The Prognosis in Palliative care Study II (PiPS2): A prospective observational validation study of a prognostic tool with an embedded qualitative evaluation.

BACKGROUND: Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of 14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs). METHODS AND FINDINGS: A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES [PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851]. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57-74% risk group (Calibration-in-the-large [CiL] -0.202; Calibration slope [CS] 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation. CONCLUSIONS: PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice. STUDY REGISTRATION: ISRCTN13688211.

Prognostic tools or clinical predictions: Which are better in palliative care?

PURPOSE: The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS). METHODS: This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse. RESULTS: Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups. CONCLUSIONS: Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.

Room temperature ballistic transport in InSb quantum well nanodevices.

We report the room temperature observation of significant ballistic electron transport in shallow etched four-terminal mesoscopic devices fabricated on an InSb/AlInSb quantum well (QW) heterostructure with a crucial partitioned growth-buffer scheme. Ballistic electron transport is evidenced by a negative bend resistance signature which is quite clearly observed at 295 K and at current densities in excess of 10(6) A/cm(2). This demonstrates unequivocally that by using effective growth and processing strategies, room temperature ballistic effects can be exploited in InSb/AlInSb QWs at practical device dimensions.

Systems mapping workshops and their role in understanding medication errors in healthcare.

Systems mapping workshops have been applied to the problem of medication errors in healthcare. The workshops were designed using experiential group work principles. They involved a range of stakeholders from within the health service as well as those who supply the health sector, including designers who may be able to enhance the safety of products and systems used in healthcare. Research has shown that the method encourages stakeholder participation, provides robust results within a limited time and enhances understanding across specialist interest groups. Additional, creative design workshops that considered the same topic showed significant promise in developing concepts from which potential solutions could be developed further.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

INTRODUCTION: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. METHODS: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. RESULTS: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. CONCLUSIONS: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Patient safety, systems design and ergonomics.

The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealing with patient safety. It also provides examples of approaches and methods that ergonomists can bring to help inform our knowledge of these systems and the potential towards improving their safety. Mapping workshops provide an example of such methods. Results from these are used to illustrate how the knowledge base required for better design requirements can be generated. The workshops were developed specifically to help improve the design of medication packaging and thereby reduce the probability of medication error. The issues raised are now the subject of further research, design requirements guidance and new design concepts. The paper illustrates the need to engage with the design community and, through the use of robust scientific methods, to generate appropriate design requirements.

Assessing investment in manual handling risk controls: a scoring system for use in observational studies.

Most UK hospitals now have manual handling policies, but few studies have assessed their impact. To facilitate such research, a system for ranking the investment in manual handling risk controls was devised and applied to 109 acute hospitals in the UK. High scoring hospitals performed well on all aspects of manual handling risk management. Low scoring hospitals had a manual handling policy and recorded accidents and sickness absence, but had limited resource for expert manpower and equipment.

Manual handling risk controls in hospitals (MARCH): a cross-sectional survey of UK hospitals.

Injury and ill health among healthcare staff associated with handling patients is an important area of risk for UK National Health Service (NHS) employers. Since the introduction of a specific legal duty to control this risk in 1992, many Trusts have developed manual handling risk management strategies. Anecdotally, however, practice varies between Trusts and there is no published description of common practice among NHS employers. The latter would be useful as a benchmark for risk managers. Therefore, we undertook a cross-sectional survey of 158 UK trusts (81% of those invited) using a structured interviewer-administered questionnaire to collect information about manual handling risk controls. Most Trusts had basic systems for risk management, including defined management accountability, written policies, provision of handling equipment, training, expert advice about manual handling and access to occupational health services and physiotherapy for injured employees. However, there was wide variation in important aspects, including the extent of expert manpower and criteria for referral to occupational health. Arrangements for monitoring risk controls were generally poor, and the variation in practice was a cause for concern. These data will help NHS employers by providing a benchmark against which to measure and develop risk management systems for manual handling. Future research should aim to develop standards through consensus opinion and ultimately evidence of effectiveness of risk controls.

Risk factors for incident neck and shoulder pain in hospital nurses.

AIM: To assess the incidence and risk factors for neck and shoulder pain in nurses. METHODS: A longitudinal study of neck and shoulder pain was carried out in female nurses at two hospitals in England. Personal and occupational risk factors were assessed at baseline. The self reported incidence of symptoms in the neck and shoulder region was ascertained at three-monthly intervals over two years. A Cox regression model was used to estimate hazard ratios (HRs) for incident neck/shoulder pain during follow up in nurses who had been pain free for at least one month at baseline. RESULTS: The baseline response rate was 56%. Of 903 women who were pain free at baseline, 587 (65%) completed at least one follow up while still in the same job. During an average of 13 months, 34% of these (202 women) reported at least one episode of neck/shoulder pain. The strongest predictor of pain in the neck/shoulder was previous history of the symptom (HRs up to 3.3). For physical exposures at work, the highest risks (HRs up to 1.7) were associated with specific patient handling tasks that involved reaching, pushing, and pulling. Nurses who reported low mood or stress at baseline were more likely to develop neck/shoulder pain later (HR 1.5). Workplace psychosocial factors (including job demands, satisfaction, and control) were not associated with incident neck/shoulder symptoms. CONCLUSIONS: Neck/shoulder pain is common among hospital nurses, and patient handling tasks that involve reaching and pulling are the most important target for risk reduction strategies.

Epidemiological study to investigate potential interaction between physical and psychosocial factors at work that may increase the risk of symptoms of musculoskeletal disorder of the neck and upper limb.

OBJECTIVES: To investigate potential interactions between physical and psychosocial risk factors in the workplace that may be associated with symptoms of musculoskeletal disorder of the neck and upper limb. METHODS: 891 of 1514 manual handlers, delivery drivers, technicians, customer services computer operators, and general office staff reported on physical and psychosocial working conditions and symptoms of neck and upper limb disorders using a self administered questionnaire (59% return rate). Of the 869 valid questionnaire respondents, 564 workers were classified in to one of four exposure groups: high physical and high psychosocial, high physical and low psychosocial, low physical and high psychosocial, and low physical and low psychosocial. Low physical and low psychosocial was used as an internal reference group. The exposure criteria were derived from the existing epidemiological literature and models for physical and psychosocial work factors. The frequency and amplitude of lifting and the duration spent sitting while experiencing vibration were used as physical exposure criteria. Ordinal values of mental demands, job control, and social support with managers and coworkers were used as psychosocial exposure criteria. RESULTS: In the multivariate analyses, the highest and significant increase in risk was found in the high physical and high psychosocial exposure group for symptoms of hand or wrist and upper limb disorders after adjusting for years at the job, age, and sex. A potential interaction effect was found for the symptoms of the hand or wrist and upper limb disorders but not for the neck symptoms. CONCLUSION: This study showed that workers highly exposed to both physical and psychosocial workplace risk factors were more likely to report symptoms of musculoskeletal disorders than workers highly exposed to one or the other. The results suggest an interaction between physical and psychosocial risk factors in the workplace that increased the risk of reporting symptoms in the upper limbs. Psychosocial risk factors at work were more important when exposure to physical risk factors at work were high than when physical exposure was low. Ergonomic intervention strategies that aim to minimise the risks of work related musculoskeletal disorders of the upper limb should not only focus on physical work factors but also psychosocial work factors.

Interactions between physical and psychosocial risk factors at work increase the risk of back disorders: an epidemiological approach.

OBJECTIVES: To investigate the possible interactions between physical and psychosocial risk factors at work that may be associated with self reported back disorders. METHODS: 891 of 1514 manual workers, delivery drivers, technicians, customer services computer operators, and general office staff reported risk factors at work and back disorders with a self administered questionnaire (59% return rate). Of the 869 respondents with a valid questionnaire, 638 workers were classified in to one of four exposure groups: high physical and high psychosocial; high physical and low psychosocial; low physical and high psychosocial; and low physical and low psychosocial. Low physical and low psychosocial was used as an internal reference group. The exposure criteria were derived from existing epidemiological publications and models for physical and psychosocial work factors. The frequency and amplitude of lifting and the duration spent sitting while experiencing vibration were used as physical exposure criteria. Ordinal values of mental demands, job control, and social support from managers and coworkers were used as psychosocial exposure criteria. RESULTS: The highest increase in risk was found in the high physical and high psychosocial exposure group for symptoms of back disorders. In the crude and multivariate analyses, a departure from an additive risk model was found for the 7 day prevalence of symptoms of a low back disorder and also for a recurrent back disorder not present before the current job but also experienced in the past 7 days. CONCLUSION: This study suggests that an interaction between physical and psychosocial risk factors at work may exist to increase the risk of self reported back disorders. Ergonomic prevention strategies that aim to minimise the risks of symptoms of work related back disorders should not only focus on physical but also on psychosocial risk factors at work. The greatest benefits are likely to be realised when both physical and psychosocial factors are put right.

Current techniques for assessing physical exposure to work-related musculoskeletal risks, with emphasis on posture-based methods.

Physical exposure to risks for potential work-related musculoskeletal injuries has been assessed using a variety of methods, including pen and paper based observation methods, videotaping and computer-aided analysis, direct or instrumental techniques, and various approaches to self-report assessment. These methods are critically reviewed in this paper. The applications of these techniques in ergonomic and epidemiologic studies are considered, and their advantages and shortcomings are highlighted. Finally, a strategy that considers both the ergonomics experts' view and the practitioners' needs for developing a practical exposure assessment tool is then discussed.

Mattress evaluation--assessment of contact pressure, comfort and discomfort.

The ergonomic evaluation of mattresses is largely ignored in the current literature. This is somewhat surprising given their importance and the length of time spent using them. This study considers some ergonomic aspects of their design, including body contact pressure and subjective ratings of comfort. Subjects (12 females) found all of the mattresses tested to be significantly more comfortable than an incompressible wooden reference surface. However, no significant differences were found between mattress types, which included orthopaedic and normal designs. Analysis of body contact pressures (measured at the shoulder, elbow, hip, knee and ankle) found few significant differences between experimental conditions. It is argued that limitations in the methodology may not take account of the change in surface area and anatomical sites of contact under different conditions of mattress compressibility. No significant associations were found between comfort ratings and peak body contact pressures. It seems likely that subjective ratings of mattress comfort are dependent on a wider set of factors than contact pressure alone, a finding reported elsewhere in studies of seating.

A questionnaire survey of the ergonomic problems associated with pipettes and their usage with specific reference to work-related upper limb disorders.

This study has considered the ergonomic problems associated with the use of pipettes through a questionnaire study of users. The study groups comprised an exposed (i.e. pipette users) and a non-exposed (i.e. non-users) cohort. Eighty questionnaire responses were returned by pipette users and 85 by non-users from six organisations; a response rate of approximately 55% for each of the study cohorts. The reported occurrence of elbow and hand complaints [using the general version of the Nordic musculoskeltal questionnaire (Kuorinka et al, 1987)] was significantly higher in the pipette user population as compared to the control population. There is an increase in the percentage of those reporting hand complaints as the duration of the working period involving continuous use of pipettes increases. Almost 90% of subjects in the longest exposure group (continuous use for more than 60 min) reported hand complaints. Users identified a number of features which made plunger operated pipettes more difficult to use: almost all of the female population who reported difficulties identified plunger operation as a design deficiency. Users also identified features of the general working environment which made the pipetting tasks more difficult. The study concludes that a number of work-related factors may affect the efficiency and comfort of staff performing laboratory tasks using pipettes.

Upper limb disorders and work: the importance of physical and psychosocial factors.

Upper limb, shoulder, and neck disorders cause both acute and chronic pain, as well as significant functional impairment. They impose a heavy financial burden on societies, industries, and individuals. Our understanding of the pathology of many of the disorders is poor. The epidemiological pursuit of causal relationships is hampered by the nature of the disorders and by the diverse and interactive exposures both at, and away from, the workplace. Current studies suggest that forceful, repetitive manual work, along with prolonged static loading and exposure to vibration are established areas of risk. Much less is known about the possible contribution of psychological factors. Perception of work characteristics, for example, low decision latitude and lack of social support, appear to show increased associations with a number of upper limb disorders, although mechanisms to explain these observations are still broadly theoretical. Research into individual factors is limited, but age and gender both appear to be important.