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Electronic Patient Records (electronic + patient_record)

Distribution by Scientific Domains

Medical Sciences	94%

Selected Abstracts

Developing Clinical Terms for Health Visiting in the United Kingdom

INTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003
June Clark
BACKGROUND The UK health visiting service provides a universalist preventive health service that focuses mainly on families with young children and the elderly or vulnerable, but anyone who wishes can access the services. The principles of health visiting have been formally defined as the search for health needs, the stimulation of awareness of health needs, influencing policies that affect health, and the facilitation of health-enhancing activities. The project is currently in its fourth phase. In phase 1, 17 health visitors recorded their encounters with families with new babies over a period of 3 months; in phase 2, 27 health visitors recorded their encounters with a wider range of clients (769 encounters with 205 families) over a period of 9 months; in phase 3, the system is being used by a variety of healthcare professionals in a specialist program that provides intensive parenting support; phase 4 is developing a prototype of an automated version for point-of-contact recording. UK nursing has no tradition of standardized language and the concept of nursing diagnosis is almost unknown. Over the past decade, however, the government has initiated the development of a standardized terminology (Read codes) to cover all disciplines and all aspects of health care, and it is likely that the emerging SNOMED-CT terminology (a merger of the Read codes with the SNOMED terminology) will be mandated for use throughout the National Health Service (NHS). MAIN CONTENT POINTS The structure and key elements of the Omaha System were retained but the terminology was modified to take account of the particular field of practice and emerging UK needs. Modifications made were carefully tracked. The Problem Classification Scheme was modified as follows: ,All terms were anglicized. ,Some areas , notably relating to antepartum/postpartum, neonatal care, child protection, and growth and development,were expanded. ,The qualifiers "actual,""potential," and "health promotion" were changed to "problem,""risk," and "no problem." ,Risk factors were included as modifiers of "risk" alongside the "signs and symptoms" that qualify problems. The Intervention Classification was modified by substituting synonymous terms for "case management" and "surveillance" and dividing "health teaching, guidance, and counseling" into two categories. The Omaha System "targets" were renamed "focus" and a new axis of "recipient" was introduced in line with SNOMED-CT. The revised terminologies were tested in use and also sent for review to 3 nursing language experts and 12 practitioners, who were asked to review them for domain completeness, appropriate granularity, parsimony, synonymy, nonambiguity, nonredundancy, context independence, and compatibility with emerging multiaxial and combinatorial nomenclatures. Review comments were generally very favourable and modifications suggested are being incorporated. CONCLUSIONS The newly published government strategy for information management and technology in the NHS in Wales requires the rapid development of an electronic patient record, for which the two prerequisites are structured documentation and the use of standardized language. The terminology developed in this project will enable nursing concepts to be incorporated into the new systems. The experiences of the project team also offer many lessons that will be useful for developing the necessary educational infrastructure. [source]

Survival analysis for degree of compliance with supportive periodontal therapy

JOURNAL OF CLINICAL PERIODONTOLOGY, Issue 12 2001
M. Ojima
Abstract Background, aims: The purpose of this investigation was to evaluate the degree of compliance for supportive periodontal therapy (SPT) and to determine factors in relation to patients who failed to continue SPT programs. Method: A sample of 1896 patients who were treated between 1988 and 1999 was studied. The patients were classified by gender, age group and the distance between their house and the hospital. The number of visits was counted based on an electronic patient record for SPT. Data were analyzed by survival analysis. Survival probabilities in SPT were estimated by the Kaplan-Meier method and compared by the generalized Wilcoxon test. Results: 28% of patients did not comply with the first visit for SPT. The older patients had higher tendencies to continue the SPT program than the younger patients. No significant differences in compliance were found between males and females or between short-distance and long-distance groups. However, when these factors were adjusted by age, significantly different patterns were shown on the curves of survival probability: in males, significant differences were found between the 20 s and 30 s (p<0.00001) and between the 50 s and 60 s (p<0.01). In females, significant differences were found between the 40 s and 50 s (p<0.001) and between the 60 s and 70 s (p<0.001). The differences of the survival probability by age group were greater in the short-distance group than in the long-distance group. Conclusions: The results suggest that age is the most important factor for compliance of the patients with SPT, not only alone but also in relation to the other factors. Zusammenfassung Ziel: Der Zweck dieser Untersuchung war es, das Ausmaß der Compliance bei perodontaler Erhaltungstherapie (SPT) zu evaluieren und Patienten bezogene Faktoren zu bestimmen, wenn diese das SPT-Programm nicht forsetzten. Material und Methoden: Eine Stichprobe von 1896 Patienten, welche zwischen 1988 und 1999 behandelt wurden nahm man in die Studie auf. Die Patienten wurden klassifiziert nach Geschlecht, Altersgruppe und der Entfernung zwischen ihrem Haus und der Klinik. Auf der Grundlage einer elektronischen Patientenakte wurde die Anzahl der Sitzungen errechnet. Die Daten wurden mittels Überlebensanalyse ausgewertet. Die Überlebenswahrscheinlichkeiten in der SPT wurde mit der Kaplan-Meier-Methode geschätzt und mit dem allgemeinen Wilkoxon-Test verglichen. Ergebnisse: 28% der Patienten zeigten keine Compliance mit dem ersten Termin für die SPT. Die älteren Patienten zeigten eine stärkere Tendenz zur Forsetzung des SPT-Programms als die jüngeren Patienten. Zwischen Männern und Frauen oder den Gruppen mit geringer und größerer Entfernung gab es keine Unterschiede in der Compliance. Wenn diese Faktoren bezüglich des Alters adjustiert wurden, konnten signifikant unterschiedliche Muster bei den Kurven für die Überlebenswahrscheinlichkeit gezeigt werden: bei den Männern fand man signifikante Unterschiede zwischen der 20er und 30er-Gruppe (p<0.00001) und zwischen der 50er und 60er-Gruppe (p<0.01). Bei den Frauen fand man signifikante Unterschiede zwischen der 40er und 50er-Gruppe (p<0.001) und zwischen der 60er und 70er-Gruppe (p<0.001). Die Unterschiede der Überlebenswahrscheinlichkeit der Altersgruppen waren in der Gruppe mit geringen Entfernung größer, als in der Gruppe mit größerer Entfernung. Schlussfolgerung: Die Ergebnisse lassen annehmen, dass das Alter der wichtigste Faktor für die Compliance der Patienten mit der SPT ist. Dies gilt nicht nur für das Alter als alleinigen Faktor sondern auch zusammen mit den anderen Faktoren. Résumé But: Le but de cette étude était d'évaluer le degré de coopération pour la thérapeutique parodontale de soutien (SPT) et de déterminer les facteurs en cause relatifs aux patients qui ne suivaient pas le programme de STP. Matériaux et méthodes: Un échantillon de 1896 patients qui furent traités entre 1988 et 1999 a étéétudié. Les patieants ont été classés par sexe, âge et distance entre leur habitation et l'hôpital. Le nombre de visite était quantifiéélectroniquement pour la STP. Les données étaient analysées par analyse de continuité. Les probabilitiés de continuité de la STP étaient estimées par la méthode de Kaplan-Meyer et comparées par le test de Wilcoxon généralisé. Résultats: 28% des patients ne coopéraient pas pour la première visite de maintenance. Les patients les plus âgés avaient une plus forte tendance à suivre leur programme de STP que les plus jeunes. Aucune différence significative pour la maintenance n'était observée entre les hommes et les femmes et pour la distance entre l'habitation et l'hôpital. Cependant, lorsque l'on ajustait ces facteurs pour l'âge, différences caractéristiques des courbes de probabilités de continuitéétaient observées: chez les hommes, des différences significatives existatient entre les groupes d'âges 20 et 30 ans (p<0.00001) et entre les groupes d'âge 50 et 60 ans (p<0.001). Chez les femmes, ces différences existaient entre les groupes d'âge 40 et 50 ans (p<0.001) et 60 et 70 ans (p<0.001). Les différences de la probabilité de continuité par groupe d'âge étaient plus grandes dans le groupe résidant près de l'hôpital que pour les patients habitant loin. Conclusion: Les résultats suggèrent que l'âge est le facteur le plus important pour la coopération des patients envers leurs SPT, non seulement seul mais aussi en relation avec les autres facteurs. [source]

Sharing specialist skills for diabetes in an inner city: A comparison of two primary care organisations over 4 years

JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2006
Abdu Mohiddin MFPHM Lecturer
Abstract Objective, To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years. Methods, In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views. Results, Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change. Conclusions, Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems. [source]

Routine and adaptive expert strategies for resolving ICT mediated communication problems in the team setting

MEDICAL EDUCATION, Issue 7 2009
Lara Varpio
Context, The use of information and communication technologies (ICTs) for supporting interprofessional communication is becoming increasingly common in health care. However, little research has explored how ICTs affect interprofessional communication, or how novices are trained to be effective interprofessional ICT users. This study explores the interprofessional communication strategies of nurses and doctors (trainees and experts) when their communications were mediated by a specific ICT: an electronic patient record (EPR). Methods, A total of 72 doctors and nurses participated in this 8-month study on a paediatric in-patient ward. Eighty hours of non-participant observations and 20 semi-structured interviews were conducted. All data were rendered anonymous prior to analysis. Using a constructivist grounded theory approach, one researcher read and analysed all data recursively. As emergent themes were identified, exemplary portions of the data were discussed with three additional researchers to resolve discrepancies and confirm the coding structure. Expertise literatures informed the final analyses. Results, Three interprofessional communication strategies were identified: (i) all participants routinely formulated ,workarounds' to circumvent problematic EPR-mediated communications; (ii) workarounds were classifiable as instances of Abandoning, Forcing or Submitting to the EPR, and (iii) novices learned workaround strategies through an informal curriculum, but they did not learn to manage the interprofessional effects of these workarounds. Conclusions, Trainees relied on workarounds as simplified routines, demonstrating routine expertise. Staff members, demonstrating adaptive expertise, used workarounds as part of a broader network of people and communication tools. Explicit training regarding this network and the ways in which workarounds conceal this network may help trainees develop adaptive expertise. [source]

Modelling nursing activities: electronic patient records and their discontents

NURSING INQUIRY, Issue 1 2000
Els Goorman
Modelling nursing activities: electronic patient records and their discontents A fully integrated and operating EPR in a clinical setting is hard to find: most applications can be found in outpatient or general practice settings or in isolated hospital wards. In clinical work practice problems with the electronic patient record (EPR) are frequent. These problems are at least partially due to the models of health care work embedded in EPRs. In this paper we will argue that these problems are at least partially due to the models of health care work embedded in current EPRs. We suggest that these models often contain projections of nurses' and doctors' work as it should be performed on the ward, rather than depicting how work is actually performed. We draw upon sociological insights to elucidate the fluid and pragmatic nature of healthcare work and give recommendations for the development of an empirically based EPR, which can support the work of nurses and other health care providers. We argue that these issues are of great importance to the nursing profession, since the EPR will help define the worksettings of the future. Since it is a tool that will impact the development of the nursing profession, nurses have and should have a stake in its development. [source]

Proinflammatory Events Are Associated with Significant Increases in Breadth and Strength of HLA-Specific Antibody

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 9 2009
J. E. Locke
Identification of factors responsible for an increase in the breadth or strength of HLA-specific antibody (HSA) is critical to the continued successful management and transplantation of sensitized patients. A retrospective review of our HLA registry identified 107 patients with known HSA and sufficient information in their electronic patient record to determine the presence or absence of a proinflammatory event. The patients were stratified according to transplant status [sensitized and on the transplant waitlist (n = 65); immunosuppressed recipients of a positive crossmatch (+XM) transplant (n = 42)]. Eighty-three percent of waitlist candidates and 55% of sensitized kidney transplant recipients with a documented proinflammatory event had an associated increase in HSA. Interestingly, among patients with a culture-proven infection, 97% of the waitlist patients and 54.8% of +XM recipients had an associated rise in HSA. Overall, proinflammatory events were associated with a greater increase among waitlist patients than +XM recipients, 5.3-fold [IRR 5.25, (95% CI 4.03,6.85), p < 0.001] versus 2.5-fold [IRR 2.54, (95% CI 1.64,3.95), p < 0.001] increase in HSA. Therefore, sensitized patients known to have an infection or undergoing surgery should be monitored for expansion of HSA. [source]

Effects of Computerized Provider Order Entry and Nursing Documentation on Workflow

ACADEMIC EMERGENCY MEDICINE, Issue 10 2008
Phillip V. Asaro MD
Abstract Objectives:, The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). Methods:, The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions. Results:, There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and/or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. Conclusions:, The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider,computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected. [source]

Feasibility and validity of low-budget telephonic follow-up interviews in routine outcome monitoring of substance abuse treatment

ADDICTION, Issue 7 2009
Suzan C.C. Oudejans
ABSTRACT Aims Routine outcome monitoring (ROM) is receiving growing attention. However, follow-up interviews are time-consuming and costly. This study examines the feasibility and validity of low-budget telephonic follow-up interviews for ROM in a substance abuse treatment centre (SATC). Design Observational study using data collected for routine outcome monitoring. Setting The study was performed in a SATC in an urban area in the Netherlands. Participants Feasibility and validity were assessed on data of 2325 patients. Measurements Data on pre-treatment socio-demographic and clinical characteristics were collected using electronic patient records (EPRs) and the European version of the Addiction Severity Index (EuropASI). Data on intensity of treatment were also collected through the EPRs. Telephonic follow-up interviews were conducted between 9 and 10 months after intake. Findings A 53% follow-up rate was achieved; 35% of the patients could not be contacted, 3% explicitly refused and in 8% other reasons accounted for non-participation. About 50% of the interviews took place in the intended time-frame. Costs were ,40 ($57) per completed interview. There were indications of selection bias, because patients with cocaine as their primary problem and patients with polysubstance abuse were under-represented in the follow-up sample; the presence of these disorders is associated with negative treatment outcome. Conclusions Implementing telephonic low-budget follow-up interviews for ROM is feasible, but selection bias threatens internal validity of data, limiting generalization to the total treatment population. Increased efforts to track patients for follow-up may improve generalization. [source]

IN BETWEEN CURING AND COUNTING: PERFORMATIVE EFFECTS OF EXPERIMENTS WITH HEALTHCARE INFORMATION INFRASTRUCTURE

FINANCIAL ACCOUNTABILITY & MANAGEMENT, Issue 3 2007
Signe Vikkelsø
Performance standards and accountability pervade modern healthcare. According to Michael Power, this may signify a new rationality of governance characterized by control of controls, which affects practices not by direct intervention, but through the processes by which practices are made auditable. The paper addresses this thesis by exploring the construction of a Danish standard for electronic patient records. It is shown that making healthcare auditable activates deep tensions between programs of clinical practice, quality control, evidence based medicine, and casemix funding, resulting in an ambiguous and unstable standard. During this process, however, particular notions of patients, diseases, and diagnoses emerge as undisputed innovations, which may come to survive the subsequent career of the standard. The paper discusses the performative effects of these innovations and argues that information infrastructure has become an analytically important site for exploring the substantial effects of new rationalities of governance in healthcare. [source]

Influence of adherence to the national guidance on nutrition screening and dietitian referral on clinical outcomes of those requiring parenteral nutrition

JOURNAL OF HUMAN NUTRITION & DIETETICS, Issue 2 2010
R. P. Vincent
Abstract Background:, National guidance in the UK on nutrition support suggests that all patients should be screened on initial admission to hospital and, where appropriate, be referred to a healthcare professional. The present study aimed to investigate whether initial nutrition screening influenced the outcome of patients who received parenteral nutrition (PN). Methods:, Data were prospectively evaluated on 100 consecutive patients referred to the multidisciplinary PN team in a teaching hospital. Information was obtained from medical notes, electronic patient records, completed PN prescription charts, dietetic record cards and nursing care plans. Patients who were treatable by nutritional supplements or enteral nutrition were not included. Patients were divided into two groups: guidance compliant and guidance noncompliant, in order to compare outcome measures such as the duration of PN treatment, total number of PN bags used per patient and length of hospital stay. Comparison of data between the two groups was carried out using either the independent samples t -test or the Mann,Whitney U -test. Results:, There was no difference in outcome measures between the guidance compliant and noncompliant groups. Patients in the guidance noncompliant group were more likely to be in general (77%) than critical wards (23%). Patients who were in the guidance compliant group received nutrition support earlier. Conclusions:, Compliance with the national guidance in the UK on screening did not improve outcomes in patients requiring parenteral nutrition in this cohort. Initial nutrition screening prior to PN administration warrants further investigation to ensure value is added to patient care. [source]

Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithm

NURSING IN CRITICAL CARE, Issue 3 2007
Kirsty Dobson
Abstract Many intensive care units (ICUs) have standard feeding protocols which promote safe early initiation of enteral feeding. The use of these protocols has been shown to increase the incidence of enteral feeding and achieve greater adequacy of nutrition support. A multidisciplinary working party developed and implemented a nurse-led enteral feeding algorithm which enabled senior nursing staff to set safe and nutritionally adequate target feed volumes based upon patient body weight. The algorithm incorporated best practice-based referral criteria so that patients at nutritional risk were referred for tailored dietetic assessment. The aims were to determine compliance with the ICU nurse-led enteral feeding algorithm and to ascertain its safety and efficacy. A 3-month prospective audit was conducted by specialist ICU dietitians. Data were obtained from electronic patient records and through observing feeding practices. Data collected included prescribed feed type and infusion rate versus volume received, frequency of gastric aspiration and prokinetic usage. In all, 90% (n = 43) of referrals received by the dietitian met the referral criteria. Absolute compliance with patients receiving correct type and volumes of feed, with a correct feed prescription and an accurate documented weight was just 2% (n = 1). Despite this finding, 60% of patients were actually receiving the correct feed regimen. If the nurse-led enteral feeding algorithm is wholly adhered to, the ICU dietitian need not formally assess every ICU patient. Nursing staff require further support in assessing patient body weight alongside an ongoing intensive educational programme for the multidisciplinary team and regular reaudit. [source]

Modelling nursing activities: electronic patient records and their discontents

Adverse drug reaction-related hospitalisations: a population-based cohort study

PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 4 2008
Cornelis S. van der Hooft MD
Abstract Purpose To evaluate the extent, characteristics and determinants of adverse drug reaction (ADR)-related hospitalisations on a population-based level in 2003. Methods We performed a cohort study in the Integrated Primary Care Information (IPCI) database, a general practitioners (GPs) research database with longitudinal data from electronic patient records of a group of 150 GP throughout the Netherlands. Hospital discharge letters and patient records were reviewed to evaluate ADR-related hospitalisations applying WHO causality criteria. The prevalence of ADR-related hospitalisations per total admissions and the incidence per drug group were calculated. Avoidability and seriousness of the ADRs causing admission were assessed applying the algorithm from Hallas. Results We identified 3515 hospital admissions, 1277 elective and 2238 acute. Of the acute admissions, 115 were caused by an ADR giving a prevalence of 5.1% (95% confidence intervals (CI): 4.3,6.1%). The prevalence of ADR-related acute admissions increased with age up to 9.8% (95%CI: 7.5,12.7) for persons >75 years. The ADRs that most frequently caused hospitalisations were gastro-intestinal bleeding with anti-thrombotics, bradycardia/hypotension with cardiovascular drugs and neutropenic fever with cytostatics. The incidence rate of ADR-related hospitalisations per drug group was highest for anti-thrombotics and anti-infectives and was relatively low for cardiovascular drugs. Fatality as a direct consequence of the ADR-related admission was 0.31%. In elderly patients 40% of the ADRs causing hospitalisation were judged to be avoidable. Conclusions The extent and potential avoidability of ADR-related hospitalisations is still substantial, especially in elderly patients. Measures need to be put into place to reduce the burden of ADRs. Copyright © 2008 John Wiley & Sons, Ltd. [source]

Prospective cohort study of adverse events monitored by hospital pharmacists

PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 2 2001
Angela Emerson BPharm, MRPharmS
Abstract Purpose To examine the feasibility of pharmacist-led intensive hospital monitoring of adverse events (AEs) associated with newly marketed drugs. Subjects/setting 303 patients admitted to Southampton Hospitals who were prescribed selected newly marketed drugs during their inpatient stay in 1998. Methods Prospective observational study. Patients were identified from computerized pharmacy records, clinical pharmacist ward rounds, dispensary records or via nursing staff. The pharmacist reviewed medical notes and recorded AEs, suspected adverse drug reactions (ADRs) and reasons for stopping drugs. Outcomes Incidence of AEs, ADRs; proportionate agreement between the physician's and pharmacist's event recording. Results 303 patients were monitored. Of the patients taking newly marketed drugs 92% were identifiable using pharmacy computer systems and pharmacist ward visits. There were 21 (7%) suspected ADRs detected during this pilot study. The types of adverse events detected were broadly similar to those identified by general practice-based prescription event monitoring. However, biochemical changes featured more frequently than in general practice. Differences between adverse events recorded by pharmacist and physician were systematic and attributed to differences in event coding. Conclusion Pharmacist-led monitoring in a typical NHS hospital setting was effective at detecting ADRs in newly marketed drugs. However, this effort might have been substantially less time-consuming and more effective were electronic patient records (EPRs) available. Pharmacy computer systems are not designed to be patient focused and are therefore unable to identify patients taking newly marketed drugs. It is argued that future EPR and computerised patient-specific prescribing systems should be designed to capture this data in the same way as some US systems are currently able to do. Copyright © 2001 John Wiley & Sons, Ltd. [source]

Latest news and product developments

PRESCRIBER, Issue 18 2008
Article first published online: 3 OCT 200
Inhaled steroids for all children with asthma? Some children with mild well-controlled asthma may not need a daily inhaled steroid, a Scandinavian study suggests (Arch Dis Child 2008;93:654-9). A total of 176 children aged 5-10 years were randomised to treatment with cromoglicate (Intal) or budesonide. Initially high doses of budesonide (400,g twice daily) were reduced after one month to 200,g twice daily for four months; subsequent treatment for a further year was 100,g twice daily as required for exacerbations or 100,g twice daily regularly. Budesonide was associated with greater improvement in lung function and fewer exacerbations compared with cromoglicate, but after 18 months lung function improvements did not differ. Regular budesonide was associated with fewer exacerbations than as-required administration (0.97 vs 1.69 per patient in months 7-18) but no difference in asthma-free days or use of rescue medication. Growth suppression was slightly greater with continuous budesonide. Interventions to reduce atypicals weight gain A systematic review has found that techniques such as cognitive behaviour therapy and nutritional counselling can reduce weight gain associated with atypical antipsychotics (Br J Psychiatry 2008;193:101-7). Analysis of 10 randomised trials lasting eight weeks to six months found that nonpharmacological intervention increased mean weight loss by about 2.5kg compared with usual care. Check flu vaccine delivery Production of flu vaccine is proceeding according to plan, the Director of Immunisation has told GPs. Practices should now contact their suppliers to confirm a delivery schedule so that clinics can be arranged. New BNF for Children The fourth BNF for Children has been published, containing new sections on HPV vaccination, contraception, treatment of pelvic inflammatory disease and the use of continuous iv infusions in neonates. BNFC 2008 is available online at bnfc.org/bnfc. MMR catch-up ,urgent' The DoH has called for urgent action to reduce the risk of a measles epidemic. Following years of relatively low uptake of MMR vaccine, the pool of unprotected children is now large enough to raise the prospect of 30 000-100 000 measles cases in England. A catch-up campaign will now target children and young people who have never been vaccinated, followed by those who have not completed their course of immunisation. Resource materials are available at www.immunisation.nhs.uk. , A new brand of MMR vaccine is now available. Sanofi Pasteur MSD has replaced MMRII with a new formulation and presentation, MMRvaxPro. The new vaccine is equivalent to its predecessor and interchangeable with Priorix. Early primary prevention with low-dose aspirin? GPs should consider prescribing low-dose aspirin for primary prevention for men aged 48 and women aged 57, say UK researchers (Heart 2008; published online 15 August 2008. doi:10.1136/hrt.2008.150698). Using data from the THIN network of electronic patient records, they modelled the age at which 10-year coronary risk changed from <10 per cent to >10 per cent in men and women without diabetes, not taking lipid-lowering therapy and with no history of cardiovascular disease. Does COPD therapy slow progression? Treatment with an inhaled steroid and long-acting beta-agonist may slow progression of COPD, according to a new analysis of the TORCH study (Am J Respir Crit Care Med 2008;178:332-8). TORCH was designed to determine the effects of COPD treatment on mortality; the primary analysis found no significant difference between fluticasone/salmeterol (Seretide) and placebo (N Engl J Med 2007;356:775-89). This analysis found that the rate of decline in FEV1 (a marker of disease progression) was significantly greater with placebo (55ml per year) than with salmeterol or fluticasone monotherapy (both 42ml per year) or their combination (39ml per year). Faster decline in FEV1 was associated with current smoking, lower BMI and more frequent exacerbations. Copyright © 2008 Wiley Interface Ltd [source]

Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method

THE MILBANK QUARTERLY, Issue 4 2009
TRISHA GREENHALGH
Context: The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Methods: Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation. Findings: Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful"). Conclusions: The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research. [source]

Tales from the frontline: the colorectal battle against SARS

COLORECTAL DISEASE, Issue 2 2004
I. M. J. Bradford
Abstract Objective The recent worldwide epidemic of Severe Acute Respiratory Disease (SARS) caused over 800 deaths and had a major impact on the health services in affected communities. The impact of SARS on colorectal surgery, particularly service provision and training, is unknown. This paper reports these changes from a single colorectal unit at the centre of the outbreak. Patients and methods Hospital databases and electronic patient records covering the 4 months duration of the SARS epidemic and an equivalent period preceding SARS were compared. Data was collected for inpatient admissions, outpatient consultations, operative surgery, colonoscopy and waiting times for appointments or surgery. Results The SARS epidemic resulted in reductions of 52% for new outpatient attendances, 59% for review attendances, 51% for admissions, 32% for surgical procedures and 48% for colonoscopies. Major emergency procedures, cancer resections and complex major procedures were unaffected. Operative procedures by trainees reduced by 48% and procedures by specialists reduced by 21%. Patients awaiting early or urgent outpatient appointments rose by 200% with waiting times for colonoscopy increased by a median 3, 5 or 9 weeks for outpatient, inpatient or non-urgent cases, respectively. The waiting time for minor elective colorectal surgery was extended by 5 months. Conclusion SARS resulted in a major reduction in the colorectal surgical caseload. The consequences were evidenced by a detrimental effect on waiting times and colorectal training. However, serious pathology requiring emergency or complex surgery was still possible within these constraints. [source]