Planning for Chaos: Developing the Concept of Emergency Preparedness through the Experience of the Paramedic.

OBJECTIVE: Emergency preparedness is a developing specialty with a limited evidence base. Published literature primarily offers a retrospective view of experience, with few studies examining and understanding the individual lived experience of practitioners prospectively. This study explores paramedics' lived experience of emergency preparedness and applies that learning. METHODS: Thirteen paramedics were recruited through purposive sampling. Face-to-face semi-structured interviews explored their individual experiences of emergency preparedness, in line with the idiographic focus of Interpretative Phenomenological Analysis. RESULTS: Through data analysis, the following superordinate themes were identified for further discussion: self-determination, control, and experience-based practice. Participants appeared to value their role and the unpredictable environment in which they worked. Personal resilience, an area that they suggested is not covered effectively within individual preparation, was viewed as important. The participants articulated that risk, threat, uncertainty, safety, trust, and control were important concepts within individual preparedness. These paramedics valued practice-based knowledge and education as credible and transferrable to their clinical work. CONCLUSION: Evidence from this study suggests that standard emergency preparedness, with the focus at organizational level, is not sufficient for the individual workers or for an overall effective response. Dimensions of individual preparedness are presented, with the paramedic central to the experience within a conceptual model (the DiEP model), creating a new form of emergency preparedness that reflects the individual paramedic's experience.

The Warwick Patient Experiences Framework: patient-based evidence in clinical guidelines.

OBJECTIVE: This paper presents the development of the Warwick Patient Experiences Framework (WaPEF) and describes how it informed the development of the NICE Guidance and Quality Standard, 'Patient experience in adult NHS services: improving the experience of care for people using adult NHS services'. DESIGN: The WaPEF was developed using a thematic qualitative overview that utilized a systematic review approach. Search strategies were developed, inclusion and exclusion criteria developed and data extracted from papers. RESULTS: The WaPEF identifies seven key generic themes that are important to a high-quality patient experience: patient as active participant, responsiveness of services, an individualized approach, lived experience, continuity of care and relationships, communication, information and support. CONCLUSIONS: The WaPEF is the first patient experiences framework with an explicit link to an underpinning patient evidence base, linking themes and sub-themes with specific references. The WaPEF informed the structure and content of the NICE Patient Experiences Guidance. The guidance, published in February 2012, will form a key part of the NHS Outcomes Framework in the UK for the future evaluation of health and social care. The proposed framework could be adapted to other country contexts and settings.

Improving the efficiency of advanced life support training: a randomized, controlled trial.

BACKGROUND: Each year, more than 1.5 million health care professionals receive advanced life support (ALS) training. OBJECTIVE: To determine whether a blended approach to ALS training that includes electronic learning (e-learning) produces outcomes similar to those of conventional, instructor-led ALS training. DESIGN: Open-label, noninferiority, randomized trial. Randomization, stratified by site, was generated by Sealed Envelope (Sealed Envelope, London, United Kingdom). (International Standardized Randomized Controlled Trial Number Register: ISCRTN86380392) SETTING: 31 ALS centers in the United Kingdom and Australia. PARTICIPANTS: 3732 health care professionals recruited between December 2008 and October 2010. INTERVENTION: A 1-day course supplemented with e-learning versus a conventional 2-day course. MEASUREMENTS: The primary outcome was performance in a cardiac arrest simulation test at the end of the course. Secondary outcomes comprised knowledge- and skill-based assessments, repeated assessment after remediation training, and resource use. RESULTS: 440 of the 1843 participants randomly assigned to the blended course and 444 of the 1889 participants randomly assigned to conventional training did not attend the courses. Performance in the cardiac arrest simulation test after course attendance was lower in the electronic advanced life support (e-ALS) group compared with the conventional advanced life support (c-ALS) group; 1033 persons (74.5%) in the e-ALS group and 1146 persons (80.2%) in the c-ALS group passed (mean difference, -5.7% [95% CI, -8.8% to -2.7%]). Knowledge- and skill-based assessments were similar between groups, as was the final pass rate after remedial teaching, which was 94.2% in the e-ALS group and 96.7% in the c-ALS group (mean difference, -2.6% [CI, -4.1% to 1.2%]). Faculty, catering, and facility costs were $438 per participant for electronic ALS training and $935 for conventional ALS training. LIMITATIONS: Many professionals (24%) did not attend the courses. The effect on patient outcomes was not evaluated. CONCLUSION: Compared with conventional ALS training, an approach that included e-learning led to a slightly lower pass rate for cardiac arrest simulation tests, similar scores on a knowledge test, and reduced costs. PRIMARY FUNDING SOURCE: National Institute of Health Research and Resuscitation Council (UK).

A summary of the methods that the National Clinical Guideline Centre uses to produce clinical guidelines for the National Institute for Health and Clinical Excellence.

The National Clinical Guideline Centre develops evidence-based clinical guidelines on behalf of the National Institute for Health and Clinical Excellence in the United Kingdom. These guidelines are developed for the National Health Service in England, Wales, and Northern Ireland and establish recommendations on best practice. The authors summarize the main methods used in development, how evidence from systematic reviews is interpreted to form recommendations, who is involved in the process, and the main outputs that are published.

Synopsis of the National Institute for Health and Clinical Excellence Guideline for management of transient loss of consciousness.

DESCRIPTION: Transient loss of consciousness (TLoC) is common and often leads to incorrect diagnosis, unnecessary investigation, or inappropriate choice of specialist referral. In August 2010, the National Institute for Health and Clinical Excellence published a guideline that addressed the initial assessment of and most appropriate specialist referral for persons who have experienced TLoC. The guideline focused on correct diagnosis and relevant specialist referral and did not make treatment recommendations. This synopsis describes the principal recommendations concerning assessment and referral of a patient with TLoC. METHODS: The National Clinical Guideline Centre developed the guidelines by using the standard methodology of the National Institute for Health and Clinical Excellence. A multidisciplinary guideline panel generated review questions, discussed evidence, and formulated recommendations. The panel included a technical team from the National Clinical Guideline Centre, who reviewed and graded all relevant evidence identified from literature searches published in English up to November 2009 and performed health-economic modeling. Both guideline development and final modifications were informed by comments from stakeholders and the public. RECOMMENDATIONS: The panel made clear recommendations regarding the assessment of a person after TLoC, which emphasized the importance of clinical reasoning in diagnosis. Persons with uncomplicated faint, situational syncope, or orthostatic hypotension should receive electrocardiography but do not otherwise require immediate further investigation or specialist referral. Persons with features that suggest epilepsy should be referred for specialist neurologic assessment; brief seizure-like activity was recognized as a common occurrence during syncope that should not be regarded as indicating epilepsy. Persons with a suspected cardiac cause for TLoC or in whom TLoC is unexplained after initial assessment should receive specialist cardiovascular assessment. Guidance was provided on the appropriate choices of cardiovascular investigation, according to the presenting clinical circumstances.

Effect of Number of Digits on Human Precision Manipulation Workspaces.

Precision manipulation, or moving small objects held in the fingertips, is likely the most heavily utilized class of dexterous within-hand manipulation and adds greatly to the capabilities of the human hand. This article focuses on studying the effects of varying the number of digits used on the resulting manipulation abilities, in terms of translational workspaces and rotational ranges, by manipulating two circular objects, 50 mm and 80 mm in diameter. In general, as the number of digits in contact with the object increases, the results show a significant reduction in precision manipulation workspace range for four of the six translation and rotation directions and no significant change in the other two, suggesting that for these particular metrics, more fingers result in a reduction in performance. Furthermore, while two digits results in the largest workspaces for five of the six translation and rotation axes, the lack of ability to control rotation in the distal-proximal direction suggests that three digits may be more desirable for overall precision manipulation dexterity.

Undergraduate training in the care of the acutely ill patient: a literature review.

OBJECTIVE: To characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions. DESIGN: Systematic literature review including Medline, EMBASE, CINAHL. Eligible studies described education and training issues focusing on caring for acutely ill patients. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation. MEASUREMENT AND RESULTS: We identified and reviewed 374 articles focusing on training or clinical aspects of caring for the acutely ill patient. Undergraduates and junior physicians lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient. There is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students. Many centres are starting to use an integrated approach to acute care teaching, with early exposure to basic life support and clinical skills, coupled with later exposure to more complex acute care topics. Clinical attachments remain a popular method for training in acute care. Acute care courses are increasingly being used to standardise delivery of practical skills and patient management training. CONCLUSION: The training of healthcare staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care.

Advanced life support cardiac arrest scenario test evaluation.

BACKGROUND: The cardiac arrest scenario test (CASTest) is a central component of the assessment strategy on the Advanced Life Support Course. The aim of this study was to establish equivalence between the four different CASTest scenarios and investigate the impact of profession, candidate order and course centre on the pass rate. MATERIALS AND METHODS: This was a cluster randomised study. CASTest scenarios were randomly allocated to candidates stratified by course centre. Candidate demographics and performance were recorded on the criterion referenced check list along with the final assessment outcome (pass/fail). Differences in pass rates according scenario; profession, course centre and candidate order were examined by Chi-squared and multiple logistic regression. RESULTS: Two thousand, four hundred and forty-nine assessments from 65 course centres were evaluated. There was no difference in pass rate between scenarios (average pass rate 74.4%). Pass rates according to course centre varied widely (40-93%, P<0.0001) as did professional group (42-100%, P<0.0001). The order that candidates took the test did not influence the pass rate. CONCLUSION: The CASTest assessment scenarios used during ALS testing appear equivalent in terms of difficulty. In contrast, the professional background of the candidate and centre at which the assessment is performed do significantly influence the likelihood of passing the assessment. Further evaluation of the reasons for differences between course centres is required.

A 'Learning conversation' as a style of feedback.

This article was migrated. The article was marked as recommended. This paper explores the history behind the introduction and use of a 'learning conversation' as a mechanism of providing effective feedback to students on resuscitation courses. The authors hope the use of this style of feedback may useful in many other contexts to provide authentic feedback. The central aim of a learning conversation is to promote and support greater self-awareness of the individual student in order to develop competence and team leadership through critical inquiry ( Harri-Augstein & Thomas 1991). Learning, particularly in the context of resuscitation is demonstrated by the utilisation of "planned experience which brings about a change of behaviour" and the process is facilitated by feedback whether during skills teaching, in workshops or in simulation. The learning conversation uses empathic, active respectful listening and discussion shared between a small group of participants, facilitated by an instructor to ensure that key learning emerges from this process duly informing future practice and behaviours. A mnemonic has been developed to facilitate acquisition of the skills involved in this feedback. Faculty also require feedback to fully develop their feedback skills but once established the process makes both faculty and students share their feelings, frustrations and learning in a very positive learning climate. The learning conversation has been in use in resuscitation courses for almost six years and the authors feel there is a wealth of literature available to support this approach which can be usefully applied to facilitate learning in many small group teaching settings and the process of delivering a Learning conversation is detailed within the paper.

The Acute Care Undergraduate TEaching (ACUTE) Initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom.

BACKGROUND: The care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation. DESIGN: Healthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale. RESULTS: A total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation. CONCLUSIONS: We propose these competencies form a core set for undergraduate training in resuscitation and acute care.

Editorial comment: How true outcomes-based commissioning can really 'liberate' healthcare services.

Editorial comment on 'How true outcomes-based commissioning can really 'liberate' healthcare services' by Diane Bell, Thomas Kelley and Nicholas Hicks.

Human precision manipulation workspace: Effects of object size and number of fingers used.

Precision manipulation, or moving small objects in the fingertips, is important for daily tasks such as writing and key insertion, as well as medically relevant tasks such as scalpel cuts and surgical teleoperation. While fingertip force coordination has been studied in some detail, few previous works have experimentally studied the kinematics of human precision manipulation with real objects. The present work focuses on studying the effects of varying object size and the number of fingers used on the resulting manipulation workspace, or range of motions that the object can be moved through. To study object size effects, seven bar-shaped objects ranging from 20 to 80 mm length were tested; after scaling object length to the equivalent for a 17.5 cm hand, the peak volume was obtained for 48-59 mm object length range (23% above average), and the minimum volume was obtained for the smallest 17-27 mm range (72% of average). 50 mm and 80 mm circular objects were used to study the effect of using different numbers of fingers; the five-finger manipulation volume dropped to less than half the two-finger volume (p<;0.001). We anticipate these results will be useful in designing devices such as hand held tools, as well as in designing protocols for effectively testing and rehabilitating hand function. Finally, the results can provide a benchmark for the manipulation capability of prosthetic hands.

Workspace Shape and Characteristics for Human Two- and Three-Fingered Precision Manipulation.

GOAL: To study precision manipulation, which involves repositioning an object in the fingertips and is used in everyday tasks such as writing and key insertion, and also for domain-specific tasks such as small scalpel cuts, using tweezers, and hand soldering. METHODS: In this study, the range of positions (workspace) through which 19 participants manipulated a 3.3-4.1 cm-diameter object are measured with a magnetic tracker. Each participant performed two conditions: a two-finger thumb-index finger condition and a three-finger thumb-index-middle finger condition. RESULTS: The observed workspaces, normalized to a 17.5 cm hand length, are small compared to free-finger trajectories; for the two-finger trials, 68% of points are within 1.05 cm of the centroid and 95% are within 2.31 cm, while the three-finger case shows a narrower distribution, with 68% of points within 0.94 cm of the centroid and 95% of points within 2.19 cm. The longest axis is a long thin arc in the proximal-palmar plane. Analysis of fingertip workspaces shows that the index fingertip workspace volume is the most linear predictor of object workspace (R(2) = 0.98). CONCLUSION: Precision manipulation workspace size and shape is shown, along with how the fingers are used during the manipulation. SIGNIFICANCE: The results have many applications, including normative data for rehabilitation, guidelines for ergonomic device design, and benchmarking prosthetic and robotic hands.

Rotational ranges of human precision manipulation when grasping objects with two to five digits.

The ability to move and manipulate objects within the hand is important for the overall performance of the human hand. Such movements are key for many tasks, including writing, using precision tools, turning knobs, and operating various haptic interfaces. In this work we analyze the ability of 17 unimpaired subjects to rotate objects 50 and 80 mm in diameter using 2 to 5 digits, while maintaining the initial finger-object contact locations. Subjects were asked to rotate the object with a particular number of fingers around one of three orthogonal hand axes for 30 seconds and explore their rotational range. The average rotational range achieved over all conditions was 47 degrees, with the largest rotation of 82 degrees for the 3 digit case around a distal-proximal axis. The rotations around the palmar-dorsal and the ulnar-radial axes showed similar trends, where the smaller object resulted in 1.3 and 1.2 times larger rotation workspaces than the larger object (p <; 0.001), respectively. The rotation around the distal-proximal axis has a different trend, where the difference in rotation amplitude between different number of finger conditions is over 50% (p <; 0.003), but the difference in object size conditions is only 10%. The results highlight that the orientation of the rotation axis has significant influence on the rotation capabilities of the human hand. In designing handheld tools and haptic devices one should carefully consider around which axes a rotation is required.

Electronic learning in advanced resuscitation training: The perspective of the candidate.

BACKGROUND: Studies have shown that blended approaches combining e-learning with face-to-face training reduces costs whilst maintaining similar learning outcomes. The preferences in learning approach for healthcare providers to this new style of learning have not been comprehensively studied. The aim of this study is to evaluate the acceptability of blended learning to advanced resuscitation training. METHODS: Participants taking part in the traditional and blended electronic advanced life support (e-ALS) courses were invited to complete a written evaluation of the course. Participants' views were captured on a 6-point Likert scale and in free text written comments covering the content, delivery and organisation of the course. Proportional-odds cumulative logit models were used to compare quantitative responses. Thematic analysis was used to synthesise qualitative feedback. RESULTS: 2848 participants from 31 course centres took part in the study (2008-2010). Candidates consistently scored content delivered face-to-face over the same content delivered over the e-learning platform. Candidates valued practical hands on training which included simulation highly. Within the e-ALS group, a common theme was a feeling of "time pressure" and they "preferred the face-to-face teaching". However, others felt that e-ALS "suited their learning style", was "good for those recertifying", and allowed candidates to "use the learning materials at their own pace". CONCLUSIONS: The e-ALS course was well received by most, but not all participants. The majority felt the e-learning module was beneficial. There was universal agreement that the face-to-face training was invaluable. Individual learning styles of the candidates affected their reaction to the course materials.

Analysis of human grasping behavior: object characteristics and grasp type.

This paper is the first of a two-part series analyzing human grasping behavior during a wide range of unstructured tasks. The results help clarify overall characteristics of human hand to inform many domains, such as the design of robotic manipulators, targeting rehabilitation toward important hand functionality, and designing haptic devices for use by the hand. It investigates the properties of objects grasped by two housekeepers and two machinists during the course of almost 10,000 grasp instances and correlates the grasp types used to the properties of the object. We establish an object classification that assigns each object properties from a set of seven classes, including mass, shape and size of the grasp location, grasped dimension, rigidity, and roundness. The results showed that 55 percent of grasped objects had at least one dimension larger than 15 cm, suggesting that more than half of objects cannot physically be grasped using their largest axis. Ninety-two percent of objects had a mass of 500 g or less, implying that a high payload capacity may be unnecessary to accomplish a large subset of human grasping behavior. In terms of grasps, 96 percent of grasp locations were 7 cm or less in width, which can help to define requirements for hand rehabilitation and defines a reasonable grasp aperture size for a robotic hand. Subjects grasped the smallest overall major dimension of the object in 94 percent of the instances. This suggests that grasping the smallest axis of an object could be a reliable default behavior to implement in grasp planners.

Analysis of human grasping behavior: correlating tasks, objects and grasps.

This paper is the second in a two-part series analyzing human grasping behavior during a wide range of unstructured tasks. It investigates the tasks performed during the daily work of two housekeepers and two machinists and correlates grasp type and object properties with the attributes of the tasks being performed. The task or activity is classified according to the force required, the degrees of freedom, and the functional task type. We found that 46 percent of tasks are constrained, where the manipulated object is not allowed to move in a full six degrees of freedom. Analyzing the interrelationships between the grasp, object, and task data show that the best predictors of the grasp type are object size, task constraints, and object mass. Using these attributes, the grasp type can be predicted with 47 percent accuracy. Those parameters likely make useful heuristics for grasp planning systems. The results further suggest the common sub-categorization of grasps into power, intermediate, and precision categories may not be appropriate, indicating that grasps are generally more multi-functional than previously thought. We find large and heavy objects are grasped with a power grasp, but small and lightweight objects are not necessarily grasped with precision grasps-even with grasped object size less than 2 cm and mass less than 20 g, precision grasps are only used 61 percent of the time. These results have important implications for robotic hand design and grasp planners, since it appears while power grasps are frequently used for heavy objects, they can still be quite practical for small, lightweight objects.

Grasp frequency and usage in daily household and machine shop tasks.

In this paper, we present results from a study of prehensile human hand use during the daily work activities of four subjects: two housekeepers and two machinists. Subjects wore a head-mounted camera that recorded their hand usage during their daily work activities in their typical place of work. For each subject, 7.45 hours of video was analyzed, recording the type of grasp being used and its duration. From this data, we extracted overall grasp frequency, duration distributions for each grasp, and common transitions between grasps. The results show that for 80 percent of the study duration the housekeepers used just five grasps and the machinists used 10. The grasping patterns for the different subjects were compared, and the overall top 10 grasps are discussed in detail. The results of this study not only lend insight into how people use their hands during daily tasks, but can also inform the design of effective robotic and prosthetic hands.

The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework.

BACKGROUND: The case has been made for more and better theory-informed process evaluations within trials in an effort to facilitate insightful understandings of how interventions work. In this paper, we provide an explanation of implementation processes from one of the first national implementation research randomized controlled trials with embedded process evaluation conducted within acute care, and a proposed extension to the Promoting Action on Research Implementation in Health Services (PARIHS) framework. METHODS: The PARIHS framework was prospectively applied to guide decisions about intervention design, data collection, and analysis processes in a trial focussed on reducing peri-operative fasting times. In order to capture a holistic picture of implementation processes, the same data were collected across 19 participating hospitals irrespective of allocation to intervention. This paper reports on findings from data collected from a purposive sample of 151 staff and patients pre- and post-intervention. Data were analysed using content analysis within, and then across data sets. RESULTS: A robust and uncontested evidence base was a necessary, but not sufficient condition for practice change, in that individual staff and patient responses such as caution influenced decision making. The implementation context was challenging, in which individuals and teams were bounded by professional issues, communication challenges, power and a lack of clarity for the authority and responsibility for practice change. Progress was made in sites where processes were aligned with existing initiatives. Additionally, facilitators reported engaging in many intervention implementation activities, some of which result in practice changes, but not significant improvements to outcomes. CONCLUSIONS: This study provided an opportunity for reflection on the comprehensiveness of the PARIHS framework. Consistent with the underlying tenant of PARIHS, a multi-faceted and dynamic story of implementation was evident. However, the prominent role that individuals played as part of the interaction between evidence and context is not currently explicit within the framework. We propose that successful implementation of evidence into practice is a planned facilitated process involving an interplay between individuals, evidence, and context to promote evidence-informed practice. This proposal will enhance the potential of the PARIHS framework for explanation, and ensure theoretical development both informs and responds to the evidence base for implementation.