Now showing items 1-20 of 1155

    • A pedometer-based physically active learning intervention: The importance of using preintervention physical activity categories to assess effectiveness

      Morris, J.L.; Daly-Smith, Andrew; Defeyter, M.A.; McKenna, J.; Zwolinsky, S.; Lloyd, S.; Fothergill, M.; Graham, P.L. (2019-08)
      Purpose: To assess physical activity outcomes of a pedometer-based physically active learning (PAL) intervention in primary school children. Methods: Six paired schools were randomly allocated to either a 6-week teacher-led pedometer-based physically active learning intervention or a control (n = 154, female = 60%, age = 9.9 [0.3] y). Accelerometers assessed total daily sedentary time, light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). Preintervention mean daily MVPA minutes grouped participants as Low Active (<45 min/d) and High Active (≥45 min/d). Results: From the final sample size, the intervention (n = 52) significantly improved LPA versus control (n = 31, P = .04), by reducing sedentary time. More intervention (+10%) than control (+3%) pupils met the 60 minutes per day guidelines. In both intervention subgroups, pupils spent less time in LPA (P < .05) versus control. The greatest nonsignificant increase was found in the Low Active pupils MVPA levels. Conclusions: Improvements in LPA were statistically significant in the intervention versus control group. In subgroup analysis, Low Active pupils in the intervention showed the greatest beneficial effects and the Most Active pupils may have replaced MVPA and sedentary time with LPA. The intervention group housed clusters of pupils showing variable responsiveness, justifying routine examination of subgroup variability in future studies.
    • Commentary on a recent article on the effects of the 'Daily Mile' on physical activity, fitness and body composition: addressing key limitations

      Daly-Smith, Andrew; Morris, J.L.; Hobbs, M.; McKenna, J. (2019-05-22)
      A recent pilot study by Chesham et al. in BMC Medicine established some initial effects of the Daily Mile™ using a quasi-experimental repeated measures design, with valid and reliable outcome assessments for moderate-to-vigorous physical activity, fitness and body composition. Their contribution is important and welcome, yet, alone, it is insufficient to justify the recent UK-wide adoption of the Daily Mile within the Childhood Obesity Plan. The study concluded that the Daily Mile had positive effects on moderate-to-vigorous physical activity, fitness and body composition, suggesting that intervention effectiveness was confirmed. However, only some of the significant limitations of the work were addressed. Herein, we identify and discuss six key limitations, which, combined, suggest a more tentative conclusion. In summary, evidence supporting the effectiveness of the Daily Mile is in its infancy and requires refinement to fully justify its widespread adoption. Further, we need to be cautious considering that the full range of its impacts, both positive and negative, remain to be fully established.
    • Introducing physically active lessons in UK secondary schools: feasibility study and pilot cluster-randomised controlled trial

      Gammon, C.; Morton, K.; Atkin, A.; Corder, K.; Daly-Smith, Andrew; Quarmby, T.; Suhrcke, M.; Turner, D.; van Sluijs, E. (2019-05)
      Assess feasibility, acceptability and costs of delivering a physically active lessons (PAL) training programme to secondary school teachers and explore preliminary effectiveness for reducing pupils' sedentary time. Secondary schools in East England; one school participated in a pre-post feasibility study, two in a pilot cluster-randomised controlled trial. In the pilot trial, blinding to group assignment was not possible. Across studies, 321 randomly selected students (51% male; mean age: 12.9 years), 78 teachers (35% male) and 2 assistant head teachers enrolled; 296 (92%) students, 69 (88%) teachers and 2 assistant head teachers completed the studies. PAL training was delivered to teachers over two after-school sessions. Teachers were made aware of how to integrate movement into lessons; strategies included students collecting data from the environment for class activities and completing activities posted on classroom walls, instead of sitting at desks. Quantitative and qualitative data were collected to assess feasibility and acceptability of PAL training and delivery. Outcomes were assessed at baseline and ~8 weeks post-training; measures included accelerometer-assessed activity, self-reported well-being and observations of time-on-task. Process evaluation was conducted at follow-up. In the feasibility study, teachers reported good acceptability of PAL training and mixed experiences of delivering PAL. In the pilot study, teachers' acceptability of training was lower and teachers identified aspects of the training in need of review, including the outdoor PAL training and learning challenge of PAL strategies. In both studies, students and assistant head teachers reported good acceptability of the intervention. Preliminary effectiveness for reducing students' sedentary time was not demonstrated in either study. No evidence of preliminary effectiveness on the primary outcome and mixed reports of teachers' acceptability of PAL training suggest the need to review the training. The results do not support continuation of research with the current intervention. ISRCTN38409550.
    • The Daily Mile™ initiative: Exploring physical activity and the acute effects on executive function and academic performance in primary school children

      Morris, J.L.; Daly-Smith, Andrew; Archbold, V.S.J.; Wilkins, E.L.; McKenna, J. (2019-11)
      For schools to consider physical activity (PA) interventions, improvements must be shown in PA and additional educational benefits such as executive function (EF) and academic performance (AP). Over 8800 schools worldwide have implemented The Daily Mile™ (TDM), without any formal assessments of its impact. Rigorous and high-quality studies are needed to explore TDM's contribution to moderate-to-vigorous PA (MVPA) guidelines and potential impact on EFs and AP. Methods: Children (14 classes, n = 303, age mean = 8.99 ± 0.5) from 11 primary schools already implementing TDM consented. At the individual level, children were randomly assigned using a 4-block process to either TDM or continued academic lessons (TDM n = 158, control n = 145). Children completed pre and post, EF tests (Trail Making Task; Digit Recall; Flanker; Animal Stroop) and a maths fluency test (Maths Addition and Subtraction, Speed and Accuracy Test). Accelerometers assessed MVPA using 15-s-epochs and Evenson cut-points. Results: Using multi-level modelling, TDM revealed significantly greater MVPA (+10.23 min) and reduced sedentary time (−9.28 min) compared to control (p ≤ 0.001, d = 4.92, 3.61 retrospectively). Maths fluency interacted with condition and time (p = 0.031, d = 0.25); post hocs revealed no significances over time (p > 0.05). No differences in EFs (all p > 0.05). Conclusions: This study is the first assessing the acute effects of TDM compared to continued academic lessons. TDM revealed no significant improvements in maths fluency or EF. These findings question justifying the widespread adoption of TDM based on enhanced cognition claims. Nonetheless, TDM may provide 10 min of MVPA, achieving a third of the daily in school recommendations to meet overall daily recommendations.
    • Systematic review of acute physically active learning and classroom movement breaks on children's physical activity, cognition, academic performance and classroom behaviour: understanding critical design features.

      Daly-Smith, Andrew; Zwolinsky, S; McKenna, J.; Tomporowski, P.D.; Defeyter, M.A.; Manley, A. (2018)
      To examine the impact of acute classroom movement break (CMB) and physically active learning (PAL) interventions on physical activity (PA), cognition, academic performance and classroom behaviour. Systematic review. PubMed, EBSCO, Academic Search Complete, Education Resources Information Center, PsycINFO, SPORTDiscus, SCOPUS and Web of Science. Studies investigating school-based acute bouts of CMB or PAL on (PA), cognition, academic performance and classroom behaviour. The Downs and Black checklist assessed risk of bias. Ten PAL and eight CMB studies were identified from 2929 potentially relevant articles. Risk of bias scores ranged from 33% to 64.3%. Variation in study designs drove specific, but differing, outcomes. Three studies assessed PA using objective measures. Interventions replaced sedentary time with either light PA or moderate-to-vigorous PA dependent on design characteristics (mode, duration and intensity). Only one study factored individual PA outcomes into analyses. Classroom behaviour improved after longer moderate-to-vigorous (>10 min), or shorter more intense (5 min), CMB/PAL bouts (9 out of 11 interventions). There was no support for enhanced cognition or academic performance due to limited repeated studies. Low-to-medium quality designs predominate in investigations of the acute impacts of CMB and PAL on PA, cognition, academic performance and classroom behaviour. Variable quality in experimental designs, outcome measures and intervention characteristics impact outcomes making conclusions problematic. CMB and PAL increased PA and enhanced time on task. To improve confidence in study outcomes, future investigations should combine examples of good practice observed in current studies. CRD42017070981.
    • Implementing physically active learning: Future directions for research, policy, and practice

      Daly-Smith, Andrew; Quarmby, T.; Archbold, V.S.J.; Routen, A.C.; Morris, J.L.; Gammon, C.; Bartholomew, J.B.; Resaland, G.K.; Llewellyn, B.; Allman, R.; et al. (2020-01)
      To identify co-produced multi-stakeholder perspectives important for successful widespread physically active learning (PAL) adoption and implementation. A total of 35 stakeholders (policymakers n = 9; commercial education sector, n = 8; teachers, n = 3; researchers, n = 15) attended a design thinking PAL workshop. Participants formed 5 multi-disciplinary groups with at least 1 representative from each stakeholder group. Each group, facilitated by a researcher, undertook 2 tasks: (1) using Post-it Notes, the following question was answered: within the school day, what are the opportunities for learning combined with movement? and (2) structured as a washing-line task, the following question was answered: how can we establish PAL as the norm? All discussions were audio-recorded and transcribed. Inductive analyses were conducted by 4 authors. After the analyses were complete, the main themes and subthemes were assigned to 4 predetermined categories: (1) PAL design and implementation, (2) priorities for practice, (3) priorities for policy, and (4) priorities for research. The following were the main themes for PAL implementation: opportunities for PAL within the school day, delivery environments, learning approaches, and the intensity of PAL. The main themes for the priorities for practice included teacher confidence and competence, resources to support delivery, and community of practice. The main themes for the policy for priorities included self-governance, the Office for Standards in Education, Children's Services, and Skill, policy investment in initial teacher training, and curriculum reform. The main themes for the research priorities included establishing a strong evidence base, school-based PAL implementation, and a whole-systems approach. The present study is the first to identify PAL implementation factors using a combined multi-stakeholder perspective. To achieve wider PAL adoption and implementation, future interventions should be evidence based and address implementation factors at the classroom level (e.g., approaches and delivery environments), school level (e.g., communities of practice), and policy level (e.g., initial teacher training).
    • ‘You get some very archaic ideas of what teaching is … ’: primary school teachers’ perceptions of the barriers to physically active lessons

      Quarmby, T.; Daly-Smith, Andrew; Kime, N. (2019-04)
      Physically active lessons present a key paradigm shift in educational practice. However, little is known about the barriers to implementing physically active lessons. To address this, 31 practising primary teachers (23 = female) from 9 primary schools across West Yorkshire, England, were engaged in focus group interviews. Drawing on the socio-ecological model, findings revealed that barriers influencing the implementation of physically active lessons are multifaceted. Teacher’s confidence and competence, concerns over classroom space, preparation time and resources, coupled with the wider school culture that is influenced by governors and parents, reinforce a didactic approach and act as barriers to physically active lessons.
    • Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

      Daly-Smith, Andrew; Quarmby, T.; Archbold, V.S.J.; Corrigan, N.; Wilson, D.; Resaland, G.K.; Bartholomew, J.B.; Singh, A.; Tjomsland, H.E.; Sherar, L.B.; et al. (2020-02)
      UK and global policies recommend whole-school approaches to improve childrens' inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure 'systems' change, a framework is required that identifies all components of a whole-school PA approach. The study's aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one 'initial' framework. Next, stakeholders reviewed the 'initial' framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers' capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. To the authors' knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives 'with' schools, while abandoning outdated traditional approaches of implementing interventions 'on' schools.
    • QualDash: Adaptable Generation of Visualisation Dashboards for Healthcare Quality Improvement

      Elshehaly, Mai; Randell, Rebecca; Brehmer, M.; McVey, L.; Alvarado, Natasha; Gale, C.P.; Ruddle, R.A. (2021-02)
      Adapting dashboard design to different contexts of use is an open question in visualisation research. Dashboard designers often seek to strike a balance between dashboard adaptability and ease-of-use, and in hospitals challenges arise from the vast diversity of key metrics, data models and users involved at different organizational levels. In this design study, we present QualDash, a dashboard generation engine that allows for the dynamic configuration and deployment of visualisation dashboards for healthcare quality improvement (QI). We present a rigorous task analysis based on interviews with healthcare professionals, a co-design workshop and a series of one-on-one meetings with front line analysts. From these activities we define a metric card metaphor as a unit of visual analysis in healthcare QI, using this concept as a building block for generating highly adaptable dashboards, and leading to the design of a Metric Specification Structure (MSS). Each MSS is a JSON structure which enables dashboard authors to concisely configure unit-specific variants of a metric card, while offloading common patterns that are shared across cards to be preset by the engine. We reflect on deploying and iterating the design of QualDash in cardiology wards and pediatric intensive care units of five NHS hospitals. Finally, we report evaluation results that demonstrate the adaptability, ease-of-use and usefulness of QualDash in a real-world scenario.
    • The effects of inter-organisational information technology networks on patient safety: a realist synthesis

      Keen, J.; Abdulwahid, M.; King, N.; Wright, J.; Randell, Rebecca; Gardner, P.; Waring, J.; Longo, R.; Nikolova, S.; Sloan, C.; et al. (2020)
      Health services in many countries are investing in inter-organisational networks, linking patients’ records held in different organisations across a city or region. The aim of the systematic review was to establish how, why, and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home. Design Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semi-structured interviews. Eligibility criteria The co-ordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital. Information sources 17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library and Applied Social Sciences Index and Abstracts (ASSIA). Outcomes Changes in patients’ clinical risks. Results We did not find any detailed accounts of the sequences of events that policy makers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories. There is good evidence that there are problems with the co-ordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high quality evidence about safety-related outcomes associated with the deployment of interoperable networks. Conclusions Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the socio-technical nature of co-ordination problems. Review registration: PROSPERO CRD42017073004
    • The association between the nationality of nurses and safety culture in maternity care units of Oman

      Al Nadabi, Waleed; Faisal, Muhammad; Muhammed, Muhammed A. (2020)
      Background: Patient safety culture/climate in maternity units has been linked to better safety outcomes. Nurses have a crucial role in patient safety and represent the majority of staff in maternity units. In many countries, nurses are recruited from abroad, bringing their own perceptions of patient safety culture. Nonetheless, little is known about the relationship between perceptions of patient safety culture and nurses’ nationality. Understanding this relationship will assist stakeholders in designing a responsive programme to improve patient safety culture. Aims: To investigate the association between nurses’ nationality and their perceptions about patient safety culture in maternity units in Ministry of Health hospitals in Oman. Methods: In 2017, the Safety Attitude Questionnaire (SAQ) was distributed to all staff (892 distributed, 735 returned) in 10 maternity units. Results: About three-quarters (74%, 541/735) of the returned SAQs were completed by nurses, of whom 34% were non-Omani, 21.8% were Omani and 44.7% did not report their nationality (missing). Overall, the mean safety score for non-Omani nurses was significantly higher than for the Omani nurses: 3.9 (SD 1.3) vs 3.6 (SD 1.2) (P < 0.001). The mean safety score for stress recognition was significantly lower for non-Omani nurses: 2.8 (SD 1.5) vs 3.2 (SD 1.3) (P < 0.001). Conclusion: Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses except in respect of stress recognition. Decision-makers, directors, and clinicians should consider these differences when designing interventions to improve patient safety culture.
    • Patient safety culture in Oman: A national study

      Al Nadabi, Waleed; Faisal, Muhammad; Mohammed, Mohammed A. (2020-10)
      Rational, aim, and objectives: A positive patient safety culture in maternity units is linked to higher quality of care and better outcomes for mothers. However, safety culture varies across maternity units. Analyses of variation in safety culture using statistical process control (SPC) methods may help provider units to learn from each other's performance. This study aims to measure patient safety culture across maternity units in Oman using SPC methods. Methods: The 36-item Safety Attitude Questionnaire (SAQ) was distributed to all doctors, nurses, and midwifes working in ten maternity care units in Oman's hospitals and analysed using SPC methods. The SAQ considers six domains: job satisfaction, perception of management, safety climate, stress recognition, teamwork, and work condition. Results: Of the 892 targeted participants, 735 (82%) questionnaires were returned. The overall percentage of positive safety responses in all hospitals ranged from 53% to 66%, but no hospital had the targeted response of above 75%. Job satisfaction had the highest safety score (4.10) while stress recognition was the lowest (3.17). SPC charts showed that the overall percentage of positive responses in three maternity units (H1, H7, and H10) was above and one (H4) was below the control limits that represent special cause variation that merits further investigation. Conclusion: Generally, the safety culture in maternity units in Oman is below target and suggests that considerable work is required to enhance safety culture. Several maternity units showed evidence of high/low special cause variation that may offer a useful starting point for understanding and enhancing safety culture.
    • The value of a Patient Access Portal in primary care: a cross-sectional survey of 62,486 registered users in the UK

      Mohammed, Mohammed A.; Montague, Jane; Faisal, Muhammad; Lamming, Laura (2020)
      In England, primary care patients have access to Patient Access Portals (PAPs), enabling them to book appointments, request repeat medication prescriptions, send/receive messages and review their medical records. Few studies have elicited user views and value of PAPs, especially in a publicly funded primary care setting. This study aimed to elicit the value users of PAPs place on online access to medical records and linked services. Secondary data analysis of the completed electronic survey (available 2 May 2015–27 June 2015) distributed via the EMIS PAP to all its registered users. EMIS designed the survey; responses were voluntary. There were 62,486 responders (95.7% self-completed). The PAP was mainly used for medication requests (86.3%) and online appointment bookings (78.4%), and, to a lesser extent, medical record viewing (18.3%) and messaging (9.5%). The majority (70%) reported a positive impact from using it. One in five rated it as their favourite online service second only to online banking. Almost three out of four responders stated that availability of online access would influence their move to another practice. Nonetheless, responders were reluctant to award a high monetary value to it. These findings correlated with the number of long-term conditions. The majority of users place a relatively high value, but not monetary value, on the PAP and report a positive impact from using it. The potential for PAPs to enhance patient experience, especially for those with long-term conditions, appears to be largely untapped. Research exploring the reasons for non-use is also required.
    • Factors associated with accelerometer measured movement behaviours among White British and South Asian children aged 6-8 years during school terms and school holidays.

      Nagy, Liana C.; Faisal, Muhammad; Horne, M.; Collins, P.; Barber, S.; Mohammed, Mohammed A. (2019-08)
      To investigate factors associated with movement behaviours among White British (WB) and South Asian (SA) children aged 6-8 years during school terms and holidays. Cross-sectional. Three primary schools from the Bradford area, UK. One hundred and sixty WB and SA children aged 6-8 years. Sedentary behaviour (SB), light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) measured by accelerometry during summer, winter and spring and during school terms and school holidays. Data were analysed using multivariate mixed-effects multilevel modelling with robust SEs. Factors of interest were ethnicity, holiday/term, sex, socioeconomic status (SES), weight status, weekend/weekday and season. One hundred and eight children (67.5%) provided 1157 valid days of data. Fifty-nine per cent of children were WB (n=64) and 41% (n=44) were SA. Boys spent more time in MVPA (11 min/day, p=0.013) compared with girls and SA children spent more time in SB (39 min, p=0.017) compared with WB children in adjusted models. Children living in higher SES areas were more sedentary (43 min, p=0.006) than children living in low SES areas. Children were more active during summer (15 min MVPA, p<0.001; 27 LPA, p<0.001) and spring (15 min MVPA, p=0.005; 38 min LPA, p<0.001) and less sedentary (−42 min and −53 min, p<0.001) compared with winter. Less time (8 min, p=0.012) was spent in LPA during school terms compared with school holidays. Children spent more time in MVPA (5 min, p=0.036) during weekend compared with weekdays. Overweight and obese children spent more time in LPA (21 min, p=0.021) than normal-weight children. The results of our study suggest that significant child level factors associated with movement behaviours are ethnicity, sex, weight-status and area SES. Significant temporal factors are weekends, school holidays and seasonality. Interventions to support health enhancing movement behaviours may need to be tailored around these factors.
    • Ethnic differences in sedentary behaviour in 6-8-year-old children during school terms and school holidays: a mixed methods study

      Nagy, Liana C.; Horne, M.; Faisal, Muhammad; Mohammed, Mohammed A.; Barber, Sally E. (2019-02)
      Sedentary behaviour (SB) in childhood is a major public health concern. Little is known about ethnic differences in SB during school and holiday weeks among White British (WB) and South Asian (SA) children, which this study aims to address through investigating inclinometer measured SB and exploring reasons for child engagement in SB. A mixed methods study, comprising of a quantitative investigation with 160, 6-8 years old children and a qualitative study with a subsample of 18 children, six parents and eight teachers was undertaken. Children of WB and SA ethnicity in three schools were invited to wear inclinometers for seven school terms (summer/winter/spring) and seven holidays (winter/spring) days during July 2016-May 2017. Total SB, SB accumulated in bouts > 30 min and breaks in SB were explored using multivariate linear mixed effects models which adjusted for wear time, sex, deprivation, overweight status, season, term, weekday and school. Nine focus groups and two interviews were carried out using the Theoretical Domains Framework to explore SB perceptions among parents, teachers and children. Data were analysed using the Framework Approach. 104/160 children provided 836 valid days of data. Children spent on average eight hours of SB/day during term time and holidays, equating to 60% of their awake time, and had on average 111 SB breaks /day. SA children had 25 fewer SB breaks/ day when compared to WB (p 
    • Impact of the level of sickness on higher mortality in emergency medical admissions to hospital at weekends

      Mohammed, Mohammed A.; Faisal, Muhammad; Richardson, D.; Howes, R.; Beatson, K.; Wright, J.; Speed, K. (2017-10-01)
      Routine administrative data have been used to show that patients admitted to hospitals over the weekend appear to have a higher mortality compared to weekday admissions. Such data do not take the severity of sickness of a patient on admission into account. Our aim was to incorporate a standardized vital signs physiological-based measure of sickness known as the National Early Warning Score to investigate if weekend admissions are: sicker as measured by their index National Early Warning Score; have an increased mortality; and experience longer delays in the recording of their index National Early Warning Score. Methods: We extracted details of all adult emergency medical admissions during 2014 from hospital databases and linked these with electronic National Early Warning Score data in four acute hospitals. We analysed 47,117 emergency admissions after excluding 1657 records, where National Early Warning Score was missing or the first (index) National Early Warning Score was recorded outside ±24 h of the admission time. Results: Emergency medical admissions at the weekend had higher index National Early Warning Score (weekend: 2.53 vs. weekday: 2.30, p
    • A prospective study of consecutive emergency medical admissions to compare a novel automated computer-aided mortality risk score and clinical judgement of patient mortality risk

      Faisal, Muhammad; Khatoon, Binish; Scally, Andy J.; Richardson, D.; Irwin, S.; Davidson, R.; Heseltine, D.; Corlett, A.; Ali, J.; Hampson, R.; et al. (2019-06)
      Objectives: To compare the performance of a validated automatic computer-aided risk of mortality (CARM) score versus medical judgement in predicting the risk of in-hospital mortality for patients following emergency medical admission. Design: A prospective study. Setting: Consecutive emergency medical admissions in York hospital. Participants: Elderly medical admissions in one ward were assigned a risk of death at the first post-take ward round by consultant staff over a 2-week period. The consultant medical staff used the same variables to assign a risk of death to the patient as the CARM (age, sex, National Early Warning Score and blood test results) but also had access to the clinical history, examination findings and any immediately available investigations such as ECGs. The performance of the CARM versus consultant medical judgement was compared using the c-statistic and the positive predictive value (PPV). Results: The in-hospital mortality was 31.8% (130/409). For patients with complete blood test results, the c-statistic for CARM was 0.75 (95% CI: 0.69 to 0.81) versus 0.72 (95% CI: 0.66 to 0.78) for medical judgements (p=0.28). For patients with at least one missing blood test result, the c-statistics were similar (medical judgements 0.70 (95% CI: 0.60 to 0.81) vs CARM 0.70 (95% CI: 0.59 to 0.80)). At a 10% mortality risk, the PPV for CARM was higher than medical judgements in patients with complete blood test results, 62.0% (95% CI: 51.2 to 71.9) versus 49.2% (95% CI: 39.8 to 58.5) but not when blood test results were missing, 50.0% (95% CI: 24.7 to 75.3) versus 53.3% (95% CI: 34.3 to 71.7). Conclusions: CARM is comparable with medical judgements in discriminating in-hospital mortality following emergency admission to an elderly care ward. CARM may have a promising role in supporting medical judgements in determining the patient's risk of death in hospital. Further evaluation of CARM in routine practice is required.
    • Performance of externally validated enhanced computer-aided versions of the National Early Warning Score in predicting mortality following an emergency admission to hospital in England: a cross-sectional study

      Faisal, Muhammad; Richardson, D.; Scally, Andy J.; Howes, R.; Beatson, K.; Mohammed, Mohammed A. (2019-11)
      OBJECTIVES: In the English National Health Service, the patient's vital signs are monitored and summarised into a National Early Warning Score (NEWS) to support clinical decision making, but it does not provide an estimate of the patient's risk of death. We examine the extent to which the accuracy of NEWS for predicting mortality could be improved by enhanced computer versions of NEWS (cNEWS). DESIGN: Logistic regression model development and external validation study. SETTING: Two acute hospitals (YH-York Hospital for model development; NH-Northern Lincolnshire and Goole Hospital for external model validation). PARTICIPANTS: Adult (≥16 years) medical admissions discharged over a 24-month period with electronic NEWS (eNEWS) recorded on admission are used to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) using the first electronically recorded NEWS (model M0) versus a cNEWS model which included age+sex (model M1) +subcomponents of NEWS (including diastolic blood pressure) (model M2). RESULTS: The risk of dying in-hospital following emergency medical admission was 5.8% (YH: 2080/35 807) and 5.4% (NH: 1900/35 161). The c-statistics for model M2 in YH for predicting mortality (in-hospital=0.82, 24 hours=0.91, 48 hours=0.88 and 72 hours=0.88) was higher than model M0 (in-hospital=0.74, 24 hours=0.89, 48 hours=0.86 and 72 hours=0.85) with higher Positive Predictive Value (PPVs) for in-hospital mortality (M2 19.3% and M0 16.6%). Similar findings were seen in NH. Model M2 performed better than M0 in almost all major disease subgroups. CONCLUSIONS: An externally validated enhanced computer-aided NEWS model (cNEWS) incrementally improves on the performance of a NEWS only model. Since cNEWS places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated to determine if it can improve care in hospitals that have eNEWS systems.
    • Exploring variation in the use of feedback from national clinical audits: a realist investigation

      Alvarado, N.; McVey, L.; Greenhalgh, J.; Dowding, D.; Mamas, M.; Gale, C.; Doherty, P.; Randell, Rebecca (2020)
      Background National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians’ time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation. Methods We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism=Outcome configurations. Results We identified five mechanisms that explained interactions between providers and NCA feedback: reputation, professionalism, competition, incentives, and professional development. Underpinned by the mechanisms professionalism and incentives, feedback was used most routinely within clinical services resourced to maintain local databases, where data were stored before upload to NCA suppliers. Local databases enabled staff to access data easily, customise reports and integrate them within governance processes. Use of feedback generated in this way was further supported where staff supporting audit participation were trusted to collect timely and accurate data. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity. Challenges accessing data from NCA supplier databases, concerns about the quality of data across participating organisations and timeliness were reported to constrain the perceived usefulness of this type of feedback as a tool for stimulating quality improvement. Conclusion The findings suggest that there are a number of mechanisms through which healthcare providers, in particular staff within clinical services, engage with NCA feedback, but that there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely within clinical services resourced to maintain local databases, where data were considered timely, trusted as accurate and could be easily accessed to customise reports for the needs of the service.
    • Eliciting Context-Mechanism-Outcome configurations: Experiences from a realist evaluation investigating the impact of robotic surgery on teamwork in the operating theatre

      Alvarado, N.; Honey, S.; Greenhalgh, J.; Pearman, A.; Dowding, D.; Cope, A.; Long, A.; Jayne, D.; Gill, A.; Kotze, A.; et al. (2017-10-01)
      This article recounts our experience of eliciting, cataloguing and prioritizing conjectured Context-Mechanism-Outcome configurations at the outset of a realist evaluation, to provide new insight into how Context-Mechanism-Outcome configurations can be generated and theorized. Our construction of Context-Mechanism-Outcome configurations centred on how, why and in what circumstances teamwork was impacted by robotic surgery, rather than how and why this technology improved surgical outcomes as intended. We found that, as well as offering resources, robotic surgery took away resources from the theatre team, by physically reconfiguring the operating theatre and redistributing the surgical task load, essentially changing the context in which teamwork was performed. We constructed Context-Mechanism-Outcome configurations that explain how teamwork mechanisms were both constrained by the contextual changes, and triggered in the new context through the use of informal strategies. We conclude by reflecting on our application of realist evaluation to understand the potential impacts of robotic surgery on teamwork.