Ian Litchfield

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives

Background The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance. Methods We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system. Results A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication. Conclusions A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions.

Test result communication in primary care: clinical and office staff perspectives

Objective. To understand how the results of laboratory tests are communicated to patients in primary care and perceptions on how the process may be improved. Design. Qualitative study employing staff focus groups. Setting. Four UK primary care practices. Participants. Staff involved in the communication of test results. Findings. Five main themes emerged from the data: (i) the default method for communicating results differed between practices; (ii) clinical impact of results and patient characteristics such as anxiety level or health literacy influenced methods by which patients received their test result; (iii) which staff member had responsibility for the task was frequently unclear; (iv) barriers to communicating results existed, including there being no system or failsafe in place to determine whether results were returned to a practice or patient; (v) staff envisaged problems with a variety of test result communication methods discussed, including use of modern technologies, such as SMS messaging or online access. Conclusions. Communication of test results is a complex yet core primary care activity necessitating flexibility by both patients and staff. Dealing with the results from increasing numbers of tests is resource intensive and pressure on practice staff can be eased by greater utilization of electronic communication. Current systems appear vulnerable with no routine method of tracing delayed or missing results. Instead, practices only become aware of missing results following queries from patients. The creation of a test communication protocol for dissemination among patients and staff would help ensure both groups are aware of their roles and responsibilities.

Test result communication in primary care: a survey of current practice

Background The number of blood tests ordered in primary care continues to increase and the timely and appropriate communication of results remains essential. However, the testing and result communication process includes a number of participants in a variety of settings and is both complicated to manage and vulnerable to human error. In the UK, guidelines for the process are absent and research in this area is surprisingly scarce; so before we can begin to address potential areas of weakness there is a need to more precisely understand the strengths and weaknesses of current systems used by general practices and testing facilities. Methods We conducted a telephone survey of practices across England to determine the methods of managing the testing and result communication process. In order to gain insight into the perspectives from staff at a large hospital laboratory we conducted paired interviews with senior managers, which we used to inform a service blueprint demonstrating the interaction between practices and laboratories and identifying potential sources of delay and failure. Results Staff at 80% of practices reported that the default method for communicating normal results required patients to telephone the practice and 40% of practices required that patients also call for abnormal results. Over 80% had no fail-safe system for ensuring that results had been returned to the practice from laboratories; practices would otherwise only be aware that results were missing or delayed when patients requested results. Persistent sources of missing results were identified by laboratory staff and included sample handling, misidentification of samples and the inefficient system for collating and resending misdirected results. Conclusions The success of the current system relies on patients both to retrieve results and in so doing alert staff to missing and delayed results. Practices appear slow to adopt available technological solutions despite their potential for reducing the impact of recurring errors in the handling of samples and the reporting of results. Our findings will inform our continuing work with patients and staff to develop, implement and evaluate improvements to existing systems of managing the testing and result communication process.

Clinical and economic assessment of different general population strategies of pertussis vaccine booster regarding number of doses and age of application for reducing whooping cough disease burden: a systematic review.

Pertussis continues to be an important cause of morbidity and mortality in children too young to be fully protected despite high vaccination coverage. This has been attributed to waning immunity in older people, leading to the development of strategies to increase levels of immunity. A systematic review was conducted to assess the clinical and cost effectiveness of four population-based strategies for pertussis booster vaccination: single booster at 12-24 months old, single pre-school booster, single adolescent booster and multiple boosters in adulthood every 10 years. Electronic databases and Internet resources were searched to June 2006. Nine observational studies, four mathematical models and eight economic evaluations were included, evaluating four different strategies. Strong evidence to recommend any of these strategies was not found.

A Preliminary Assessment of the Role of Ambient Nitric Oxide Exposure in Hospitalization with Respiratory Syncytial Virus Bronchiolitis

Some in vitro studies have indicated a possible link between respiratory syncytial virus (RSV) infection and exposure to Nitric Oxide (NO). However, these studies used much higher NO concentrations than normally found in the ambient environment. This preliminary study explored whether an association was present with short-term exposure to NO in the environment. RSV-related admission data between November 2011 and February 2012 were obtained from Sheffield Children’s Hospital. The dates of admission were linked to contemporaneous ambient NO derived from sentinel air monitors. The case-crossover design was used to study the relationship between daily RSV admissions and NO, controlling for temperature and relative humidity. We found little evidence of association between daily RSV admission rates and exposure to ambient NO at different lags or average exposure across several lags. The findings should, however, be viewed with caution due to the low number of events observed during the time frame. It is possible that the apparent lack of association may be accounted for by the timing of the seasonal RSV epidemic in relation to peaks in NO concentrations. A larger study incorporating a wider range of RSV and NO peaks would determine whether said peaks enhanced the number of RSV hospitalizations in children.

The future role of receptionists in primary care

The postmillennial family practice has moved far beyond its cottage industry origins. The broader range of services and treatments on offer in modern primary care are maintained by sophisticated medical technologies and an equally diverse and specialised set of care providers. In addition, the service is relied on to promote health and deal with a wider scope of social and psychological issues in the face of disappearing social care and increasing fragmentation of families.1 The growing complexity of the primary care environment and the increasing expectations of patients and policymakers are placing huge demands on the primary care workforce. Recent reports on the challenges and opportunities facing primary care in the UK acknowledge that, to meet these demands, we must realise the potential of all members of the primary care team, including both clinical and non-clinical staff.2,3 Arguably the most visible among the primary care workforce are receptionists, required to work under unprecedented levels of pressure and scrutiny, yet without any concurrent change in their training or support. Their position at the point of entry to the healthcare system means they are the most accessible member of the care team4 and have a significant influence on patients’ perception of their care. They frequently embody the frustrations of patients: a recent survey of complaints in primary care found those concerning receptionists were responsible for nearly half of upheld complaints, the largest figure of any staff group.5 This dissatisfaction with reception staff can have serious implications for non-attendance, increased A&E visits, and health outcomes.6 Apparently overlooked by policymakers and undervalued by GPs and patients, receptionists are viewed chiefly as either administrators, undertaking clerical duties …

Protocol for using mixed methods and process improvement methodologies to explore primary care receptionist work

Introduction The need to cope with an increasingly ageing and multimorbid population has seen a shift towards preventive health and effective management of chronic disease. This places general practice at the forefront of health service provision with an increased demand that impacts on all members of the practice team. As these pressures grow, systems become more complex and tasks delegated across a broader range of staff groups. These include receptionists who play an essential role in the successful functioning of the surgery and are a major influence on patient satisfaction. However, they do so without formal recognition of the clinical implications of their work or with any requirements for training and qualifications. Methods and analysis Our work consists of three phases. The first will survey receptionists using the validated Work Design Questionnaire to help us understand more precisely the parameters of their role; the second involves the use of iterative focus groups to help define the systems and processes within which they work. The third and final phase will produce recommendations to increase the efficiency and safety of the key practice processes involving receptionists and identify the areas and where receptionists require targeted support. In doing so, we aim to increase job satisfaction of receptionists, improve practice efficiency and produce better outcomes for patients. Ethics and dissemination Our work will be disseminated using conferences, workshops, trade journals, electronic media and through a series of publications in the peer reviewed literature. At the very least, our work will serve to prompt discussion on the clinical role of receptionists and assess the advantages of using value streams in conjunction with related tools for process improvement.

Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study.

BACKGROUND Eleven million people suffer a fire-related injury worldwide every year, and 71% have significant scarring. Pressure garment therapy (PGT) is a standard part of burn scar management, but there is little evidence of its clinical effectiveness or cost-effectiveness. OBJECTIVE To identify the barriers to, and the facilitators of, conducting a randomised controlled trial (RCT) of burn scar management with and without PGT and test whether or not such a trial is feasible. DESIGN Web-based surveys, semistructured individual interviews, a pilot RCT including a health economic evaluation and embedded process evaluation. SETTING UK NHS burns services. Interviews and the pilot trial were run in seven burns services. PARTICIPANTS Thirty NHS burns services and 245 staff provided survey responses and 15 staff participated in individual interviews. Face-to-face interviews were held with 24 adult patients and 16 parents of paediatric patients who had undergone PGT. The pilot trial recruited 88 participants (57 adults and 31 children) who were at risk of hypertrophic scarring and were considered suitable for scar management therapy. Interviews were held with 34 participants soon after recruitment, with 23 participants at 12 months and with eight staff from six sites at the end of the trial. INTERVENTIONS The intervention was standard care with pressure garments. The control was standard care comprising scar management techniques involving demonstration and recommendations to undertake massage three or four times per day with moisturiser, silicone treatment, stretching and other exercises. MAIN OUTCOME MEASURES Feasibility was assessed by eligibility rates, consent rates, retention in allocated arms, adherence with treatment and follow-up and completion of outcome assessments. The outcomes from interview-based studies were core outcome domains and barriers to, and facilitators of, trial participation and delivery. RESULTS NHS burns services treat 2845 patients per annum (1476 paediatric and 1369 adult) and use pressure garments for 6-18 months, costing £2,171,184. The majority of staff perceived a need for a RCT of PGT, but often lacked equipoise around the research question and PGT as a treatment. Strong views about the use of PGT have the potential to influence the conduct of a full-scale RCT. A range of outcome domains was identified as important via the qualitative research: perceptions of appearance, specific scar characteristics, function, pain and itch, broader psychosocial outcomes and treatment burden. The outcome tools evaluated in the pilot trial did not cover all of these domains. The planned 88 participants were recruited: the eligibility rate was 88% [95% confidence interval (CI) 83% to 92%], the consent rate was 47% (95% CI 40% to 55%). Five (6%) participants withdrew, 14 (16%) were lost to follow-up and 8 (9%) crossed over. Adherence was as in clinical practice. Completion of outcomes was high for adult patients but poorer from parents of paediatric patients, particularly for quality of life. Sections on range of movement and willingness to pay were found to be challenging and poorly completed. LIMITATIONS The Brisbane Burn Scar Impact Profile appears more suitable in terms of conceptual coverage than the outcome scales that were used in the trial but was not available at the time of the study. CONCLUSIONS A definitive RCT of PGT in burn scar management appears feasible. However, staff attitudes to the use of pressure garments may lead to biases, and the provision of training and support to sites and an ongoing assessment of trial processes are required. FUTURE WORK We recommend that any future trial include an in-depth mixed-methods recruitment investigation and a process evaluation to account for this. TRIAL REGISTRATION Current Controlled Trials ISRCTN34483199. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 36. See the NIHR Journals Library website for further project information.

Clinical reminder alert fatigue in healthcare: a systematic literature review protocol using qualitative evidence

BackgroundIntegrated reminders within clinical systems have become more prevalent due to the use of electronic health records and evidence demonstrating an increase in compliance within practice. Clinical reminders are assessed for effectiveness on an individual basis, rather than in combination with existing prompts for other conditions. The growing number of prompts may be counter-productive as healthcare professionals are increasingly suffering from “reminder fatigue” meaning many reminders are ignored. This work will review the qualitative evidence to identify barriers and enablers of existing prompts found within computerised decision support systems. Our focus will be on primary care where clinicians have to negotiate a plethora of reminders as they deal with increasingly complex patients and sophisticated treatment regimes. The review will provide a greater understanding of existing systems and the way clinicians interact with them to inform the development of more effective and targeted clinical reminders.MethodsA comprehensive search using piloted terms will be used to identify relevant literature from 1960 (or commencement of database) to 2017. MEDLINE, MEDLINE In Process, EMBASE, HMIC, PsycINFO, CDSR DARE, HTA, CINAHL and CPCI, will be searched, as well as grey literature and references and citations of included papers. Manuscripts will be assessed for eligibility, bias and quality using the CASP tool with narrative data being included and questionnaire based studies excluded. Inductive thematic analysis will be performed in order to produce a conceptual framework defining the key barriers around integrated clinical reminders.DiscussionIndications of alert and reminder fatigue are found throughout the current literature. However, this has not been fully investigated using a robust qualitative approach, particularly in a rapidly growing body of evidence. This review will aid people forming new clinical systems so that alerts can be incorporated appropriately.Systematic review registrationPROSPERO: CRD42016029418

Assessing the extent of drug interactions among patients with multimorbidity in primary and secondary care in the West Midlands (UK): a study protocol for the Mixed Methods Multimorbidity Study (MiMMS)

Introduction The numbers of patients with three or more chronic conditions (multimorbidity) are increasing, and will rise to 2.9 million by 2018 in the UK alone. Currently in the UK, conditions are mainly managed using over 250 sets of single-condition guidance, which has the potential to generate conflicting recommendations for lifestyle and concurrent medication for individual patients with more than one condition. To address some of these issues, we are developing a new computer-based tool to help manage these patients more effectively. For this tool to be applicable and relevant to current practice, we must first better understand how existing patients with multimorbidity are being managed, particularly relating to concerns over prescribing and potential polypharmacy. Methods and analysis Up to four secondary care centres, two community pharmacies and between four and eight primary care centres in the West Midlands will be recruited. Interviewees will be purposively sampled from these sites, up to a maximum of 30. In this mixed methods study, we will perform a dual framework analysis on the qualitative data; the first analysis will use the Theoretical Domains Framework to assess barriers and enablers for healthcare professionals around the management of multimorbid patients; the second analysis will use Normalisation Process Theory to understand how interventions are currently being successfully implemented in both settings. We will also extract quantitative anonymised patient data from primary care to determine the extent of polypharmacy currently present for patients with multimorbidity in the West Midlands. Discussion We aim to combine these data so that we can build a useful, fully implementable tool which addresses the barriers most amenable to change within both primary and secondary care contexts. Ethics and dissemination Favourable ethical approval has been granted by The University of Birmingham Research Ethics Committee (ERN_16–0074) on 17 May 2016. Our work will be disseminated through peer-reviewed literature, trade journals and conferences. We will also use the dedicated web page hosted by the University to serve as a central point of contact and as a repository of our findings. We aim to produce a minimum of three articles from this work to contribute to the international scientific literature. Protocol registration number NIHR Clinical Research Network Portfolio Registration CPMS ID 30613.