National Standards Of Care Research Articles

Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study.

BackgroundDespite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China’s health system—characterized by a movement toward “integrated care” and promotion of initial contact with grassroots providers—will affect the care of TB patients.Methods/FindingsUnannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in 3 provinces of China in July 2015. The SPs successfully completed 274 interactions across all 3 tiers of China’s rural health system, interacting with providers in 46 village clinics, 207 township health centers, and 21 county hospitals. Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%–67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01–0.25, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0–0.17, p < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%–53%) higher with 24 percentage points (95% CI: −33% to −15%) fewer antibiotic prescriptions. Relative to the current system, where patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%. The main limitations of the study are 2-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method.ConclusionsThere were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the “know-do” gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers.

No. 245-Alcohol Use and Pregnancy Consensus Clinical Guidelines.

To establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence. Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table1). The Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada. These consensus guidelines have been endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women's Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk. RECOMMENDATIONS.

Impact of early initiation versus national standard of care of antiretroviral therapy in Swaziland\u2019s public sector health system: study protocol for a stepped-wedge randomized trial

BackgroundThere is robust clinical evidence to support offering early access to antiretroviral treatment (ART) to all HIV-positive individuals, irrespective of disease stage, to both improve patient health outcomes and reduce HIV incidence. However, as the global treatment guidelines shift to meet this evidence, it is still largely unknown if early access to ART for all (also referred to as “treatment as prevention” or “universal test and treat”) is a feasible intervention in the resource-limited countries where this approach could have the biggest impact on the course of the HIV epidemics. The MaxART Early Access to ART for All (EAAA) implementation study was designed to determine the feasibility, acceptability, clinical outcomes, affordability, and scalability of offering early antiretroviral treatment to all HIV-positive individuals in Swaziland’s public sector health system.MethodsThis is a three-year stepped-wedge randomized design with open enrollment for all adults aged 18 years and older across 14 government-managed health facilities in Swaziland’s Hhohho Region. Primary endpoints are retention and viral suppression. Secondary endpoints include ART initiation, adherence, drug resistance, tuberculosis, HIV disease progression, patient satisfaction, and cost per patient per year.Sites are grouped to transition two at a time from the control (standard of care) to intervention (EAAA) stage at each four-month step. This design will result in approximately one half of the total observation time to accrue in the intervention arm and the other half in the control arm. Our estimated enrolment number, which is supported by conservative power calculations, is 4501 patients over the course of the 36-month study period.A multidisciplinary, mixed-methods approach will be adopted to supplement the randomized controlled trial and meet the study aims. Additional study components include implementation science, social science, economic evaluation, and predictive HIV incidence modeling.DiscussionA stepped-wedge randomized design is a causally strong and robust approach to determine if providing antiretroviral treatment for all HIV-positive individuals is a feasible intervention in a resource-limited, public sector health system. We expect our study results to contribute to health policy decisions related to the HIV response in Swaziland and other countries in sub-Saharan Africa.Trial registrationClinicalTrials.gov, NCT02909218. Registered on 10 July 2016.

First in the Nation: One Unit's Journey to Achieving Fragility Fracture Certification.

Osteoporosis is related to more than 2 million fractures and $19 billion in healthcare costs each year (). A fragility fracture (FF) is a low-energy fracture of the distal radius, proximal humerus, ankle, or proximal femur (hip) from minimal trauma such as a fall from a standing height. In addition to cost, FFs often result in the loss of independence and productivity (). In 2015, our orthopaedic unit received the first certification ever awarded for FFs. Fragility fracture certification is a new certification demonstrating that a healthcare facility complies with national patient care standards and uses evidence-based practice guidelines to deliver quality outcomes. Orthopaedic nurses have a critical role in optimizing future bone health and fracture prevention. Our story describes the process and challenges faced becoming the first organization in the nation to be successfully surveyed for The Joint Commission's Fragility Fracture Certification.

Investigating the management of diabetes in nursing homes using a mixed methods approach

As populations age there is an increased demand for nursing home (NH) care and a parallel increase in the prevalence of diabetes. Despite this, there is growing evidence that the management of diabetes in NHs is suboptimal. The reasons for this are complex and poorly understood. This study aimed to identify the current level of diabetes care in NHs using a mixed methods approach. The nursing managers at all 44 NHs in County Galway in the West of Ireland were invited to participate. A mixed methods approach involved a postal survey, focus group and telephone interviews. The survey response rate was 75% (33/44) and 27% (9/33) of nursing managers participated in the qualitative research. The reported prevalence of diagnosed diabetes was 14% with 80% of NHs treating residents with insulin. Hypoglycaemia was reported as 'frequent' in 19% of NHs. A total of 36% of NHs have staff who have received diabetes education or training and 56% have access to diabetes care guidelines. Staff education was the most cited opportunity for improving diabetes care. Focus group and interview findings highlight variations in the level of support provided by GPs and access to dietetic, podiatry and retinal screening services. There is a need for national clinical guidelines and standards of care for diabetes management in nursing homes, improved access to quality diabetes education for NH staff, and greater integration between healthcare services and NHs to ensure equity, continuity and quality in diabetes care delivery.

Evidence-based guidance for peer review “best practices” in radiation oncology.

180 Background: Peer review (PR) is an essential component of quality assurance in radiation oncology practice, endorsed by Canadian cancer agencies as a national standard of quality care. However, reported patterns of care studies indicate that PR practice varies considerably, including which contours (e.g., target volumes, organs at risk (OARs)), which dose parameters (e.g., OAR constraints, homogeneity criteria), which decision making points (e.g., decision to treat, selection of anatomical regions), and which treatment imaging parameters are included in the PR process. Both qualitative and quantitative evidence support the need for guidance on PR best practices. Here we report processes for the establishment of best-practice guidelines/minimal standards for PR. Methods: A comprehensive literature review was done to quantify PR findings for each of 3 cancer streams: head/neck, lung, and breast. This evidence summarized which aspects of radiotherapy plans were most frequently "flagged" at PR. A modified Delphi process was used to develop cancer site-specific PR guidance documents: appropriate stakeholders were first identified; a pre-meeting survey determined opinions on which plan elements are essential/important to review; a face-to-face meeting considered the evidence base and survey results to reach consensus. Parallel processes were conducted separately for each stream. Results: The literature findings were compiled to summarize the reported proportion of plans flagged by PR, and the nature of the flag (i.e. volumes, dose, OARs, other) for each cancer stream. Stakeholders included radiation oncologists, physicists, radiation therapists, and patients, specific to each stream. Draft guidance documents were created on the basis of stakeholder consensus regarding which components of PR were deemed essential; other important or “second tier” elements were also identified. Conclusions: Guidance documents including minimum standards for PR can be successfully created based on structured consensus development informed by available evidence. This guidance promises to reduce variation in PR thereby optimizing the efficiencies of PR processes, and increasing the quality of radiation treatment plans.

The National Competency Framework for Registered Nurses in Adult Critical Care: An overview.

In the years following the abolition of the English National Board for Nursing, Midwifery and Health Visiting in 2002, concerns were raised within the Critical Care nursing community about a lack of consistency in post-registration education programmes. In response to this, the Critical Care Network National Nurse Leads (CC3N) formed a sub-group, the Critical Care Nurse Education Review Forum (CCNERF) to address these concerns. A review of UK course provision confirmed marked inconsistency in the length, content and associated academic award. The CCNERF commenced a two-phase project, first developing national standards for critical care nurse education such as length of course and academic credit level, followed by the development of a national competency framework. Following significant review and revision, version two of the National Competency Framework for Registered Nurses in Adult Critical Care was published by CC3N in 2015. This paper introduces the National Competency Framework and provides an overview of its background, development and implementation. It then considers the future direction of UK post-registration Critical Care nurse education.

Clinical Tools to Assess Asthma Control in Children.

Asthma affects an estimated 7 million children and causes significant health care and disease burden. The most recent iteration of the National Heart, Lung and Blood Institute asthma guidelines, the Expert Panel Report 3, emphasizes the assessment and monitoring of asthma control in the management of asthma. Asthma control refers to the degree to which the manifestations of asthma are minimized by therapeutic interventions and the goals of therapy are met. Although assessment of asthma severity is used to guide initiation of therapy, monitoring of asthma control helps determine whether therapy should be maintained or adjusted. The nuances of estimation of asthma control include understanding concepts of current impairment and future risk and incorporating their measurement into clinical practice. Impairment is assessed on the basis of frequency and intensity of symptoms, variations in lung function, and limitations of daily activities. "Risk" refers to the likelihood of exacerbations, progressive loss of lung function, or adverse effects from medications. Currently available ambulatory tools to measure asthma control range are subjective measures, such as patient-reported composite asthma control score instruments or objective measures of lung function, airway hyperreactivity, and biomarkers. Because asthma control exhibits short- and long-term variability, health care providers need to be vigilant regarding the fluctuations in the factors that can create discordance between subjective and objective assessment of asthma control. Familiarity with the properties, application, and relative value of these measures will enable health care providers to choose the optimal set of measures that will adhere to national standards of care and ensure delivery of high-quality care customized to their patients.

Assessing healthcare quality using routine data: evaluating the performance of the national tuberculosis programme in South Africa.

To assess the performance of healthcare facilities by means of indicators based on guidelines for clinical care of TB, which is likely a good measure of overall facility quality. We assessed quality of care in all public health facilities in South Africa using graphical, correlation and locally weighted kernel regression analysis of routine TB test data. Facility performance falls short of national standards of care. Only 74% of patients with TB provided a second specimen for testing, 18% received follow-up testing and 14% received drug resistance testing. Only resistance testing rates improved over time, tripling between 2004 and 2011. National awareness campaigns and changes in clinical guidelines had only a transient impact on testing rates. The poorest performing facilities remained at the bottom of the rankings over the period of study. The optimal policy strategy requires both broad-based policies and targeted resources to poor performers. This approach to assessing facility quality of care can be adapted to other contexts and also provides a low-cost method for evaluating the effectiveness of proposed interventions. Devising targeted policies based on routine data is a cost-effective way to improve the quality of public health care provided.

Engagement in a statewide oral oncolytic collaborative and practice impact.

89 Background: The rapid shift to oral oncolytic therapy presents challenges to oncology practitioners. The purpose of this study is to describe how participation in a statewide oral oncolytic improvement collaborative where best practices and resources were shared can readily impact quality of care as measured by national standards. Methods: The Michigan Oncology Quality Consortium (MOQC) hosted a series of learning collaborative sessions focused on topics and deployment of resources specific to oral oncolytic management and quality improvement. Participating practices performed pre/post self-assessments in Oct. 2013 and Apr. 2015 (n = 3). Concordance with national ASCO QOPI and ONS standards was compared, including documentation (5 measures), patient education (7 measures), and follow-up/monitoring (4 measures). A response scale of always, sometimes, and never was used. Specifically, practices were surveyed to assess which evidence-based MOQC resources were implemented: patient intake template, drug-specific self-management guides, start date mailer, medication calendar, primary care physician communication template, Edmonton Symptom Assessment Scale (ESAS), and patient adherence questionnaires. Results: Practice A showed improvement in documentation, patient education, and monitoring. This practice used the initial oral chemotherapy template, ESAS, patient education templates, and patient calendar (Table). Practice B implemented 6 resources and demonstrated improvements in 15 metrics. Practice C implemented 4 resources, namely patient-focused resources, to improve all patient education and monitoring metrics. Conclusions: Use of the collaborative model and supplying oncology teams with scientific evidence, standard workflows, and resources improves concordance with national standards of care. Large-scale deployment of this model program may provide a clinically efficient and effective mechanism to enhance widespread change. [Table: see text]

A national initiative to advance school mental health performance measurement in the US

AbstractStandardized health performance measurement has increasingly become an imperative for assuring quality standards in national health care systems. As compared to somatic health performance measures, behavioral health performance measures are less developed. There currently is no national standardized performance measurement system for monitoring comprehensive school mental health in the USA. Drawing upon related initiatives in the school mental health field and national performance standards for behavioral health care in non-school settings, the current study describes the identification, development, and refinement of quality and sustainability performance measures for comprehensive school mental health. A three-phase method involving literature review and expert consensus, nominal group decision-making, and a modified Delphi process resulted in the development of two performance assessments, which include 12 domains and 67 indicators. Future directions for national performance measurement among s...

Nurse Practitioner Practice Patterns for Management of Heart Failure in Long-Term Care Facilities.

Purpose: This study examined nurse practitioners' (NPs) practice patterns for heart failure (HF) management, specifically regarding the use of angiotensin-converting enzyme inhibitors (ACEIs), beta antagonists, diuretic monotherapy, and echocardiograms for older adults residing in long-term care facilities. Methodology: A Web-based survey was developed to identify NP practice patterns for HF management in long-term care settings. The Checklist for Reporting Results of Internet E-Surveys and expert opinion guided the survey design. The survey was distributed via e-mail to Gerontological Advanced Practice Nurses Association members. Results: Most NPs used ACEIs for ongoing therapy, initiated appropriate therapy for symptomatic patients, continued beta-antagonist therapy in patients with HF, used echocardiograms in the diagnosis and evaluation of HF, and prescribed monotherapy diuretics in accordance with HF care standards. Implications for Practice: Based on these findings, NP practice patterns for management of HF in the long-term care setting are in alignment with national standard of care regardless of certification or level of physician oversight. NPs need to be cognizant of the cardiovascular risk factors for HF and adjust treatment to add an ACEI or beta antagonist to diuretic monotherapy when the clinical diagnosis of HF is suspected or established.

A 10-year history of perinatal care at the Brockington Mother and Baby Unit Stafford.

Perinatal mother and baby units are an essential service for women suffering from perinatal mental illness by allowing the baby to stay with the mother whilst receiving inpatient mental health care. Such units enable the mother to develop a relationship with her baby in a safe and supportive environment whilst caring for her mental health needs and allow her to gain confidence in her role as a mother. This article presents the development of the Brockington Mother and Baby unit and its progressive advancement towards an exemplary service for women suffering from perinatal mental illness. The Brockington Mother and Baby unit (MBU) at South Staffordshire and Shropshire Healthcare Foundation Trust (SSSFT) is celebrating its 10th anniversary and is one of six MBUs accredited as excellent by the Royal College of Psychiatry (RCPsych). The unit is a member of the Royal College of Psychiatrists' Quality Care Network and thereby adheres to their national standard of care. This article describes the journey from a single lone worker in perinatal mental health to an exemplary service caring for women with perinatal mental illness during the first 12months following the birth of their child.

Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

IntroductionNational guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk.MethodsMortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification.ResultsThe actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%.Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening).Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01).DiscussionPre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively.ConclusionsIn the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient.

20 A Minap-Like e-registry for the First Time in NHS Scotland? A Proof-of-Concept Report from the Pilot Project

Background The Myocardial Ischaemia National Audit Project (MINAP) provides data on national standards of care for patients with myocardial infarction (MI) in England and Wales but not in Scotland. In the West of Scotland (WoS), electronic patient records are being implemented in place of paper records. We aimed to record-link hospital patient episodes using the new e-systems in order to develop a secondary care e-registry for hospitalised patients with an acute coronary syndrome (ACS), including suspected STEMI, NSTEMI or unstable angina (UA). Methods The systems are (1) Trakcare Patient Admin System with extracts data based on ICD-10 diagnosis codes, (2) SCI-Gateway e-referrals for invasive cardiovascular procedures, (3) a hospital-level integrated patient record including cardiac catheter laboratory data (CATHI), (4) the WoS NHS Safe Haven for healthcare data including hospitalisation and mortality. We implemented a pilot study with data extraction for 1 Oct – 31 Dec 2013 for all admissions with an ICD-10 diagnosis of angina (I200-I209), MI (I210-I229), Other Ischaemic Heart Disease (IHD) (I240-I249), and heart failure (I50). The project involved identification of the NHS referral pathways, case e-record linkage, and quality assurance. Results The regional ACS network involves 7 acute hospitals in WoS (population 2.2 million) including the Golden Jubilee National Hospital, a regional hub for invasive cardiology. During the 3-month pilot, 930 unique patients had 1090 admissions involving 969 distinct spells (i.e. index admission and early out-patient re-admission for angiography). Of these spells, the final diagnosis was IHD in 775 (80%) patients, including 164 (16.9%) with STEMI, 287 (29.6%) with NSTEMI, 26 (2.7%) with unstable angina, 249 (25.7%) with stable angina, 5 with other IHD (0.5%), 43 (4.4%) with ‘other chest pain’ and 194 with a non-IHD final diagnosis (20%) (e.g. pericarditis). The pathways were mapped in 100% of the patients including 25.8% admitted directly to the invasive centre, 5.6% via local A&E to the invasive centre, 22.3% via the local hospital followed by in-patient transfer to the invasive centre, 8.9% discharged from the local hospital then readmitted to the invasive centre for planned early out-patient angiography, 4.6% within the local hospital only (no transfer), and 32.8% directly admitted on an elective basis to the invasive centre (non-acute). The mean duration of stay was similar for patients with a diagnosis of STEMI (5.2 days) or NSTEMI (4.6 days), but less for patients with UA (2.2 days) and more for other IHD diagnosis (9.1 days). Data on health outcomes will be presented at the conference. Conclusions For the first time, the pilot e-Registry has generated MINAP-like data in NHS Scotland. Information on admissions with or without a final ACS diagnosis is collected. NHS Scotland has emerging potential to contribute to MINAP.

Care homes.

Essential facts: About 450,000 mainly older people live in more than 17,000 care and nursing homes in England. Following concerns about mistreatment and the standard of care some residents receive, the Care Quality Commission (CQC) introduced a new inspection regime for care homes in October last year. A recent report on almost 10,000 care homes in England found that one in five failed to meet national standards for safety and care.

Abstract T P303: Early Mobility after Thrombolysis for Stroke is Safe and Improves Outcomes

Purpose: To evaluate safety and outcome of mobilizing patients to their functional ability within 24 hours of receiving thrombolytic therapy (IV tPA) for stroke at two Primary Stroke Centers. Background: Bed rest for 24 hours after tPA for stroke is the national standard of care, though there are no data to support this practice. Additionally, tPA patients are not typically mobilized early due to a perceived risk of increased complication or falls. However, data show that early mobility in other critical care populations improves outcomes and shortens length of stay (LOS). Studies to date among tPA-treated patients suggest favorable outcomes but with small clinical trial data. Methods: A validated Stroke Early Mobility Assessment Protocol was implemented within 24 hours in all patients receiving tPA for stroke and mobilizing them to their highest functionally safe level. Data from pre (Jan 2009-June 2012) and post (July 2012-March 2014) implementation were compared for safety and outcome, including complications, falls, discharge destination, and LOS. Chi square and t-tests were used to determine significant differences in outcomes before and after implementation. Results: Between 2009 and 2014, 331 stroke patients received tPA (177 pre-implementation and 154 post). Among those receiving tPA after implementation, 129 were mobilized per protocol, 16 were not, and 8 were placed on comfort care. There were no falls among tPA patients pre or post implementation. Post implementation patients mobilized early were more likely to be discharged home, 56.5% vs. 40.1%, and less likely to expire or discharge to hospice, 9.6% vs 4.5% (p&lt;0.01). There was no significant change in symptomatic hemorrhagic complications or LOS. Conclusion: Using a validated protocol, early mobilization of patients after tPA does not cause an increase in falls or neurologic or other complications. Early mobilization may improve the likelihood of discharge to home and reduce in-hospital mortality, but does not change LOS. Future analyses will include multivariate models to determine the direct relationship between early mobilization and outcomes among ICU patients receiving tPA.

Encouraging Reflective Practice with Future Early Childhood Teachers to Support the National Standards: An Australian Case Study

THE NATIONAL QUALITY STANDARDS (NQS) for early childhood education and care (ECEC) were implemented in Australia in 2012. A thorough understanding of the Standards is important for educators to improve and enhance quality in the sector. This imperative also applies in early childhood teacher education where capabilities to incorporate the NQS are essential to enhance the knowledge and understanding of future early childhood teachers. This investigation reports on the creation and evaluation of the effectiveness of a Reflective Template, based on Bloom's revised taxonomy to scaffold pre-service teacher understanding about early childhood practices and to specifically link to/unpack these policy documents' desired outcomes. The Reflective Template was utilised with 29 pre-service teachers undertaking study in a Bachelor of Education (Primary) program who were specialising in early childhood education. The findings revealed the template enabled movement beyond observing and recounting a situation to creating questions to reflect on their own practice and transfer of higher order reflection that was deeper than experienced in other teacher education subjects.

P56 Impact Of Pharmacist-led Asthma And Copd Reviews In General Practice

<h3>Introduction</h3> Asthma and chronic obstructive pulmonary disease (COPD) account for a significant burden of disease in the UK. In a local initiative, a respiratory pharmacist carried out structured asthma and COPD reviews aimed at improving clinical outcomes in a primary care setting. <h3>Aims and objectives</h3> This study aims to assess the impact of asthma and COPD reviews in accordance with national guidelines and standards of care. <h3>Methods</h3> The study was carried out prospectively, during one day a week basis, over a twelve month period across six GP surgeries. Patients were included based on use of high dose inhaled corticosteroid and bronchodilator preparations (ICS/LABA) and/or presence of previous exacerbations, accident and emergency (A&amp;E) or hospital admissions. <h3>Results</h3> 231 patients with asthma (n = 146, 63.2%) and COPD (n = 85, 36.8%) were reviewed, with 370 consultations carried out (62.4% follow up). 20.8% (n = 48) patients were followed up at the 6 or 12 month stage. Mean age was 53.0 and 67.6 years, with 34.2% and 56.5% males in the asthma and COPD groups respectively. Table 1, below, shows a significant proportion of patients had uncontrolled disease. This was likely to be due to poor adherence to maintenance inhalers and poor inhaler technique in a large proportion of patients. Interventions were made in all patients, including reducing the beclomethasone dipropionate (BDP) equivalence in the asthma group by 625.8 mcg (37.5%). Annual drug cost savings attributed to appropriate step down and cessation of therapy showed amounted to £51.8 K (asthma: £36.4 K; COPD: £15.4 K). Follow up exacerbation data is ongoing, with 48 patients (20.8%) having been seen at the 6 or 12 month stage, showing significant reductions from 1.7% to 0.04% and 3.0% to 0.14% in asthma and COPD respectively. <h3>Conclusions</h3> Structured asthma and COPD reviews have shown that a significant proportion of patients have uncontrolled disease despite use of extensive and high dose pharmacological therapy. Structured reviews by the pharmacist resulted in significant interventions that improved ACT and CAT scores and reduced unwarranted healthcare utilisation. Furthermore, it showed that appropriate prescribing and disease management in line with national standards of care also resulted in significant drug cost savings.

A review of the quality of care following prolonged seizures in 1–18 year olds with epilepsies

PurposeTo review the quality of care of children and young people with epilepsies who, following a prolonged seizure, received high-dependency or intensive care. To identify and learn from clinical, organisational, management or personal issues that contributed to these admissions, in order to inform practice and improve clinical services for children across the UK. MethodNotifications were collected from consultant paediatricians in England, Wales, Scotland and Northern Ireland over a 10-month period. For all eligible cases a clinical questionnaire was sent to the notifying clinician. A sample of these cases were selected for a detailed case note review. Case notes were reviewed by paediatrician–nurse pairs using a purpose-built assessment tool derived from national guidelines. ResultsData were collected from 135 clinical questionnaires, and 36 sets of case notes were reviewed. Findings were compared to national standards of care and emerging themes identified. There was evidence of good epilepsy management in many cases. In some cases there was evidence of a lack of clear emergency care plans, of delays in administration of emergency medication, and of deviation from established national guidelines. ConclusionThe findings of this review suggest there have been improvements in the care of children and young people with epilepsies presenting with prolonged seizures compared to previous studies. Nevertheless, further improvements are needed, particularly in communication with families and prompt administration of emergency medication.