Exploring two distinct gentamicin prescribing protocols in UK hospitals: a mixed-methods realist evaluation.

OBJECTIVES: Gentamicin is the aminoglycoside antibiotic of choice in the UK. It has a narrow therapeutic index: underdosing results in inefficacy while overdosing is characterised by nephrotoxicity and ototoxicity. To improve patient safety, hospitals have protocols for the prescription of gentamicin, which vary in complexity and approach. This study aimed to explore two distinct protocols for prescribing gentamicin in hospital settings, in order to understand the mechanisms they trigger and the outcomes they achieve. SETTING: A mixed-methods realist evaluation explored gentamicin prescribing protocols in two hospital surgical admissions units in South West England between January and August 2018. Site 1 had a traditional, complex protocol, while site 2 took a simplified protocol. PARTICIPANTS: Testing the initial programme theory (IPT) involved semi-structured audio-recorded interviews of a volunteer sample of healthcare professionals (HCPs) involved in the prescribing and administering process, alongside a clinical audit reviewing accuracy of gentamicin prescribing. OUTCOME MEASURES: Three sequential phases were used to identify factors in a successful protocol: IPT generation; testing; refinement of the IPT. The IPT was generated by literature search and analysis of existing protocols of sites 1 and 2. Refinement of the IPT synthesised the results of the quantitative and qualitative research to identify the key characteristics of a successful protocol. RESULTS: One hundred gentamicin prescriptions were reviewed, with a mean accuracy of gentamicin prescribing at site 1 of 65.67% and at site 2 of 78.79% (p<0.01). Thirty HCPs were interviewed. Key contexts were identified including prescriptiveness, experience and availability of patient information. These triggered hidden mechanisms including uncertainty, fear, confidence and frustration leading to both intended outcomes but also unintended outcomes such as deviation from protocol and unnecessary gentamicin levels. CONCLUSIONS: A simplified prescribing protocol for gentamicin is better accepted by prescribers, leading to better adherence to protocol and more accurate prescribing.

Quality of life in restorative versus non-restorative resections for rectal cancer: systematic review.

BACKGROUND: Low rectal cancers could be treated using restorative (anterior resection, AR) or non-restorative procedures with an end/permanent stoma (Hartmann's, HE; or abdominoperineal excision, APE). Although the surgical choice is determined by tumour and patient factors, quality of life (QoL) will also influence the patient's future beyond cancer. This systematic review of the literature compared postoperative QoL between the restorative and non-restorative techniques using validated measurement tools. METHODS: The review was registered on PROSPERO (CRD42020131492). Embase and MEDLINE, along with grey literature and trials websites, were searched comprehensively for papers published since 2012. Inclusion criteria were original research in an adult population with rectal cancer that reported QoL using a validated tool, including the European Organization for Research and Treatment of Cancer QLQ-CR30, QLQ-CR29, and QLQ-CR38. Studies were included if they compared AR with APE (or HE), independent of study design. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Outcomes of interest were: QoL, pain, gastrointestinal (GI) symptoms (stool frequency, flatulence, diarrhoea and constipation), and body image. RESULTS: Nineteen studies met the inclusion criteria with a total of 6453 patients; all papers were observational and just four included preoperative evaluations. There was no identifiable difference in global QoL and pain between the two surgical techniques. Reported results regarding GI symptoms and body image documented similar findings. The ROBINS-I tool highlighted a significant risk of bias across the studies. CONCLUSION: Currently, it is not possible to draw a firm conclusion on postoperative QoL, pain, GI symptoms, and body image following restorative or non-restorative surgery. The included studies were generally of poor quality, lacked preoperative evaluations, and showed considerable bias in the data.

The Exeter Knee Infection Multi Disciplinary Team approach to managing prosthetic knee infections: A qualitative analysis.

BACKGROUND: A Knee Infection Multi-Disciplinary Team meeting was established in Exeter. This study was designed to qualitatively evaluate the impact of the MDT on those involved. MATERIALS AND METHODS: Semi-structured interviews of all members of the MDT at Exeter were undertaken and analysed using Nvivo software. Data was coded to identify common patterns and trends. RESULTS: The common themes identified were improved communication and standardisation of care. The main challenges identified were the timing of the meetings and funding. CONCLUSION: This study has used established qualitative techniques to evaluate the impact of the Exeter Knee Infection MDT.