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2.
J Environ Radioact ; 257: 107075, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36462454

RESUMO

Ultra-low-level measurements of radionuclides in air have been conducted at the Savannah River National Laboratory (SRNL) to determine the atmospheric concentration of fission products released following the Fukushima Daiichi reactor accident on March 11, 2011. Air filter samples were acquired from two high-volume collection systems (a traditional filter-based system and an electrostatic precipitator-based system) to monitor airborne radionuclide concentrations in the period covering from 2 weeks to 3 years after the disaster. The world-wide spread of low-level concentrations of airborne fission products from the Fukushima event provided a unique opportunity to demonstrate SRNL's electrostatic particle collection technology and other improvements in environmental monitoring developed at the Savannah River Site (SRS). Detecting and analyzing the release allowed a comprehensive test of SRS systems for monitoring environmental radioactivity. Gamma-ray-emitting fission products (131,132I, 134,136,137Cs, and 129,132Te) and cosmogenic isotopes (7Be and 22Na) in air were detected and quantified by high-resolution gamma-ray spectroscopy at concentrations as low as 0.07 µBq per standard cubic meter (SCM) (50 mBq total 137Cs), while plutonium content was quantified by thermal ionization mass spectrometry (TIMS) at concentrations as low as 6.5 × 10-21 g/SCM (3.0 fg 239+240Pu). Isotope concentrations measured at SRNL from gamma-ray spectroscopy were compared to independent measurements from Chapel Hill, NC, located approximately 370 km (230 mi) NE of SRNL. Meteorological modeling was also used to predict radionuclide transport from the location of release to both measurement locations.


Assuntos
Poluentes Radioativos do Ar , Acidente Nuclear de Fukushima , Monitoramento de Radiação , Poluentes Radioativos do Ar/análise , Monitoramento de Radiação/métodos , Radioisótopos de Césio/análise , Espectrometria de Massas , Rios , Japão
3.
Age Ageing ; 51(10)2022 10 06.
Artigo em Inglês | MEDLINE | ID: mdl-36273344

RESUMO

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM: To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS: Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS: A qualitative research design using semi-structured interviews. RESULTS: Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS: The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.


Assuntos
Planejamento Antecipado de Cuidados , Serviços Médicos de Emergência , Humanos , Casas de Saúde , Pesquisa Qualitativa , Comunicação
4.
BMJ Open ; 12(9): e063495, 2022 09 20.
Artigo em Inglês | MEDLINE | ID: mdl-36127084

RESUMO

OBJECTIVES: To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. DESIGN: Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. SETTING AND PARTICIPANTS: Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. RESULTS: There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). CONCLUSIONS: We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. TRIAL REGISTRATION NUMBER: ISCRTN5178022.


Assuntos
Clínicos Gerais , Serviço Hospitalar de Emergência , Hospitalização , Humanos , Pacientes Internados , Estudos Retrospectivos
5.
Pain Med ; 22(12): 2884-2895, 2021 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-34180996

RESUMO

OBJECTIVE: A qualitative study of patients' experiences and the impacts of peer support groups that patients maintained after UK NHS group pain management programs (PMPs). DESIGN: Long-term impacts of group PMPs remain unclear, with indications that positive effects can fade. We evaluated a model of continued peer support, co-produced by patients and clinicians, to maintain the therapeutic impact of PMP groups. A protocol was implemented that encouraged patients to continue to meet in their established PMP group for patient-led peer support (without clinical input) after PMPs finished. Peer support aimed to consolidate self-management, and advance social life recovery. We examined the impacts that groups had on attendees, and why some dropped out. METHODS: Semi-structured interviews with 38 patients and 7 clinicians, analyzed thematically. RESULTS: Friendship bonds and mutual understandings of effective ways of coping with pain encouraged participants to maintain recovery following PMPs. After PMP professional involvement has ended, these meetings enabled patients to develop greater agency from the shared sense of helping bring about new achievements or averting setbacks. Peer support extended the understanding of what is possible when living with pain. However, continuing meetings were not right for all. Reasons for not attending included lack of connection with peers. CONCLUSIONS: Co-produced peer support groups after PMPs can be a low-cost, effective social intervention, providing emotional, practical and social benefits, with improved self-management skills, stronger social connections and some reduced use of health services. Project resources for developing peer support meetings after PMPs are freely available online.


Assuntos
Dor Crônica , Manejo da Dor , Dor Crônica/terapia , Humanos , Grupo Associado , Pesquisa Qualitativa , Grupos de Autoajuda , Apoio Social
6.
Int J Nurs Stud ; 120: 103980, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34107355

RESUMO

BACKGROUND: Emergency Department attendance is increasing internationally, of which a significant proportion could be managed in general practice. In England, policies backed by substantial capital funding require such patients attending Emergency Departments be directed or 'streamed' to General Practitioners working in or parallel to Emergency Departments. However, evidence for streaming is limited and the processes of streaming patients attending Emergency Departments to General Practitioners lacks exploration. OBJECTIVES: This paper explores streaming to General Practitioners in and alongside Emergency Departments at ten sites across England. It highlights positive streaming practice, as well as issues that may contribute to poor streaming practice, in order to inform future service improvement. METHODS: A longitudinal qualitative study was conducted with data collected between October 2017 and December 2019 across 10 case study sites throughout England as part of a broader mixed methods study. 186 non-participant observations and 226 semi-structured interviews with 191 health professionals working in Emergency Departments or related General Practitioner Services were thematically analysed in relation to streaming processes and experiences. RESULTS: Six interconnected themes influencing streaming were identified: implementing and maintaining structural support; developing and supporting streaming personnel; implementing workable and responsive streaming protocols; negotiating primary/secondary care boundaries; developing and maintaining interprofessional relationships and concerns for patient safety. Streaming was considered central to the success of General Practitioners in/parallel to Emergency Departments. The importance of the skills of streaming nurses in delivering an optimal and safety critical service was highlighted, as was the skillset of General Practitioners and interprofessional relationships between streamers and General Practitioners. There was no distinct streaming model or method associated with good streaming practice to General Practitioners in/alongside Emergency Departments, instead factors for success were identified and key recommendations suggested. 'Inappropriate' streaming was identified as a problem, where patients streamed to General Practitioners in or parallel to Emergency Departments required Emergency Department management, or patients suitable for General Practitioner care were kept in the Emergency Department. CONCLUSION: Despite adopting differing methods, commonalities across case sites in the delivery of good streaming practice were identified, leading to identification of key recommendations which may inform development of streaming services. STUDY REGISTRATION: ISRCTN51780222. Tweetable abstract: Workplace culture and the skillset of streamers and General Practitioners is crucial to streaming of patients to General Practitioners in Emergency Departments.


Assuntos
Medicina Geral , Clínicos Gerais , Serviço Hospitalar de Emergência , Inglaterra , Humanos , Pesquisa Qualitativa
7.
BMJ Open ; 11(5): e045453, 2021 05 24.
Artigo em Inglês | MEDLINE | ID: mdl-34031113

RESUMO

OBJECTIVES: To explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These 'expectations of impact' can be used to generate hypotheses that will inform future implementations and evaluations of GPED. DESIGN: Qualitative study consisting of 228 semistructured interviews. SETTING: 10 acute National Health Service (NHS) hospitals and the wider healthcare system in England. Interviews were undertaken face to face or via telephone. Data were analysed thematically. PARTICIPANTS: 124 health professionals and 94 patients and carers. 10 service leaders representing a range of national organisations and government departments across England (eg, NHS England and Department of Health) were also interviewed. RESULTS: A range of GPED models are being implemented across the NHS due to different interpretations of national policy and variation in local context. This has resulted in stakeholders and organisations interpreting the aims of GPED differently and anticipating a range of potential impacts. Participants expected GPED to affect the following areas: ED performance indicators; patient outcome and experience; service access; staffing and workforce experience; and resources. Across these 'domains of influence', arguments for positive, negative and no effect of GPED were proposed. CONCLUSIONS: Evaluating whether GPED has been successful will be challenging. However, despite uncertainty surrounding the direction of effect, there was agreement across all stakeholder groups on the areas that GPED would influence. As a result, we propose eight domains of influence that will inform our subsequent mixed-methods evaluation of GPED. TRIAL REGISTRATION NUMBER: ISRCTN51780222.


Assuntos
Clínicos Gerais , Serviço Hospitalar de Emergência , Inglaterra , Humanos , Pesquisa Qualitativa , Medicina Estatal
8.
Emerg Med J ; 38(10): 780-783, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33619158

RESUMO

BACKGROUND: In 2017, general practitioners in or alongside the emergency department (GPED), an approach that employs GPs in or alongside the ED to address increasing ED demand, was advocated by the National Health Service in England and supported by capital funding. However, little is known about the models of GPED that have been implemented. METHODS: Data were collected at two time points: September 2017 and December 2019, on the GPED model in use (if any) at 163/177 (92%) type 1 EDs in England. Models were categorised according to a taxonomy as 'inside/integrated', 'inside/parallel', 'outside/onsite' or 'outside/offsite'. Multiple data sources used included: on-line surveys, interviews, case study data and publicly available information. RESULTS: An increase of EDs using GPED was observed from 81% to 95% over the study period. 'Inside/parallel' was the most frequently used model: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The adoption of 'inside/integrated' models fell from 26% (38/149) to 9% (15/159). Capital funding was received by 87% (142/163) of the EDs sampled. We identified no significant difference between the GPED model adopted and observable characteristics of EDs of annual attendance, 4-hour wait, rurality and deprivation within the population served. CONCLUSION: The majority of EDs in England have now adopted GPED. The availability of capital funding to finance structural changes so that separate GP services can be provided may explain the rise in parallel models and the decrease in integrated models. Further research is required to understand the relative effectiveness of the various models of GPED identified.


Assuntos
Comportamento Cooperativo , Serviço Hospitalar de Emergência/tendências , Clínicos Gerais/tendências , Serviço Hospitalar de Emergência/organização & administração , Inglaterra , Humanos , Pesquisa Qualitativa
9.
Glob Qual Nurs Res ; 7: 2333393620930024, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32596418

RESUMO

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals' standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients' care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making.

10.
Arch Environ Contam Toxicol ; 79(1): 131-146, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32285161

RESUMO

Former nuclear weapons material production at the U.S. Department of Energy's Savannah River Site (SRS) has resulted in contamination of certain terrestrial and aquatic ecosystems on site with legacy wastes such as radiocesium (137Cs), tritium (3H), and metals. We collected fish and invertebrates from five beaver ponds (sites) above, adjacent, and downgradient of three SRS facilities (H-, F-, and C-Areas) to evaluate whether the accumulation of metals and radionuclides in biota were associated with specific facility operations and if the measured levels could pose risks to aquatic organisms. We compared concentrations of various metals, 137Cs, and 3H in fish, as well as in water (3H only), among sites along the stream gradient. Fish collected from sites adjacent to H-Area had significantly higher 137Cs concentrations compared to fish from other sites. Both biota and water samples indicated significantly greater levels of 3H in sites adjacent to and downstream of C-Area. Concentrations of zinc (Zn), copper (Cu), and mercury (Hg) in some samples exceeded effects levels reported for fish and may pose a risk to fish populations. This study reported fish tissue concentrations of 137Cs and 3H, which have not been documented extensively in ecotoxicological studies. Our results suggested that industrial operations such as nuclear material production at SRS could have long-lasting impact on the aquatic ecosystem via the release of radionuclides and metals, and long-term monitoring of physiological effects and population level impact in biota exposed to these contaminants are recommended.


Assuntos
Organismos Aquáticos/química , Armas Nucleares , Monitoramento de Radiação/métodos , Rios/química , Poluentes Radioativos da Água/análise , Animais , Organismos Aquáticos/efeitos dos fármacos , Radioisótopos de Césio/análise , Peixes/metabolismo , Invertebrados/química , Invertebrados/efeitos dos fármacos , Metais Pesados/análise , Lagoas/química , South Carolina , Trítio/análise
11.
J Clin Nurs ; 29(7-8): 1267-1275, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31944438

RESUMO

AIMS AND OBJECTIVES: To explore the extent to which a checklist designed to support patient safety in hospital Emergency Departments was recognised and used by staff. BACKGROUND: Patient crowding in UK Emergency Departments makes it difficult for staff to monitor all patients for signs of clinical deterioration. An Emergency Department Safety Checklist was developed at a UK hospital to ensure patients are regularly monitored. It was subsequently implemented in six hospitals and recommended for use across the National Health Service in England. METHODS: This was a qualitative study in two UK hospital Emergency Departments. Data collection consisted of sixty-six hours of nonparticipant observation and interviews with twenty-six staff. Observations were sampled across different days and times. Interviews sampled a range of staff. Data were analysed thematically. The study was undertaken in accordance with COREQ guidelines. RESULTS: Staff described the Emergency Department Safety Checklist as a useful prompt and reminder for monitoring patients' vital signs and other aspects of care. It was also reported as effective in communicating patient care status to other staff. However, completing the checklist was also described as a task which could be overlooked during busy periods. During implementation, the checklist was promoted to staff in ways that obscured its core function of maintaining patient safety. CONCLUSIONS: The Emergency Department Safety Checklist can support staff in maintaining patient safety. However, it was not fully recognised by staff as a core component of everyday clinical practice. RELEVANCE TO CLINICAL PRACTICE: The Emergency Department Safety Checklist is a response to an overcrowded environment. To realise the potential of the checklist, emergency departments should take the following steps during implementation: (a) focus on the core function of clinical safety, (b) fully integrate the checklist into the existing workflow and (c) employ a departmental team-based approach to implementation and training.


Assuntos
Lista de Checagem/métodos , Serviço Hospitalar de Emergência/organização & administração , Segurança do Paciente/normas , Inglaterra , Feminino , Humanos , Masculino , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Pesquisa Qualitativa , Melhoria de Qualidade , Fluxo de Trabalho
12.
BMJ Open ; 8(10): e022528, 2018 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-30368449

RESUMO

OBJECTIVES: Early warning scores were developed to improve recognition of clinical deterioration in acute hospital settings. In England, the National Early Warning Score (NEWS) is increasingly being recommended at a national level for use outside such settings. In 2015, the West of England Academic Health Science Network supported the roll-out of NEWS across a range of non-acute-hospital healthcare sectors. Research on the use of NEWS outside acute hospitals is limited. The objective of this study was to explore staff experiences of using NEWS in these new settings. DESIGN: Thematic analysis of qualitative semi-structured interviews with purposefully sampled healthcare staff. SETTING: West of England healthcare settings where NEWS was being used outside acute hospitals-primary care, ambulance, referral management, community and mental health services. PARTICIPANTS: Twenty-five healthcare staff interviewed from primary care (9), ambulance (3), referral management/acute interface (5), community (4) and mental health services (3), and service commissioning (1). RESULTS: Participants reported that NEWS could support clinical decision-making around escalation of care, and provide a clear means of communicating clinical acuity between clinicians and across different healthcare organisations. Challenges with implementing NEWS varied-in primary care, clinicians had to select patients for NEWS and adopt different methods of clinical assessment, whereas for paramedics it fitted well with usual clinical practice and was used for all patients. In community services and mental health, modifications were 'needed' to make the tool relevant to some patient populations. CONCLUSIONS: This study demonstrated that while NEWS can work for staff outside acute hospital settings, the potential for routine clinical practice to accommodate NEWS in such settings varied. A tailored approach to implementation in different settings, incorporating guidance supported by further research on the use of NEWS with specific patient groups in community settings, may be beneficial, and enhance staff confidence in the tool.


Assuntos
Atitude do Pessoal de Saúde , Deterioração Clínica , Serviços Médicos de Emergência/métodos , Atenção à Saúde/tendências , Serviço Hospitalar de Emergência , Inglaterra , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa
13.
Br J Gen Pract ; 68(672): e478-e486, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29866710

RESUMO

BACKGROUND: The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. AIM: The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. DESIGN AND SETTING: The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. METHOD: Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. RESULTS: Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery. CONCLUSION: A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations.


Assuntos
Medicina Geral/organização & administração , Recepcionistas de Consultório Médico , Gerenciamento da Prática Profissional/organização & administração , Encaminhamento e Consulta/organização & administração , Antropologia Cultural , Agendamento de Consultas , Comunicação , Inglaterra , Medicina Geral/tendências , Pesquisa sobre Serviços de Saúde , Humanos , Recepcionistas de Consultório Médico/organização & administração , Recepcionistas de Consultório Médico/tendências , Gerenciamento da Prática Profissional/tendências , Escócia
14.
Br J Gen Pract ; 68(669): e293-e300, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29378697

RESUMO

BACKGROUND: NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives. AIM: To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice. DESIGN AND SETTING: Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016. METHOD: Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the 'one sheet of paper' mind-map method to identify the line of argument in each thematic report. RESULTS: Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other's practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face consultation as the ideal. CONCLUSION: Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team.


Assuntos
Antropologia Cultural , Medicina Geral , Satisfação do Paciente/estatística & dados numéricos , Consulta Remota , Adulto , Atitude do Pessoal de Saúde , Feminino , Medicina Geral/organização & administração , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Relações Médico-Paciente , Gerenciamento da Prática Profissional , Reino Unido , Carga de Trabalho
15.
BMC Health Serv Res ; 17(1): 436, 2017 06 24.
Artigo em Inglês | MEDLINE | ID: mdl-28646876

RESUMO

BACKGROUND: Increasing pressure in the United Kingdom (UK) urgent care system has led to Emergency Departments (EDs) failing to meet the national requirement that 95% of patients are admitted, discharged or transferred within 4-h of arrival. Despite the target being the same for all acute hospitals, individual Trusts organise their services in different ways. The impact of this variation on patient journey time and waiting is unknown. Our study aimed to apply the Lean technique of Value Stream Mapping (VSM) to investigate care processes and delays in patient journeys at four contrasting hospitals. METHODS: VSM timing data were collected for patients accessing acute care at four hospitals in South West England. Data were categorised according to waits and activities, which were compared across sites to identify variations in practice from the patient viewpoint. We included Public and Patient Involvement (PPI) to fully interpret our findings; observations and initial findings were considered in a PPI workshop. RESULTS: One hundred eight patients were recruited, comprising 25,432 min of patient time containing 4098 episodes of care or waiting. The median patient journey was 223 min (3 h, 43 min); just within the 4-h target. Although total patient journey times were similar between sites, the stage where the greatest proportion of waiting occurred varied. Reasons for waiting were dominated by waits for beds, investigations or results to be available. From our sample we observed that EDs without a discharge/clinical decision area exhibited a greater proportion of waiting time following an admission or discharge decision. PPI interpretation indicated that patients who experience waits at the beginning of their journey feel more anxious because they are 'not in the system yet'. CONCLUSIONS: The novel application of VSM analysis across different hospitals, coupled with PPI interpretation, provides important insight into the impact of care provision on patient experience. Measures that could reduce patient waiting include automatic notification of test results, and the option of discharge/clinical decision areas for patients awaiting results or departure. To enhance patient experience, good communication with patients and relatives about reasons for waits is essential.


Assuntos
Procedimentos Clínicos , Serviço Hospitalar de Emergência , Tratamento de Emergência , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Técnicas de Observação do Comportamento , Inglaterra , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Adulto Jovem
16.
Mar Pollut Bull ; 117(1-2): 178-183, 2017 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-28162252

RESUMO

We compared total mercury (Hg) concentrations in whole blood of harlequin ducks (Histrionicus histrionicus) sampled within and among two geographically distinct locations and across three years in southwest Alaska. Blue mussels were collected to assess correlation between Hg concentrations in locally available forage and birds. Mercury concentrations in harlequin duck blood were significantly higher at Unalaska Island (0.31±0.19 mean±SD, µg/g blood) than Kodiak Island (0.04±0.02 mean±SD, µg/g blood). We found no evidence for annual variation in blood Hg concentration between years at Unalaska Island. However, blood Hg concentration did vary among specific sampling locations (i.e., bays) at Unalaska Island. Findings from this study demonstrate harlequin ducks are exposed to environmental sources of Hg, and whole blood Hg concentrations are associated with their local food source.


Assuntos
Patos/sangue , Monitoramento Ambiental , Mercúrio/sangue , Mytilus edulis/química , Poluentes Químicos da Água/sangue , Alaska , Animais , Poluentes da Água/sangue
17.
Br J Gen Pract ; 66(648): e460-6, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27215571

RESUMO

BACKGROUND: The ubiquitous use of communication technologies has led to an expectation that a similar approach should extend to health care. Despite considerable rhetoric about the need for general practices to offer alternatives to face-to-face consultations, such as telephone, email, and internet video consultations, the extent to which such technologies are actually used at present is unclear. AIM: The aim of the survey was to identify the frequency and range of ways in which general practices are providing (or planning) alternatives to face-to-face consultations. DESIGN AND SETTING: A postal survey of practices around Bristol, Oxford, Lothian, the Highlands, and the Western Isles of Scotland. METHOD: A postal questionnaire survey was sent to each of the GPs and practice managers of 421 practices between January and May 2015. RESULTS: A response was received from 319/421 practices (76%). Although the majority of the practices reported that they were conducting telephone consultations frequently (n = 211/318, 66%), fewer were implementing email consultations (n = 18/318, 6%), and most (n = 169/318, 53%) had no plans to introduce this. None were currently using internet video, and 86% (n = 273/318) had no plans to introduce internet video consultations. These findings were repeated in the reported use of alternatives to face-to-face consultations at an individual GP level. Optional free text responses were completed by 28% of responders, and offered an explanation for the (often perceived) barriers and incentives for implementation. CONCLUSION: Despite policy pressure to introduce consultations by email and internet video, there is a general reluctance among GPs to implement alternatives to face-to-face consultations. This identifies a substantial gap between rhetoric and reality in terms of the likelihood of certain alternatives (email, video) changing practice in the near future.


Assuntos
Atitude do Pessoal de Saúde , Medicina Geral/métodos , Internet , Consulta Remota/organização & administração , Correio Eletrônico , Inglaterra , Pesquisas sobre Atenção à Saúde , Humanos , Internet/estatística & dados numéricos , Satisfação do Paciente , Gerenciamento da Prática Profissional/organização & administração , Prevalência , Escócia , Gravação em Vídeo , Carga de Trabalho
18.
Sci Rep ; 6: 21512, 2016 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-26898531

RESUMO

Owing to the rich history of heavy element production in the unique high flux reactors that operated at the Savannah River Site, USA (SRS) decades ago, trace quantities of plutonium with highly unique isotopic characteristics still persist today in the SRS terrestrial environment. Development of an effective sampling, processing, and analysis strategy enables detailed monitoring of the SRS environment, revealing plutonium isotopic compositions, e.g., (244)Pu, that reflect the unique legacy of plutonium production at SRS. This work describes the first long-term investigation of anthropogenic (244)Pu occurrence in the environment. Environmental samples, consisting of collected foot borne debris, were taken at SRS over an eleven year period, from 2003 to 2014. Separation and purification of trace plutonium was carried out followed by three stage thermal ionization mass spectrometry (3STIMS) measurements for plutonium isotopic content and isotopic ratios. Significant (244)Pu was measured in all of the years sampled with the highest amount observed in 2003. The (244)Pu content, in femtograms (fg = 10(-15) g) per gram, ranged from 0.31 fg/g to 44 fg/g in years 2006 and 2003 respectively. In all years, the (244)Pu/(239)Pu atom ratios were significantly higher than global fallout, ranging from 0.003 to 0.698 in years 2014 and 2003 respectively.

19.
Environ Sci Technol ; 49(3): 1286-93, 2015 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-25535652

RESUMO

This work presents the findings of a long-term plutonium (Pu) study at Savannah River Site (SRS) conducted between 2003 and 2013. Terrestrial environmental samples were obtained at the Savannah River National Laboratory (SRNL) in the A-Area. Plutonium content and isotopic abundances were measured over this time period by α particle and thermal ionization mass spectrometry (3STIMS). We detail the complete process of the sample collection, radiochemical separation, and measurement procedure specifically targeted to trace plutonium in bulk environmental samples. Total plutonium activities were determined to be not significantly above atmospheric global fallout. However, the (238)Pu/(239+240)Pu activity ratios attributed to SRS are substantially different than fallout due to past (238)Pu production on the site. The (240)Pu/(239)Pu atom ratios are reasonably consistent from year to year and are lower than fallout indicating an admixture of weapons-grade material, while the (242)Pu/(239)Pu atom ratios are higher than fallout values, again due to actinide production activities. Overall, the plutonium signatures obtained in this study reflect a distinctive mixture of weapons-grade, heat source, and higher burn-up plutonium with fallout material. This study provides a unique opportunity for developing and demonstrating a blue print for long-term low-level monitoring of trace plutonium in the environment.


Assuntos
Sedimentos Geológicos/química , Plutônio/análise , Monitoramento de Radiação/métodos , Rios , Poluentes Radioativos do Solo/análise , Estudos Longitudinais , Espectrometria de Massas/métodos , Radioisótopos/análise , Estados Unidos
20.
Environ Toxicol Chem ; 33(12): 2711-5, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25242147

RESUMO

Climatic variation, including precipitation amounts and timing, has been linked to abundance and breeding success of many avian species. Less studied, but also of significance, is the consequence of climatic variability on the exposure and uptake of nutrients and contaminants by wildlife. The authors examined mercury (Hg) concentrations in nestling wood stork feathers in a coastal setting over a 16-yr period to understand the influence of rainfall amounts on Hg transfer by parental provisioning relative to habitat use, assuming differential bioavailability of Hg within freshwater and saltwater habitat types. Coastal Hg uptake by stork nestlings was linked to freshwater habitat use, as indicated by stable carbon isotope (δ(13)C) analyses. Cumulative rainfall amounts exceeding 220 cm in the 23 mo preceding the breeding seasons resulted in greater use of freshwater wetlands as foraging habitat and greater Hg accumulation by nestling storks.


Assuntos
Mercúrio/metabolismo , Chuva , Poluentes Químicos da Água/análise , Áreas Alagadas , Animais , Aves , Isótopos de Carbono/química , Ecossistema , Plumas/química , Água Doce/química , Espectrometria de Massas , Mercúrio/análise , Comportamento de Nidação , Isótopos de Nitrogênio/química
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