Caregiver experience of the Norwegian manual for individual cognitive stimulation therapy (iCST): a qualitative study.

OBJECTIVES: This research project investigated how family carers in Norway experienced delivering iCST, their need for supervision and the potential for co-occupation. METHODS: Reflexive thematic analysis was used to understand the experiences of 11 carers using iCST for 8 wk. Three semi-structured interviews were conducted with each participant, including a pre-assessment of caregiver burden and a rating of dementia severity. RESULTS: Most carers described the manual as self-instructive. Some felt overwhelmed when starting iCST. It was important to plan and individualise the sessions to the specific needs of the person with dementia. After delivering iCST the carers described new insights into the person with dementia's resources and challenges. Obstacles to doing iCST were related to the context, the manual or to specific challenges linked to the person with dementia or to the carer. Most participants described positive experiences, in which shared interaction, engagement and mastery were common. CONCLUSION: When the carer understands the iCST programme as a tool and adapts it to the specific needs of the person with dementia then co-occupation and positive interactions happen. However, some carers would benefit from supervision and the iCST programme did not address all persons with dementia.

[The Operationalized Psychodynamic Diagnostic of Children and Adolescents (OPD-KJ-2) in Everyday Clinical Practice with the Plämobox: Applicability and Interrater Reliability]. / Die Operationalisierte Psychodynamische Diagnostik des Kindes- und Jugendalters (OPD-KJ-2) im klinischen Alltag mit dem Plämokasten.

The Operationalized Psychodynamic Diagnostic of Children and Adolescents (OPD-KJ-2) in Everyday Clinical Practice with the Plämobox: Applicability and Interrater Reliability Abstract: Objective: The OPD-CA2 manual for assessing psychodynamic aspects in children and adolescents is well established in clinical practice. However, publications regarding its reliability and validity are limited to (1) adolescents, (2) the structure of the first version of the manual and not to the comprehensive revision of the OPD-CA2, (3) the axes "structure" and (partly) "conflict" but not the axis "relationship," and (4) missing applicability in everyday clinical practice. Methodology: The present study comprised 42 children aged 6-12 years (age level 2 of the OPD-CA2), with and without mental illness, and assessed them using two randomly assigned raters. We assessed them using a low-structured diagnostic symbol game with miniature figurines and objects based on videotapes. We also tested the interrater reliability of the OPD-CA2 axes. Results: The overall assessment of structure and the assessment of the four subdimensions succeeded with good to very good agreement. We could also determine the presence of relevant conflict dynamics with very high agreement, while not recognizing specific conflicts in the clinical sample. Our assessment of the items of the relationship axis shows a low level of agreement. Conclusions: Overall, we can confirm the reliability of the OPD-CA2 for everyday clinical assessment in the younger age groups. Finally, we discuss which factors contribute to the heterogeneous picture.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

SCAI publications committee manual of standard operating procedures.

Evidence-based recommendations for clinical practice are intended to help health care providers and patients make decisions, minimize inappropriate practice variation, promote effective resource use, improve clinical outcomes, and direct future research. The Society for Cardiovascular Angiography and Interventions (SCAI) has been engaged in the creation and dissemination of clinical guidance documents since the 1990s. These documents are a cornerstone of the society's education, advocacy, and quality improvement initiatives. The publications committee is charged with oversight of SCAI's clinical documents program and has created this manual of standard operating procedures to ensure consistency, methodological rigor, and transparency in the development and endorsement of the society's documents. The manual is intended for use by the publications committee, document writing groups, external collaborators, SCAI representatives, peer reviewers, and anyone seeking information about the SCAI documents program.

Patient Engagement With an Automated Telephone Symptom Management Intervention: Predictors and Outcomes.

BACKGROUND: Self-management of symptoms related to cancer and its treatment is important for maintaining treatment regimens and improving outcomes. PURPOSE: To determine factors associated with engagement in a symptom self-management intervention among patients initiating oral anticancer treatment. METHODS: This secondary analysis included 127 patients randomized to the medication adherence reminder and symptom management intervention in a recently completed trial. Patients were recruited from six Comprehensive Cancer Centers, interviewed at intake, and mailed a Symptom Management Toolkit (Toolkit) with self-care management strategies for 18 symptoms. During eight automated telephone weekly calls, patients were asked to use the Toolkit to manage elevated symptoms. Toolkit use and symptoms were tracked weekly, and generalized linear mixed-effects models were used to determine factors predictive of Toolkit use. General linear modeling was used to relate the Toolkit use during intervention to postintervention symptom severity. RESULTS: Better cognitive function at intake into the trial and higher symptom burden were predictive of the patients' initial decision to try the Toolkit during Week 1. In subsequent weeks, Toolkit use in the previous week and worsening of symptoms were associated with greater odds of Toolkit use. The extent of Toolkit use modified the relationship between intake and 8 week symptom severity: among patients with higher levels of severity at intake, use of the Toolkit conferred greater benefit at 8 weeks. CONCLUSIONS: Patients make realistic decisions regarding when to use a self-directed approach to self-management and are likely to use strategies when their symptoms are higher and to forego use once symptoms subside. CLINICAL TRIAL REGISTRATION: NCT02043184.

Clinical Uses and Impacts of Emergency Manuals During Perioperative Crises.

BACKGROUND: Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts. METHODS: We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises. RESULTS: Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval [CI], 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%). CONCLUSIONS: This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.

Printed educational materials: effects on professional practice and healthcare outcomes.

BACKGROUND: Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review. OBJECTIVES: To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes. SEARCH METHODS: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews. SELECTION CRITERIA: We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS: Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies. MAIN RESULTS: We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend. AUTHORS' CONCLUSIONS: The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Effectiveness of a health intervention based on WHO food safety manual in Iran.

BACKGROUND: Food safety manual was developed by the World Health Organization (WHO) to train professionals to reduce the burden of foodborne diseases as a global strategy. The present pioneering research aimed to explore the effectiveness of an intervention based on the manual of five keys to safer food by WHO in enhancing the knowledge, attitude and behavior of Iranian Female Community Health Volunteers (FCHVs). METHODS: In the present quasi-experimental research, FCHVs (n = 125) were selected and assigned to two groups, an intervention and a control. A modified version of the questionnaire based on WHO manual was used to measure knowledge, attitude and behavior of the sample. The questionnaire was first completed at the outset of the study (pre-test) and then once again in 2 months of the intervention (post-test). Face and content validity of the questionnaire was tested and confirmed. Cronbach's alpha was used to test the reliability of the questionnaire along with the test-retest method of testing reliability. The data entered SPSS16 for statistical analysis. To this aim, Chi-squared test, dependent and independent samples T-test, ANOVA and ANCOVA were run. Partial population attributable risks were calculated and corresponding 95% confidence intervals (95% CIs) were estimated using a bootstrap method. RESULTS: The two groups showed no statistically significant difference in the pretest (p > .05). In the post-test, the mean scores for all variables was higher in the intervention group than the control, and this difference between the two research groups was statistically significant (p < .001). When the volunteers were adjusted for age and experience in healthcare centers, the mean scores were significantly higher in the intervention group than the control (p < .001). CONCLUSION: It was revealed in the present study that the educational intervention based on five keys to food safety manual by WHO managed to improve participants' knowledge, attitude and behavior. Translation of the target guideline in future can be a great help to researchers in prospective research. TRIAL REGISTRATION: Retrospectively registered: Iranian Registry of Clinical Trials IRCT20160822029485N4, at 2020-03-16.

American College of Physicians Ethics Manual: Seventh Edition.

Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.

[A protestant pastor as the pioneer of emergency medicine : Sebastianus Albinus published the first emergency manual 400 years ago]. / Ein evangelischer Pfarrer als Pionier der Notfallmedizin : Vor 400 Jahren ließ Sebastianus Albinus die erste Notfallfibel drucken.

In 1588 Sebastian Weiß, the son of a miller, became the first Lutheran pastor of Dittersbach in Saxony. At home he had repeatedly witnessed successful resuscitation of drowned persons by means of simple measures by his parents. Missing appropriate recommendations in the medical literature, in 1620 as "Sebastianus Albinus" he published a booklet with measures for reviving apparently drowned persons. This Kurtze Bericht und Handgrieff (Brief report and handgrip) attracted great attention amongst physicians, especially the reprint of 1675 of which a few copies still exist. The first printed edition from 1620 was lost until, some years ago, the apparently only still existing copy was rediscovered in the Herzog August Library in Wolfenbüttel.

Enabling Community Health Worker Recognition and Referral of Surgical Diseases: Pilot Study Results of a Pictorial Guide.

BACKGROUND: Access to surgical care is a pressing challenge, particularly for vulnerable populations. Informal and formal community health workers (CHWs), including lay people, increasingly function in pivotal roles in primary care, however, remain disconnected from surgical care in most environments. This study examined the degree to which CHW understanding of surgical conditions could be improved through the use of a pictorially based manual. METHODS: A manual and associated situational problem-solving questionnaire instrument were developed and contextualized through focus groups in Central America. A baseline assessment was obtained. In the program implementation, cohorts of formal and informal CHWs were introduced and trained to use the manual through a short curriculum. Assessment was repeated in program implementation, first with access to relevant manual content only, and then after the teaching session. Participants were also surveyed about manual scheme, usability, and utility. RESULTS: A total of 100 subjects (67% female) participated in baseline assessment, and 403 subjects (68% female) were assessed through the program implementation. Baseline problem-solving averaged 11.8 (SD 2.46) out of a possible 20 points. Mean score increased to 15.4 (SD 3.10) when participants had access to relevant surgical manual content and again to 15.9 (SD 3.09, p < 0.0001) following participation with an instructive curriculum. Participant score while utilizing the manual correlated with amount of education completed (r = 0.26), but baseline score did not. High readability 389 (96%) and high self-reported willingness for use 398 (96%) were noted. CONCLUSION: Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.

Emergency Manual Implementation in a Large Academic Anesthesia Practice: Strategy and Improvement in Performance on Critical Steps.

BACKGROUND: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps. METHODS: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds. RESULTS: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19-25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16-20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation. CONCLUSIONS: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.

How do we target the factors that maintain anorexia nervosa? A behaviour change taxonomical analysis.

All psychological treatments for anorexia nervosa appear to have equal (albeit modest) effects. This may be explained because they target similar processes. Although different psychological treatments have been developed for anorexia nervosa treatment, their taxonomical components have not been compared. This study undertook a taxonomical analysis of behaviour change techniques (BCTs), using the CALO-RE analysis tool, from the manuals of Enhanced Cognitive Behavioural Therapy (CBT-E), Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), Family Based Therapy (FBT), Specialist Supportive Clinical Management (SSCM), and Focal Psychodynamic Psychotherapy (FPT). The highest number of BCTs were found in FPT (72,5%), and the lowest were in SSCM (30%). The other interventions had a similar range of BCTs which mainly focused on goal planning (FBT (50%), CBT-E (47.5%), MANTRA (42.5%)). Modelling, shaping, and training communication, self-monitoring, and fear arousal were the less commonly used BCTs across manuals. Manualized psychological interventions for people with anorexia nervosa share a substantial number of behaviour change techniques which might explain their similar levels of effectiveness. New strategies may be needed in order to improve outcomes.

A manual propofol infusion regimen for neonates and infants.

AIMS: Manual propofol infusion regimens for neonates and infants have been determined from clinical observations in children under the age of 3 years undergoing anesthesia. We assessed the performance of these regimens using reported age-specific pharmacokinetic parameters for propofol. Where performance was poor, we propose alternative dosing regimens. METHODS: Simulations using a reported general purpose pharmacokinetic propofol model were used to predict propofol blood plasma concentrations during manual infusion regimens recommended for children 0-3 years. Simulated steady state concentrations were 6-8 µg.mL-1 in the first 30 minutes that were not sustained during 100 minutes infusions. Pooled clinical data (n = 161, 1902 plasma concentrations) were used to determine an alternative pharmacokinetic parameter set for propofol using nonlinear mixed effects models. A new manual infusion regimen for propofol that achieves a steady-state concentration of 3 µg.mL-1 was determined using a heuristic approach. RESULTS: A manual dosing regimen predicted to achieve steady-state plasma concentration of 3 µg.mL-1 comprised a loading dose of 2 mg.kg-1 followed by an infusion rate of 9 mg.kg-1 .h-1 for the first 15 minutes, 7 mg.kg-1 .h-1 from 15 to 30 minutes, 6 mg.kg-1 .h-1 from 30 to 60 minutes, 5 mg.kg-1 .h-1 from 1 to 2 hours in neonates (38-44 weeks postmenstrual age). Dose increased with age in those aged 1-2 years with a loading dose of 2.5 mg.kg-1 followed by an infusion rate of 13 mg.kg-1 .h-1 for the first 15 minutes, 12 mg.kg-1 .h-1 from 15 to 30 minutes, 11 mg.kg-1 .h-1 from 30 to 60 minutes, and 10 mg.kg-1 .h-1 from 1 to 2 hours. CONCLUSION: Propofol clearance increases throughout infancy to reach 92% that reported in adults (1.93 L.min.70 kg-1 ) by 6 months postnatal age and infusion regimens should reflect clearance maturation and be cognizant of adverse effects from concentrations greater than the target plasma concentration. Predicted concentrations using a published general purpose pharmacokinetic propofol model were similar to those determined using a new parameter set using richer neonatal and infant data.

Development and evaluation of a hearing aid manual in the Malay language.

OBJECTIVE: This study aimed to (a) translate a hearing aid (HA) manual into Malay language and revise the translated manual based on best practice guidelines; (b) compare the effectiveness of the translated and the revised Malay HA manuals in helping individuals to perform HA management tasks. DESIGN: Cross-sectional, randomised, single-blinded study. STUDY SAMPLE: An Oticon-Dynamo HA manual was translated and revised based on best practice guidelines. Ninety participants aged 55 years and above participated in this study. They were randomly assigned into the control group (received translated manual) and the experimental group (received the revised translated manual). The Hearing Aid Management (HAM) test, which was developed in a previous study, was conducted to evaluate participant's ability to perform HA management tasks using the translated and the revised version of Malay HA manual. RESULTS: The revised Malay HA manual had a lower reading grade level relative to the initial translated Malay HA manual. The ability to perform HA management tasks was better in the experimental group (mean = 12.2, SD = 1.15) versus the control group (mean = 8.7, SD = 2.11). CONCLUSION: Further revision of existing HA manuals based on best practice guidelines is recommended to help individuals better manage their HAs.

[Actual status of children with food allergies and food provision at residential nurseries and children's care homes: Comparison of groups using and not using guidelines or manuals].

Objectives　To elucidate the actual status of children with food allergies and the measures of allergy-appropriate food provisions at residential nurseries and children's care homes. We also compared institutions that used guidelines, manuals, etc. with those that did not.Methods　Self-administered questionnaires were administered to residential nurseries and children's care homes in Japan. Responses were received from 394 institutions, yielding a response rate of 53.6%. The prevalence of food allergies was assessed in 392 institutions. To investigate the relationship between using guidelines and the status of the children, the analysis included 230 institutions where there were children with food allergies. The relationships between the presence or absence of guidelines and (i) occurrence or non-occurrence of anaphylactic shock or other allergy-related events and (ii) each step of food service were evaluated.Results　The prevalence of food allergies at the 392 institutions was found to be 3.31%. It was difficult to obtain information concerning food allergies at admission to the institutions because a high proportion of children were reported as "children with no physician's diagnostic record," "children admitted without confirmation of allergy information," or "children with discrepancies between the information at admission and actual state."　Of the 230 institutions studied, guidelines were followed at 25.0% of the institutions. Even when institutions with other written rules were included, this proportion only increased to 32.1%. The statistical analysis involved adjustments for different types of institutions. A multivariate logistic regression analysis showed that the odds ratio for institutions where treatment was based on guidelines were significant for the following items: children with no physician's diagnostic record (0.35), existence of a consistent documentation method for collection of information (5.04), regular revisions of information being made (2.85), and reports being submitted when mistakes in food provided to children with allergies were made or narrowly avoided (2.49). In addition, strong correlations were found for the following: children who experienced anaphylactic shock during the previous 3 years (9.72) and children admitted without confirmation of a food allergy (3.12).Conclusions　When rule-based approaches were established, the preparation of information collection forms, revision of information, and reporting of food provision mistakes proceeded more efficiently than when rule-based approaches were not used. Although the prevalence of children experiencing anaphylactic shock and the cases in which information was not confirmed at admission were higher in the institutions using guidelines, this survey revealed that when guidelines were followed, appropriate measures were taken after the admission of children to the institution and that physicians' medical diagnoses were obtained.

Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool.

BACKGROUND: An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises. METHODS: In a case study of a single crisis, an EM was used during a cardiac arrest at a tertiary care hospital that had systematically implemented perioperative EMs. Semistructured interviews were conducted with all six clinicians present, interview transcripts were iteratively coded, and thematic analysis was performed. RESULTS: All clinician participants stated that EM use enabled effective team functioning via reducing stress of individual clinicians, fostering a calm work environment, and improving teamwork and communication. These impacts in turn improved the delivery of patient care during a clinical crisis and influenced participants' intended EM use during future appropriate crises. CONCLUSION: In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.

Preventing and treating trench foot: validation of an educational manual for military personnel.

OBJECTIVE:: To develop and validate an educational manual on the prevention and treatment of trench foot for military personnel. METHOD:: This is a prospective, descriptive, observational study. A manual was developed based on a literature review of books, theses and articles published in the last 10 years. The manual was evaluated by an expert committee of the Brazilian Army, and tested and validated by military students from an Army Sargent School in Brazil. Students evaluated the following parameters: definition of trench foot, risk of trench foot development among the military, risk factors, identification of trench foot, preventive measures, treatment of trench foot, and final considerations. RESULTS:: A total of 99 military students participated in the testing. Some parameters were exclusively evaluated by the experts, 12 physicians and 11 nurses, and rated as 'good or very good' as follows: thematic content (100%), graphic display (100%), topic sequence (100%), clarity of language and comprehension of information (91.3%) and illustrations (95.6%). Other parameters were rated as 'good or very good' by both the experts and military students, as follows: definition of trench foot (100% and 85.8%), risk of trench foot among the military (95.6% and 86.8%), risk factors (100% and 82.8%), identification of trench foot (100% and 86.8%), preventive measures (100% and 81.8%), treatment (95.6% and 84.8%) and final considerations (95.6% and 81.82 %), respectively. Cronbach's alpha was 0.891 for consistency and 0.854 for reliability. CONCLUSION:: The educational manual was validated by health professionals, tested by military students, and showed to be a consistent, reliable and valid educational instrument for the prevention and treatment of trench foot.

Development of an operational manual for a consultation-liaison psychiatry service.

OBJECTIVES: Consultation-liaison psychiatry (CLP) services sit between mental health and the general hospital, and risk being poorly understood by both systems. The aim of this study was to develop an operational manual for a CLP service, which defined functions and governance. METHODS: The CLP literature was reviewed with a focus on descriptions of CLP roles, organisational processes, quality measures and service development. The CLP team held service planning meetings and met with members of the mental health and hospital executives. Site visits and collaboration with other CLP services occurred in defining the roles of the CLP service and organisational governance. RESULTS: A CLP operational document was developed, including a description of the service, its functions, staff roles and governance. Procedural information such as the CLP timetable, referral process, triage and assessment, documentation, activity recording, quality assurance and relevant policies were outlined. CONCLUSIONS: The development of a dedicated operational manual for CLP clarified the roles, functions and governance of CLP within the general hospital and mental health systems. The development process facilitated the engagement of key clinicians and administrators of these systems, the determination of quality improvement targets and greater transparency and accountability.

Development of a cognitive behavioural therapy-based guided self-help intervention for adults with intellectual disability.

BACKGROUND: Despite strong evidence for cognitive behaviour therapy (CBT) in treating mental health, its use, thus far, has been limited for people with intellectual disabilities. This study describes a CBT-based guided self-help (CBT-GSH) manual for individuals with intellectual disability, and focus groups explore the views of clinicians, therapists, support staff and managers. MATERIAL AND METHODS: Using a qualitative methodology, an expert team adapted the manual. Focus groups provided feedback, followed by thematic content analysis for modifications. RESULTS: Participants supported using the manual, with varying views about the delivery. Quality of relationships and competence of the administrator determined the best person to deliver the treatment. Heterogeneity in the intellectual disability population was a challenge to delivering manual-based interventions. Participants made suggestions about language and organization. CONCLUSIONS: Amendments were made to the manual in line with expert feedback. An evaluation is warranted to test for feasibility, delivery, acceptability and efficacy.