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Background: Many children attend Emergency Departments (ED) and Out of Hours (OoH) frequently for acute asthma. Follow up care is often suboptimal leaving these children at risk of a future attacks. We report on the development, implementation and evaluation of a safe asthma discharge care pathway (SADCP). Methods: This is a retrospective report on the development, implementation and evaluation of outcomes of a SADCP. The pathway was based on the Teach-to-goal educational methodology that supported the mastery correct inhaler technique and ability to action the personalized asthma action plan (PAAP). Children with frequent asthma attacks were entered as they were discharged from the Emergency Department or ward. The first training session occurred within 1-3 weeks of the index asthma attack with 2 further sessions in the following 8 weeks. Children exiting the pathway were discharged either back to primary care or to a hospital clinic. Results: 81 children entered the pathway (median age 5 years) with 72 discharged from the ED and 9 from the medical wards of the Royal Belfast Hospital for Sick Children. At pathway entry 13% had correct inhaler technique, 10% had a Personalized Asthma Action Plan (PAAP), and 5% had >80% (45% >50%) repeat refill evidence of adherence to inhaled corticosteroid over the previous 12 months. On pathway exit all children demonstrated correct inhaler technique and were able to action their PAAP. One year later 51% and 95% had refill evidence of >80% and >50% adherence. Comparisons of the 12 months before and 12 months after exit from the pathway the median number of emergency ED or OoH asthma attendances and courses of oral corticosteroids reduced to zero with >75% having no attacks requiring this level of attention. Similar findings resulted when the SADCP was implemented in a district general hospital pediatric unit. Conclusion: Implementing an asthma care pathway, using Teach-to-Goal skill training methods and frequent early reviews after an index asthma attack can reduce the future risk of asthma attacks in the next 6 to 12 months.
RESUMO
Background: Umbilical cord prolapse is a rare obstetric emergency requiring rapid coordination of a multidisciplinary team to effect urgent delivery. The decision to delivery interval (DDI) is a marker of quality of teamwork. Multidisciplinary team simulation-based training can be used to improve clinical and teamwork performance. Aim: To assess the DDI for cord prolapse before and after the introduction of simulation-based training at a quaternary maternity unit in Australia. Method: A retrospective, observational cohort study comparing the DDI before and after the introduction of simulation-based training activities. The general linear model was used to estimate the association between DDI and simulation training while adjusting for potential confounders including model of care (public or private) and time of birth (regular or after hours). Results: After the introduction of simulation training, mean DDI decreased by 4.1 min (difference -4.1, 95% CI -6.2 to -1.9), after adjustment for confounding factors. Despite this, there was no difference in selected neonatal outcomes including Apgar score at 5 min and arterial cord pH. Conclusions: The introduction of simulation-based training was associated with a decrease in the DDI in the setting of cord prolapse.
RESUMO
This paper reports on the results of two studies investigating the role of allophony in cueing phonemic contrasts. In Cochabamba Quechua, the uvularvelar place distinction is often cued by additional differences in the height of the surrounding vowels. An acoustic study documents the lowering effect of a preceding tautomorphemic or a following heteromorphemic uvular on the high vowels /i u/. A discrimination study finds that vowel height is a significant cue to the velar-uvular place contrast. These findings support a view of contrasts as collections of distinguishing properties, as opposed to oppositions in a single distinctive feature.