Our aim was to explore the approaches to and the challenges and benefits of implementing Electronic Patient Record systems (EPRs) into NHS acute, mental health and community care hospitals throughout England. A mixed methods approach was adopted that comprised an online survey (n = 59) and semi-structured telephone interviews (n = 8) with chief information officers (or heads of EPR projects) at NHS trusts throughout England. Survey analysis was descriptive, whilst the qualitative interviews were analysed thematically. A range of devices and approaches to implementing EPRs were described with 32 % of survey respondents utilising a best of breed approach. Interviewees' perceived and expected benefits of implementing an EPR included efficiency, availability and accessibility of clinical information, and patient safety. Key challenges to EPR implementation were securing clinician involvement, difficulties posed by government and national policy and limited availability of financial and human resources. There was no single approach regarding the approaches taken to implementing EPRs among participating English NHS trusts, with various benefits and challenges cited. Policymakers and researchers need to provide clearer guidance for trusts at various stages of implementation ensuring intelligence is shared across England's NHS trusts.
Background Falls are a major cause of morbidity among older people. A multifaceted podiatry intervention may reduce the risk of falling. This study evaluated such an intervention. Design Pragmatic cohort randomised controlled trial in England and Ireland. 1010 participants were randomised (493 to the Intervention group and 517 to Usual Care) to either: a podiatry intervention, including foot and ankle exercises, foot orthoses and, if required, new footwear, and a falls prevention leaflet or usual podiatry treatment plus a falls prevention leaflet. The primary outcome was the incidence rate of self-reported falls per participant in the 12 months following randomisation. Secondary outcomes included: proportion of fallers and those reporting multiple falls, time to first fall, fear of falling, Frenchay Activities Index, Geriatric Depression Scale, foot pain, health related quality of life, and cost-effectiveness. Results In the primary analysis were 484 (98.2%) intervention and 507 (98.1%) control participants. There was a small, non statistically significant reduction in the incidence rate of falls in the intervention group (adjusted incidence rate ratio 0.88, 95% CI 0.73 to 1.05, p = 0.16). The proportion of participants experiencing a fall was lower (49.7 vs 54.9%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00, p = 0.05) as was the proportion experiencing two or more falls (27.6% vs 34.6%, adjusted odds ratio 0.69, 95% CI 0.52 to 0.90, p = 0.01). There was an increase (p = 0.02) in foot pain for the intervention group. There were no statistically significant differences in other outcomes. The intervention was more costly but marginally more beneficial in terms of health-related quality of life (mean quality adjusted life year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314) and had a 65% probability of being cost-effective at a threshold of £30,000 per QALY gained. Conclusion There was a small reduction in falls. The intervention may be cost-effective. Trial Registration ISRCTN ISRCTN68240461
BackgroundAssessing diabetic foot ulcers (DFUs) for infection is difficult because clinical symptoms and signs may be masked by neuropathy and vasculopathy and there are no objective tests available at point of care to guide clinicians.Empirical prescription of antibiotics compromises antibiotic stewardship, while missing early infection may lead to severe infection and amputation.In 2011-12, the cost of managing DFUs and associated amputations borne by NHS England was £650 million, nearly 1% of its budget.Our INDUCE study had two aims: (1) to develop an online educational tool for DFU infection and (2) to conduct a pilot study investigating C-reactive protein (CRP) and procalcitonin from venous blood and calprotectin from wound exudate as inflammatory biomarkers of mild DFU infection.Methods Yola software was used to develop an online educational tool covering DFU history and examination, arterial assessment, microbiology, radiology and management of osteomyelitis.The tool contains links to NICE guidance and other relevant learning resources.A quiz using patient scenarios is included.Feedback from podiatrists was elicited by questionnaires and a focus group.Patients with non-infected or mildly infected DFUs were recruited from community podiatry clinics in 2 UK regions.Exclusion criteria included immunosuppression or receipt of antibiotics within the previous 2 weeks.Antibiotics were prescribed based on clinical judgement at the baseline assessment.Our gold standard defining DFU infection was the clinician's judgement one week later, while still blinded to test results, factoring in the response to antibiotic therapy, if prescribed.All 3 inflammatory biomarkers were measured at weeks 0 and 1, including assessment of CRP using a point-of-care device. ResultsFeedback regarding the educational tool from end-users ranging from trainee to senior podiatrists was very positive.The main improvement requested was a printable certificate after successful completion of the quiz and provision of CPD points.Between September 2014 and September 2015, the INDUCE study recruited 67 patients with DFUs, from a total of 363 potential participants.Primary endpoints were available for 37 participants with non-infected ulcers and 28 with mild infection, following early study withdrawal by one patient in each group.Median CRP was slightly higher in the infected ulcer group, 7.50 mg/ml compared to 6.00 mg/ml for noninfected ulcers, but the area under the receiver operating characteristic curve (AUROC) was only 0.52, demonstrating poor predictive efficacy.Most of the procalcitonin results were below the lower limit of the assay and levels were lower in the infected DFU group.Median calprotectin levels were nearly doubled in infected ulcers, 1437 ng/ml compared with 879 ng/ml in non-infected DFUs, but with an insufficient AUROC of 0.56.Conclusions Feedback from a range of podiatrists confirmed that assessment of DFU infection remains challenging and showed that the INDUCE tool is a useful learning resource.The tool will be made freely available via the internet.Based on their sensitivity and specificity, neither venous CRP or procalcitonin should be pursued as biomarkers of DFU infection, alone or in combination.Calprotectin in wound exudate may have value, but only in combination with other biomarkers.
Our aim was to explore NHS staff perceptions and experiences of the impact on patient safety of introducing a maternity system. Qualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives, health care assistants), staff grades (consultant and midwife grades) and wards within a maternity unit. Participants represented a single maternity unit at a NHS teaching hospital in the North of England. Interviews were conducted during the first 12 months of the system being implemented and were analysed thematically. Participants perceived there to be an elevated risk to patient safety during the system’s implementation. The perceived risks were attributed to a range of social and technical factors. For example, poor system design and human error which resulted in an increased potential for missing information and inputting error. The first 12 months of introducing the maternity system was perceived to and in some cases had already caused actual risk to patient safety. Trusts throughout the NHS are facing increasing pressure to become paperless and should be aware of the potential adverse impacts on patient safety that can occur when introducing electronic systems. Given the potential for increased risk identified, recommendations for further research and for NHS trusts introducing electronic systems are proposed.
This study compared genetic nurse counsellors with standard services for breast cancer genetic risk counselling services in two regional genetics centres, in Grampian region, North East Scotland and in Cardiff, Wales. Women referred for genetic counselling were randomised to an initial genetic counselling appointment with either a genetic nurse counsellor (intervention) or a clinical geneticist (current service, control). Participants completed postal questionnaires before, immediately after the counselling episode and 6 months later to assess anxiety, general health status, perceived risk and satisfaction. A parallel economic evaluation explored factors influencing cost-effectiveness. The two concurrent randomised controlled equivalence trials were conducted and analysed separately. In the Grampian trial, 289 patients (193 intervention, 96 control) and in the Wales trial 297 patients (197 intervention and 100 control) returned a baseline questionnaire and attended their appointment. Analysis suggested at least likely equivalence in anxiety (the primary outcome) between the two arms of the trials. The cost per counselling episode was 11.54 UK pounds less for nurse-based care in the Grampian trial and 12.50 UK pounds more for nurse-based care in Cardiff. The costs were sensitive to the grade of doctor (notionally) replaced and the extent of consultant supervision required by the nurse. In conclusion, care based on genetic nurse counsellors was not significantly different from conventional cancer genetic services in both trial locations.
The HTA Programme was set up in 1993.Its role is to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS.'Health technologies' are broadly defined to include all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care, rather than settings of care.The HTA programme commissions research only on topics where it has identified key gaps in the evidence needed by the NHS.Suggestions for topics are actively sought
Background: Electronic Patient Records (EPRs) are being introduced into many healthcare organisations around the world. In the UK, EPRs are seen as one mechanism through which the NHS can become safer and more efficient. The policy and financial support for NHS hospitals to implement these systems, implies a strong evidence base supporting the rationale that electronic records improve health outcomes and quality of care. In reality, there is limited evidence to support this, with a lack of understanding as to the best approaches to and the benefits, barriers and impact of implementing EPRs; particularly within the NHS. In this thesis, the implementation of EPRs into NHS secondary care organisations is explored.
Methods: A range of methods were used to explore the implementation of EPRs into NHS secondary care organisations. A policy analysis studied national NHS IT policy documents and evaluations of national NHS IT policy between 1998 and 2015 to investigate whether progress has been made in relation to implementing EPRs into NHS secondary care organisations. A mixed methods approach was adopted to explore the approaches to and challenges and benefits of implementing EPRs in NHS trusts throughout England; this comprised an online survey and semi-structured interviews with chief information officers. Lastly, qualitative interviews explored NHS staffs’ perceptions and experiences of the benefits, barriers and disadvantages of implementing a maternity information system into a single maternity unit.
Results: There has been little progress in implementing EPRs in secondary care since 1998, the reasons for which are multifaceted and include a paucity of guidance surrounding the optimum approaches to implementing EPRs with a range of additional social and technical factors. Proposed benefits of EPRs largely related to improved: information availability, accessibility, transfer and legibility; with a limited number of efficiency and patient safety benefits also reported.
Conclusions: This thesis adds to a limited UK evidence base and provides a greater understanding of the approaches to and various social and technical factors associated with implementing EPRs into NHS secondary care organisations.
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