Thirst for change in a challenging environment: healthcare providers' perceptions of safety culture in a large Irish teaching hospital.

BACKGROUND: The Irish healthcare system is currently recognised as being understaffed and under-resourced due to historic underfunding and the aftermath of the 2008 global financial crisis. This descriptive study investigated healthcare providers' perceptions of the safety culture in a large Irish teaching hospital. AIM: The aim of this study was to investigate healthcare workers' perceptions of the safety culture in a large Irish teaching hospital in a climate of national under-resourcing of healthcare. METHODS: Seventeen semi-structured interviews were carried out with patient-attending staff between February and June 2019. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTS: Two predominant themes emerged from the interviews: (1) challenging environment and (2) thirst for change. Study participants described the poor working conditions in the hospital, but also recognised the importance of teamwork and communication in maintaining patient safety and had a strong appetite for change regarding the safety culture in the hospital. CONCLUSION: This study highlights the complex relationship between working conditions and safety culture. Hospital staff were committed to providing the best possible care for their patients but struggled to provide safe care in a challenging work environment. A clear appetite for change was identified amongst HCPs regarding patient safety culture in Irish healthcare.

A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients.

PURPOSE: Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community. METHODS: 183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method. RESULTS: From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective. CONCLUSIONS: Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Overcoming hurdles: measurement of health-related outcomes associated with national level medicines usage in Ireland.

Public discourse on medicine provision predominantly focuses on overall expenditure. However, current literature suggests measurement of alternative indicators can provide a method to benchmark or ameliorate medicine provision. Previous research has investigated the viability of using health-related outcome metrics, such as the number of patients treated, quality-adjusted life-year gain and life-year gain, to provide macro-level estimates on medicines' societal contributions. This editorial provides an overview of the evolving healthcare landscape surrounding medicine usage estimation and valuation in Ireland and offers recommendations on how improved methods of measuring health-related outcomes may help ameliorate efficiencies and the sustainability of a healthcare system.

Safety culture in a major accredited Irish university teaching hospital: a mixed methods study using the safety attitudes questionnaire.

BACKGROUND: The measurement of safety culture, the way in which members of an organisation think about and prioritise safety, in a hospital can provide valuable insight and inform quality improvement strategies. AIMS: The aim of this study is to describe the safety culture of a university teaching hospital in the Republic of Ireland. METHODS: This is a mixed methods survey study using the Safety Attitudes Questionnaire (SAQ). The SAQ was distributed to all staff in the study hospital. Staff attitudes towards six domains of patient safety culture were assessed over 32 Likert-scaled items. Thematic analysis was performed on qualitative data. RESULTS: A total of 768 staff members completed and returned a copy of the SAQ. The hospital scored above the international benchmark in five out of six domains, indicating a positive safety culture, but scored below the international benchmark in the domain 'Working Conditions'. This positive safety culture was not mirrored in the qualitative data, from which five themes emerged; three major-Staffing Issues, Patient-Focused Care and Hospital Environment-and two minor-Safe Reporting Culture and Training and Education. CONCLUSIONS: In this study, a mixed methods approach was successfully used to investigate the safety culture in a large Irish hospital. Although the SAQ results indicated a positive safety culture, the qualitative data revealed a number of issues that the hospital staff felt impacted negatively on patient safety. The results of this study will inform future work on the design of an intervention to improve patient safety in the hospital.

Out of pocket or out of control: A qualitative analysis of healthcare professional stakeholder involvement in pharmaceutical policy change in Ireland.

BACKGROUND: Mandatory co-payments attached to prescription medicines on the Irish public health insurance [General Medical Services (GMS)] scheme have undergone multiple iterations since their introduction in October 2010. To date, whilst patients' opinions on said co-payments have been evaluated, the perspectives of community pharmacists and general practitioners (GPs) have not. OBJECTIVE: To explore the involvement and perceptions of community pharmacists and GPs on this pharmaceutical policy change. METHODS: A qualitative study using purposive sampling alongside snowballing recruitment was used. Nineteen interviews were conducted in a Southern region of Ireland. Data were analysed using the Framework Approach. RESULTS: Three major themes emerged: 1) the withered tax-collecting pharmacist; 2) concerns and prescribing patterns of physicians; and 3) the co-payment system - impact and sustainability. Both community pharmacists and GPs accepted the theoretical concept of a co-payment on the GMS scheme as it prevents moral hazard. However, there were multiple references to the burden that the current method of co-payment collection places on community pharmacists in terms of direct financial loss and reductions in workplace productivity. GPs independently suggested that a co-payment system may inhibit moral hazard by GMS patients in the utilisation of GP services. It was unclear to participants what evidence is guiding the GMS co-payment fee changes. CONCLUSION: Interviewees accepted the rationale for the co-payment system, but reform is warranted.

Health policy triangle framework: Narrative review of the recent literature.

Background: Developed in the late 20th century, the health policy triangle (HPT) is a policy analysis framework used and applied ubiquitously in the literature to analyse a large number of health-related issues. Objective: To explore and summarise the application of the HPT framework to health-related (public) policy decisions in the recent literature. Methods: This narrative review consisted of a systematic search and summary of included articles from January 2015 January 2020. Six electronic databases were searched. Included studies were required to use the HPT framework as part of their policy analysis. Data were analysed using principles of thematic analysis. Results: Of the 2217 studies which were screened for inclusion, the final review comprised of 54 studies, mostly qualitative in nature. Five descriptive categorised themes emerged (i) health human resources, services and systems, (ii) communicable and non-communicable diseases, (iii) physical and mental health, (iv) antenatal and postnatal care and (v) miscellaneous. Most studies were conducted in lower to upper-middle income countries. Conclusion: This review identified that the types of health policies analysed were almost all positioned at national or international level and primarily concerned public health issues. Given its generalisable nature, future research that applies the HPT framework to smaller scale health policy decisions investigated at local and regional levels, could be beneficial.

Cost Minimization Analysis of Intravenous or Subcutaneous Trastuzumab Treatment in Patients With HER2-Positive Breast Cancer in Ireland.

BACKGROUND: Two large acute Irish University teaching hospitals changed the manner in which they treated human epidermal growth factor receptor (HER)2-positive breast cancer patients by implementing the administration of trastuzumab via the subcutaneous (SC) route into their clinical practice. The study objective is to compare the trastuzumab SC and trastuzuamb intravenous (IV) treatment pathways in both hospitals and assess which route is more cost-effective and time saving in relation to active health care professional (HCP) time. MATERIALS AND METHODS: A prospective observational study in the form of cost minimization analysis constituted the study design. Active HCP time for trastuzumab SC- and IV-related tasks were recorded. Staff costs were calculated using fully loaded salary costs. Loss of productivity costs for patients were calculated using the human capital method. RESULTS: On average, the total HCP time saved per trastuzumab SC treatment cycle relative to trastuzumab IV treatment cycle was 59.21 minutes. Time savings in favor of trastuzumab SC resulted from quicker drug reconstitution, no IV catheter installation/removal, and less HCP monitoring. Over a full treatment course of 17 cycles, average HCP time saved accumulates to 16.78 hours, with an estimated direct cost saving of €1609.99. Loss of productivity for patients receiving trastuzumab IV (2.15 days) was greater than that of trastuzumab SC (0.60 days) for a full treatment course. CONCLUSION: Trastuzumab SC treatment has proven to be a more cost-effective option than trastuzumab IV treatment that generated greater HCP time savings in both study sites. Healthcare policymakers should consider replacing trastuzumab IV with trastuzumab SC treatment in all eligible patients.

Discovery of Small Molecule Splicing Modulators of Survival Motor Neuron-2 (SMN2) for the Treatment of Spinal Muscular Atrophy (SMA).

Spinal muscular atrophy (SMA), a rare neuromuscular disorder, is the leading genetic cause of death in infants and toddlers. SMA is caused by the deletion or a loss of function mutation of the survival motor neuron 1 (SMN1) gene. In humans, a second closely related gene SMN2 exists; however it codes for a less stable SMN protein. In recent years, significant progress has been made toward disease modifying treatments for SMA by modulating SMN2 pre-mRNA splicing. Herein, we describe the discovery of LMI070/branaplam, a small molecule that stabilizes the interaction between the spliceosome and SMN2 pre-mRNA. Branaplam (1) originated from a high-throughput phenotypic screening hit, pyridazine 2, and evolved via multiparameter lead optimization. In a severe mouse SMA model, branaplam treatment increased full-length SMN RNA and protein levels, and extended survival. Currently, branaplam is in clinical studies for SMA.

Cost-Effectiveness Analysis of a Physician-Implemented Medication Screening Tool in Older Hospitalised Patients in Ireland.

BACKGROUND: A recent randomised controlled trial conducted in an Irish University teaching hospital that evaluated a physician-implemented medication screening tool, demonstrated positive outcomes in terms of a reduction in incident adverse drug reactions. OBJECTIVE: The present study objective was to evaluate the cost effectiveness of physicians applying this screening tool to older hospitalised patients compared with usual hospital care in the context of the earlier randomised controlled trial. METHOD: We used a cost-effectiveness analysis alongside a conventional outcome analysis in a cluster randomised controlled trial. Patients in the intervention arm (n = 360) received a multifactorial intervention consisting of medicines reconciliation, communication with patients' senior medical team, and generation of a pharmaceutical care plan in addition to usual medical and pharmaceutical care. Control arm patients (n = 372) received usual medical and pharmaceutical care only. Incremental cost effectiveness was examined in terms of costs to the healthcare system and an outcome measure of adverse drug reactions during inpatient hospital stay. Uncertainty in the analysis was explored using a cost-effectiveness acceptability curve. RESULTS: On average, the intervention arm was more costly but was also more effective. Compared with usual care (control), the intervention was associated with a non-statistically significant increase of €877 (95% confidence interval - €1807, €3561) in the mean healthcare cost, and a statistically significant decrease of - 0.164 (95% confidence interval - 0.257, - 0.070) in the mean number of adverse drug reaction events per patient. The associated incremental cost-effectiveness ratio per adverse drug reaction averted was €5358. The probability of the intervention being cost effective at threshold values of €0, €5000 and €10,000 was 0.236, 0.455 and 0.680, respectively. CONCLUSION: Based on the evidence presented, this physician-led intervention is not likely to be cost effective compared with usual hospital care. To inform future healthcare policy decisions in this field, more economic analyses of structured medication reviews by other healthcare professionals and by computerised clinical decision support software need to be conducted.

Computerised interventions designed to reduce potentially inappropriate prescribing in hospitalised older adults: a systematic review and meta-analysis.

Background: computerised interventions have been suggested as an effective strategy to reduce potentially inappropriate prescribing (PIP) for hospitalised older adults. This systematic review and meta-analysis examined the evidence for efficacy of computerised interventions designed to reduce PIP in this patient group. Methods: an electronic literature search was conducted using eight databases up to October 2017. Included studies were controlled trials of computerised interventions aiming to reduce PIP in hospitalised older adults (≥65 years). Risk of bias was assessed using Cochrane's Effective Practice and Organisation of Care criteria. Results: of 653 records identified, eight studies were included-two randomised controlled trials, two interrupted time series analysis studies and four controlled before-after studies. Included studies were mostly at a low risk of bias. Overall, seven studies showed either a statistically significant reduction in the proportion of patients prescribed a potentially inappropriate medicine (PIM) (absolute risk reduction {ARR} 1.3-30.1%), or in PIMs ordered (ARR 2-5.9%). However, there is insufficient evidence thus far to suggest that these interventions can routinely improve patient-related outcomes. It was only possible to include three studies in the meta-analysis-which demonstrated that intervention patients were less likely to be prescribed a PIM (odds ratio 0.6; 95% CI 0.38, 0.93). No computerised intervention targeting potential prescribing omissions (PPOs) was identified. Conclusions: this systematic review concludes that computerised interventions are capable of statistically significantly reducing PIMs in hospitalised older adults. Future interventions should strive to target both PIMs and PPOs, ideally demonstrating both cost-effectiveness data and clinically significant improvements in patient-related outcomes.

The Blurred Line between Form and Process: A Comparison of Stream Channel Classification Frameworks.

Stream classification provides a means to understand the diversity and distribution of channels and floodplains that occur across a landscape while identifying links between geomorphic form and process. Accordingly, stream classification is frequently employed as a watershed planning, management, and restoration tool. At the same time, there has been intense debate and criticism of particular frameworks, on the grounds that these frameworks classify stream reaches based largely on their physical form, rather than direct measurements of their component hydrogeomorphic processes. Despite this debate surrounding stream classifications, and their ongoing use in watershed management, direct comparisons of channel classification frameworks are rare. Here we implement four stream classification frameworks and explore the degree to which each make inferences about hydrogeomorphic process from channel form within the Middle Fork John Day Basin, a watershed of high conservation interest within the Columbia River Basin, U.S.A. We compare the results of the River Styles Framework, Natural Channel Classification, Rosgen Classification System, and a channel form-based statistical classification at 33 field-monitored sites. We found that the four frameworks consistently classified reach types into similar groups based on each reach or segment's dominant hydrogeomorphic elements. Where classified channel types diverged, differences could be attributed to the (a) spatial scale of input data used, (b) the requisite metrics and their order in completing a framework's decision tree and/or, (c) whether the framework attempts to classify current or historic channel form. Divergence in framework agreement was also observed at reaches where channel planform was decoupled from valley setting. Overall, the relative agreement between frameworks indicates that criticism of individual classifications for their use of form in grouping stream channels may be overstated. These form-based criticisms may also ignore the geomorphic tenet that channel form reflects formative hydrogeomorphic processes across a given landscape.

Rapid assembly of quinolizidines via consecutive nucleophilic cyclizations onto activated amides.

A new approach to the synthesis of quinolizidines involving a cascade of nucleophilic cyclizations triggered by chemoselective amide activation is reported. Particular attention was given to the effect of the nature of the tethered nucleophiles on the cascade of cyclizations. As a result, simple acyclic amides gave rapid access to functionalized quinolizidines bearing either a tertiary or quaternary center at the ring junction. Such a fused bicyclic motif is found in several alkaloids.

A 6-year prospective study of 620 stress-diversion surface (SDS) dental implants.

A 6-year prospective study was conducted to assess the clinical success rates and crestal bone response of a dental implant system with a stress-diversion design. Mathematical modeling, digital radiography with applied isodensity, and finite element analysis were used to highlight the effect of the stress distribution design. A total of 386 hydroxyapatite-coated prototypes and 234 commercial grit-blasted external hex implants were placed in virgin bone as well as various grafted maxillary regions, with 36% of the posterior implants being immediately loaded. Prototypes achieved 96.6% survival over a 3-year period. The grit-blasted implant, placed from 2000 to 2003, showed a 95% survival rate. There were no significant changes in crestal bone levels after the first 12 months of prosthetic loading. Engineering evaluations suggested that undesirable stresses were distributed from the crest of the ridge down through the center of the implant body.

Speaking out against abortion.

In response to Abortion and nurses who say no (Nursing Standard Letters, June 12), I appeal to nurses who participate in abortions to examine their practice in terms of the UK Central Council's Code of Professional Conduct.