Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study.

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM: To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS: Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS: A qualitative research design using semi-structured interviews. RESULTS: Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS: The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.

Experiences of Patient-Led Chronic Pain Peer Support Groups After Pain Management Programs: A Qualitative Study.

OBJECTIVE: A qualitative study of patients' experiences and the impacts of peer support groups that patients maintained after UK NHS group pain management programs (PMPs). DESIGN: Long-term impacts of group PMPs remain unclear, with indications that positive effects can fade. We evaluated a model of continued peer support, co-produced by patients and clinicians, to maintain the therapeutic impact of PMP groups. A protocol was implemented that encouraged patients to continue to meet in their established PMP group for patient-led peer support (without clinical input) after PMPs finished. Peer support aimed to consolidate self-management, and advance social life recovery. We examined the impacts that groups had on attendees, and why some dropped out. METHODS: Semi-structured interviews with 38 patients and 7 clinicians, analyzed thematically. RESULTS: Friendship bonds and mutual understandings of effective ways of coping with pain encouraged participants to maintain recovery following PMPs. After PMP professional involvement has ended, these meetings enabled patients to develop greater agency from the shared sense of helping bring about new achievements or averting setbacks. Peer support extended the understanding of what is possible when living with pain. However, continuing meetings were not right for all. Reasons for not attending included lack of connection with peers. CONCLUSIONS: Co-produced peer support groups after PMPs can be a low-cost, effective social intervention, providing emotional, practical and social benefits, with improved self-management skills, stronger social connections and some reduced use of health services. Project resources for developing peer support meetings after PMPs are freely available online.

Current provision of general practitioner services in or alongside emergency departments in England.

BACKGROUND: In 2017, general practitioners in or alongside the emergency department (GPED), an approach that employs GPs in or alongside the ED to address increasing ED demand, was advocated by the National Health Service in England and supported by capital funding. However, little is known about the models of GPED that have been implemented. METHODS: Data were collected at two time points: September 2017 and December 2019, on the GPED model in use (if any) at 163/177 (92%) type 1 EDs in England. Models were categorised according to a taxonomy as 'inside/integrated', 'inside/parallel', 'outside/onsite' or 'outside/offsite'. Multiple data sources used included: on-line surveys, interviews, case study data and publicly available information. RESULTS: An increase of EDs using GPED was observed from 81% to 95% over the study period. 'Inside/parallel' was the most frequently used model: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The adoption of 'inside/integrated' models fell from 26% (38/149) to 9% (15/159). Capital funding was received by 87% (142/163) of the EDs sampled. We identified no significant difference between the GPED model adopted and observable characteristics of EDs of annual attendance, 4-hour wait, rurality and deprivation within the population served. CONCLUSION: The majority of EDs in England have now adopted GPED. The availability of capital funding to finance structural changes so that separate GP services can be provided may explain the rise in parallel models and the decrease in integrated models. Further research is required to understand the relative effectiveness of the various models of GPED identified.

Legacy Contaminants in Aquatic Biota in a Stream Associated with Nuclear Weapons Material Production on the Savannah River Site.

Former nuclear weapons material production at the U.S. Department of Energy's Savannah River Site (SRS) has resulted in contamination of certain terrestrial and aquatic ecosystems on site with legacy wastes such as radiocesium (137Cs), tritium (3H), and metals. We collected fish and invertebrates from five beaver ponds (sites) above, adjacent, and downgradient of three SRS facilities (H-, F-, and C-Areas) to evaluate whether the accumulation of metals and radionuclides in biota were associated with specific facility operations and if the measured levels could pose risks to aquatic organisms. We compared concentrations of various metals, 137Cs, and 3H in fish, as well as in water (3H only), among sites along the stream gradient. Fish collected from sites adjacent to H-Area had significantly higher 137Cs concentrations compared to fish from other sites. Both biota and water samples indicated significantly greater levels of 3H in sites adjacent to and downstream of C-Area. Concentrations of zinc (Zn), copper (Cu), and mercury (Hg) in some samples exceeded effects levels reported for fish and may pose a risk to fish populations. This study reported fish tissue concentrations of 137Cs and 3H, which have not been documented extensively in ecotoxicological studies. Our results suggested that industrial operations such as nuclear material production at SRS could have long-lasting impact on the aquatic ecosystem via the release of radionuclides and metals, and long-term monitoring of physiological effects and population level impact in biota exposed to these contaminants are recommended.

The introduction of a safety checklist in two UK hospital emergency departments: A qualitative study of implementation and staff use.

AIMS AND OBJECTIVES: To explore the extent to which a checklist designed to support patient safety in hospital Emergency Departments was recognised and used by staff. BACKGROUND: Patient crowding in UK Emergency Departments makes it difficult for staff to monitor all patients for signs of clinical deterioration. An Emergency Department Safety Checklist was developed at a UK hospital to ensure patients are regularly monitored. It was subsequently implemented in six hospitals and recommended for use across the National Health Service in England. METHODS: This was a qualitative study in two UK hospital Emergency Departments. Data collection consisted of sixty-six hours of nonparticipant observation and interviews with twenty-six staff. Observations were sampled across different days and times. Interviews sampled a range of staff. Data were analysed thematically. The study was undertaken in accordance with COREQ guidelines. RESULTS: Staff described the Emergency Department Safety Checklist as a useful prompt and reminder for monitoring patients' vital signs and other aspects of care. It was also reported as effective in communicating patient care status to other staff. However, completing the checklist was also described as a task which could be overlooked during busy periods. During implementation, the checklist was promoted to staff in ways that obscured its core function of maintaining patient safety. CONCLUSIONS: The Emergency Department Safety Checklist can support staff in maintaining patient safety. However, it was not fully recognised by staff as a core component of everyday clinical practice. RELEVANCE TO CLINICAL PRACTICE: The Emergency Department Safety Checklist is a response to an overcrowded environment. To realise the potential of the checklist, emergency departments should take the following steps during implementation: (a) focus on the core function of clinical safety, (b) fully integrate the checklist into the existing workflow and (c) employ a departmental team-based approach to implementation and training.

Not all waits are equal: an exploratory investigation of emergency care patient pathways.

BACKGROUND: Increasing pressure in the United Kingdom (UK) urgent care system has led to Emergency Departments (EDs) failing to meet the national requirement that 95% of patients are admitted, discharged or transferred within 4-h of arrival. Despite the target being the same for all acute hospitals, individual Trusts organise their services in different ways. The impact of this variation on patient journey time and waiting is unknown. Our study aimed to apply the Lean technique of Value Stream Mapping (VSM) to investigate care processes and delays in patient journeys at four contrasting hospitals. METHODS: VSM timing data were collected for patients accessing acute care at four hospitals in South West England. Data were categorised according to waits and activities, which were compared across sites to identify variations in practice from the patient viewpoint. We included Public and Patient Involvement (PPI) to fully interpret our findings; observations and initial findings were considered in a PPI workshop. RESULTS: One hundred eight patients were recruited, comprising 25,432 min of patient time containing 4098 episodes of care or waiting. The median patient journey was 223 min (3 h, 43 min); just within the 4-h target. Although total patient journey times were similar between sites, the stage where the greatest proportion of waiting occurred varied. Reasons for waiting were dominated by waits for beds, investigations or results to be available. From our sample we observed that EDs without a discharge/clinical decision area exhibited a greater proportion of waiting time following an admission or discharge decision. PPI interpretation indicated that patients who experience waits at the beginning of their journey feel more anxious because they are 'not in the system yet'. CONCLUSIONS: The novel application of VSM analysis across different hospitals, coupled with PPI interpretation, provides important insight into the impact of care provision on patient experience. Measures that could reduce patient waiting include automatic notification of test results, and the option of discharge/clinical decision areas for patients awaiting results or departure. To enhance patient experience, good communication with patients and relatives about reasons for waits is essential.

Plutonium isotopes in the terrestrial environment at the Savannah River Site, USA: a long-term study.

This work presents the findings of a long-term plutonium (Pu) study at Savannah River Site (SRS) conducted between 2003 and 2013. Terrestrial environmental samples were obtained at the Savannah River National Laboratory (SRNL) in the A-Area. Plutonium content and isotopic abundances were measured over this time period by α particle and thermal ionization mass spectrometry (3STIMS). We detail the complete process of the sample collection, radiochemical separation, and measurement procedure specifically targeted to trace plutonium in bulk environmental samples. Total plutonium activities were determined to be not significantly above atmospheric global fallout. However, the (238)Pu/(239+240)Pu activity ratios attributed to SRS are substantially different than fallout due to past (238)Pu production on the site. The (240)Pu/(239)Pu atom ratios are reasonably consistent from year to year and are lower than fallout indicating an admixture of weapons-grade material, while the (242)Pu/(239)Pu atom ratios are higher than fallout values, again due to actinide production activities. Overall, the plutonium signatures obtained in this study reflect a distinctive mixture of weapons-grade, heat source, and higher burn-up plutonium with fallout material. This study provides a unique opportunity for developing and demonstrating a blue print for long-term low-level monitoring of trace plutonium in the environment.

Ultra-low-level measurements of airborne fission products from the Fukushima Daiichi reactor accident using high volume collection systems at Savannah River National Laboratory.

Ultra-low-level measurements of radionuclides in air have been conducted at the Savannah River National Laboratory (SRNL) to determine the atmospheric concentration of fission products released following the Fukushima Daiichi reactor accident on March 11, 2011. Air filter samples were acquired from two high-volume collection systems (a traditional filter-based system and an electrostatic precipitator-based system) to monitor airborne radionuclide concentrations in the period covering from 2 weeks to 3 years after the disaster. The world-wide spread of low-level concentrations of airborne fission products from the Fukushima event provided a unique opportunity to demonstrate SRNL's electrostatic particle collection technology and other improvements in environmental monitoring developed at the Savannah River Site (SRS). Detecting and analyzing the release allowed a comprehensive test of SRS systems for monitoring environmental radioactivity. Gamma-ray-emitting fission products (131,132I, 134,136,137Cs, and 129,132Te) and cosmogenic isotopes (7Be and 22Na) in air were detected and quantified by high-resolution gamma-ray spectroscopy at concentrations as low as 0.07 µBq per standard cubic meter (SCM) (50 mBq total 137Cs), while plutonium content was quantified by thermal ionization mass spectrometry (TIMS) at concentrations as low as 6.5 × 10-21 g/SCM (3.0 fg 239+240Pu). Isotope concentrations measured at SRNL from gamma-ray spectroscopy were compared to independent measurements from Chapel Hill, NC, located approximately 370 km (230 mi) NE of SRNL. Meteorological modeling was also used to predict radionuclide transport from the location of release to both measurement locations.

Refinement of the distress management problem list as the basis for a holistic therapeutic conversation among UK patients with cancer.

OBJECTIVE: Originally devised in the USA, the Distress Thermometer is being deployed in many cancer settings in the UK. It is commonly used with a Problem List (PL), which has never been validated with a UK population. This study aimed to refine the PL items based upon the concerns of a sample of UK patients attending a regional cancer centre. METHODS: Existing versions of the PL were scrutinised by a focus group comprising five ex-patients, six health care staff and two academics. This group considered the intelligibility, ambiguity and redundancy of items, sometimes making alternative suggestions or pooling items. The resulting 46 candidate items were sent to 735 patients with mixed cancer, asking them to endorse items that had been 'a source of concern or distress' during their recently finished treatment. We used multivariate logistic regression to evaluate the association between the prevalence of problems and patient characteristics. RESULTS: In this study, 395 (53%) people responded. 'Fatigue, exhaustion or extreme tiredness' (70%), 'worry, fear or anxiety' (45%) and 'sleep problems' (38%) were the most frequently endorsed items. Items not appearing on the original PL were commonly endorsed such as 'memory or concentration' (30%) and 'loneliness or isolation' (15%), suggesting that they should be routinely included in the Distress Thermometer Problem List. CONCLUSIONS: The current study offers a more comprehensive PL, on the basis of actual patients' concerns, using words that are understood by UK patients. The reluctance of some patients to volunteer their concerns suggests that screening for distress should be undertaken within the context of a structured conversation.

Mercury concentrations in nestling wading birds relative to diet in the southeastern United States: a stable isotope analysis.

Mercury (Hg) is a ubiquitous environmental contaminant that is transferred trophically through aquatic and terrestrial food webs. To better understand the routes of Hg uptake in organisms that rely on both aquatic and terrestrial food resources, we analyzed feather and down samples from nestling wading birds of varying trophic positions in both inland and coastal colonies. We used stable nitrogen and carbon isotope analyses to evaluate trophic positions of individual species (δ(15)N) and differences in foraging habitat use (δ(13)C). Inland, aquatic species had higher trophic status than the single terrestrial species examined, and the expected positive relationship between δ(15)N and Hg content of feathers was observed. However, the same was not true for all species from coastal colonies. Feathers from species that primarily consumed saltwater prey were relatively high in δ(15)N value and low in Hg content, which is opposite of the trend expected due to Hg biomagnification in food chains. In contrast, coastal species foraging in freshwater or a combination of freshwater and saltwater habitats displayed greater Hg contents in feathers. The apparent differential use of the two aquatic systems (freshwater and saltwater) in coastal environments by wading bird species results in variations in δ(15)N values and Hg contents in nestling feathers not found in species associated with only freshwater systems.

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study.

OBJECTIVES: To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. DESIGN: Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. SETTING AND PARTICIPANTS: Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. RESULTS: There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). CONCLUSIONS: We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. TRIAL REGISTRATION NUMBER: ISCRTN5178022.

Factors influencing streaming to General Practitioners in emergency departments: A qualitative study.

BACKGROUND: Emergency Department attendance is increasing internationally, of which a significant proportion could be managed in general practice. In England, policies backed by substantial capital funding require such patients attending Emergency Departments be directed or 'streamed' to General Practitioners working in or parallel to Emergency Departments. However, evidence for streaming is limited and the processes of streaming patients attending Emergency Departments to General Practitioners lacks exploration. OBJECTIVES: This paper explores streaming to General Practitioners in and alongside Emergency Departments at ten sites across England. It highlights positive streaming practice, as well as issues that may contribute to poor streaming practice, in order to inform future service improvement. METHODS: A longitudinal qualitative study was conducted with data collected between October 2017 and December 2019 across 10 case study sites throughout England as part of a broader mixed methods study. 186 non-participant observations and 226 semi-structured interviews with 191 health professionals working in Emergency Departments or related General Practitioner Services were thematically analysed in relation to streaming processes and experiences. RESULTS: Six interconnected themes influencing streaming were identified: implementing and maintaining structural support; developing and supporting streaming personnel; implementing workable and responsive streaming protocols; negotiating primary/secondary care boundaries; developing and maintaining interprofessional relationships and concerns for patient safety. Streaming was considered central to the success of General Practitioners in/parallel to Emergency Departments. The importance of the skills of streaming nurses in delivering an optimal and safety critical service was highlighted, as was the skillset of General Practitioners and interprofessional relationships between streamers and General Practitioners. There was no distinct streaming model or method associated with good streaming practice to General Practitioners in/alongside Emergency Departments, instead factors for success were identified and key recommendations suggested. 'Inappropriate' streaming was identified as a problem, where patients streamed to General Practitioners in or parallel to Emergency Departments required Emergency Department management, or patients suitable for General Practitioner care were kept in the Emergency Department. CONCLUSION: Despite adopting differing methods, commonalities across case sites in the delivery of good streaming practice were identified, leading to identification of key recommendations which may inform development of streaming services. STUDY REGISTRATION: ISRCTN51780222. Tweetable abstract: Workplace culture and the skillset of streamers and General Practitioners is crucial to streaming of patients to General Practitioners in Emergency Departments.

Potential impacts of general practitioners working in or alongside emergency departments in England: initial qualitative findings from a national mixed-methods evaluation.

OBJECTIVES: To explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These 'expectations of impact' can be used to generate hypotheses that will inform future implementations and evaluations of GPED. DESIGN: Qualitative study consisting of 228 semistructured interviews. SETTING: 10 acute National Health Service (NHS) hospitals and the wider healthcare system in England. Interviews were undertaken face to face or via telephone. Data were analysed thematically. PARTICIPANTS: 124 health professionals and 94 patients and carers. 10 service leaders representing a range of national organisations and government departments across England (eg, NHS England and Department of Health) were also interviewed. RESULTS: A range of GPED models are being implemented across the NHS due to different interpretations of national policy and variation in local context. This has resulted in stakeholders and organisations interpreting the aims of GPED differently and anticipating a range of potential impacts. Participants expected GPED to affect the following areas: ED performance indicators; patient outcome and experience; service access; staffing and workforce experience; and resources. Across these 'domains of influence', arguments for positive, negative and no effect of GPED were proposed. CONCLUSIONS: Evaluating whether GPED has been successful will be challenging. However, despite uncertainty surrounding the direction of effect, there was agreement across all stakeholder groups on the areas that GPED would influence. As a result, we propose eight domains of influence that will inform our subsequent mixed-methods evaluation of GPED. TRIAL REGISTRATION NUMBER: ISRCTN51780222.

An exploration into physiological and self-report measures of stress in pre-registration doctors at the beginning and end of a clinical rotation.

The first year practising medicine, pre-registration, is considered to be a stressful time for junior doctors. The aims of this study were to explore how levels of psychological distress were affected by changes in the working environment and to examine these effects across subjective (i.e. self-report) and objective (i.e. stress hormone cortisol) indices of psychological distress. A cohort of 36 pre-registration house officers (males = 15) completed a battery of psychosocial measures and collected salivary samples for the measurement of diurnal cortisol at the beginning and end of a 3-4-month clinical rotation with the assumption that the end of a rotation would be less stressful than the beginning. Results from the self-report measures remained constant over the two-time points suggesting no perceived change in emotional well-being on a subjective level. However, there is some evidence of neuro-endocrine changes across the two time points suggestive of hypothalamic-pituitary-adrenal axis dysregulation. In particular, there was a significant difference between the cortisol awakening rise with the greatest rise seen at the beginning of a rotation. In addition, the daily cortisol decline (diurnal slope) was also significantly less at this test time. These findings have implications for the discord apparent between self-report and physiological measures of psychological stress.

Admission Decision-Making in Hospital Emergency Departments: The Role of the Accompanying Person.

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals' standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients' care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making.

Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England.

OBJECTIVES: Early warning scores were developed to improve recognition of clinical deterioration in acute hospital settings. In England, the National Early Warning Score (NEWS) is increasingly being recommended at a national level for use outside such settings. In 2015, the West of England Academic Health Science Network supported the roll-out of NEWS across a range of non-acute-hospital healthcare sectors. Research on the use of NEWS outside acute hospitals is limited. The objective of this study was to explore staff experiences of using NEWS in these new settings. DESIGN: Thematic analysis of qualitative semi-structured interviews with purposefully sampled healthcare staff. SETTING: West of England healthcare settings where NEWS was being used outside acute hospitals-primary care, ambulance, referral management, community and mental health services. PARTICIPANTS: Twenty-five healthcare staff interviewed from primary care (9), ambulance (3), referral management/acute interface (5), community (4) and mental health services (3), and service commissioning (1). RESULTS: Participants reported that NEWS could support clinical decision-making around escalation of care, and provide a clear means of communicating clinical acuity between clinicians and across different healthcare organisations. Challenges with implementing NEWS varied-in primary care, clinicians had to select patients for NEWS and adopt different methods of clinical assessment, whereas for paramedics it fitted well with usual clinical practice and was used for all patients. In community services and mental health, modifications were 'needed' to make the tool relevant to some patient populations. CONCLUSIONS: This study demonstrated that while NEWS can work for staff outside acute hospital settings, the potential for routine clinical practice to accommodate NEWS in such settings varied. A tailored approach to implementation in different settings, incorporating guidance supported by further research on the use of NEWS with specific patient groups in community settings, may be beneficial, and enhance staff confidence in the tool.

Receptionists' role in new approaches to consultations in primary care: a focused ethnographic study.

BACKGROUND: The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. AIM: The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. DESIGN AND SETTING: The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. METHOD: Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. RESULTS: Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery. CONCLUSION: A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations.

Alternatives to the face-to-face consultation in general practice: focused ethnographic case study.

BACKGROUND: NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives. AIM: To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice. DESIGN AND SETTING: Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016. METHOD: Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the 'one sheet of paper' mind-map method to identify the line of argument in each thematic report. RESULTS: Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other's practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face consultation as the ideal. CONCLUSION: Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team.

Geographic and temporal patterns of variation in total mercury concentrations in blood of harlequin ducks and blue mussels from Alaska.

We compared total mercury (Hg) concentrations in whole blood of harlequin ducks (Histrionicus histrionicus) sampled within and among two geographically distinct locations and across three years in southwest Alaska. Blue mussels were collected to assess correlation between Hg concentrations in locally available forage and birds. Mercury concentrations in harlequin duck blood were significantly higher at Unalaska Island (0.31±0.19 mean±SD, µg/g blood) than Kodiak Island (0.04±0.02 mean±SD, µg/g blood). We found no evidence for annual variation in blood Hg concentration between years at Unalaska Island. However, blood Hg concentration did vary among specific sampling locations (i.e., bays) at Unalaska Island. Findings from this study demonstrate harlequin ducks are exposed to environmental sources of Hg, and whole blood Hg concentrations are associated with their local food source.