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Yahia A, Szlávecz Á, Knopp JL, Norfiza Abdul Razak N, Abu Samah A, Shaw G, Chase JG, Benyo B. Estimating Enhanced Endogenous Glucose Production in Intensive Care Unit Patients with Severe Insulin Resistance. J Diabetes Sci Technol 2022; 16:1208-1219. [PMID: 34078114 PMCID: PMC9445352 DOI: 10.1177/19322968211018260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Critically ill ICU patients frequently experience acute insulin resistance and increased endogenous glucose production, manifesting as stress-induced hyperglycemia and hyperinsulinemia. STAR (Stochastic TARgeted) is a glycemic control protocol, which directly manages inter- and intra- patient variability using model-based insulin sensitivity (SI). The model behind STAR assumes a population constant for endogenous glucose production (EGP), which is not otherwise identifiable. OBJECTIVE This study analyses the effect of estimating EGP for ICU patients with very low SI (severe insulin resistance) and its impact on identified, model-based insulin sensitivity identification, modeling accuracy, and model-based glycemic clinical control. METHODS Using clinical data from 717 STAR patients in 3 independent cohorts (Hungary, New Zealand, and Malaysia), insulin sensitivity, time of insulin resistance, and EGP values are analyzed. A method is presented to estimate EGP in the presence of non-physiologically low SI. Performance is assessed via model accuracy. RESULTS Results show 22%-62% of patients experience 1+ episodes of severe insulin resistance, representing 0.87%-9.00% of hours. Episodes primarily occur in the first 24 h, matching clinical expectations. The Malaysian cohort is most affected. In this subset of hours, constant model-based EGP values can bias identified SI and increase blood glucose (BG) fitting error. Using the EGP estimation method presented in these constrained hours significantly reduced BG fitting errors. CONCLUSIONS Patients early in ICU stay may have significantly increased EGP. Increasing modeled EGP in model-based glycemic control can improve control accuracy in these hours. The results provide new insight into the frequency and level of significantly increased EGP in critical illness.
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Affiliation(s)
- Anane Yahia
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
- Anane Yahia, Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, 2. Magyar tudosok Blvd., Budapest, H-1117, Hungary.
| | - Ákos Szlávecz
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
| | - Jennifer L. Knopp
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | | | - Asma Abu Samah
- Institute of Energy Infrastructure, Universiti Tenaga Nasional, Jalan Ikram-UNITEN, Kajang, Selangor, Malaysia
| | - Geoff Shaw
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | - J. Geoffrey Chase
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | - Balazs Benyo
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
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Abstract
BACKGROUND Stress-induced hyperglycemia is frequently experienced by critically ill patients and the use of glycemic control (GC) has been shown to improve patient outcomes. For model-based approaches to GC, it is important to understand and quantify model parameter assumptions. This study explores endogenous glucose production (EGP) and the use of a population-based parameter value in the intensive care unit context. METHOD Hourly insulin sensitivity (SI) was fit to clinical data from 145 patients on the Specialized Relative Insulin and Nutrition Titration GC protocol for at least 24 hours. Constraint of SI at a lower bound was used to explore likely EGP variability due to stress response. Minimum EGP was estimated during times when the model SI was constrained, and time and duration of events were examined. RESULTS Constrained events occur for 1.6% of patient hours. About 70% of constrained events occur in the first 12 hours and most events (~80%) occur when there is no exogenous nutrition given. Enhanced EGP values ranged from 1.16 mmol/min (current population value) to 2.75 mmol/min, with most being below 1.5 mmol/min (21% increase). CONCLUSION The frequency of constrained events is low and the current population value of 1.16 mmol/min is sufficient for more than 98% of patient hours, however, some patients experience significantly raised EGP probably due to an extreme stress response early in patient stay.
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Affiliation(s)
- Jennifer J. Ormsbee
- Department of Mechanical Engineering, Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Jennifer L. Knopp
- Department of Mechanical Engineering, Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
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The goldilocks problem: Nutrition and its impact on glycaemic control. Clin Nutr 2021; 40:3677-3687. [PMID: 34130014 DOI: 10.1016/j.clnu.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/25/2021] [Accepted: 05/01/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glucose intolerance and insulin resistance manifest as hyperglycaemia in intensive care, which is associated with mortality and morbidities. Glycaemic control (GC) may improve outcomes, though safe and effective control has proven elusive. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. This study aims to examine BG outcomes in the context of nutritional management during GC. METHODS Retrospective cohort analysis of 5 glycaemic control cohorts spanning 4 years (n = 273) from Christchurch Hospital Intensive Care Unit (ICU). GC is delivered using a single model-based protocol (STAR), with default 4.4-8.0 mmol/L target range via. modulation of insulin and nutrition. Clinical adaptations/cohorts include variations on upper target (UL-9 with 9.0 mmol/L, reducing workload and nutrition responsiveness), and insulin only (IO) with clinically set nutrition at 3 glucose concentrations (71 g/L vs. 120 and 180 g/L in the TARGET study). RESULTS Percent of BG hours in the 4.4-8.0 mmol/L range highest under standard STAR conditions (78%), and was lower at 64% under UL-9, likely due to reduced time-responsiveness of nutrition-insulin changes. By comparison, IO only resulted in 64-69% BG in range across different nutrition types. A subset of patients receiving high glucose nutrition under IO were persistently hyperglycaemic, indicating patient-specific glucose tolerance. CONCLUSION STAR GC is most effective when nutrition and insulin are modulated together with timely responsiveness to persistent hyperglycaemia. Results imply modulation of nutrition alongside insulin improves GC, particularly in patients with persistent hyperglycaemia/low glucose tolerance.
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Bochicchio GV, Nasraway SA, Moore LJ, Furnary AP, Nohra EA, Bochicchio KM, Boyd JC, Bruns DI, Hirsch IB, Preiser JC, Krinsley JS. Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients. J Diabetes Sci Technol 2021; 15:279-286. [PMID: 31744315 PMCID: PMC8256060 DOI: 10.1177/1932296819886917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients. METHODS An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%. RESULTS At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial. CONCLUSION Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.
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Affiliation(s)
| | | | - Laura J. Moore
- Department of Surgery, University of
Texas, McGovern Medical School, Houston, TX, USA
- Memorial Hermann Hospital, Houston, TX,
USA
| | - Anthony P. Furnary
- Providence St Vincent Medical Center,
Portland, OR, USA
- Oregon Med Laser Center, Portland, OR,
USA
- Portland Diabetes Project, OR, USA
| | - Eden A. Nohra
- Washington University, St. Louis School
of Medicine, MO, USA
| | | | - James C. Boyd
- University of Virginia Health System,
Charlottesville, VA, USA
| | - David I. Bruns
- University of Virginia Health System,
Charlottesville, VA, USA
| | - Irl B. Hirsch
- University of Washington School of
Medicine, Seattle, WA, USA
| | | | - James S. Krinsley
- Division of Critical Care, Stamford
Hospital and Columbia Vagelos College of Physicians and Surgeons, CT, USA
- James S. Krinsley, MD, FCCM, FCCP, Columbia
Vagelos College of Physicians and Surgeons, Division of Critical Care,
Department of Medicine, Stamford Hospital, 1 Hospital Plaza, Stamford, CT 06902,
USA.
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Chase JG, Shaw GM, Preiser JC, Knopp JL, Desaive T. Risk-Based Care: Let's Think Outside the Box. Front Med (Lausanne) 2021; 8:535244. [PMID: 33718394 PMCID: PMC7947294 DOI: 10.3389/fmed.2021.535244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 01/22/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- James Geoffrey Chase
- Centre for Bioengineering, Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, University of Otago Christchurch School of Medicine, Christchurch, New Zealand
| | | | - Jennifer L Knopp
- Centre for Bioengineering, Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA In Silico Medicine, University of Liege, Liege, Belgium
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Uyttendaele V, Chase JG, Knopp JL, Gottlieb R, Shaw GM, Desaive T. Insulin sensitivity in critically ill patients: are women more insulin resistant? Ann Intensive Care 2021; 11:12. [PMID: 33475909 PMCID: PMC7818291 DOI: 10.1186/s13613-021-00807-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 01/12/2021] [Indexed: 02/07/2023] Open
Abstract
Background Glycaemic control (GC) in intensive care unit is challenging due to significant inter- and intra-patient variability, leading to increased risk of hypoglycaemia. Recent work showed higher insulin resistance in female preterm neonates. This study aims to determine if there are differences in inter- and intra-patient metabolic variability between sexes in adults, to gain in insight into any differences in metabolic response to injury. Any significant difference would suggest GC and randomised trial design should consider sex differences to personalise care. Methods Insulin sensitivity (SI) levels and variability are identified from retrospective clinical data for men and women. Data are divided using 6-h blocks to capture metabolic evolution over time. In total, 91 male and 54 female patient GC episodes of minimum 24 h are analysed. Hypothesis testing is used to determine whether differences are significant (P < 0.05), and equivalence testing is used to assess whether these differences can be considered equivalent at a clinical level. Data are assessed for the raw cohort and in 100 Monte Carlo simulations analyses where the number of men and women are equal. Results Demographic data between females and males were all similar, including GC outcomes (safety from hypoglycaemia and high (> 50%) time in target band). Females had consistently significantly lower SI levels than males, and this difference was not clinically equivalent. However, metabolic variability between sexes was never significantly different and always clinically equivalent. Thus, inter-patient variability was significantly different between males and females, but intra-patient variability was equivalent. Conclusion Given equivalent intra-patient variability and significantly greater insulin resistance, females can receive the same benefit from safe, effective GC as males, but may require higher insulin doses to achieve the same glycaemia. Clinical trials should consider sex differences in protocol design and outcome analyses.
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Affiliation(s)
- Vincent Uyttendaele
- GIGA-In silico Medicine,, University of Liège, Allée du 6 Août 19, Bât. B5a, 4000, Liège, Belgium. .,Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Jennifer L Knopp
- GIGA-In silico Medicine,, University of Liège, Allée du 6 Août 19, Bât. B5a, 4000, Liège, Belgium
| | - Rebecca Gottlieb
- Medtronic Diabetes, 18000 Devonshire St, Northridge, CA, 91325, USA
| | - Geoffrey M Shaw
- Christchurch Hospital, Dept of Intensive Care, Christchurch, New Zealand and University of Otago, School of Medicine, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA-In silico Medicine,, University of Liège, Allée du 6 Août 19, Bât. B5a, 4000, Liège, Belgium
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Uyttendaele V, Chase JG, Knopp JL, Gottlieb R, Shaw GM, Desaive T. Insulin sensitivity in critically ill patients: are women more insulin resistant? Ann Intensive Care 2021. [PMID: 33475909 DOI: 10.1186/s13613-021-00807-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Glycaemic control (GC) in intensive care unit is challenging due to significant inter- and intra-patient variability, leading to increased risk of hypoglycaemia. Recent work showed higher insulin resistance in female preterm neonates. This study aims to determine if there are differences in inter- and intra-patient metabolic variability between sexes in adults, to gain in insight into any differences in metabolic response to injury. Any significant difference would suggest GC and randomised trial design should consider sex differences to personalise care. METHODS Insulin sensitivity (SI) levels and variability are identified from retrospective clinical data for men and women. Data are divided using 6-h blocks to capture metabolic evolution over time. In total, 91 male and 54 female patient GC episodes of minimum 24 h are analysed. Hypothesis testing is used to determine whether differences are significant (P < 0.05), and equivalence testing is used to assess whether these differences can be considered equivalent at a clinical level. Data are assessed for the raw cohort and in 100 Monte Carlo simulations analyses where the number of men and women are equal. RESULTS Demographic data between females and males were all similar, including GC outcomes (safety from hypoglycaemia and high (> 50%) time in target band). Females had consistently significantly lower SI levels than males, and this difference was not clinically equivalent. However, metabolic variability between sexes was never significantly different and always clinically equivalent. Thus, inter-patient variability was significantly different between males and females, but intra-patient variability was equivalent. CONCLUSION Given equivalent intra-patient variability and significantly greater insulin resistance, females can receive the same benefit from safe, effective GC as males, but may require higher insulin doses to achieve the same glycaemia. Clinical trials should consider sex differences in protocol design and outcome analyses.
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Affiliation(s)
- Vincent Uyttendaele
- GIGA-In silico Medicine,, University of Liège, Allée du 6 Août 19, Bât. B5a, 4000, Liège, Belgium. .,Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Jennifer L Knopp
- GIGA-In silico Medicine,, University of Liège, Allée du 6 Août 19, Bât. B5a, 4000, Liège, Belgium
| | - Rebecca Gottlieb
- Medtronic Diabetes, 18000 Devonshire St, Northridge, CA, 91325, USA
| | - Geoffrey M Shaw
- Christchurch Hospital, Dept of Intensive Care, Christchurch, New Zealand and University of Otago, School of Medicine, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA-In silico Medicine,, University of Liège, Allée du 6 Août 19, Bât. B5a, 4000, Liège, Belgium
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Knopp JL, Chase JG, Shaw GM. Increased insulin resistance in intensive care: longitudinal retrospective analysis of glycaemic control patients in a New Zealand ICU. Ther Adv Endocrinol Metab 2021; 12:20420188211012144. [PMID: 34123348 PMCID: PMC8173630 DOI: 10.1177/20420188211012144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Critical care populations experience demographic shifts in response to trends in population and healthcare, with increasing severity and/or complexity of illness a common observation worldwide. Inflammation in critical illness impacts glucose-insulin metabolism, and hyperglycaemia is associated with mortality and morbidity. This study examines longitudinal trends in insulin sensitivity across almost a decade of glycaemic control in a single unit. METHODS A clinically validated model of glucose-insulin dynamics is used to assess hour-hour insulin sensitivity over the first 72 h of insulin therapy. Insulin sensitivity and its hour-hour percent variability are examined over 8 calendar years alongside severity scores and diagnostics. RESULTS Insulin sensitivity was found to decrease by 50-55% from 2011 to 2015, and remain low from 2015 to 2018, with no concomitant trends in age, severity scores or risk of death, or diagnostic category. Insulin sensitivity variability was found to remain largely unchanged year to year and was clinically equivalent (95% confidence interval) at the median and interquartile range. Insulin resistance was associated with greater incidence of high insulin doses in the effect saturation range (6-8 U/h), with the 75th percentile of hourly insulin doses rising from 4-4.5 U/h in 2011-2014 to 6 U/h in 2015-2018. CONCLUSIONS Increasing insulin resistance was observed alongside no change in insulin sensitivity variability, implying greater insulin needs but equivalent (variability) challenge to glycaemic control. Increasing insulin resistance may imply greater inflammation and severity of illness not captured by existing severity scores. Insulin resistance reduces glucose tolerance, and can cause greater incidence of insulin saturation and resultant hyperglycaemia. Overall, these results have significant clinical implications for glycaemic control and nutrition management.
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Affiliation(s)
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
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Uyttendaele V, Knopp JL, Shaw GM, Desaive T, Chase JG. Risk and reward: extending stochastic glycaemic control intervals to reduce workload. Biomed Eng Online 2020; 19:26. [PMID: 32349750 PMCID: PMC7191799 DOI: 10.1186/s12938-020-00771-6] [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] [Received: 12/16/2019] [Accepted: 04/17/2020] [Indexed: 01/08/2023] Open
Abstract
Background STAR is a model-based, personalised, risk-based dosing approach for glycaemic control (GC) in critically ill patients. STAR provides safe, effective control to nearly all patients, using 1–3 hourly measurement and intervention intervals. However, the average 11–12 measurements per day required can be a clinical burden in many intensive care units. This study aims to significantly reduce workload by extending STAR 1–3 hourly intervals to 1 to 4-, 5-, and 6-hourly intervals, and evaluate the impact of these longer intervals on GC safety and efficacy, using validated in silico virtual patients and trials methods. A Standard STAR approach was used which allowed more hyperglycaemia over extended intervals, and a STAR Upper Limit Controlled approach limited nutrition to mitigate hyperglycaemia over longer intervention intervals. Results Extending STAR from 1–3 hourly to 1–6 hourly provided high safety and efficacy for nearly all patients in both approaches. For STAR Standard, virtual trial results showed lower % blood glucose (BG) in the safe 4.4–8.0 mmol/L target band (from 83 to 80%) as treatment intervals increased. Longer intervals resulted in increased risks of hyper- (15% to 18% BG > 8.0 mmol/L) and hypo- (2.1% to 2.8% of patients with min. BG < 2.2 mmol/L) glycaemia. These results were achieved with slightly reduced insulin (3.2 [2.0 5.0] to 2.5 [1.5 3.0] U/h) and nutrition (100 [85 100] to 90 [75 100] % goal feed) rates, but most importantly, with significantly reduced workload (12 to 8 measurements per day). The STAR Upper Limit Controlled approach mitigated hyperglycaemia and had lower insulin and significantly lower nutrition administration rates. Conclusions The modest increased risk of hyper- and hypo-glycaemia, and the reduction in nutrition delivery associated with longer treatment intervals represent a significant risk and reward trade-off in GC. However, STAR still provided highly safe, effective control for nearly all patients regardless of treatment intervals and approach, showing this unique risk-based dosing approach, modulating both insulin and nutrition, to be robust in its design. Clinical pilot trials using STAR with different measurement timeframes should be undertaken to confirm these results clinically.
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Affiliation(s)
- Vincent Uyttendaele
- GIGA-In Silico Medicine, University of Liège, Allée Du 6 Août 19, Bât. B5a, 4000, Liège, Belgium. .,Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - Jennifer L Knopp
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Dept of Intensive Care, Christchurch Hospital, Christchurch, New Zealand.,School of Medicine, University of Otago, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA-In Silico Medicine, University of Liège, Allée Du 6 Août 19, Bât. B5a, 4000, Liège, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
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Young J, Snowden A. A J curve of interprofessional change: co-locating non-health partners in an oncology unit. ACTA ACUST UNITED AC 2020; 29:S10-S16. [PMID: 32053440 DOI: 10.12968/bjon.2020.29.3.s10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Internationally, clinicians face increased demand, pressure on resources and unmet patient needs. A community social support service was co-located within cancer clinics in Glasgow, Scotland to help address some of these needs. AIM To analyse the impact of the service on clinical staff and to propose an explanatory theory of change. METHOD Qualitative exploratory design, using thematic analysis of semistructured interviews with 8 nurse specialists and 2 medical oncologists from lung, breast, head and neck, and gastrointestinal oncology teams in Glasgow in 2018-2019. FINDINGS Four themes captured this process: 'The conversation', 'A better experience', 'Freedom to focus' and 'Working hand in hand'. CONCLUSION Together, these four themes explained the process of effective interprofessional working. This process would have been predicted by the J-curve literature on diffusion of innovations. Linking J-curve theory to this successful process provides new understanding that could prove essential for clinical teams who are implementing change within their practice.
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Affiliation(s)
- Jenny Young
- Research Fellow, Edinburgh Napier University
| | - Austyn Snowden
- Chair in Mental Health, School of Health and Social Care, Edinburgh Napier University
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