Staff Changes Research Articles

Healthcare Providers' Experiences With and Perspective on Delivering the Enhanced Recovery After Elective Caesarean Birth Pathway With Next-Day Discharge: Qualitative Analysis.

To understand the perspectives and experiences of healthcare providers who have experience working with an enhanced recovery care after elective caesarean birth pathway with next-day discharge and home midwifery. This study applies a qualitative study design with a pragmatic realist approach. The realist framework was used while also taking a post-positivist philosophy. The work was conducted in South Australia, Australia between May and October 2019. Twenty-three semi-structured interviews were completed with 5 doctors and 18 midwives who had occupational experience working with the pathway. Interviews were analysed using following the six-phase qualitative thematic analysis process outlined by Braun and Clarke. COREQ guidelines were followed. Four main themes and 11 sub-themes were identified. Main themes identified were as follows: The pathway is more than just early discharge; experiences with the process; staff engagement with the pathway; and the impact of the pathway within the health system. Healthcare providers generally accepted the pathway and found enhanced recovery care to be a positive and beneficial model of care. Staff identified five main challenges with implementing the pathway: early discharge; eligible women's automatic inclusion on the pathway; engaging women; change for staff and organisational constraints and procedures. Elements that support integration include the following: education for women; reassurance and communication with women and families; prepared care and supports including home midwifery; staff education and communication of the evidence; clear guidelines and protocols; defined staff roles; enough clinical time and clinical flexibility. Knowledge from staff in this study would be useful for other health services to consider when looking to deliver similar models of care. The health service and health providers were involved with the initiation and development of the research aims and design.

An integrated, multidisciplinary management team intervention to improve patient-centeredness, HIV, and maternal-child outcomes in Lesotho: formative research on participatory implementation strategies

BackgroundReducing perinatal HIV transmission and optimizing maternal and child health (MCH) outcomes in high HIV prevalence settings is an urgent, but complex, priority. Extant interventions over-emphasize individual-level provider and patient behaviors, and neglect critical health systems-level changes. The ‘Integrated Management Team to Improve Maternal-Child Outcomes (IMPROVE)’ study implemented a three-part, patient-centered, health-systems-level intervention to improve MCH and HIV outcomes in Lesotho. Ensuring intervention fit within the health systems context is important, but often overlooked. This manuscript describes implementation research conducted to tailor and adapt intervention implementation to optimize appropriateness, acceptability, and feasibility. It identifies resulting implementation variation across study sites and lessons learned.MethodsThe research team reviewed intervention implementation documentation and conducted structured reflections to: 1) assess implementation strategy adaptations, 2) identify facility-specific strategies employed to improve the MCH patient experience, and 3) synthesize lessons.ResultsFacility-based, integrated, multi-disciplinary management teams (MDT) were feasible and acceptable to establish through engagement with facility leadership and facilitation of a participatory training curriculum that established shared values between cadres supporting MCH, and identified facility-specific service delivery gaps and potential solutions. Ongoing MDT meetings provided coordination between facility and community-based MCH service providers to implement early ANC follow-up. Facility-specific improvement strategies included fee, staffing, and patient documentation-based changes. Piloting Positive Health, Dignity, and Prevention-focused counseling approaches resulted in tailored job aids pre-implementation. Leadership involvement was critical for improved coordination while staff turnover and competing donor priorities challenged MDT efforts.ConclusionsIMPROVE created facility-specific adaptation opportunities through participatory intervention implementation practices. The MDTs, benefitting from leadership support, built relationships between HCW cadres, led facility-specific quality improvements, and, importantly, offered HCWs sought-after positive feedback by recognizing HCW efforts. The coordination, monitoring and cross-cadre communication functions of the MDTs supported implementation of other interventions, and may serve as a valuable platform for improving patient-centered care practices in similar settings and for other health services. Trial registration number: NCT04598958, 05 October 2020, retrospectively registered.Trial registrationClinicalTrials.gov, NCT04598958. Registered 05 October 2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04598958

“Every Day I was Crying about Something”: Lingering Effects of the COVID-19 Pandemic on People Working in Juvenile Prisons

Staff working in prison settings experience high rates of job-related stress which was amplified during the COVID-19 pandemic. Twenty staff members from a juvenile prison were interviewed to determine the unique mental health symptoms and stressors several years after initial shutdown procedures. Anxiety, PTSD symptoms, and sleep disturbances were reported; sometimes resulting in staff avoiding interactions with youth. Some positive aspects were noted, but overall, results indicated a continued need for mental health support and policy changes for staff. As noted by one participant, “If you don’t have the direct care staff, you don’t have a facility.”

Midwives as trainers for a neonatal clinical decision support system at four rural health facilities in eastern Uganda: a mixed-methods observational study

ObjectivesTo evaluate acceptability and effectiveness of midwives as trainers for NoviGuide, a neonatal clinical decision support system (CDSS).DesignA 20-months, mixed-methods open cohort study.Settings and participantsNurse-midwives at four rural health facilities...

Employing School Librarians: What Decision-Makers Tell Us

Although research has shown that having a school librarian benefits students, librarian positions are being cut in schools across the U.S. SLIDE — The School Librarian Investigation: Decline or Evolution? — examined federal data on school library staffing and interviewed 49 district leaders about their decisions to eliminate or add librarian positions. Keith Curry Lance, Debra E. Kachel, and Caitlin Gerrity report that of 54 total decisions leaders made related to changes in librarian staffing, 28 resulted in librarian increases and 26 resulted in librarian decreases. Decisions to add or eliminate positions were generally related to changes in district priorities. Although leaders expressed that they value librarians’ role in providing information literacy instruction and support and had positive experiences with librarians, some had to allocate resources to other positions. Others had trouble finding librarians with the necessary qualifications. When making staffing decisions, leaders need to consider what benefits librarians offer and how to meet student and staff needs for information and media literacy.

Socialist Wardens and Guards in Czechoslovakia and East Germany: The Replacement and Political Indoctrination of Prison Staff

Abstract This article focuses on the replacement of prison staff in Czechoslovakia and East Germany, later the German Democratic Republic after 1945. The main focus is on the question of how the replacement of prison staff took place, what strategies Czechoslovakia and East Germany used to accomplish this task, and the extent to which local conditions and the overall evolution of the prison systems of the two countries played a role in the process. The other aim of the article is to understand the place of political indoctrination in the staffing of prisons in the two socialist countries and to show how the system of teaching new members of the prison staff changed over time. Comparing the replacement of prison staff shows that although both states were under Soviet influence and transformed their prison systems according to the Soviet model, the implementation of staff changes greatly depended on the distinct political, economic and social conditions of the two states.

Implementation of a tailored multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for urinary tract infections in frail older adults (ImpresU) in four European countries: a process evaluation alongside a pragmatic cluster randomized controlled trial

BackgroundWe previously performed a pragmatic cluster randomized controlled trial (RCT) in general practices and older adult care organizations in Poland, the Netherlands, Norway, and Sweden. We found that a multifaceted antibiotic stewardship intervention (ASI) substantially reduced antibiotic use for suspected urinary tract infections (UTIs) in frail older adults compared with usual care. We aimed to evaluate the implementation process of the ASI to provide recommendations for clinical practice.MethodsWe conducted a process evaluation alongside the cluster RCT. The ASI consisted of a decision-tool and a toolbox, which were implemented using a participatory-action-research (PAR) approach with sessions for education and evaluation. We documented the implementation process of the intervention and administered a questionnaire to health care professionals (HCPs) from participating organizations in the intervention and usual care clusters. We evaluated the multiple components of the intervention and its implementation following a structured framework.ResultsThe questionnaire was completed by 254 HCPs from the 38 participating clusters. All components were largely delivered according to plan and evaluated as useful. The decision-tool and toolbox materials were reported to facilitate decision-making on UTIs. Regarding the PAR approach, educational sessions focusing on the distinction between UTIs and asymptomatic bacteriuria were held in all 19 intervention clusters. In 17 out of these 19 clusters, evaluation sessions took place, which were reported to help remind HCPs to implement the ASI. During both sessions, HCPs valued the reflection that took place and the resulting awareness of their behavior. It allowed them to explore implementation barriers and to tailor their local implementation process to overcome these. For example, HCPs organized extra educational sessions or revised local policies to incorporate the use of the decision-tool. Various HCPs took key roles in implementation. Staff changes and the COVID-19 pandemic were important contextual barriers.ConclusionsWe found each component of the multifaceted ASI and its implementation to have added value in the process to improve antibiotic prescribing for suspected UTIs in a heterogeneous older adult care setting. We recommend using a multifaceted, multidisciplinary approach that enables HCPs to reflect on their current practice and accordingly tailor local implementation.Trial registrationClinicalTrials.gov NCT03970356. Registered on May 31, 2019.

THE IMPACT OF CLOUD-BASED MANAGEMENT INFORMATION SYSTEMS ON HRM EFFICIENCY: AN ANALYSIS OF SMALL AND MEDIUM-SIZED ENTERPRISES (SMEs)

Cloud-based management information systems (MIS) are becoming integral to the operational success of small and medium-sized enterprises (SMEs), particularly in enhancing the efficiency of human resource management (HRM) processes. This article, based on a comprehensive review of 75 peer-reviewed studies, investigates how the adoption of cloud-based MIS positively impacts critical HRM functions such as employee management, recruitment, training, and performance monitoring. The findings indicate that cloud-based systems significantly streamline these HR tasks by reducing time, costs, and the administrative burdens traditionally associated with manual or localized HR operations. Moreover, the integration of real-time data analytics through cloud-based platforms enhances decision-making capabilities, enabling HR professionals to make data-driven and timely decisions that improve overall workforce management. The reviewed studies also emphasize that cloud-based MIS are essential for improving strategic HR planning. These systems allow SMEs to access advanced tools for workforce analytics, employee engagement, and performance tracking, which were previously only accessible to larger corporations. The flexibility and scalability offered by cloud-based MIS enable SMEs to quickly adapt to changes in staffing needs, business growth, and external market conditions without the need for costly infrastructure. Furthermore, the review highlights the role of cloud technology in fostering innovation within HR departments by supporting predictive analytics and AI-driven decision-making, which can further enhance operational efficiency. In addition to operational benefits, cloud-based MIS facilitate a more seamless integration of HR functions across geographically dispersed teams, allowing for enhanced collaboration and communication. This capability is especially critical as SMEs continue to adopt remote and hybrid work models.

The Influence of Hospital Physician Integration on Culture of Patient Safety.

Medical errors are responsible for a large number of deaths every year in the Unites States. Hospitals use various strategies including leadership, staffing, and structural changes to deal with this concerning issue. Hospital physician integration is a structural strategy to possibly improve patient safety. Using the conceptual lens of Donabedian's Structure Process Outcome model, this study aims to investigate how hospital physician integration affects organizational, management, and communication attributes of patient safety culture. A pooled cross sectional study design using the Hospital Survey on Patient Safety Culture, the American Hospital Association data, and Area Health Resource File was used to analyze the relationship between hospital physician integration and organizational and management patient safety culture attributes. The dataset comprised of hospital level data from 2021 and 2022 for patient safety culture and hospital characteristics and contained a final sample of 205 observations. The independent variable was levels of integration across five levels. Three attributes of safety culture were chosen-positive perceptions of communication openness, organizational learning, and hospital management support for patient safety. The control variables were organizational characteristics. Multivariable linear regression was used as the analytic method. Findings demonstrated a statistically significant correlation between higher level of hospital physician integration and positive perceptions of hospital management support for patient safety. There are 0.063 higher positive perceptions of hospital management support for patient safety for higher levels of integration compared with lower levels of integration (P < 0.05). Perceptions of communication openness and organizational learning did not demonstrate a statistically significant correlation with any level of hospital physician integration. Hospital physician integration and hospital management support for patient safety were moderately but significantly related. Hospital physician integration allows resources to become available for physician. As physicians take on management roles management of resources and eventually performance can improve, there is a need for future research in this area to examine if integration is a step in the right direction to overcome the challenges of patient safety and if investments in resources and training can be beneficial to safety culture.

Effective Communication Strategies for Business Analysts to Bridge the Gap between IT and Finance

As organizations depend more on technology to stay ahead of the competition, their information technology (IT) and business departments must work together closely. However, cultural differences and understanding between the specialized fields often make it hard for them to work together effectively. If these issues are fixed, they could make it easier to finish projects, stick to budgets, and agree on the company's goals. Many companies use business analysts to help people talk to each other by acting as liaisons knowledgeable in technology and finances. However, there is limited information in the literature about how analysts can connect the tasks. This study fills that gap by looking into the problems when IT and finance work together and suggesting specific steps analysts can take to improve strategic alignment. Looking at past studies shows that common differences make it hard for people to work together. IT and finance use different vocabularies for technical terms and project-based versus financial terms, leading to misunderstandings. They also set other priorities. It emphasizes speed of innovation and technical practicality, while finance emphasizes reducing risk, accuracy, and returns. There are also differences in the amount of knowledge and skill that people in IT and finance have regarding technical solution details and financial effects. They also use different ways to make decisions. IT bases judgments on technological factors, while finance assesses business impact. Besides, cultural norms diverge between the flexible and creative IT culture and the rigorous and methodical finance culture. Business analysts should utilize several focused communication strategies to close these gaps. Creating a shared vocabulary helps terms from diverse fields fit. Regular mapping and stakeholder conversations help you grasp other perspectives. Actively listening, repeating, asking questions, and summarizing shows you comprehend. Educating on decision-making variables and expertise broadens perspectives. Discussing cultural meanings and making sure individuals understand questions improves discussion. Using shared goals like increasing sales or lowering costs is another way to unite people around similar goals. By using these specific methods, business experts can help IT and finance work together despite cultural differences. Mapping and teaching regularly help keep relationships strong even as needs and staff change. By focusing on active listening, aligning vocabulary, and highlighting shared interests, you can build good working relationships necessary to get strategic benefits from technology investments.

Ensure new coaches adhere to pre‐existing medical restrictions for student‐athletes

A recent lawsuit filed by a collegiate football player who claimed that he received substandard medical care and was pressured to participate in excess of his medical restrictions highlights the potential liability concerns that can arise after a staffing change.

System-Based Intervention for Medical Providers to Improve Dental Attendance in Adult Primary Care.

There are minimal evidence-based outcomes from clinical trials for medical-dental integration. This formative work and pilot study is a precursor to a larger cluster-randomized clinical trial in adult primary care practices to test an electronic health record (EHR) structured workflow for primary care providers (physicians/nurse practitioners [NPs]) and medical staff (medical assistants [MAs] and nurses) with oral health (OH) screening and referral for Medicaid-enrolled adults ≥55 years. This study was conducted in 2 practices with providers, medical staff, and older adults. Focus groups preceded the pilot study to gain stakeholder insights prior to the multilevel interventions of systems changes and provider education. The system-level EHR changes for medical staff included ask (OH screening), advise (visit dentist soon/annually), assess (need for referral: eReferral to co-located dentists or structured referral to community dentists), and connect (referral; resources). Provider education (didactic and skills) was based on the Common-Sense Model of Self-Regulation (CSM) to deliver OH facts to older adults at primary care visits. Descriptive analysis was used to report on process outcomes of reach, adoption, and implementation/fidelity. After stakeholder input, the CSM-based didactic and skills curriculum was developed, and 4 physicians were trained. Changes in the Epic EHR were implemented, and 19 medical staff were trained in this new structured workflow together with physicians. In terms of reach, 83% (N = 80) of older adults were enrolled out of 96 approached (female: 66%; non-Hispanic: 83%; Caucasian: 43%). Workflow adoption was 100% of MAs completing the EHR questions and 89% of providers documenting giving OH facts. About 94% of older adults reported their physician giving them OH facts indicating implementation/fidelity of the intervention. About 60% of older adults reported no dental visits in the past year, and 66% requested eReferrals. This study presents an innovative systems-based multilevel intervention for medical-dental integration. The results of this study can be used by practice leadership and clinicians when incorporating oral health into primary care for older adults. Considering adoption and implementation costs, this information could lead to a more complete approach to address oral health with patients.

Supporting kindergarten staff’s agency in inclusion through long-term in-service training

ABSTRACT Supporting teachers’ agency is essential for implementing inclusive education, as agentic teachers tend to take more responsibility for making a change and focus more on activities that benefit the children they teach. Lack of teacher agency might be one of the reasons why inclusive education has not been applied successfully in kindergartens. In our study, we focused on supporting teacher agency for inclusive education according to the ecological model of agency. Our approach to inclusive education was drawn from the holistic model of inclusive education. We developed an in-service training program to support the three dimensions of agency across different levels outlined in the model of the implementation of inclusive education. The aim of this study was to explore the improvement in participants’ agency during the in-service training program. We applied pre- and post-questionnaires to explore the agency of kindergarten staff members who attended the in-service training program. The results showed statistically significant changes in kindergarten staff’s agency in the iterational and projective dimensions of agency in implementing inclusion. Therefore, we can conclude that a long-term team-based in-service course is effective in supporting teacher agency related to inclusion.

Evaluating and identifying changes in the rate of unplanned discharge among Department of Veterans Affairs (VA) facilities providing substance use disorder residential care

IntroductionQuality improvement (QI) methods play a critical role in ensuring that patients receive high-quality and timely care. Healthcare systems should use valid and reliable measures to inform QI efforts. Mental health settings including substance use disorder (SUD) residential programs have been slow to develop and incorporate quality measurement into routine practice. Unplanned discharge is of particular concern because this event is associated with harm including suicide. Healthcare systems require criteria that they can use to operationalize unplanned discharge as a quality measure in SUD residential programs. MethodsThe study included all discharges from the Department of Veterans Affairs (VA) residential SUD programs between 2018 and 2022. The study calculated crude and adjusted rates of irregular discharge. The study used the first two years of observation (2018–2019) in a logistic regression model to determine the parameter estimates for three important covariates, age, risk for homelessness, and principal diagnosis. The study tested permutations of bin size (N) and days (D) per bin to identify a single set of parameters to enable small and large facilities to have sufficient power to detect out-of-control processes (i.e., significant worsening or improvement in rates). Aligned with standard nomenclature, the study calculated the control limits based on three standard deviations (SD). Values that fell above or below three SD were statistically significant. ResultsThe cohort included 56 facilities (26,361 discharges). Irregular discharge was associated with younger age (18–40 years) and a principal diagnosis of a drug use disorder. Testing parameter values of 100 discharges (N) over 120 days (D) would yield enough power to detect modest relative changes to the irregular discharge rate for small and large facilities while testing frequently enough to make the evaluations temporally relevant. Because secular trends such as staff changes over time will impact results, the quality control method should allow for real-time feedback to those most proximal to the event. ConclusionsThe study created a set of parameters and a methodology that residential SUD programs can use to operationalize unplanned discharge locally. These data could assist programs in conducting QI work to address unplanned discharge and related harms.

Building a culture of safety in Australian residential aged care facilities: protocol for a longitudinal mixed methods research programme

IntroductionThe quality and safety of care within residential aged care facilities (RACFs) have been linked to their organisational culture. However, evidence for understanding and improving culture in this setting is...

One small state university library’s transformation through rightsizing

PurposeAcademic libraries are having to reconsider personnel, collections, space, and budget. This paper provides examples of how rightsizing opportunities in those areas can be approached in a positive way.Design/methodology/approachLibrarians at a small, rural, public university library approached rightsizing as an opportunity to shape the library in positive ways. This paper provides a reflection on those efforts in personnel, collections, space, and budget that have taken place over the past decade at this university, and highlights how the library’s role as the driver of these changes helped foster a positive culture.FindingsThis paper explains the ways the library is viewed both internally and externally as a more student-focused service and location. Examples in this paper may provide ideas for other libraries to utilize in their rightsizing efforts.Originality/valueHistorically, this library encountered forced cuts due to lower than anticipated enrollments and reduced funding from the state. This contributed to low morale and understandably defensive attitudes; however, these did not serve the library well. Post 2013, the library transitioned to a self-initiated approach to making changes. Some of these changes came about due to stagnation in budgets while others can be attributed to changes in staff due to retirements and new hires. Through this shift to proactive rightsizing, our library team has recognized we are adaptable and nimble. This has benefitted morale and helped the library grow a positive reputation on campus.

Evolving through multiple, co-existing pressures to change: a case study of self-organization in primary care during the COVID-19 pandemic in Canada

BackgroundPrimary care is often described as slow to change. But conceptualized through complexity theory, primary care is continually changing in unpredictable, non-linear ways through self-organization processes. Self-organization has proven hard to study directly. We aimed to develop a methodology to study self-organization and describe how a primary care clinic self-organizes over time.MethodologyWe completed a virtual case study of an urban primary care clinic from May-Nov 2021, applying methodological insights from actor-network theory to examine the complexity theory concept of self-organization. We chose to focus our attention on self-organization activities that alter organizational routines. Data included fieldnotes of observed team meetings, document collection, interviews with clinic members, and notes from brief weekly discussions to detect actions to change clinical and administrative routines. Adapting schema analysis, we described changes to different organizational routines chronologically, then explored intersecting changes. We sought feedback on results from the participating clinic.FindingsRe-establishing equilibrium remained challenging well into the COVID-19 pandemic. The primary care clinic continued to self-organize in response to changing health policies, unintended consequences of earlier adaptations, staff changes, and clinical care initiatives. Physical space, technologies, external and internal policies, guidelines, and clinic members all influenced self-organization. Changing one created ripple effects, sometimes generating new, unanticipated problems. Member checking confirmed we captured most of the changes to organizational routines during the case study period.ConclusionsThrough insights from actor-network theory, applied to studying actions taken that alter organizational routines, it is possible to operationalize the theoretical construct of self-organization. Our methodology illuminates the primary care clinic as a continually changing entity with co-existing and intersecting processes of self-organization in response to varied change pressures.

Probation practice and attention-deficit hyperactivity disorder.

Twenty-one Community Rehabilitation Companies were set up following the division of the National Probation Services during 'Transforming Rehabilitation' in England and Wales, under a 2013 Ministry of Justice initiative. Reunification commenced in 2018. A study completed prior to these changes suggested that probation officers had had little training in recognising attention-deficit hyperactivity disorder (ADHD) and may have been underestimating its prevalence among their clientele. Given the substantial changes in probation staffing and organisation since 2018, a new study seems warranted. The aim of the study was to understand experiences of people under a community sentence who reported having ADHD and of probation staff working with them. Using a qualitative research design, one-to-one semi-structured interviews were conducted with client facing probation staff recruited from one Community Rehabilitation Company. Service users undertaking a community sentence who had been diagnosed with or self-identified as having ADHD were then identified and recruited by these staff; those who consented were also interviewed. Transcripts were analysed using a thematic analytic approach. Thirteen probation staff and six male offenders under community sentences, agreed to participate and completed interviews. The overarching themes emerging from the two groups were similar, both reflecting on descriptions of ADHD; treatment of ADHD; experiences of having or working with ADHD in the wider community and in the criminal justice system specifically and visions of future support needs tied to the order. In addition, probation officers specifically raised the matter of payment by results. Both service users and probation staff identified gaps in knowledge, experience and services, but areas of good practice were also identified. The findings highlight the continuing under-acknowledgement of tailored clinical support for people serving a community sentence who have ADHD together with a lack of support and training about ADHD for probation staff. Return to the national organisation of probation services and recognition of need for a range of relevant skills offers a great opportunity for re-evaluating supervision and management of offenders under community sentences who have ADHD. These findings provide the basis for a template for developing knowledge and support provision for probation staff to recognise ADHD, or its likelihood, and their capacity to follow through with appropriately informed personalised supervision plans and access to specialist service advice and support.

P-723 Egg-conomized frozen embryo transfer

Abstract Study question Is home-based monitoring of ovulation cost effective compared with hospital-controlled ovulation in women undergoing frozen embryo transfer in the natural cycle? Summary answer Home-based monitoring to time frozen-embryo-transfer is cost-effective compared to hospital-controlled ovulation, as it results in lower cost with no difference in ongoing pregnancy rates. What is known already Women undergoing frozen embryo transfer treated by home-based monitoring of ovulation or hospital-controlled ovulation have comparable ongoing pregnancy rates. We found no differences in secondary outcomes, including the risk of undetected ovulation. Complete home-based monitoring of ovulation with LH hormone kits is feasible and requires no hospital visits at lower costs since ultrasound monitoring and hCG injection are no longer needed. Both consequences imply potentially lower costs after home-based monitoring of ovulation. Study design, size, duration We performed an economic evaluation of home-based monitoring of ovulation compared with hospital-controlled ovulation in a national multicentre randomised controlled trial in women undergoing frozen embryo transfer (ANTARCTICA-2 RCT Dutch TrialRegister Trial NL6414). 1464 women were randomly assigned between April 10, 2018, and April 13, 2022, with 732 allocated to home-based monitoring and 732 to hospital-controlled monitoring. All randomized patients were included according to the intention-to-treat principle. Participants/materials, setting, methods We performed a cost-effectiveness analysis from a hospital and societal perspective. We compared the direct medical costs of home-based monitoring of ovulation and hospital-controlled ovulation during one cycle until an ongoing pregnancy occurred. Direct medical costs included digital ovulation tests, transvaginal ultrasound monitoring of the dominant follicle followed by hCG trigger, hormone measurements in blood, treatment for miscarriage or ectopic pregnancy. Nonparametric bootstrapping was used to calculate cost estimates and differences with 95% confidence intervals. Main results and the role of chance Ongoing pregnancy rates were 20·8% in the home-based monitoring group and 20·9% in the hospital-controlled group (risk ratio [RR] 0·99 [90% CI 0·81 to 1·22]; risk difference [RD] -0·14 [90% CI -3·63 to 3·36]). No differences in ectopic pregnancies or miscarriages were found. Home-based monitoring required less travelling to the hospital, less ultrasounds by doctors or nurses, less hormone measurements in blood, and less medication (hCG injections). Mean direct medical costs per woman in the home-based monitoring of ovulation group and in the hospital-controlled ovulation group were €752 versus €991, respectively, with a mean difference of €239. The ICER consistently showed home-based monitoring to be less costly with no difference in effectiveness. Consequently, the cost difference from a societal perspective was larger. The mean costs per woman in the home-based monitoring of ovulation group and in the hospital-controlled ovulation group were €787 versus €1395, respectively, with a mean difference of €607 in favour of home-based monitoring. Limitations, reasons for caution We report on one cycle per women. Women usually undergomultiple frozen-embryo-cycles. This is of importance for clinical decision making aboutimplementation of home-based monitoring, since the cumulative benefit of multiple cycles perwoman should be taken into account. Wider implications of the findings The results of our trial show that home-based monitoring time frozen embryo transfer is equally effective but less costly compared with hospital-controlled ovulation. In this era of climate change and shortages of hospital staff and waiting lists, any process that takes less human labour is important. Trial registration number Dutch Trial Register (Trial NL6414)

846 Implant Waste and Associated Costs in Trauma and Orthopaedic Surgery: A Systematic Review

Abstract Aim Trauma and orthopaedic (T&amp;O) surgery relies heavily on medical devices of different unrecyclable materials. This specialty generates significant metalwork wastage through implants, screws, nails and plates, placing a large economical strain on healthcare. Finding sustainable solutions is vital given globally increasing life expectancies and heavier dependency on invasive interventions, such a knee or hip arthroplasties. Our primary outcome is to quantify implant wastage across the literature, and secondarily investigate the associated costs. Method PRISMA guidelines were followed in the design, conduct and reporting. We searched through three databases (Scopus, PubMed and Embase) using MeSh terms including “implant waste” and “trauma and orthopaedic surgery”. We included observational and randomised controlled trials reporting patients undergoing T&amp;O surgery, where the wastage or associated costs was provided. Results Our final analysis included 15 articles, screened from a total of 2,145 articles. 25,025 procedures were included, but there was limited and unmatched data. Implant waste ranged, occurring in 0.8%-25.1% procedures and costing on average $167,139.13. Screws and nails were amongst the most wasted material (up to 91% and 48% respectively), however intramedullary nails were the greatest cost contributor, making up to 47.6% of total wastage cost. Up to 95% of waste was attributable to human error. Conclusions Balancing implant wastage and hospital costs with patient safety is a challenge for many T&amp;O subspecialties. The largest factors contributing to waste were human factors, such as surgeon or staff error, miscommunication and changing decision. We hope this review will inform future guidelines in encouraging implant waste mindfulness.