Local Working Group Research Articles

A Multi-disciplinary Journey to Developing a Delirium Friendly Emergency Department

Abstract Background Delirium is a syndrome characterized by an acute change in attention, awareness and cognition. It has an organic cause and is likely to be reversible or preventable. It is a medical emergency that can often go undetected in an acute hospital setting. Currently the best management strategies for a delirium are multi-domain interventions that focus on treating precipitating conditions, medication review, managing distress and mitigating complications. An audit in 2022 identified that 40% of patients in the Emergency Department (ED) had an undetected delirium. A quality improvement initiative using Plan, Do, Study, Act (PDSA) methodology was undertaken to address this. A multi-disciplinary local working group was developed. The overall aim was to improve the patient's journey through early identification and management of delirium. This involved environmental changes such as high support chairs, signage and a delirium trolley. All staff received training on the identification and management of a delirium. In December 2023 delirium screening on all patients > 65 years was introduced in the ED as part of a delirium pathway. In April 2024 the pathway was re-audited. Methods Retrospective audit of the delirium pathway. Medical and nursing notes on all patients >65 years presenting to the ED over a 30-hour period were reviewed. Results (n=40) patients > 65 years presented to the ED over the 30-hour period. 6 medical notes could not be retrieved. (n=34) medical records were reviewed. The audit showed 14.7% of patients had a delirium screen recorded in their medical notes. One patient had an acute delirium on the ward that was not identified in the ED. There was no positive delirium score. Conclusion Delirium screening in the ED is sub-optimal. It is unclear from the audit why delirium screening compliance is so low. Conclusions can be drawn that processes around the identification of delirium need to be reviewed.

Enhancing local governance through community‐based conservation: lessons learned from a Utah local working group

AbstractBecause home ranges for many sensitive wildlife species often transcend jurisdictions, species conservation requires collaborative efforts to engage multiple stakeholders. The West Box Elder County Coordinated Resource Management (CRM) in northwestern Utah initially organized as a greater sage‐grouse (Centrocercus urophasianus) local working group (LWG), evolved through a CRM process, to enhance local governance across jurisdictional boundaries by engaging a wider range of public and private partners in species conservation and community development. By completing landscape scale management and development projects, the CRM has benefitted wildlife and local ranchers and contributed to enhancing the social and economic well‐being of rural residents in the county. In 2019, to identify the operational mechanisms of governance that enabled the CRM to achieve long‐term sustainability while meeting community and species conservation needs, we interviewed 17 key stakeholders (8 private, 6 state, and 3 federal) who had been involved in both the LWG and CRM since their inception. Each interview addressed the CRM's origin, support and synergy, administration, communications, outcomes, and improvements. Qualitative analysis of responses revealed that 1) participation by representatives of federal and state government agencies was paramount for funding and program structure, 2) landowner involvement was necessary for long‐term stability and persistence, 3) intergroup communication has improved, and 4) trust of local landowners between state and federal agencies has been enhanced. However, respondents were concerned that the CRM governance process should be re‐evaluated periodically to mitigate stakeholder burnout and group cohesion deterioration. The re‐evaluation could help temper unrealistic expectations relative to sustaining momentum the CRM has achieved over the last decade and establish new goals to better address current conservation issues. Our results may be applicable by other rural communities who desire enhanced local governance to identify and address emerging community development needs and species conservation.

A Participatory Approach for “Circular” Adaptive Reuse of Cultural Heritage. Building a Heritage Community in Salerno, Italy

Cultural heritage is recognized as a key element for local sustainable development, contributing to the identity of territories and cultural diversity of local communities. The concept of “heritage community”, as expressed by the Faro Convention, can be enhanced in decision-making processes for the adaptive reuse and valorization of cultural heritage to build shared and sustainable development scenarios. Communities represent fundamental actors able to drive active reflection and implement the exercise of civic responsibility and (inter)cultural policies. This paper explores how local communities can have an active and effective role in the adaptive reuse and valorization of cultural heritage, through a field experimentation conducted within the Horizon 2020 project “CLIC—Circular models Leveraging Investments in Cultural heritage adaptive reuse” in the area of Rufoli, Salerno (Italy), in the perspective of the circular economy/circular city model. Starting from heritage mapping and key stakeholder’s engagement, a local working group was built, and processes of knowledge building, envisioning, and community engagement were activated. The results showed that building a heritage community can be an effective starting point for “circular” adaptive reuse of cultural heritage, stimulating not only its recovery but also community bonds, civic responsibility, and potential entrepreneurial activities for longer-term sustainable development.

The utility of a local multidisciplinary working group to oversee the establishment of rapidly evolving standards of care and to support trial recruitment during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) was first identified in December 2019 in Wuhan, China. The first analyses of cases described high numbers of critically ill patients requiring intensive care admission with significant late inflammatory features. By the time the first cases of SARS-CoV-2 infection were diagnosed in the UK, a wide range of drugs were under consideration and it became clear that the input of clinicians covering all organ systems (in particular, infectious diseases, haematology, rheumatology, renal medicine and intensive care) and of expert specialist pharmacists was necessary at the local level. Thus, an expert multidisciplinary (MDT) group within our organisation was convened to offer a standardised approach and robust clinical governance for the treatment of COVID-19 patients admitted to our hospitals and rapidly develop standards of care as evidence evolved. This commentary explores the methods and mechanisms for creating an MDT COVID-19 treatment working group which are applicable to any hospital likely to admit and care for high numbers of COVID-19 patients and demonstrates how the structure and governance of the group allowed for rapid adoption of both dexamethasone and tocilizumab into standard of care as data became available.

Investigating the Qualities of a Recreational Forest: Findings from the Cross-Sectional Hallerwald Case Study.

Prior research shows that forests contribute to human health and well-being. In this sense, this cross-sectional case study, adopting the principles of citizen science, assessed the restorative potential of places in the Hallerwald, an Austrian community forest. A convenience sample of adult forest visitors (n = 99, 64% females) completed a survey during a guided 2.5 h forest tour. The German questionnaire assessed the qualities of defined places in the forest. We also investigated changes in mood states, perceived stress, restoration, connectedness, and mindfulness before and after visiting the forest. In cooperation with a local working group, we developed the new Widen One’s Mind (WOM) scale, which showed good scale characteristics. All places received high scores in their potential to increase restoration and vitality and to widen one’s mind. Positive affect, restoration, connectedness with nature and the forest, and mindfulness increased pre- versus post-visits, whereas negative affect and perceived stress decreased. The findings of this study suggest that in recreational forests, visitors experience beneficial mental effects such as stress reduction in addition to physical exercise. To facilitate regional development goals, we recommend evaluating places in forests regarding the potential effects on the health and well-being as well as citizen participation before initiating extensive remodeling.

Community-Based Chronic Disease Prevention and Management for Aboriginal People in New South Wales, Australia: Mixed Methods Evaluation of the 1 Deadly Step Program.

BackgroundChronic diseases account for over 70% of health gaps between Aboriginal people and the rest of the Australian population. The 1 Deadly Step program involves community-based events that use a sporting platform and cultural ambassadors to improve chronic disease prevention and management in New South Wales (NSW).ObjectiveThis study aimed to evaluate the feasibility and acceptability of a community-based chronic disease screening program for Aboriginal people.MethodsIn 2015, the program was enhanced to include an iPad app for screening assessments, a results portal for nominated care providers, and a reporting portal for program administrators and implemented in 9 NSW community events. A mixed methods evaluation comprising survey data, analytics obtained from iPad and Web portal usage, and key informant interviews was conducted.ResultsOverall, 1046 people were screened between April 2015 and April 2016 (mean age 40.3 years, 640 (61.19%) female, 957 (91.49%) Aboriginal or Torres Strait Islander). High chronic disease rates were observed (231 [22.08%] participants at high cardiovascular disease (CVD) risk, 173 [16.54%] with diabetes, and 181 [17.30%] with albuminuria). A minority at high risk of CVD (99/231 [42.9%]) and with diabetes (73/173 [42.2%]) were meeting guideline-recommended management goals. Overall, 297 participants completed surveys (response rate 37.4%) with 85.1% reporting satisfaction with event organization and information gained and 6.1% experiencing problems with certain screening activities. Furthermore, 21 interviews were conducted. A strong local working group and processes that harnessed community social networks were key to implementation success. Although software enhancements facilitated screening and data management, some technical difficulties (eg, time delays in processing blood test results) impeded smooth processing of information. Only 51.43% of participants had a medical review recorded postevent with wide intersite variability (10.5%-85.6%). Factors associated with successful follow-up included clinic managers with overall program responsibility and availability of medical staff for immediate discussion of results on event day. The program was considered highly resource intensive to implement and support from a central coordinating body and integration with existing operational processes was essential.Conclusions1 Deadly Step offers an effective and acceptable strategy to engage Aboriginal communities in chronic disease screening. High rates of risk factors and management gaps were encountered, including people with no previous knowledge of these issues. Strategies to improve linkage to primary care could enhance the program’s impact on reducing chronic disease burden.

Management and treatment of relapsed or refractory Ph(-) B-precursor ALL: a web-based, double-blind survey of EU clinicians.

BackgroundThe prognosis for adult patients with Ph(-) B-precursor acute lymphoblastic leukaemia (ALL) who are refractory to treatment or experience relapse (R/R), is poor; over 90 % of these patients die from the disease, typically within a few months. While there are some national guidelines published for the treatment of adult patients with ALL, and local working group recommendations do exist, there is very little detail and no preferred treatment regimens for adult patients with R/R Ph(-) B-precursor ALL. The aim of this study was to describe current real-world clinical practice in Europe for the management and treatment of adult R/R Ph(–) B-precursor ALL.MethodsA web-based, double-blind survey was conducted in November/December 2013 in France, Germany, Italy, Spain, and the UK. The survey was developed following consultation with specialist clinicians and a critical review of published literature. Eligible clinicians (15 per country) were board-certified in haemato-oncology or haematology; had at least 4 years of experience in their current role and had treated at least five patients with adult ALL in the 36 months before the survey, including at least one with R/R Ph(−) B-precursor ALL.ResultsClinicians across the five countries consulted 16 guidelines and local working group recommendations for the diagnosis and treatment of R/R Ph(–) B-precursor ALL. Thirty three regimens for salvage therapy were reported; the most frequently cited was augmented hyper-CVAD (15 %), with vincristine the most commonly used agent. Salvage therapy regimens involved a range of agents, and most respondents reported using at least one cytotoxic agent; across respondents 10 different cytotoxic agents were cited. All respondents reported that toxicity was common for the regimens they used to treat R/R Ph(–) B-precursor ALL.ConclusionsThis study provides evidence of current management and treatment patterns of R/R Ph(–) B-precursor ALL in the real-world clinical practice in Europe. The approach to the treatment of R/R Ph(–) B-precursor ALL is heterogeneous, reflecting the lack of any clearly superior chemotherapeutic option, thus it appears that clinicians are trying a wide variety of therapies. These findings show a clear need for effective, tolerable treatments for R/R Ph(–) B-precursor ALL.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-015-1745-4) contains supplementary material, which is available to authorized users.

Reviewing The Benefits of Health Workforce Stability

This paper examines the issue of workforce stability and turnover in the context of policy attempts to improve retention of health workers. The paper argues that there are significant benefits to supporting policy makers and managers to develop a broader perspective of workforce stability and methods of monitoring it. The objective of the paper is to contribute to developing a better understanding of workforce stability as a major aspect of the overall policy goal of improved retention of health workers. The paper examines some of the limited research on the complex interaction between staff turnover and organisational performance or quality of care in the health sector, provides details and examples of the measurement of staff turnover and stability, and illustrates an approach to costing staff turnover. The paper concludes by advocating that these types of assessment can be valuable to managers and policy makers as they examine which policies may be effective in improving stability and retention, by reducing turnover. They can also be used as part of advocacy for the use of new retention measures. The very action of setting up a local working group to assess the costs of turnover can in itself give managers and staff a greater insight into the negative impacts of turnover, and can encourage them to work together to identify and implement stability measures.

Capacity building in rural Guatemala by implementing a solid waste management program

The development and implementation of a solid waste management program served to build local capacity in San Mateo Ixtatán between 2002 and 2003 as part of a public health action plan. The program was developed and implemented in two phases: (1) the identification and education of a working team from the community; and (2) the completion of a solid waste classification and quantification study. Social capital and the water cycle were two public health approaches utilized to build a sustainable program. The activities accomplished gained support from the community and municipal authorities. A description of the tasks completed and findings of the solid waste classification and quantification performed by a local working group are presented in this paper.

Le facteur VII activé recombinant hors Autorisation de mise sur le marché à l'heure de la tarification à l'activité : enquête de pratique

Objectives To evaluate the impact of local recommendations on off label use of recombinant activated factor VII. Type of study Observational, retrospective. Material and methods Recommendations have been diffused by a local working group in 2004, concerning seven groups of indications (traumatology, cardiac, hepatic and various surgeries, obstetrics, neurology and haematology). Conformity to recommendations was studied according to 4 axes: respect of prescribing procedure, indication, posology, and pre ones required with the administration. Results There were thirty-one uses from 2004 to 2006. Thirty patients presented a massive haemorrhage (blood products before administration of recombinant activated factor VII expressed in median [min–max]: red blood cell unit = 15 [0–37], fresh frozen plasma = 11 [0–21]). Gravity score at the admission: SAPSII = 55 ± 22 (average ± SD), 87% patients presented haemorrhagic shock. Prescribing procedure was in conformity with recommendations in 45%, indications were correct in 74%, posology in 55%, and 16% of prescriptions were completely conform. Conclusion With the tariffing to the activity reform, the reimbursement of off label use of expensive molecules will depend on the respect of the evidence-based medicine. According to this study, the observance of local recommendations was insufficient. Rationalizing prescriptions for practice improvement seemed to be difficult and challenging.

Control of tuberculosis in an urban setting in Nepal: public-private partnership.

To implement and evaluate a public-private partnership to deliver the internationally recommended strategy DOTS for the control of tuberculosis (TB) in Lalitpur municipality, Nepal, where it is estimated that 50% of patients with TB are managed in the private sector. A local working group developed a public-private partnership for control of TB, which included diagnosis by private practitioners, direct observation of treatment and tracing of patients who missed appointments by nongovernmental organizations, and provision of training and drugs by the Nepal National TB Programme (NTP). The public-private partnership was evaluated through baseline and follow-up surveys of private practitioners, private pharmacies, and private laboratories, together with records kept by the Nepal NTP. In the first 36 months, 1328 patients with TB were registered in the public-private partnership. Treatment success rates were >90%, and <1% of patients defaulted. Case notification of sputum-positive patients in the study area increased from 54 per 100 000 to 102 per 100 000. The numbers of patients with TB started on treatment by private practitioners decreased by more than two-thirds, the number of private pharmacies that stocked anti-TB drugs by one-third, the number of pharmacies selling anti-TB drugs by almost two-thirds, and sales of anti-TB drugs in pharmacies by almost two-thirds. Private practitioners were happy to refer patients to the public-private partnership. Not all private practitioners had to be involved: many patients bypassed private practitioners and went directly to free DOTS centres. A combination of the strengths of private practitioners, nongovernmental organizations, and the public sector in a public-private partnership can be used to provide a service that is liked by patients and gives high rates of treatment success and increased rates of patient notification. Similar public-private partnerships are likely to be replicable elsewhere, as inputs are not large and no special requirements exist.