Urgent Care Services Research Articles

Accidents with motorcycles: a view of nurses of the urgent mobile care services

Objetivo: conhecer a percepção dos enfermeiros sobre os acidentes motociclísticos atendidos pelo Serviço de Atendimento Móvel de Urgência (SAMU) de Sobral. Método: trata-se de um estudo exploratório descritivo, com abordagem qualitativa realizado com enfermeiros do SAMU do município de Sobral-Ceará, atualmente composto por oito enfermeiros. Resultados: os resultados da pesquisa evidenciaram que os enfermeiros do SAMU, tem conhecimento sobre a práxis das intercorrências dos motociclistas. Neste sentido, a associação entre os condutores com a não utilização de capacete e a imprudência no trânsito prevaleceram entre as principais morbidades; e dentre as principais lesões, as abrasões e as fraturas destacam-se como mais comuns. Conclusão: evidenciou-se que a atuação da enfermagem é imprescindível em todo processo de assistência à população-alvo do atendimento pré-hospitalar (APH), desde a prevenção de eventos à orientação e educação em saúde.

A service evaluation and stakeholder perspectives of an innovative digital minor illness referral service from NHS 111 to community pharmacy.

The management of minor conditions represents a significant burden for urgent and emergency care services and reduces the capacity to provide specialist care for higher acuity healthcare need. A pilot Digital Minor Illness Service (DMIRS) was commenced in the North East of England in December 2017 to feasibility test the NHS 111 referral to community pharmacy for patients presenting with minor conditions. A formative evaluation of the service activity data and qualitative investigation of stakeholders involved in the service design, management, delivery and use, aims to present and investigate the service outcomes. Routine service activity data was evaluated during Jan-Dec 2018 to investigate the demographics of patients included in the service; the presenting conditions; and how those referrals were managed by community pharmacies. Semi-structured interviews with NHS 111 call handlers, project team members, community pharmacists and patients were undertaken to investigate the design, management, implementation and delivery of the service. 13,246 NHS 111 patient calls were referred to community pharmacy during the evaluative period. The most common presenting conditions were acute pain (n = 1144, 8.6%) and cough (n = 887, 6.7%). A large volume of complaints (47.1%, 6233) were resolved in community pharmacy. Stakeholders explained the structured approach to service design, organisation and implementation facilitated successful delivery and management. Patients reported positive experiences with accessing care via DMIRS. DMIRS demonstrated that patients could be referred to community pharmacy for the management of minor conditions, shifting a burden away from urgent and emergency care. The service data provides key information for further optimisation of service design, and stakeholder training and awareness. The service was acceptable and valued by patients. Evidence from the DMIRS pilot has been utilised to inform recent national healthcare policy and practice around the management of minor conditions within the urgent and emergency care setting.

Framework for development of urgent care services towards strengthening primary healthcare in India - Joint position paper by the Academy of Family Physician of India and the Academic College of Emergency Experts.

Urgent care practice (UCP) is a novel concept for India. Urgent care primarily deals with injuries or illnesses requiring immediate care. Medical emergency and urgency can happen anywhere unannounced. Research has shown that 90% of the morbidities can be resolved within the community by primary care physicians lead teams. Given the changing professional demands, non-specialists tend to refer away far too many cases to specialists, undermining generalist medical care, particularly in Indian settings. The spillover of the patient load from the primary care setting to the tertiary care centers is enormous leading to resource mismatch. Family physicians and other primary care providers are best positioned to develop practices and provide good quality urgent care to society. Family physicians, general practitioners, and medical officers are already functioning as the frontline care providers for any emergency or medical urgency arising within communities. Urgent care is essentially ambulatory care or outpatient care outside of a traditional hospital emergency room. “UCP aims to provide timely support, which is easily accessible with a focus on good clinical outcomes, e.g. survival, recovery, lack of adverse events, and complications. Core interventions of urgent care are centered on the 4Rs - Rescue, Resuscitate, Relate, and Refer. At present, there are no available, established training model for future faculty, residents, and medical students on “UCP“ in India.

Violências e acidentes nos idosos assistidos no atendimento pré-hospitalar no Espírito Santo, Brasil

A transição demográfica tem representado um processo de modificação das relações sociais no Brasil. Associado a isso, as violências e os acidentes se mantêm em um movimento de ascensão epidemiológica por décadas e vêm impondo maior impacto sobre a população idosa. Propõe-se uma reflexão acerca da violência e acidentes contra os idosos. Realizou-se uma análise da base de dados do Sistema de Informação sobre Mortalidade do SUS e um estudo transversal das ocorrências de acidentes e violências realizadas pelo Serviço de Atendimento Móvel de Urgência do Espírito Santo (SAMU-ES) de 2015. Concluiu-se que os óbitos no Brasil em idosos por acidentes e violências aumentou nos últimos 10 anos e que 6% dos pacientes assistidos pelo SAMU-ES são idosos vitimados por essas ocorrências. As quedas são as principais causas de agravos e sugere-se que parte dos seus registros se referem à violência doméstica ocultada.

Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review

Background The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups. Objective Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions. Review methods We conducted an initial mapping review to assess the quantity and nature of the published research evidence relating to seven vulnerable groups (socioeconomically deprived people and families, migrants, ethnic minority groups, the long-term unemployed/inactive, people with unstable housing situations, people living in rural/isolated areas and people with substance abuse disorders). Databases, including MEDLINE and the Cumulative Index to Nursing and Allied Health Literature, and other sources were searched between 2008 and 2018. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. In addition, we searched for UK interventions and initiatives by examining press reports, commissioning plans and casebooks of ‘good practice’. We carried out a detailed intervention analysis, using an adapted version of the TIDieR (Template for Intervention Description and Replication) framework for describing interventions, and an analysis of current NHS practice initiatives. Results We identified nine different types of interventions: care navigators [three studies – moderate GRADE (Grading of Recommendations, Assessment, Development and Evaluations)], care planning (three studies – high), case finding (five studies – moderate), case management (four studies – high), front of accident and emergency general practice/front-door streaming model (one study – low), migrant support programme (one study – low), outreach services and teams (two studies – moderate), rapid access doctor/paramedic/urgent visiting services (one study – low) and urgent care clinics (one systematic review – moderate). Few interventions had been targeted at vulnerable populations; instead, they represented general population interventions or were targeted at frequent attenders (who may or may not be from vulnerable groups). Interventions supported by robust evidence (care navigators, care planning, case finding, case management, outreach services and teams, and urgent care clinics) demonstrated an effect on the general population, rather than specific population effects. Many programmes mixed intervention components (e.g. case finding, case management and care navigators), making it difficult to isolate the effect of any single component. Promising UK initiatives (front of accident and emergency general practice/front-door streaming model, migrant support programmes and rapid access doctor/paramedic/urgent visiting services) lacked rigorous evaluation. Evaluation should therefore focus on the clinical effectiveness and cost-effectiveness of these initiatives. Conclusions The review identified a limited number of intervention types that may be useful in addressing the needs of specific vulnerable populations, with little evidence specifically relating to these groups. The evidence highlights that vulnerable populations encompass different subgroups with potentially differing needs, and also that interventions seem particularly context sensitive. This indicates a need for a greater understanding of potential drivers for varying groups in specific localities. Limitations Resources did not allow exhaustive identification of all UK initiatives; the examples cited are indicative. Future work Research is required to examine how specific vulnerable populations differentially benefit from specific types of alternative service provision. Further exploration, using primary mixed-methods data and potentially realist evaluation, is required to explore what works for whom under what circumstances. Rigorous evaluation of UK initiatives is required, including a specific need for economic evaluations and for studies that incorporate effects on the wider emergency and urgent care system. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Strengths and weaknesses of the acute care systems in the United Kingdom and the Netherlands: what can we learn from each other?

BackgroundThe demand on Emergency Departments and acute medical services is increasing internationally, creating pressure on health systems and negatively influencing the quality of delivered care. Visible consequences of the increased demand on acute services is crowding and queuing. This manifests as delays in the Emergency Departments, adverse clinical outcomes and poor patient experience.OverviewDespite the similarities in the UK’s and Dutch health care systems, such as universal health coverage, there are differences in the number of patients presenting at the Emergency Departments and the burden of crowding between these countries. Given the similarities in funding, this paper explores the similarities and differences in the organisational structure of acute care in the UK and the Netherlands. In the Netherlands, less patients are seen at the ED than in England and the admission rate is higher. GPs and so-called GP-posts serve 24/7 as gatekeepers in acute care, but EDs are heterogeneously organised. In the UK, the acute care system has a number of different access points and the accessibility of GPs seems to be suboptimal. Acute ambulatory care may relieve the pressure from EDs and Acute Medical Units. In both countries the ageing population leads to a changing case mix at the ED with an increased amount of multimorbid patients with polypharmacy, requiring generalistic and multidisciplinary care.ConclusionThe acute and emergency care in the Netherlands and the UK face similar challenges. We believe that each system has strengths that the other can learn from. The Netherlands may benefit from an acute ambulatory care system and the UK by optimizing the accessibility of GPs 24/7 and improving signposting for urgent care services. In both countries the changing case mix at the ED needs doctors who are superspecialists instead of subspecialists. Finally, to improve the organisation of health care, doctors need to be visible medical leaders and participate in the organisation of care.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

BackgroundPolicy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.ObjectivesTo describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.DesignMixed-methods sequential design.SettingFour counties in southern England coterminous with a NHS 111 provider area.MethodsA literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.FindingsThe literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).LimitationsThe sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.ConclusionsMuch of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.Future workA whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.Study registrationThis study is registered as UKCRN 32207.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Extending the scope of community pharmacists’ practice to patients requiring urgent care – An evaluation of a training programme using the Theoretical Domains Framework

Redesigned health systems could meet the rising demand for healthcare, with community pharmacy currently an underused resource for the treatment and management of patients requiring urgent care. This study aimed to investigate whether a training intervention delivered over 2days to community pharmacists resulted in behaviour and practice change. Validated measures of psychological motivation and capability factors relevant to understanding behaviour and behaviour change were collected 1week before, 1week after and 2months after training in a non-controlled before and after study design. Two targeted behaviours of the intervention were the primary outcome measures: taking a structured history and applying clinical examination techniques to patients requiring urgent care. Secondary outcomes measured participants' reported patient management behaviours to investigate possible bridging of gaps in the health system. Training was provided in 14 locations in the UK to 258 community pharmacists, with data collection occurring from July 2015 to September 2016. In total, 81 participants completed all three rounds of data collection (31.4%). Findings suggest that 1-week post-training significant changes in psychological capability had taken place, and that these were sustained 2months later: of the eight domains influencing behaviour and stimulating behaviour change, knowledge, skills, professional role, beliefs about capabilities and goals all increased significantly between T1 and T2, and T1 and T3 (all p<0.0001). At T3, participants were more likely to have taken a structured history than performed a clinical examination, and reported both managing patients themselves and changing referral practices to other healthcare providers. Participants reported workload and the need for liability insurance as structural and contextual barriers to implementation. While findings suggest the potential to transform models of care through training to extend community pharmacists' practice these barriers to successful implementation of the urgent care service would need to be addressed if this service is rolled out nationally.

Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population.

The purpose of this study was to estimate the extent of potential antidepressant overprescribing in a geographically defined U.S. population, and to determine the indications and factors that account for it. We conducted a cohort study of new antidepressant prescriptions for elderly residents of Olmsted County, Minnesota, 2005‐2012, using the Rochester Epidemiology Project medical records‐linkage system. Indications for antidepressants were abstracted from health records for all cohort members. Potential antidepressant overprescribing was defined based on regulatory approval, the level of evidence identified from a standardized drug information database, and multidisciplinary expert review. Predictors of potential antidepressant overprescribing were investigated using logistic regression models, stratified by general antidepressant indication (general medical indication, specific psychiatric diagnosis, and non‐specific psychiatric symptoms). Potential antidepressant overprescribing occurred in 24% of 3199 incident antidepressant prescriptions during the study period, and involved primarily newer antidepressants that were prescribed for non‐specific psychiatric symptoms and subthreshold diagnoses. Potential antidepressant overprescribing was associated with nursing home residence, having a higher number of comorbid medical conditions and outpatient prescribers, taking more concomitant medications, having greater use of urgent or acute care services in the year preceding the index antidepressant prescription, and being prescribed antidepressants via telephone, e‐mail, or patient portal. In conclusion, potential antidepressant overprescribing occurred in elderly persons and involved mainly newer antidepressants used for non‐specific psychiatric symptoms and subthreshold diagnoses, and was associated with indicators of higher clinical complexity or severity and with prescribing without face‐to‐face patient contact.

Navigating and making sense of urgent and emergency care processes and provision.

BackgroundWhilst many health systems offer a range of urgent and emergency care services to deal with the need for unscheduled care, these can be problematic to navigate.ObjectiveTo explore how lay people make sense of urgent care provision and processes.DesignQualitative study, incorporating citizen panels and longitudinal semi‐structured qualitative interviews.Setting and ParticipantsTwo citizens’ panels, comprising purposively selected public populations—a group of regular users and a group of potentially marginalized users of urgent and emergency care. Semi‐structured interviews were conducted with 100 people, purposively sampled to include those over 75, aged 18‐26 years, and from East/Central Europe. A sub‐sample of 41 people received a second interview at +6‐12 months. Framework analysis was thematic and comparative, moving through coding to narrative and interpretive summaries.Findings and DiscussionParticipants narratives illuminated considerable uncertainty and confusion regarding urgent and emergency care provision which in part could be traced to the contingent nature of urgent and emergency care need. Accounts of emergency care provision were underpinned by strong moral positioning of appropriate help‐seeking, demarcating legitimate service use that echoed policy rhetoric, but did not necessarily translate into individual behaviour. People struggled to make sense of urgent care provision making navigating “appropriate” use problematic.ConclusionsThe focus on help‐seeking behaviour, rather than sense‐making, makes it difficult to move beyond the polarization of “appropriate” and “inappropriate” service use. A deeper analysis of sense‐making might shift the focus of attention and allow us to intervene to reshape understandings before this point.

1269. HIV Testing in a Large Community Health Center Serving a Multi-cultural Population: A Qualitative Study of Providers

BackgroundIn the United States, 15% of people with HIV (PWH) do not know their serostatus, leading to both individual morbidity and HIV transmission to others. While CDC guidelines recommend HIV screening for all individuals aged 13–64 years, racial and ethnic minorities in the United States continue to present to care with advanced HIV infection.MethodsOur objective was to assess providers’ perspectives on barriers to and facilitators of HIV testing at an urban community health center serving a predominantly racial/ethnic minority population of low socio-economic status. Study staff conducted five focus groups from January 2017 to November 2017 with 74 health center staff: 20 adult medicine/primary care providers, 28 community health workers (CHWs), six urgent care physicians, six community health administrators, and 14 behavioral health providers. Each focus group ranged from six to 20 participants. In addition to exploring participants’ views on HIV testing in this setting, we also explored potential interventions to improve HIV testing. Interviews were digitally recorded. Data were analyzed using a grounded theory approach. We used open coding to develop themes and compared themes among provider groups.ResultsThe main facilitators of routine HIV testing were clinical training in HIV/hepatitis care and CHWs engaging patients in topics that intersect with HIV risk factors. Providers’ perceptions of key barriers were patients’ cultural perceptions of HIV (e.g. HIV-related stigma), patients’ concerns about test confidentiality, competing medical and social issues, and provider lack of HIV knowledge. All groups agreed that HIV testing should occur through the primary care provider though acknowledged that patients may be seeking healthcare more frequently through mental health, urgent care, or social services than primary care. Primary care physicians wanted easier mechanisms to identify patients in need of HIV testing and assistance with offering the test to non-English language speaking patients.ConclusionSpecific, focused efforts can lead to improved HIV testing in racial ethnic minorities in community health centers. Training to improve provider comfort, increasing CHW engagement, and a focus on patients’ cultural beliefs may all have an impact.Disclosures All authors: No reported disclosures.

Assessing the effectiveness of advanced nurse practitioners undertaking home visits in an out of hours urgent primary care service in England.

To measure the effectiveness of advanced nurse practitioners (ANPs) against national quality requirements for out-of-hours (OOH) care, to compare ANP effectiveness with that of doctors working in the same service, and to evaluate the impact of ANPs on the service. There is little documented evidence of ANPs undertaking urgent home visits in the OOH setting. This study advances current knowledge of this aspect of the OOH service and makes recommendations for the management of the ANP urgent home visiting service. Analysis of 1,539 ANP home-visit patient electronic case notes over a 12-month period, a focus group of eight GPs, and interviews with six ANPs. Advanced nurse practitioners are as effective as GPs in undertaking urgent home visits. Their documentation is more consistent and their refer-on rate to secondary care is less than that of GP colleagues. Advanced nurse practitioners can provide equivalent clinical outcomes to GPs when undertaking urgent home visits. This study adds to the body of evidence for the positive impact of ANPs on OOH service delivery and managers can be assured that they are practising at a level that makes them effective and safe to undertake this role.

How do organisational configuration and context influence the quantity and quality of NHS services provided by English community pharmacies? A qualitative investigation

Community pharmacies are expanding their role into medicines-related healthcare and public health services, previously the domain of physicians and nurses, driven by policies to improve healthcare access for patients and to address problems of increasing demands and rising costs in primary and urgent care services. Understanding the organisational context into which this expansion is taking place is necessary given concerns over the extent to which pharmacies prioritise service volume over the quality of service provision. As part of a larger programme of work, this paper aims to explore stakeholder perceptions of the organisational and extra-organisational factors associated with service quality and quantity in community pharmacy as an established exemplar of private sector organisations providing publicly-funded healthcare. With ethics committee approval, forty semi-structured interviews were conducted with service commissioners, superintendent and front-line pharmacists, purposively selected from across nine geographical areas and a range of community pharmacy organisational types in England. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Findings highlight the perceived importance of appropriate staffing and skill-mix for promoting service quantity and quality in community pharmacy. Organisational cultures which supported team development were viewed as facilitatory whereas those prioritising business targets over service quality seen to be inhibitive. Older local populations and low patient expectations were thought to limit service uptake as was poor integration with wider primary care services. The contractual framework and commissioning processes were also seen as a barrier to increasing service quality, quantity and integration in this sector. These findings suggest that healthcare administrations should take account of organisational and extra-organisational drivers and barriers when commissioning services from private sector providers such as community pharmacies to ensure that the quality of service provision is incentivised in addition to service quantity. Additionally, collaborative working should be encouraged through integrated commissioning mechanisms.

Refining and testing the diagnostic accuracy of an assessment tool (PAT-POPS) to predict admission and discharge of children and young people who attend an emergency department: protocol for an observational study

BackgroundIncreasing attendances by children (aged 0–16 years) to United Kingdom Emergency Departments (EDs) challenges patient safety within the National Health Service (NHS) with health professionals required to make complex judgements on whether children attending urgent and emergency care services can be sent home safely or require admission. Health regulation bodies have recommended that an early identification systems should be developed to recognise children developing critical illnesses. The Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score (PAT-POPS) was developed as an ED-specific tool for this purpose. This study aims to revise and improve the existing tool and determine its utility in determining safe admission and discharge decision making.Methods/designAn observational study to improve diagnostic accuracy using data from children and young people attending the ED and Urgent Care Centre (UCC) at three hospitals over a 12 month period. The data being collected is part of routine practice; therefore opt-out methods of consent will be used. The reference standard is admission or discharge. A revised PAT-POPs scoring tool will be developed using clinically guided logistic regression models to explore which components best predict hospital admission and safe discharge. Suitable cut-points for safe admission and discharge will be established using sensitivity and specificity as judged by an expert consensus meeting. The diagnostic accuracy of the revised tool will be assessed, and it will be compared to the former version of PAT-POPS using ROC analysis.DiscussionThis new predictive tool will aid discharge and admission decision-making in relation to children and young people in hospital urgent and emergency care facilities.Trial registrationNIHR RfPB Grant: PB-PG-0815-20034.ClinicalTrials.gov: 213469. Retrospectively registered on 11 April 2018.

Do healthcare services behave as complex systems? Analysis of patterns of attendance and implications for service delivery

BackgroundThe science of complex systems has been proposed as a way of understanding health services and the demand for them, but there is little quantitative evidence to support this. We analysed patterns of healthcare use in different urgent care settings to see if they showed two characteristic statistical features of complex systems: heavy-tailed distributions (including the inverse power law) and generative burst patterns.MethodsWe conducted three linked studies. In study 1 we analysed the distribution of number of contacts per patient with an urgent care service in two settings: emergency department (ED) and primary care out-of-hours (PCOOH) services. We hypothesised that these distributions should be heavy-tailed (inverse power law or log-normal) in keeping with typical complex systems. In study 2 we analysed the distribution of bursts of contact with urgent care services by individuals: correlated bursts of activity occur in complex systems and represent a mechanism by which overall heavy-tailed distributions arise. In study 3 we replicated the approach of study 1 using data systematically identified from published sources.ResultsStudy 1 involved data from a PCOOH service in Scotland (725,000) adults, 1.1 million contacts) and an ED in New Zealand (60,000 adults, 98,000 contacts). The total number of contacts per individual in each dataset was statistically indistinguishable from an inverse power law (p > 0.05) above 4 contacts for the PCOOH data and 3 contacts for the ED data. Study 2 found the distribution of contact bursts closely followed a heavy-tailed distribution (p < 0.008), indicating the presence of correlated bursts. Study 3 identified data from 17 studies across 8 countries and found distributions similar to study 1 in all of them.ConclusionsUrgent healthcare use displays characteristic statistical features of large complex systems. These studies provide strong quantitative evidence that healthcare services behave as complex systems and have important implications for urgent care. Interventions to manage demand must address drivers for consultation across the whole system: focusing on only the highest users (in the tail of the distribution) will have limited impact on efficiency. Bursts of attendance — and ways to shorten them — represent promising targets for managing demand.

The Response of an Oral Surgery Department during the COVID-19 Pandemic

As we begin to see the light at the end of the tunnel and some routine activity beginning, we are slowly adapting to our new ‘normal’. The question is when will true normality resume, and what the effect this momentary pause will have for the future of our profession.At the Royal National ENT and Eastman Dental Hospitals, a new service was established during the COVID-19 pandemic, to provide urgent dental care to the communities of North, East and Central London. We use this article to share our experiences and approach of tackling the COVID-19 pandemic in a busy elective Oral Surgery department, where there was not an existing urgent dental care service. This article demonstrates the steps, processes and considerations taken in setting up an urgent dental hub in a short period of time to tackle the consequence of the global pandemic on dental care. We highlight the management strategy implemented including the barriers and challenges faced by an urgent dental care centre at a time when primary dental care was unavailable, highlighting the lessons learnt that can be used and further developed in the case of a further peak or pandemic in the future.

Effects of a 1-Time Nurse-Led Telephone Call After Pediatric Discharge

Families often struggle after discharge of a child from the hospital. Postdischarge challenges can lead to increased use of urgent health care services. To determine whether a single nurse-led telephone call after pediatric discharge decreased the 30-day reutilization rate for urgent care services and enhanced overall transition success. This Hospital-to-Home Outcomes (H2O) randomized clinical trial included 966 children and adolescents younger than 18 years (hereinafter referred to as children) admitted to general medicine services at a free-standing tertiary care children's hospital from May 11 through October 31, 2016. Data were analyzed as intention to treat and per protocol. A postdischarge telephone call within 4 days of discharge compared with standard discharge. The primary outcome was the 30-day reutilization rate for urgent health care services (ie, unplanned readmission, emergency department visit, or urgent care visit). Secondary outcomes included additional utilization measures, as well as parent coping, return to normalcy, and understanding of clinical warning signs measured at 14 days. A total of 966 children were enrolled and randomized (52.3% boys; median age [interquartile range], 2.4 years [0.5-7.8 years]). Of 483 children randomized to the intervention, the nurse telephone call was completed for 442 (91.5%). Children in the intervention and control arms had similar reutilization rates for 30-day urgent health care services (intervention group, 77 [15.9%]; control group, 63 [13.1%]; P = .21). Parents of children in the intervention group recalled more clinical warning signs at 14 days (mean, 1.8 [95% CI, 1.7-2.0] in the intervention group; 1.5 [95% CI, 1.4-1.6] in the control group; ratio of intervention to control, 1.2 [95% CI, 1.1-1.3]). Although postdischarge nurse contact did not decrease the reutilization rate of postdischarge urgent health care services, this method shows promise to bolster postdischarge education. ClinicalTrials.gov Identifier: NCT02081846.

The changing role of management in the first 70 years of the NHS

British Journal of Healthcare ManagementVol. 24, No. 7 NHS at 70The changing role of management in the first 70 years of the NHSAdam LaylandAdam LaylandSearch for more papers by this authorAdam LaylandPublished Online:2 Jul 2018https://doi.org/10.12968/bjhc.2018.24.7.346AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Abualrub RF, Gharaibeh HF, Bashayreh AEI. The relationships between safety climate, teamwork, and intent to stay at work among Jordanian hospital nurses'. Nursing Forum. 2012;47(1):65–75. https://doi.org/https://doi.org/10.1111/j.1744-6198.2011.00253.x Crossref, Google ScholarBerwick D (2013) A promise to learn – a commitment to act. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf (accessed 13 June 2018) Google ScholarDarzi A (2008) High Quality Care for All NHS Next Stage Review Final Report. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf (accesed 13 June 2018) Google ScholarFrancis R (2013)Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf (accessed 13 June 2018) Google ScholarGreengross P, Grant K, Collins E. The history and development of the UK National Health Service 1948-1999. Health Systems Resource Centre: London; 1999 Google ScholarGriffiths R (1983) NHS Management Inquiry. http://www.nhshistory.net/griffiths.html (accessed 13 June 2018) Google ScholarKeogh B (2014) Transforming urgent and emergency care services in England. https://www.england.nhs.uk/wp-content/uploads/2015/06/trans-uec.pdf (accessed 13 June 2018) Google ScholarMinistry of Health (1954) Report of the committee on the internal administration of hospitals. https://navigator.health.org.uk/content/bradbeer-committee-report-internal-administration-hospitals-central-health-services-council (accessed 13 June 2018) Google ScholarMinistry of Health (1967) First Report of the Joint Working Party on the Organisation of Medical Work in Hospitals. Google ScholarRhodes D (2018) ‘Hospitals recruit managers faster than doctors or nurses’. BBC. http://www.bbc.co.uk/news/uk-england-43794816 (accessed 15 May 2018) Google ScholarRose L (2015) Better leadership for tomorrow: NHS Leadership Review. https://www.gov.uk/government/publications/better-leadership-for-tomorrow-nhs-leadership-review (accessed 13 June 2018) Google ScholarSofarelli D, Brown D. The need for nursing leadership in uncertain times. Journal of Nursing Management. 1998;6:201–7 Crossref, Google ScholarFurther readingJones D. A brief history of the National Health Service. BJHCM. 2015;21(2):77–79. https://doi.org/https://doi.org/10.12968/bjhc.2015.21.2.77 Google Scholar FiguresReferencesRelatedDetailsCited byChange management in the NHS: distributed leadershipBryan McIntosh, Adam Layland17 July 2019 | British Journal of Healthcare Management, Vol. 25, No. 7Paramedic leaders: past, present and futureAdam Layland5 October 2018 | Journal of Paramedic Practice, Vol. 10, No. 10 2 July 2018Volume 24Issue 7ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 2 July 2018 Published in print 2 July 2018 Information© MA Healthcare LimitedPDF download

Developmental Disorders and Medical Complications Among Infants with Subclinical Intrauterine Opioid Exposures.

The objective was to compare diagnosis rates representing developmental outcomes and medical complications between infants with intrauterine opioid exposures who did not receive pharmacologic treatment for neonatal abstinence syndrome at the time of birth and infants for whom no exposure to substances of abuse were detected. This retrospective, descriptive study included approximately 95% of Hamilton County, Ohio resident births in 2014 and 2015. Universal maternal drug test results, performed at the time of birth, were documented and linked to electronic health records representing pediatric primary and subspecialty follow-up care as well as urgent care, emergency care, and inpatient services provided by Cincinnati Children's Hospital Medical Center through 2017, when all children were at least 24 months old. Diagnosis rates were compared between drug exposure groups using chi-square tests. Among infants born at >34 weeks gestation and without other complex clinical conditions, infants with subclinical opioid exposures (N = 473) were more likely than infants with no drug exposures (N = 14,933) to be diagnosed with behavioral or emotional disorders (3.0% vs 1.1%, P = 0.0008), developmental delay (15.6% vs 7.6%, P < 0.0001), speech disorder (10.1% vs 6.5%, P = 0.001), or strabismus (3.4% vs 1.0%, P < 0.0001), and more likely to be exposed to the hepatitis C virus (6.8% vs 0.1%, P < 0.0001). Increased diagnosis rates among all opioid exposed infants, regardless of withdrawal severity, may warrant the additional allocation of resources for screening and follow-up. Awareness of the increased risk for certain developmental delays and medical conditions is critical to early intervention and treatment supporting improved outcomes.

The “Bundle Busters”: Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty

BackgroundRecently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle busters. We aimed at determining the incidence, etiology, and costs of postacute complications after total joint arthroplasty (TJA). MethodsA retrospective study was conducted using a prospectively collected database of patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2015 to April 2016. Nurse navigators performed postoperative surveillance to identify patients with complications and unplanned clinical events in the 90-day postoperative period. This was combined with episode-of-care costs provided by third-party payers to derive the mean and per capita costs of postacute complications and clinical events. ResultsAmong 3018 THA and 5389 TKA patients, 3.35% of THA and 2.62% of TKA patients sought emergency department or urgent care services, 2.62% of THA and 3.69% of TKA patients required hospital readmission, and 3.99% of TKA patients required manipulation. Joint-related complications were more common following THA, whereas medical complications were more frequent after TKA. The most costly complications after THA were periprosthetic fracture, dislocation, and myocardial infarction, compared to deep infection, myocardial infarction, and pulmonary embolism after TKA. ConclusionJoint-related complications were among the most costly events after TJA, and given their higher incidence after THA, had a larger impact on per capita costs. Medical complications were more common after TKA and more costly. Despite these events, postacute complications made up less than 5% of the total 90-day costs of TJA.