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Zasada W, Cholerzyńska H, Kłosiewicz T, Rozmarynowska M, Konieczka P, Lasik J, Jankowski T, Kubiak S, Bielska IA. Why do patients who are triaged as low-acuity visit the emergency department? - A Polish perspective. Int Emerg Nurs 2024; 76:101506. [PMID: 39182473 DOI: 10.1016/j.ienj.2024.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 08/01/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Emergency departments (EDs) worldwide are dealing with overcrowding, system fragmentation, and coordination problems, which impact patient wait times, staff job satisfaction, and patient outcomes. Inappropriate ED visits, particularly those for low acuity conditions, exacerbate these challenges. However, the motivations behind these visits are poorly understood, with limited data from the patient perspective. This study investigated patient-reported motives behind ED visits triaged as low acuity in Poznan, Poland, to propose health care system flow enhancements. MATERIAL AND METHODS A cross-sectional survey and retrospective chart review were conducted in the ED of the Hipolit Cegielski Medical Center in Poznań, Poland, over three months in 2022-23. Patients who were triaged to have low acuity conditions were invited to participate in the survey. The data collected through the questionnaire included patient and ED visit characteristics. Additional information on the visits was extracted from the patient charts. MAIN RESULTS This study involved 293 patients who underwent low-acuity triage. Among them, 58 % were deemed to have conditions that could have been treated in primary care. Most of the patients (74 %) visited the ED of their own volition due to concerns about their health. Other reasons for ED attendance were challenges accessing primary care or a specialist clinic (11 %), system navigation problems (5 %), or a lack of trust in their primary care provider (2 %). CONCLUSIONS This study showed that of the patients surveyed, the majority had conditions that could have been treated outside of the ED setting. We recommend prioritizing education, particularly among younger adults, to increase awareness about nonurgent care options while improving health care policies.
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Affiliation(s)
- Wiktoria Zasada
- Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Hanna Cholerzyńska
- Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland.
| | - Tomasz Kłosiewicz
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Monika Rozmarynowska
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Patryk Konieczka
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Julian Lasik
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Tomasz Jankowski
- University Clinical Hospital in Poznań, 49 Przybyszewskiego Street, 60-355 Poznań, Poland
| | - Sebastian Kubiak
- University Clinical Hospital in Poznań, 49 Przybyszewskiego Street, 60-355 Poznań, Poland
| | - Iwona A Bielska
- Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Jackson LE, Skains RM, Mudano A, Techarukpong N, Booth JS, Saag KG, Fraenkel L, Danila MI. An Emergency Department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture. JBMR Plus 2024; 8:ziae038. [PMID: 38681999 PMCID: PMC11055962 DOI: 10.1093/jbmrpl/ziae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/18/2023] [Accepted: 01/12/2024] [Indexed: 05/01/2024] Open
Abstract
Falls and osteoporosis are risk factors for fragility fractures. Bone mineral density (BMD) assessment is associated with better preventative osteoporosis care, but it is underutilized by those at high fracture risk. We created a novel electronic medical record (EMR) alert-driven protocol to screen patients in the Emergency Department (ED) for fracture risk and tested its feasibility and effectiveness in generating and completing referrals for outpatient BMD testing after discharge. The EMR alert was configured in 2 tertiary-care EDs and triggered by the term "fall" in the chief complaint, age (≥65 years for women, ≥70 years for men), and high fall risk (Morse score ≥ 45). The alert electronically notified ED study staff of potentially eligible patients. Participants received osteoporosis screening education and had BMD testing ordered. From November 15, 2020 to December 4, 2021, there were 2,608 EMR alerts among 2,509 patients. We identified 558 patients at high-risk of fracture who were screened for BMD testing referral. Participants were excluded for: serious illness (N = 141), no documented health insurance to cover BMD testing (N = 97), prior BMD testing/recent osteoporosis care (N = 58), research assistant unavailable to enroll (N = 53), concomitant fracture (N = 43), bedridden status (N = 38), chief complaint of fall documented in error (N = 38), long-term care residence (N = 34), participation refusal (N = 32), or hospitalization (N = 3). Of the 16 participants who had BMD testing ordered, 7 scheduled and 5 completed BMD testing. EMR alerts can help identify subpopulations who may benefit from osteoporosis screening, but there are significant barriers to identifying eligible and willing patients for screening in the ED. In our study targeting an innovative venue for osteoporosis care delivery, only about 1% of patients at high-risk of fracture scheduled BMD testing after an ED visit. Adequate resources during and after an ED visit are needed to ensure that older adults participate in preventative osteoporosis care.
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Affiliation(s)
- Lesley E Jackson
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Rachel M Skains
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL 35233, United States
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Norma Techarukpong
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - James S Booth
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Liana Fraenkel
- Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, CT 06510, United States
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL 35233, United States
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Cooper A, Edwards M, Davies F, Price D, Anderson P, Carson-Stevens A, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Hepburn J, Hibbert P, Hughes TC, Porter A, Siriwardena AN, Watkins A, Snooks H, Edwards A. Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation. Emerg Med J 2024; 41:287-295. [PMID: 38649248 PMCID: PMC11041563 DOI: 10.1136/emermed-2023-213426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. METHODS We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. RESULTS GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. CONCLUSION GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Barbara Harrington
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Julie Hepburn
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | | | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Alan Watkins
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Davies F, Edwards M, Price D, Anderson P, Carson-Stevens A, Choudhry M, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Harris S, Hepburn J, Hibbert P, Hughes T, Hussain F, Islam S, Pockett R, Porter A, Siriwardena AN, Snooks H, Watkins A, Edwards A, Cooper A. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-152. [PMID: 38687611 DOI: 10.3310/jwqz5348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Background Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. Objectives To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Design Mixed-methods realist evaluation. Methods Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. Results General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. Limitations The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Conclusion Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. Future work The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration This study is registered as PROSPERO CRD42017069741. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Freya Davies
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Bangor Institute for Health and Medical Research, Bangor University, Wales, UK
| | | | - Mazhar Choudhry
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | - Jeremy Dale
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | | | - Bridie Angela Evans
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Julie Hepburn
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Faris Hussain
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rhys Pockett
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Alison Porter
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Helen Snooks
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alan Watkins
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
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5
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Martinez N. Guest Editorial: The Time Is Now: A Call for Research in Emergency Care. Adv Emerg Nurs J 2024; 46:91-92. [PMID: 38736092 DOI: 10.1097/tme.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Affiliation(s)
- Nicole Martinez
- Associate Professor, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
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6
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Al Meslamani AZ. Why are outcome-based drug safety research studies scarce? Insights into operational challenges and potential solutions. Expert Opin Drug Saf 2024; 23:145-148. [PMID: 38214223 DOI: 10.1080/14740338.2024.2305368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Affiliation(s)
- Ahmad Z Al Meslamani
- College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
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Stuckenschneider T, Schmidt L, Speckmann EM, Koschate J, Zieschang T. Recruiting patients for falls prevention in the emergency department - worth the challenge. BMC Geriatr 2023; 23:880. [PMID: 38129767 PMCID: PMC10740331 DOI: 10.1186/s12877-023-04607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Severe falls escalate the risk of future falls and functional decline as indicated by recent global guidelines. To establish effective falls prevention, individuals at highest risk must be thoroughly studied and, therefore, successfully recruited. OBJECTIVE Recruiting from an emergency department (ED) may mitigate common selection biases, such as overrepresentation of individuals with a higher social status and healthier lifestyle. However, this approach presents unique challenges due to ED-specific conditions. Hence, we present the successes and challenges of an ED-based recruitment for an observational study. METHODS The SeFallED study targets older adults aged ≥60 years, who present to either of two hospitals in Oldenburg after a fall without subsequent admission. A study nurse addressed individuals in the EDs. Subsequently, potential participants were contacted by phone to arrange a home visit for obtaining written consent. Data of participants were compared with total admissions during the recruitment period to determine recruitment rate and compare patients' characteristics. RESULTS Over 1.500 individuals met the inclusion criteria. Of these, 288 participants were successfully recruited. Most patients presented to the ED outside of the study team's working hours, and some opted not to participate (main reason: too unwell (40%)). Compared to working hours, a participant was recruited every 14 h. Comparing characteristics, a trend towards better health and younger age was observed. CONCLUSION ED-based recruitment offers the opportunity to include more diverse individuals in falls prevention. To achieve adequate sample sizes, flexibility in working days and hours of the research team are obligatory. TRIAL REGISTRATION DRKS00025949.
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Affiliation(s)
- Tim Stuckenschneider
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany.
| | - Laura Schmidt
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
| | - Elisa-Marie Speckmann
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
| | - Jessica Koschate
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
| | - Tania Zieschang
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
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8
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Kehoe MacLeod K, Flores KN, Chandra K. Identifying facilitators and barriers to integrated and equitable care for community-dwelling older adults with high emergency department use from historically marginalized groups. Int J Equity Health 2023; 22:97. [PMID: 37208757 PMCID: PMC10198019 DOI: 10.1186/s12939-023-01900-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/27/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND High rates of emergency department (ED) use by older adults persist despite attempts to improve accessibility of appropriate and comprehensive care. Understanding the drivers of ED visits from the perspective of older adults from historically marginalized groups could help reduce ED use by patients with needs that are preventable or could have been treated in a more appropriate setting. This interpretivist, feminist study aims to explore the unmet care needs of older adults (age 65 +) with high ED use and belonging to historically marginalized groups to better understand how social and structural inequities reinforced by neoliberalism; federal and provincial governance structures and policy frameworks; and regional processes and local institutional practices, shape the experiences of these older adults, particularly those at risk of poor health outcomes based on the social determinants of health (SDH). METHODS/DESIGN This mixed methods study will employ an integrated knowledge translation (iKT) approach, starting with a quantitative phase followed by a qualitative phase. Older adults self-identifying as belonging to a historically marginalized group, having visited an ED three or more times in the past 12 months, and living in a private dwelling, will be recruited using flyers posted at two emergency care sites and by an on-site research assistant. Data obtained through surveys, short answer questions, and chart review will be used to compile case profiles of patients from historically marginalized groups with potentially avoidable ED visits. Descriptive and inferential statistical analyses and inductive thematic analysis will be conducted. Findings will be interpreted using the Intersectionality-Based Policy Analysis Framework to identify the interconnections between unmet care needs, potentially avoidable ED admissions, structural inequalities, and the SDH. Semi-structured interviews will be conducted with a subset of older adults at risk of poor health outcomes based on SDH, family care partners, and health care professionals to validate preliminary findings and collect additional data on perceived facilitators and barriers to integrated and accessible care. DISCUSSION Exploring the linkages between potentially avoidable ED visits by older adults from marginalized groups and how their care experiences have been shaped by inequities in the systems, policies, and institutions that structure health and social care provision will enable researchers to offer recommendations for equity-focused policy and clinical practice reforms to improve patient outcomes and system integration.
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Affiliation(s)
- Krystal Kehoe MacLeod
- Bruyère Research Institute, Ottawa, Ontario, Canada.
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
- Horizon Health Network, Saint John, New Brunswick, Canada.
| | - Karyle Nama Flores
- Horizon Health Network, Saint John, New Brunswick, Canada
- Faculty of Health Sciences and Nursing, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Kavish Chandra
- Horizon Health Network, Saint John, New Brunswick, Canada
- Faculty of Medicine, Dalhousie University, Saint John, New Brunswick, Canada
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9
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Wait S. Engaging nurses in patient recruitment to research trials in the emergency department. Emerg Nurse 2023; 31:27-31. [PMID: 35968613 DOI: 10.7748/en.2022.e2137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
Research is essential for the implementation of evidence-based practice and can lead to improvements and innovations in care delivery. Although ultimately beneficial for patients and staff, the data collection involved in research often presents challenges, particularly in the emergency department (ED) setting. This article describes the challenges of undertaking a feasibility trial in a city centre ED. The target research population were adult patients who presented to the ED with an issue related to opioid misuse, for example opioid overdose, injection site wounds and/or abscess, or injury sustained during opioid intoxication. Challenges experienced during this trial included a demanding work environment, ED attendees not being suitable for recruitment into research, and suspension of the trial during the coronavirus disease 2019 (COVID-19) pandemic. The author details the strategies introduced to ensure effective patient recruitment to the trial, including nurse secondment onto the research team, offering incentives, raising awareness of the trial among ED staff and implementing flexible training. These strategies continued to be effective after a period of suspension due to the COVID-19 pandemic.
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Affiliation(s)
- Sarah Wait
- emergency department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
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10
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Schneider A, Wagenknecht A, Sydow H, Riedlinger D, Holzinger F, Figura A, Deutschbein J, Reinhold T, Pigorsch M, Stasun U, Schenk L, Möckel M. Primary and secondary data in emergency medicine health services research - a comparative analysis in a regional research network on multimorbid patients. BMC Med Res Methodol 2023; 23:34. [PMID: 36739382 PMCID: PMC9898937 DOI: 10.1186/s12874-023-01855-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/30/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND This analysis addresses the characteristics of two emergency department (ED) patient populations defined by three model diseases (hip fractures, respiratory, and cardiac symptoms) making use of survey (primary) and routine (secondary) data from hospital information systems (HIS). Our aims were to identify potential systematic inconsistencies between both data samples and implications of their use for future ED-based health services research. METHODS The research network EMANET prospectively collected primary data (n=1442) from 2017-2019 and routine data from 2016 (n=9329) of eight EDs in a major German city. Patient populations were characterized using socio-structural (age, gender) and health- and care-related variables (triage, transport to ED, case and discharge type, multi-morbidity). Statistical comparisons between descriptive results of primary and secondary data samples for each variable were conducted using binomial test, chi-square goodness-of-fit test, or one-sample t-test according to scale level. RESULTS Differences in distributions of patient characteristics were found in nearly all variables in all three disease populations, especially with regard to transport to ED, discharge type and prevalence of multi-morbidity. Recruitment conditions (e.g., patient non-response), project-specific inclusion criteria (e.g., age and case type restrictions) as well as documentation routines and practices of data production (e.g., coding of diagnoses) affected the composition of primary patient samples. Time restrictions of recruitment procedures did not generate meaningful differences regarding the distribution of characteristics in primary and secondary data samples. CONCLUSIONS Primary and secondary data types maintain their advantages and shortcomings in the context of emergency medicine health services research. However, differences in the distribution of selected variables are rather small. The identification and classification of these effects for data interpretation as well as the establishment of monitoring systems in the data collection process are pivotal. TRIAL REGISTRATION DRKS00011930 (EMACROSS), DRKS00014273 (EMAAGE), NCT03188861 (EMASPOT).
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Affiliation(s)
- Anna Schneider
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany.
| | - Andreas Wagenknecht
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany.
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany.
| | - Hanna Sydow
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Social Medicine, Epidemiology and Health Economics, Berlin, Germany
| | - Dorothee Riedlinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Berlin, Germany
| | - Andrea Figura
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychosomatic Medicine, Berlin, Germany
| | - Johannes Deutschbein
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Thomas Reinhold
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Social Medicine, Epidemiology and Health Economics, Berlin, Germany
| | - Mareen Pigorsch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Ulrike Stasun
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Liane Schenk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Evans BA, Carson‐Stevens A, Cooper A, Davies F, Edwards M, Harrington B, Hepburn J, Hughes T, Price D, Siriwardena NA, Snooks H, Edwards A. Implementing public involvement throughout the research process-Experience and learning from the GPs in EDs study. Health Expect 2022; 25:2471-2484. [PMID: 35894169 PMCID: PMC9615054 DOI: 10.1111/hex.13566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/26/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Public involvement in health services research is encouraged. Descriptions of public involvement across the whole research cycle of a major study are uncommon and its effects on research conduct are poorly understood. AIM This study aimed to describe how we implemented public involvement, reflect on process and effects in a large-scale multi-site research study and present learning for future involvement practice. METHOD We recorded public involvement roles and activities throughout the study and compared these to our original public involvement plan included in our project proposal. We held a group interview with study co-applicants to explore their experiences, transcribed the recorded discussion and conducted thematic analysis. We synthesized the findings to develop recommendations for future practice. RESULTS Public contributors' activities went beyond strategic study planning and management to include active involvement in data collection, analysis and dissemination. They attended management, scrutiny, planning and task meetings. They also facilitated public involvement through annual planning and review sessions, conducted a Public Involvement audit and coordinated public and patient input to stakeholder discussions at key study stages. Group interview respondents said that involvement exceeded their expectations. They identified effects such as changes to patient recruitment, terminology clarification and extra dissemination activities. They identified factors enabling effective involvement including team and leader commitment, named support contact, building relationships and demonstrating equality and public contributors being confident to challenge and flexible to meet researchers' timescales and work patterns. There were challenges matching resources to roles and questions about the risk of over-professionalizing public contributors. CONCLUSION We extended our planned approach to public involvement and identified benefits to the research process that were both specific and general. We identified good practice to support effective public involvement in health services research that study teams should consider in planning and undertaking research. PUBLIC CONTRIBUTION This paper was co-conceived, co-planned and co-authored by public contributors to contribute research evidence, based on their experiences of active involvement in the design, implementation and dissemination of a major health services research study.
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Affiliation(s)
- Bridie Angela Evans
- Swansea University Medical SchoolSwansea UniversitySwanseaUK
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
| | - Andrew Carson‐Stevens
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Alison Cooper
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Freya Davies
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Michelle Edwards
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Barbara Harrington
- Public Contributor, c/o Swansea University Medical SchoolSwansea UniversitySwanseaUK
| | - Julie Hepburn
- Public Contributor, c/o Swansea University Medical SchoolSwansea UniversitySwanseaUK
| | | | - Delyth Price
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | | | - Helen Snooks
- Swansea University Medical SchoolSwansea UniversitySwanseaUK
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
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Price D, Edwards M, Davies F, Cooper A, McFadzean J, Carson-Stevens A, Cooke M, Dale J, Evans BA, Harrington B, Hepburn J, Siriwardena AN, Snooks H, Edwards A. Patients' experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation. BMC Emerg Med 2022; 22:12. [PMID: 35065616 PMCID: PMC8783419 DOI: 10.1186/s12873-021-00562-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/07/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patient experience is an important outcome and indicator of healthcare quality, and patient reported experiences are key to improving quality of care. While patient experience in emergency departments (EDs) has been reported in research, there is limited evidence about patients' specific experiences with primary care services located in or alongside EDs. We aim to identify theories about patient experience and acceptability of being streamed to a primary care clinician in an ED. METHODS Using theories from a rapid realist review as a basis, we interviewed 24 patients and 106 staff members to generate updated theories about patient experience and acceptability of streaming to primary care services in EDs. Feedback from 56 stakeholders, including clinicians, policymakers and patient and public members, as well as observations at 13 EDs, also contributed to the development of these theories, which we present as a programme theory. RESULTS We found that patients had no expectations or preferences for which type of clinician they were seen by, and generally found being streamed to a primary care clinician in the ED acceptable. Clinicians and patients reported that patients generally found primary care streaming acceptable if they felt their complaint was dealt with suitably, in a timely manner, and when clinicians clearly communicated the need for investigations, and how these contributed to decision-making and treatment plans. CONCLUSIONS From our findings, we have developed a programme theory to demonstrate that service providers can expect that patients will be generally satisfied with their experience of being streamed to, and seen by, primary care clinicians working in these services. Service providers should consider the potential advantages and disadvantages of implementing primary care services at their ED. If primary care services are implemented, clear communication is needed between staff and patients, and patient feedback should be sought.
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Affiliation(s)
- Delyth Price
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Freya Davies
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - Alison Cooper
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - Joy McFadzean
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | | | - Matthew Cooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Barbara Harrington
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - Julie Hepburn
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | | | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - Adrian Edwards
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
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Knisley L, Le A, Scott SD. An online survey to assess parents' preferences for learning about child health research. Nurs Open 2021; 8:3143-3151. [PMID: 34390222 PMCID: PMC8510747 DOI: 10.1002/nop2.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/07/2021] [Accepted: 07/25/2021] [Indexed: 11/11/2022] Open
Abstract
Aim Ethical and logistical issues often exacerbate recruitment problems in child health studies. This study aims: (a) to provide new knowledge on how parents want to hear about child health research and (b) to inform the KidsCAN PERC iPCT initiative's re‐examination of recruitment and retention strategies for pediatric emergency department research studies. Design We employed a cross‐sectional, survey design. Methods An online survey was distributed to participants (i.e., parents) through partner organizations' advisory group mailing lists. Frequencies and measures of central tendency guided data analysis. Results Parents are interested in hearing about child health research opportunities, particularly during general practitioner, pediatrician or walk‐in clinic visits. Most parents wanted updates on the research team, progress and results and support to participate, such as reimbursement of travel and childcare costs. Results can inform research teams in the planning of communications to effectively share research opportunities, progress and results with parents.
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Affiliation(s)
- Lisa Knisley
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Anne Le
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Ho K, Novak Lauscher H, Cordeiro J, Hawkins N, Scheuermeyer F, Mitton C, Wong H, McGavin C, Ross D, Apantaku G, Karim ME, Bhullar A, Abu-Laban R, Nixon S, Smith T. Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study. JMIR Form Res 2021; 5:e24509. [PMID: 34081015 PMCID: PMC8212633 DOI: 10.2196/24509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/18/2020] [Accepted: 03/16/2021] [Indexed: 01/29/2023] Open
Abstract
Background Patients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life. Objective Our objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial. Methods Patients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient’s condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods. Results Seventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management. Conclusions Results from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia. Trial Registration ClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384
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Affiliation(s)
- Kendall Ho
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Helen Novak Lauscher
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Cordeiro
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Colleen McGavin
- BC Support for People & Patient-Oriented Research & Trials, Vancouver, BC, Canada
| | - Dianne Ross
- Vancouver General Hospital, Vancouver, BC, Canada
| | - Glory Apantaku
- Centre for Clinical Epidemiology & Evaluation, University of British Columbia, Vancouver, BC, Canada
| | - Mohammad Ehsan Karim
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Amrit Bhullar
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Suzanne Nixon
- University of British Columbia, Vancouver, BC, Canada
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Evans BA, Gallanders J, Griffiths L, Harris-Mayes R, James M, Jones S, Joseph-Williams N, Nettle M, Rolph M, Snooks H, Wallace C, Edwards A. Public involvement and engagement in primary and emergency care research: the story from PRIME Centre Wales. Int J Popul Data Sci 2020; 5:1363. [PMID: 33644413 PMCID: PMC7894248 DOI: 10.23889/ijpds.v5i3.1363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Policy throughout the United Kingdom promotes involvement of patients and public members in research to benefit patient care and health outcomes. PRIME Centre Wales is a national research centre, developing and coordinating research about primary and emergency care which forms 90% of health service encounters. In this paper, we describe our approach to public involvement and engagement in PRIME Centre Wales (hereafter called PRIME), in particular: how this approach has developed; ways in which public members contribute to PRIME activity; the strengths and limitations of our approach, challenges and future opportunities. PRIME ensures work is relevant to service users, carers, the public and policy makers by incorporating comprehensive patient and public involvement in every phase of our work. APPROACH PRIME has policies and processes to enable and promote successful public involvement and engagement across research activities. This ensures public perspectives and patient experiences are integrated throughout research development, implementation and dissemination and in managing and delivering PRIME strategy over a 10 year timescale. A public/patient group called SUPER is a key resource providing wide-ranging perspectives via email and face-to-face discussion. We collect information on processes and experiences to assess value and impact, to guide ongoing involvement and engagement. A funded post provides leadership and support to staff and to public/patient contributors to facilitate collaborations. DISCUSSION A stable, well-resourced structure has provided the timescales to build strong relationships and embed diverse approaches to public involvement and engagement within PRIME. Researchers and public contributors have committed to collaborations, developed knowledge and skills and sustained relationships. Effective approaches incorporate values and actions which, when operating together, strengthen processes and outcomes of public involvement and engagement. CONCLUSION Supportive context, motivation and time are necessary to foster values and practices that enable effective public involvement and engagement. PRIME has embedded public involvement and engagement across research activities and structures. Central is the public/patient group SUPER offering experience-based expertise to add value to the research cycle. This innovative model, aligned with best practice, enhances relevance and quality of primary and emergency care research to benefit patients and the general population.
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Affiliation(s)
- Bridie Angela Evans
- Swansea University Medical School, ILS 2, Singleton Campus, Swansea, SA2 8PP, UK
| | - John Gallanders
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | - Lesley Griffiths
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | - Robert Harris-Mayes
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | - Mari James
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | - Sian Jones
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | | | - Mary Nettle
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | - Martin Rolph
- SUPER, c/o Swansea University Medical School ILS 2, Singleton Campus Swansea, SA2 8PP, UK
| | - Helen Snooks
- Swansea University Medical School, ILS 2, Singleton Campus, Swansea, SA2 8PP, UK
| | - Carolyn Wallace
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, CF37 1DL, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, Wales, CF10 3AT, UK
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