after at least 2 months of wearing ITMA or TB. Forty-five patients treated with ITMA (18 boys, 27 girls, mean age 13.6 years, SD ± 1.54) and 23 patients treated with TB (13 boys, 10 girls, mean age 10.60 years, SD ± 1.92) were included. More patients using the TB found their appliance to be visually intimidating as compared with patients using the ITMA (21.7% vs 8.9%). TB was more noticeable than the ITMA (69.6% vs 25%). Appliance insertion was more difficult for TB patients (21.8% vs 4.44% for ITMA). After several months, there were more reports of tooth soreness and lip/cheek soreness in the ITMA group. TB patients were more embarrassed even after several months (14.3% vs 0% for ITMA). More TB patients required extra appointments for breakage (50% vs 22.2% for ITMA). Speech, drooling, and jaw and lip/cheek soreness worsened initially for both groups but improved over time. There were no differences between the groups regarding visible facial changes, satisfaction with treatment experience, or time to acclimatize to the appliance. TB and ITMA patients shared similar experiences for most of the parameters measured, but there were significant differences between the groups regarding appliance wear and management, discomfort, and function.

Reducing the waitlist of referred patients in a medical specialist outpatient clinic: an observational study

PurposeLong waitlists in outpatient clinics are a widely recognised problem. The purpose of this paper is to describe and report the impact of a waitlist reduction strategy for an epilepsy clinic.Design/methodology/approachThis observational study described the local impact of a methodical approach to tackling a long waiting list, using targeted strategies supported by a modest additional budget. The interventions were described using the template for intervention description and replication (TIDieR).FindingsOver an eight-month period, the waitlist for the epilepsy clinic was reduced from 599 to 24 patients without increasing the number of days until the next available appointment. Most referrals were removed from the waitlist without an appointment. Auditing revealed a high proportion of patients no longer required the service or referrals remained on the waitlist due to administration error. A short-term increase in clinic capacity of 51 extra appointments met the needs of the remaining waiting patients. The additional project funding invested in this process was AUD $10,500 and a time-limited amount of extra work was absorbed by using existing clinic resources.Practical implicationsThis waitlist reduction strategy resulted in a very small waitlist for the epilepsy clinic, which is now well placed to trial further interventions with the aim of sustaining the service with minimal waiting times. Not every referral on the waitlist, particularly the very long waiters, required an appointment. Other outpatient clinics may be able to apply this process to reduce their waitlists using a modest budget.Originality/valueAlthough there are reports of successful waitlist reduction, few report the intervention in detail. Use of the TIDieR in reporting enables the intervention to be appraised or adapted to other settings where long waitlists are problematic. Considerations related to implementation of policy are discussed and in this case, a locally led and executed change management strategy was a key to achieving the result.

O14 Transitions in diagnosis and between services in juvenile idiopathic arthritis: living and learning

O14 Transitions in diagnosis and between services in juvenile idiopathic arthritis: living and learning

First-Time Mothers Have a Desire to Be Offered Professional Breastfeeding Support by Pediatric Nurses: An Evaluation of the Mother-Perceived-Professional Support Scale.

Background Although the World Health Organization recommends exclusive breastfeeding for six months, the rate of breastfeeding has decreased worldwide. Breastfeeding is the natural way of feeding a baby, but it is a process that has to be learnt. It is not unusual for problems to occur and hence support for breastfeeding is vital. The aim of this study was to explore first-time mothers' experiences of the breastfeeding support offered by pediatric nurses, as well as to develop and evaluate the Mother Perceived Support from Professionals (MoPPS) scale. Methods A qualitative design involving both inductive and deductive approaches was chosen. Nine first-time mothers were interviewed regarding their experiences of the breastfeeding support offered by pediatric nurses. Semistructured interviews were conducted. The mothers were also asked to grade their experiences of breastfeeding support on the MoPPS scale. A qualitative content analysis was applied when analyzing the data obtained using both the inductive (interviews) and deductive (MoPPS scale) approaches. Results The results revealed that the mothers felt the desire to breastfeed, although they all experienced some difficulties. They wanted the pediatric nurses to be perceptive and provide professional support based on their own experiences. When the pediatric nurses took time and booked extra appointments, the mothers felt supported. The inductive analysis resulted in one theme: “When wanting to breastfeed, mothers have a desire to be offered professional breastfeeding support”. Two main categories were identified, namely “Mothers wanted but lacked breastfeeding support” and “Mothers received professional support.” The deductive analysis of the MoPPS scale showed similar results, and the questions were perceived as relevant to the aim. The mothers considered it important that the pediatric nurses had sufficient knowledge about breastfeeding. It was also considered important that the pediatric nurses involved the mothers' partners in the breastfeeding support. Therefore, we suggest that these areas should be included in the MoPPS scale for pediatric nurses. Conclusions The MoPPS scale can be a useful tool for helping pediatric nurses to offer mothers professional breastfeeding support. Indeed, when offering breastfeeding support, pediatric nurses can use the items included on the MoPPS scale as guidance.

Can GPs find time for a million extra appointments a year?

NHS England makes grand claims about the potential impact of its Time for Care programme, which has GPs leading efficiency drives in primary care. Ann Robinson examines whether the savings...

Universities and primary care organisations working together to recruit GPs: a qualitative evaluation of the Enfield clinical teaching fellow programme.

BackgroundGeneral practice recruitment is in difficulty in the UK as many experienced GPs retire or reduce their commitment. The numbers of junior doctors choosing to specialise in the discipline is also falling, leading to primary care workforce issues particularly in 'hard to serve' areas.AimTo evaluate an academic service collaboration on GP recruitment between a primary care organisation (PCO), Enfield CCG, and a university, University College London (UCL).Design & settingEvaluation of an academic service collaboration in the Enfield CCG area of north east London.MethodAn action research method utilising qualitative methodology was used to evaluate a local service intervention, undertaken by the participants themselves. The qualitative data were analysed by one researcher but themes were agreed by the whole team. Enfield CCG, an NHS PCO, funded a collaboration with UCL to employ five GPs as clinical teaching fellows to work in Enfield, to increase patients' access, to provide input to CCG development projects, and to provide undergraduate medical student teaching in practice.ResultsFive teaching fellows were employed for ≤2 years and provided 18 266 extra appointments, engaged with development projects, and delivered local undergraduate teaching. The themes identified by stakeholders were the challenges of these organisations working together, recruiting GPs to an underserved area, and perceptions of the model’s value for money.ConclusionThe evaluation showed that the collaboration of an NHS PCO and a higher education institution can work, and the prestige of being associated with a universty and clinical variety ensured GP recruitment in an area that had previously struggled. However, the project’s costs were high, which affected perceptions of its value.

Is the efficacy of sacral nerve stimulation for faecal incontinence dependent on the number of active electrode poles achieved during permanent lead insertion?

Sacral nerve stimulation (SNS) is effective for faecal incontinence (FI). Little is known about the relationship between the implantation technique and the functional outcome. This study aimed to explore the relationship between the numbers of active electrode poles (AEP) achieved during permanent lead placement and subsequent function, therapeutic amplitude and the need for extra appointments between scheduled follow-up visits. One hundred and eighty-six patients with FI who underwent permanent implantation between May 2009 and March 2015 with a tined (barbed) lead (3093/3080, Medtronic) using the straight stylet were registered on the European two-centre SNS prospective database (SNSPD). Correlation between the number of AEP, function, stimulation amplitude and the need for extra visits was analysed. The numbers of patients having an intra-operative motor response on stimulation of one, two, three and four poles were 18 (9.7%), 75 (40.3%), 61 (32.8%) and 32 (17.2%). The Wexner incontinence score was significantly reduced from 15 (±2.8) at baseline to 9.2 (±4.8) at the latest follow-up after a mean 878±561days (SD; P<0.001). No correlation was found between the number of AEP and the functional outcome (P>0.05). Patients with four-AEP had a reduced therapeutic amplitude up to 289 (±146) days of follow-up (P<0.03). The number of AEP did not influence the need for extra follow-up visits (P<0.223). The functional outcome and number of extra visits after SNS for FI did not depend on the number of AEP achieved. The therapeutic amplitude was reduced during the first postoperative year if four AEP were achieved during lead placement.

Referral patterns among patients with metastatic breast cancer in an integrated palliative care program.

163 Background: ASCO recommends palliative care (PC) concurrently with oncologic treatment for patients with metastatic disease and there is emerging data about the benefits of early PC. However, little is known about referral patterns to specialty PC among patients who die of metastatic breast cancer. Methods: After years of offering a stand-alone outpatient PC consult service in our comprehensive cancer center, we established an integrated PC program in breast oncology (the “Advanced Breast Cancer (ABC) Program”) with a care coordinator, PC physician, and co-location with oncology. Among patients who died, we analyzed referral patterns, program participation, and end-of-life quality outcomes from October 2014 through May 2015. Results: 38 of 108 patients (35.2%) referred to and seen in ABC died, with an average of 2.9 PC visits (range 1-17) and 7 months (range 0-20) between referral and death. Reasons for referral among ABC patients who died included: symptom management (15 patients, 39.5%); goals of care discussions (12, 31.6%); psychosocial support (5, 13.2%); discharge referral from the inpatient PC team (4, 10.5%); and new diagnosis of metastatic disease (3, 7.9%). At the time of referral, average time since metastatic diagnosis was 23.6 months (range: 0-106); 10 patients (26.3%) had received &gt; 3 lines of treatment. 15 referred patients (13.9%) died but were not seen by ABC: of those, 6 initiated hospice before they could be seen; 5 initially declined or deferred the referral but then were too sick to be seen in clinic by the time they agreed; and 4 were unwilling to accept extra appointments or did not follow-up to repeated outreach. 24 ABC patients who died (63.2%) were seen early (&gt; 90 days before death), whereas in the year prior to the ABC clinic, among patients who died, only 11 of 44 (25%) who had received PC consultation received it early. 19 of 33 (57.6%) ABC patients for whom data was available utilized hospice, with only 2 (5.3%) using hospice &lt; 3 days. Conclusions: Embedding and integrating a PC practice in breast oncology resulted in patients being seen earlier. Future efforts should be directed at further increases in earlier referrals by oncologists and in facilitating patient acceptance of early referrals.

Wound Dehiscence after Wisdom Tooth Removal in Mandibular Mesioangular Class IB Impactions: Triangular Transposition Flap versus Envelope Flap.

Background and aims. Wound dehiscence after lower third molar surgery extends the postoperative treatment period and may cause long-standing pain. The aim of this study was to compare wound dehiscence after removal of wisdom teeth in the most prevalent mandibular impaction (mesioangular class IB) by two different soft tissue flap designs.Materials and methods. Partially-erupted mandibular third molars with mesioangular class IB impaction (Pell and Gregory classification) were selected. Split mouth technique was used to compare the two flap designs (envelope vs. triangular transposition flap—TTF). The patients were recalled one week and a month later and rechecked for dehiscence, infection, and dry socket formation.Results. There were no cases of infection in either group. However, three cases of dry socket in the envelope group and four in the TTF group were recorded. In the envelope group, dehiscence occurred in 43% of cases during the first week, with 67% of cases being a large dehiscence (diameters of more than 5 mm). Extra appointments (those requested by the patient exclusively related to the problem of the hole distal to the second molar) were scheduled in 10% of cases in the envelope group. In the TTF group, dehiscence occurred during the first week for the same impaction in 19% of cases with large dehiscence cases occurring in 65% of cases and extra appointment rate at 4.1%.Conclusion. According to theresults in the evaluated operation, TTF may prevent postoperative wound dehiscence more probably than the envelope flap.

PTH-078 Forward Progress Or Financial Extravagance? Counting The Cost Of Nice Guidelines For Chronic Hepatitis B

IntroductionAn estimated 180,000 people in the UK are chronically infected with hepatitis B (HBV). NICE guidelines published in 2013 advocate changes in the management of this patient group. Recommendation toward...

Routine testing of fetal Rhesus D status in Rhesus D negative women using cell‐free fetal DNA: an investigation into the preferences and information needs of women

ObjectiveThe goal of this study is to investigate women's preferences and information needs for routine implementation of fetal Rhesus D (RhD) typing using cell-free fetal DNA.MethodsA questionnaire was developed following focus groups and interviews with both health professionals and RhD negative (RhD−) women offered fetal RhD genotyping within a research study and distributed to RhD− women attending routine antenatal appointments in four National Health Service hospitals. Current knowledge of blood types, anti-D administration, fetal RhD genotyping and future practices were explored.ResultsA total of 19 respondents participated in interviews and focus groups, and 270 respondents completed the questionnaires. Questionnaire respondents overwhelmingly felt that the test should be offered to all RhD− women (92.1%), and 75.9% said that they would accept this test. Most were happy to have the test even if it involved extra blood tests (89.3%) or appointments (79%). The knowledge of blood groups was poor. Although 90.7% knew that the baby could have a different blood group from themselves, only 34% knew that blood groups are inherited from both parents. More than 40% were not aware that anti-D would not be required if their baby was RhD−.ConclusionsWomen would welcome the introduction of routine fetal RhD genotyping. Information leaflets and training of midwives will be essential for implementation to ensure good understanding regarding testing. © 2013 The Authors. Prenatal Diagnosis published by John Wiley & Sons Ltd.

SAT0568 Evaluating the Perceptions and Barriers towards Clinical Research in Rheumatology Patients

BackgroundAdvances in the rheumatology treatments rely on recruitment and retention of patients to clinical trials. National surveys reflective of the UK population by the National Institute of Health Research and...

PMO-221 Appropriateness of follow-up indications after colonic polyp removal: audit of current practice in a district general hospital

IntroductionDemand for colonoscopy is increasing worldwide due to the implementation of colon cancer screening programmes. According to current guidelines, the indication and timing for surveillance colonoscopy after removal of colonic...

Cost analysis of HIV treatment and drug-related adverse events when fixed-dose combinations of antiretrovirals (FDCAs) were stopped, versus continuation with FDCAs

BackgroundThe launch of a generic form of lamivudine (g3TC), included in several fixed-dose combinations of antiretrovirals (FDCAs), led to considering switching stable patients from lamivudine and emtricitabine-containing FDCAs to separate...

The development of a guideline for the screening of pregnancies potentially affected by maternal red cell antibodies

BackgroundParticularly for the less haemolytic antibodies, there is limited evidence to aid management. New Scottish guidelines are in production. To provide evidence for their development, we sought to study over...

Satisfaction, demand, and opening hours in primary care: an observational study

The ease with which patients can make primary care appointments in the UK has been subject to a pay for performance scheme since 2004. A separate scheme, extended hours - the provision of extra appointments outside normal office hours -was introduced in 2008. To examine how the provision of additional morning, evening, and weekend appointments influences patient satisfaction with opening hours. An observational study in primary care. The study collated information on extended hours for all practices in 13 English primary care trusts (n = 639). After examining the descriptive statistics the study ran a series of clustered logistic regression models, comparing additional periods of service provision to practice characteristics and to patient satisfaction with access and opening hours in the GP Patient Surveys. Practices offering Saturday appointments saw a relative decline in demand for additional hours. Practices offering other time periods did not see this. Satisfaction with opening hours improved slightly for practices offering extra appointments, but was not linked to anytime period. The terms and conditions of the extended hours scheme are loosely implemented and this may have limited the apparent effectiveness of the scheme. Demand for additional opening in primary care is only influenced by Saturday appointments. Satisfaction with opening hours responds to increased capacity, but is not linked to a specific time period.

Non use of drains in breast surgery

The use of drains in breast surgery is routine and is accepted to allow for healing of wounds without complications. The disadvantages of using drains after breast surgery include increased length of stay, discomfort, blockage and infection, extra clinic appointments, monitoring of outflow, patients inconvenience, increased nursing time, service implications and costs. Over the past years we changed our policy and have not used drains during breast operations.