Outdoor air pollution and near-fatal/fatal asthma attacks in children: A systematic review

BACKGROUND

Globally, observational studies have demonstrated an association between high levels of air pollution and asthma attacks in children. It remains unclear whether and to what extent exposure may be associated with increased near-fatal/fatal attacks.

OBJECTIVE

To systematically review the evidence for an association between ambient outdoor air pollution and fatal and/or near-fatal asthma (NFA).

METHODS

Following Cochrane methodology, we searched MEDLINE, EMBASE, Web of Science, Scopus, and Open Grey electronic databases for studies reporting the association of fatal/NFA and air pollution (particulate matter [PM], sulfur dioxide, nitrogen dioxide, black carbon and ozone [O3]) in children. NFA was defined as requiring intensive care unit (ICU) management.

RESULTS

Two reviewers independently screened 1358 papers. A total of 276 studies identified asthma attacks related to air pollution, 272 did not meet inclusion criteria after full-text review. Four observational studies described fatal/NFA, of which three addressed NFA. PM2.5 (per 12.5 µg/m3 increase) and O3 (per 22 ppb increase) were associated with NFA in one study (PM2.5, relative risk: 1.26, confidence interval [CI] [1.10-1.44]), O3 (1.19 [1.01-1.40]). PM10 was associated with ICU admission in the context of thunderstorm asthma. Elemental carbon was associated equally with NFA that did not require an ICU admission (p = 0.67). Studies of fatal asthma including children did not demarcate age within the analysis.

CONCLUSIONS

Ozone and PM2.5 have been associated with NFA in children but synthesis is limited by the paucity of studies and methodological heterogeneity. Poor reporting of severities of asthma attacks hinders the assessment of whether outdoor air pollution is associated with an increased number of NFA/fatal attacks in children.

Lung clearance index (LCI2.5) changes after initiation of Elexacaftor/Tezacaftor/Ivacaftor in children with cystic fibrosis aged between 6 and 11 years: The "real-world" differs from trial data

BACKGROUND

Elexacaftor in combination with Tezacaftor and Ivacaftor (ETI) became licensed in the United Kingdom in early 2022 for children aged 6-11 years with cystic fibrosis (CF) and an eligible mutation. Many in this age group have excellent prior lung health making quantitative measurement of benefit challenging. Clinical trials purport that lung clearance index (LCI2.5) measurement is most suitable for this purpose.

OBJECTIVES

This study aimed to understand the clinical utility of LCI2.5 in detecting change after commencing ETI in the real world.

PATIENT SELECTION/METHODS

Baseline anthropometric data were collected along with spirometry (forced expiratory volume in 1 s [FEV1], forced vital capacityFV and LCI2.5 measures in children aged 6-11 years with CF before starting ETI. Measures were repeated after a mean (range) of 8.2 (7-14) months of ETI treatment. The primary endpoint was a change in LCI2.5, with secondary endpoints including change in FEV1 and change in body mass index (BMI) also reported.

RESULTS

Twelve children were studied (seven male, mean age 9.5 years at baseline). Our study population had a mean (SD) LCI2.5 of 7.01 (1.14) and FEV1 of 96 (13) %predicted at baseline. Mean (95% confidence interval) changes in LCI2.5 [-0.7 (-1.4, 0), p = .06] and BMI [+0.7 (+0.1, +1.3), p = .03] were observed, along with changes in FEV1 of +3.1 (-1.9, +8.1) %predicted.

CONCLUSIONS

Real-world changes in LCI2.5 (-0.7) are different to those reported in clinical trials (-2.29). Lower baseline LCI2.5 as a result of prior modulator exposure, high baseline lung health, and new LCI2.5 software analyses all contribute to lower LCI2.5 values being recorded in the real world of children with CF.

Efficacy of oral corticosteroids for acute preschool wheeze: a systematic review and individual participant data meta-analysis of randomised clinical trials

BACKGROUND

Oral corticosteroids are commonly used for acute preschool wheeze, although there is conflicting evidence of their benefit. We assessed the clinical efficacy of oral corticosteroids by means of a systematic review and individual participant data (IPD) meta-analysis.

METHODS

In this systematic review with IPD meta-analysis, we systematically searched eight databases (PubMed, Ovid Embase, CINAHLplus, CENTRAL, ClinicalTrials.gov, EudraCT, EU Clinical Trials Register, WHO Clinical Trials Registry) for randomised clinical trials published from Jan 1, 1994, to June 30, 2020, comparing oral corticosteroids with placebo in children aged 12 to 71 months with acute preschool wheeze in any setting based on the Population, Intervention, Comparison, Outcomes framework. We contacted principal investigators of eligible studies to obtain deidentified individual patient data. The primary outcome was change in wheezing severity score (WSS). A key secondary outcome length of hospital stay. We also calculated a pooled estimate of six commonly reported adverse events in the follow-up period of IPD datasets. One-stage and two-stage meta-analyses employing a random-effects model were used. This study is registered with PROSPERO, CRD42020193958.

FINDINGS

We identified 16 102 studies published between Jan 1, 1994, and June 30, 2020, from which there were 12 eligible trials after deduplication and screening. We obtained individual data from seven trials comprising 2172 children, with 1728 children in the eligible IPD age range; 853 (49·4%) received oral corticosteroids (544 [63·8%] male and 309 [36·2%] female) and 875 (50·6%) received placebo (583 [66·6%] male and 292 [33·4%] female). Compared with placebo, a greater change in WSS at 4 h was seen in the oral corticosteroids group (mean difference -0·31 [95% CI -0·38 to -0·24]; p=0·011) but not 12 h (-0·02 [-0·17 to 0·14]; p=0·68), with low heterogeneity between studies (I2=0%; τ2<0·001). Length of hospital stay was significantly reduced in the oral corticosteroids group (-3·18 h [-4·43 to -1·93]; p=0·0021; I2=0%; τ2<0·001). Subgroup analyses showed that this reduction was greatest in those with a history of wheezing or asthma (-4·54 h [-5·57 to -3·52]; pinteraction=0·0007). Adverse events were infrequently reported (four of seven datasets), but oral corticosteroids were associated with an increased risk of vomiting (odds ratio 2·27 [95% CI 0·87 to 5·88]; τ2<0·001). Most datasets (six of seven) had a low risk of bias.

INTERPRETATION

Oral corticosteroids reduce WSS at 4 h and length of hospital stay in children with acute preschool wheeze. In those with a history of previous wheeze or asthma, oral corticosteroids provide a potentially clinically relevant effect on length of hospital stay.

FUNDING

Asthma UK Centre for Applied Research.

Substantial Burden of Nonmedically Attended RSV Infection in Healthy-Term Infants: An International Prospective Birth Cohort Study

BACKGROUND

During the first year of life, 1 in 4 infants develops a symptomatic respiratory syncytial virus (RSV) infection, yet only half seek medical attention. The current focus on medically attended RSV therefore underrepresents the true societal burden of RSV. We assessed the burden of nonmedically attended RSV infections and compared with medically attended RSV.

METHODS

We performed active RSV surveillance until the age of 1 year in a cohort (n = 993) nested within the Respiratory Syncytial Virus Consortium in EUrope (RESCEU) prospective birth cohort study enrolling healthy term-born infants in 5 European countries. Symptoms, medication use, wheezing, and impact on family life were analyzed.

RESULTS

For 97 of 120 (80.1%) nonmedically attended RSV episodes, sufficient data were available for analysis. In 50.5% (49/97), symptoms lasted ≥15 days. Parents reported impairment in usual daily activities in 59.8% (58/97) of episodes; worries, 75.3% (73/97); anxiety, 34.0% (33/97); and work absenteeism, 10.8% (10/93). Compared with medically attended RSV (n = 102, 9 hospital admissions), Respiratory Syncytial Virus NETwork (ReSViNET) severity scores were lower (3.5 vs 4.6, P < .001), whereas duration of respiratory symptoms and was comparable.

CONCLUSIONS

Even when medical attendance is not required, RSV infection poses a substantial burden to infants, families, and society. These findings are important for policy makers when considering the implementation of RSV immunization. Clinical Trials Registration. ClinicalTrials.gov (NCT03627572).

Validated respiratory drug deposition predictions from 2D and 3D medical images with statistical shape models and convolutional neural networks

For the one billion sufferers of respiratory disease, managing their disease with inhalers crucially influences their quality of life. Generic treatment plans could be improved with the aid of computational models that account for patient-specific features such as breathing pattern, lung pathology and morphology. Therefore, we aim to develop and validate an automated computational framework for patient-specific deposition modelling. To that end, an image processing approach is proposed that could produce 3D patient respiratory geometries from 2D chest X-rays and 3D CT images. We evaluated the airway and lung morphology produced by our image processing framework, and assessed deposition compared to in vivo data. The 2D-to-3D image processing reproduces airway diameter to 9% median error compared to ground truth segmentations, but is sensitive to outliers of up to 33% due to lung outline noise. Predicted regional deposition gave 5% median error compared to in vivo measurements. The proposed framework is capable of providing patient-specific deposition measurements for varying treatments, to determine which treatment would best satisfy the needs imposed by each patient (such as disease and lung/airway morphology). Integration of patient-specific modelling into clinical practice as an additional decision-making tool could optimise treatment plans and lower the burden of respiratory diseases.

The clinical impact of serious respiratory disease in children under the age of two years during the 2021-2022 bronchiolitis season in England, Scotland and Ireland

BACKGROUND

Interventions introduced to reduce the spread of SARS-CoV-2 led to a widespread reduction in childhood infections. However, from spring 2021 onwards the United Kingdom and Ireland experienced an unusual out-of-season epidemic of respiratory disease.

METHODS

We conducted a prospective observational study (BronchStart), enrolling children 0-23 months of age presenting with bronchiolitis, lower respiratory tract infection or first episode of wheeze to 59 Emergency Departments across England, Scotland and Ireland from May 2021 to April 2022. We combined testing data with national admissions datasets to infer the impact of respiratory syncytial virus (RSV) disease.

RESULTS

The BronchStart study collected data on 17,899 presentations for 17,164 children. Risk factors for admission and escalation of care included prematurity and congenital heart disease, but most admissions were for previously healthy term-born children. Of those aged 0-11 months who were admitted and tested for RSV, 1,907/3,912 (48.7%) tested positive. We estimate that every year in England and Scotland 28,561 (95% confidence interval 27,637-29,486) infants are admitted with RSV infection.

CONCLUSIONS

RSV infection was the main cause of hospitalisations in this cohort, but 51.3% of admissions in infants were not associated with the virus. The majority of admissions were in previously healthy term-born infants.

Mental health and academic outcomes over the first year at university in international compared to domestic Canadian students

OBJECTIVE

To compare risk factors and associated mental health and academic outcomes between international and domestic students.

PARTICIPANTS

Canadian university undergraduate students.

METHODS

Electronic surveys were completed at university entry and the end of first year. Surveys assessed demographics, risk factors, symptoms of mental disorders, and access to support. Academic outcomes were obtained from university databases.

RESULTS

International students had comparable or lower rates of clinically significant anxiety, depression, and insomnia. Domestic female students reported the highest screening rates for common mental disorders. However, international students were more likely to report having attempted suicide. International students felt less connected to the university community and had lower academic performance. Psychosocial risk factor profiles and proportions accessing mental health services were similar.

CONCLUSIONS

The scope of mental health need appears more similar than different between international and domestic students; however, international students may benefit from targeted academic and social support initiatives.

Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia

Background

Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications.

Methods

Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP.

Results

We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours.

Discussion

If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients.

Conclusion

s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.

Near-fatal and fatal asthma and air pollution: are we missing an opportunity to ask key questions?

There is an increasing body of evidence supporting the link between asthma attacks and air pollution in children. To our knowledge, there has only been one reported case of a fatal asthma attack in a child associated with air pollution and this was in the UK. This article considers why there is a lack of evidence on fatal/near-fatal asthma and air pollution. We also explore three challenges. First, fatal and near-fatal asthma events are rare and not yet well understood. Second, measuring and interpreting personal exposure to air pollution with sufficient temporal and spatial detail are challenging to interpret in the context of individual fatal or near-fatal asthma attacks. Third, current studies are not designed to answer the question of whether or to what extent air pollution is associated with fatal/near-fatal asthma attacks in children. Conclusive evidence is not yet available and systems of data collection for both air pollution and fatal and near-fatal asthma attacks should be enhanced to ensure risk can be determined and impact minimised.

Feasibility and acceptability of bubble continuous positive airway pressure oxygen therapy for the treatment of childhood severe pneumonia and hypoxaemia in Bangladeshi children

Background

Effective management of hypoxaemia is key to reducing pneumonia deaths in children. In an intensive care setting within a tertiary hospital in Bangladesh, bubble continuous positive airway pressure (bCPAP) oxygen therapy was beneficial in reducing deaths in this population. To inform a future trial, we investigated the feasibility of introducing bCPAP in this population in non-tertiary/district hospitals in Bangladesh.

Methods

We conducted a qualitative assessment using a descriptive phenomenological approach to understand the structural and functional capacity of the non-tertiary hospitals (Institute of Child and Mother Health and Kushtia General Hospital) for the clinical use of bCPAP. We conducted interviews and focus group discussions (23 nurses, seven physicians, 14 parents). We retrospectively (12 months) and prospectively (three months) measured the prevalence of severe pneumonia and hypoxaemia in children attending the two study sites. For the feasibility phase, we enrolled 20 patients with severe pneumonia (age two to 24 months) to receive bCPAP, putting in place safeguards to identify risk.

Results

Retrospectively, while 747 of 3012 (24.8%) children had a diagnosis of severe pneumonia, no pulse oxygen saturation information was available. Of 3008 children prospectively assessed with pulse oximetry when attending the two sites, 81 (3.7%) had severe pneumonia and hypoxaemia. The main structural challenges to implementation were the inadequate number of pulse oximeters, lack of power generator backup, high patient load with an inadequate number of hospital staff, and inadequate and non-functioning oxygen flow meters. Functional challenges were the rapid turnover of trained clinicians in the hospitals, limited post-admission routine care for in-patients by hospital clinicians due to their extreme workload (particularly after official hours). The study implemented a minimum of four hourly clinical reviews and provided oxygen concentrators (with backup oxygen cylinders), and automatic power generator backup. Twenty children with a mean age of 6.7 (standard deviation (SD) = 5.0)) months with severe pneumonia and hypoxaemia (median (md) SpO₂ = 87% in room air, interquartile range (IQR) = 85-88)) with cough (100%) and severe respiratory difficulties (100%) received bCPAP oxygen therapy for a median of 16 hours (IQR = 6-16). There were no treatment failures or deaths.

Conclusions

Implementation of low-cost bCPAP oxygen therapy is feasible in non-tertiary/district hospitals when additional training and resources are allocated.

Implementation frameworks for polypharmacy management within healthcare organisations: a scoping review

BACKGROUND

Several guidelines support polypharmacy management in individual patients. More organisational-level focus is needed on the use of implementation frameworks.

AIM

To characterise the peer reviewed literature on implementation frameworks, focussing on barriers and facilitators to implementation at organisational level in the context of polypharmacy management.

METHOD

A scoping review protocol was devised, supporting retrieval of studies published in English, reporting from any sector of practice. Medline, International Pharmaceutical Abstracts, Cumulative Index of Nursing and Allied Health Literature and Business Source Complete were searched to January 2022 using Medical Subject Headings including: 'polypharmacy', 'deprescriptions', 'strategic planning' and 'organizational innovation'. A narrative approach to data synthesis was applied. Searching, data extraction and synthesis were undertaken independently by two reviewers.

RESULTS

After screening 797 records eight papers remained. Two were descriptive outlining details of specific initiatives, six used qualitative methods to explore determinants for implementation including barriers and enablers. Organisation level barriers included: poor organisational culture with a lack of sense of urgency and national plans, resource availability and communication issues including patient information and at transitions of care. Organisational facilitators included availability of government funding and regulatory environment promoting patient safety, a national emphasis on quality of care for older adults, co-ordinated national efforts and local evidence.

CONCLUSION

Limited literature focusses on the use of implementation frameworks at organisational levels. This review highlights the need for further work on implementation frameworks in this context to help achieve effective organisational change.

Multi-Modal Portable Respiratory Rate Monitoring Device for Childhood Pneumonia Detection

Accurate assessment of Respiratory Rate (RR) is the most important mechanism in detecting pneumonia in low-resource settings. Pneumonia is a disease with one of the highest mortality rates among young children under five. However, the diagnosis of pneumonia for infants remains challenging, especially in low- and middle-income countries (LMIC). In such situations, RR is most often measured manually with visual inspection. Accurate RR measurement requires the child to remain calm without any stress for a few minutes. The difficulty in achieving this with a sick child in a clinical environment can result in errors and misdiagnosis, even more so when the child is crying and non-cooperating around unfamiliar adults. Therefore, we propose an automated novel RR monitoring device built with textile glove and dry electrodes which can make use of the relaxed posture when the child is resting on the carer's lap. This portable system is non-invasive and made with affordable instrumentation integrated on customized textile glove. The glove has multi-modal automated RR detection mechanism that simultaneously uses bio-impedance and accelerometer data. This novel textile glove with dry electrodes can easily be worn by a parent/carer and is washable. The real-time display on a mobile app shows the raw data and the RR value, allowing a healthcare professional to monitor the results from afar. The prototype device has been tested on 10 volunteers with age variation of 3 years to 33 years, including male and female. The maximum variation of measured RR with the proposed system is ±2 compared to the traditional manual counting method. It does not create any discomfort for either the child or the carer and can be used up to 60 to 70 sessions/day before recharging.

Economic burden and health-related quality-of-life among infants with respiratory syncytial virus infection: A multi-country prospective cohort study in Europe

BACKGROUND

Respiratory syncytial virus (RSV) causes a considerable disease burden in young children globally, but reliable estimates of RSV-related costs and health-related quality-of-life (HRQoL) are scarce. This study aimed to evaluate the RSV-associated costs and HRQoL effects in infants and their caregivers in four European countries.

METHODS

Healthy term-born infants were recruited at birth and actively followed up in four European countries. Symptomatic infants were systematically tested for RSV. Caregivers recorded the daily HRQoL of their child and themselves, measured by a modified EQ-5D with Visual Analogue Scale, for 14 consecutive days or until symptoms resolved. At the end of each RSV episode, caregivers reported healthcare resource use and work absenteeism. Direct medical costs per RSV episode were estimated from a healthcare payer's perspective and indirect costs were estimated from a societal perspective. Means and 95% confidence intervals (CI) of direct medical costs, total costs (direct costs + productivity loss) and quality-adjusted life-day (QALD) loss per RSV episode were estimated per RSV episode, as well as per subgroup (medical attendance, country).

RESULTS

Our cohort of 1041 infants experienced 265 RSV episodes with a mean symptom duration of 12.5 days. The mean (95% CI) cost per RSV episode was €399.5 (242.3, 584.2) and €494.3 (317.7, 696.1) from the healthcare payer's and societal perspective, respectively. The mean QALD loss per RSV episode of 1.9 (1.7, 2.1) was independent of medical attendance (in contrast to costs, which also differed by country). Caregiver and infant HRQoL evolved similarly.

CONCLUSION

This study fills essential gaps for future economic evaluations by prospectively estimating direct and indirect costs and HRQoL effects on healthy term infants and caregivers separately, for both medically attended (MA) and non-MA laboratory-confirmed RSV episodes. We generally observed greater HRQoL losses than in previous studies which used non-community and/or non-prospective designs.

The ability of non-physician health workers to identify chest indrawing to detect pneumonia in children below five years of age in low- and middle-income countries: A systematic review and meta-analysis

Background

Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low- and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers' ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs.

Methods

We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity.

Results

We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97).

Conclusions

We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children. New studies are needed to assess the new generation of health workers.

Registration

PROSPERO (CRD42022306954).

Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds

Chronic wounds adversely affect the quality of life of individuals and odour is a well-recognised associated factor. Odour can affect sleep, well-being, social interactions, diet and potentially wound healing. This systematic review aims to examine the effectiveness of topical interventions in the management of odour associated with chronic and malignant fungating wounds. A systematic review guided by PRISMA recommendations of randomised controlled trials where odour intensity/odour is the primary outcome was undertaken. Inclusion criteria were adults (18 years and over) with chronic venous, arterial, diabetic or pressure ulcers or with malignant fungating wounds where odour has been managed through topical application of pharmacological/non-pharmacological agents. Searches were conducted in CENTRAL, CINAHL, EMBASE, MEDLINE, Scopus, and Web of Science. Eligibility screening, risk of bias assessment and data extraction was completed by authors working independently. Searches retrieved 171 titles and abstracts (157 post de-duplication). Thirteen studies were retained for full text review of which five (n = 137 individuals) examining the following treatments remained: metronidazole (n = 4), silver (n = 1). Meta-analysis was not possible but individual studies suggest improved outcomes (i.e., reduced odour) using metronidazole. Treatment options to manage wound odour are limited and hampered by lack of clinical trials, small sample sizes, and absence of standardised outcomes and consistent measurement. Whereas metronidazole and silver may have a role in controlling wound odour, robust and well-designed interventions with rigorous procedures and standardised odour outcomes are necessary to evaluate their contribution.

Exercise as airway clearance therapy (ExACT) in cystic fibrosis: a UK-based e-Delphi survey of patients, caregivers and health professionals

Replacing traditional airway clearance therapy (tACT) with exercise (ExACT) in people with cystic fibrosis (pwCF) is a top research priority. A UK-based e-Delphi consensus was performed to inform the type(s), duration and intensity of ExACT. The expert panel comprised CF physiotherapists, doctors, pwCF and parents/partners. Exercise ACT was considered to be aerobic activity, of at least 20 min duration and intense enough to elicit deep breathing. Consensus was reached that assessment breaths, coughs and huffs should accompany exercise to remove loose secretions, with support for trials to investigate ExACT versus tACT during times of stable disease but not pulmonary exacerbations.

Exercise as an Airway Clearance Technique in people with Cystic Fibrosis (ExACT-CF): rationale and study protocol for a randomised pilot trial

Background

Chest physiotherapy is an established cornerstone of care for people with cystic fibrosis (pwCF), but is often burdensome. Guidelines recommend at least one chest physiotherapy session daily, using various airway clearance techniques (ACTs). Exercise (with huffs and coughs) may offer an alternative ACT, however the willingness of pwCF to be randomised into a trial needs testing. The 'ExACT-CF: Exercise as an Airway Clearance Technique in people with Cystic Fibrosis' trial will test the feasibility of recruiting pwCF to be randomised to continue usual care (chest physiotherapy) or replace it with exercise ACT (ExACT) for 28-days. Secondary aims include determining the short-term clinical impact (and safety) of stopping routine chest physiotherapy and replacing it with ExACT, and effects on physical activity, sleep, mood, quality of life and treatment burden, alongside preliminary health economic measures and acceptability.

Methods

Multi-centre, two-arm, randomised (1:1 allocation using minimisation), pilot trial at two sites. Fifty pwCF (≥10 years, FEV 1 >40% predicted, stable on Elexacaftor/Tezacaftor/Ivacaftor (ETI)) will be randomised to an individually-customised ExACT programme (≥once daily aerobic exercise of ≥20-minutes duration at an intensity that elicits deep breathing, with huffs and coughs), or usual care. After baseline assessments, secondary outcomes will be assessed after 28-days, with additional home lung function and exacerbation questionnaires at 7, 14 and 21-days, physical activity and sleep monitoring throughout, and embedded qualitative and health-economic components. Feasibility measures include recruitment, retention, measurement completion, adverse events, interviews exploring the acceptability of trial procedures, and a trial satisfaction questionnaire.

Discussion

Co-designed with the UK CF community, the ExACT-CF pilot trial is the first multi-centre RCT to test the feasibility of recruiting pwCF stable on ETI into a trial investigating ExACT. This pilot trial will inform the feasibility, design, management, likely external validity for progression to a main phase randomised controlled trial.

Registration

Clinicaltrials.gov ( NCT05482048).

Interprofessional education during experiential learning placements for student pharmacists in Scotland. Exploring current support provision and stakeholder views

Introduction

Increasing global awareness that interprofessional team working is essential within modern healthcare systems has led to regulatory bodies mandating the inclusion of interprofessional education (IPE) within undergraduate curricula. The General Pharmaceutical Council specifies in the 2021 initial education and training standards the requirement for an interprofessional learning plan in which “IPE must mirror practice”.1 Pharmacy educators are intensifying their efforts to ensure student pharmacists are presented with opportunities to develop collaborative competencies. Curricular development and implementation initiatives must explore structures and processes to ensure that experiential learning (EL) environments are conducive to supporting student pharmacists’ interprofessional learning.

Aim

To explore structures and processes needed to support effective planned and unplanned IPE during EL placements for student pharmacists.

Methods

A mixed methods approach underpinned by the Biggs 3P theoretical framework was adopted.2 This included (1) A document analysis reviewing resources including student pharmacist/EL facilitator university handbooks and NHS Education for Scotland Preparation for Facilitating Experiential Learning (PFEL) training - a mandatory requirement for all EL facilitators hosting student pharmacists on placement in Scotland. (2) A pre-piloted online survey distributed to EL facilitators. Survey development, guided by the Interprofessional Facilitation Scale, aimed to encourage EL facilitators to self-evaluate their own IPE facilitation skills.3 The final survey tool included ten items with responses rated on a 4-point Likert scale (Poor, Fair, Good and Excellent) and a demographic section (3) Online semi-structured focus groups/dyadic interviews conducted with six EL facilitators, four practice educators and two academic staff were recorded and transcribed. Descriptive statistics were employed for quantitative data generated from the survey tool; for qualitative data content analysis was applied to develop emerging themes. Ethical approval was granted (S292) from the School of Pharmacy and Life Sciences Ethics Review Committee at Robert Gordon University.

Results

(1) The document analysis concluded that although the resources reviewed could not be specifically classed as training to support IPE, data collected provided context to EL placements and the training and pre-activities that student pharmacists and EL facilitators complete. Three main themes emerged: “Lack of specific IPE training focus”, “Varied terminology”, “Lack of IPE pre-learning activities”. (2) The survey was completed by ninety EL facilitators working in various practice settings: hospital 41.1% (n=37); primary care 25.6% (n=23); community 21.1% (n=19); academia 2.2% (n=2); other 8.9% (n=8). Survey responses indicated that 51.1% (n=46) and 42.2% (n=38) of respondents rated their ability to role model positive interactions with other healthcare professionals as good and excellent. However, responses to items relating more specifically to IPE facilitation skills indicated a lower confidence level. (3) Initial themes emerging from focus groups/dyadic interviews include “Profession-related perceptions of IPE”, “Factors influencing IPE delivery and student learning”, “Factors influencing future developments”.

Discussion/Conclusion

This exploratory study has provided valuable insight into multifactorial aspects affecting IPE during EL placements; this will be used to guide future development of IPE initiatives. One limitation is that student pharmacists were not included in this study; the next phase of this research programme will explore student pharmacists’ perceptions of IPE in EL.

References

1. General Pharmaceutical Council. Standards for the initial education and training of pharmacists. [homepage on the Internet]. London: GPhC; 2021. Available from: https://www.pharmacyregulation.org/sites/default/files/document/standards-for-the-initial-education-and-training-of-pharmacists-january-2021.pdf

2. Biggs, J.B. From Theory to Practice: A Cognitive Systems Approach. High Educ Res Dev, 1993, 12(1), 73-85

3. Sargeant J., Hill T., Breau L. Development and testing of a scale to assess interprofessional education (IPE) facilitation skills. J Cont Educ Health Prof, 2010, 30(2), 126-131

Developing a video expert panel as a reference standard to evaluate respiratory rate counting in paediatric pneumonia diagnosis: protocol for a cross-sectional study

INTRODUCTION

Manual counting of respiratory rate (RR) in children is challenging for health workers and can result in misdiagnosis of pneumonia. Some novel RR counting devices automate the counting of RR and classification of fast breathing. The absence of an appropriate reference standard to evaluate the performance of these devices is a challenge. If good quality videos could be captured, with RR interpretation from these videos systematically conducted by an expert panel, it could act as a reference standard. This study is designed to develop a video expert panel (VEP) as a reference standard to evaluate RR counting for identifying pneumonia in children.

METHODS AND ANALYSIS

Using a cross-sectional design, we will enrol children aged 0-59 months presenting with suspected pneumonia at different levels of health facilities in Dhaka and Sylhet, Bangladesh. We will videorecord a physician/health worker counting RR manually and also using an automated RR counter (Children's Automated Respiration Monitor) from each child. We will establish a standard operating procedure for capturing quality videos, make a set of reference videos, and train and standardise the VEP members using the reference videos. After that, we will assess the performance of the VEP as a reference standard to evaluate RR counting. We will calculate the mean difference and proportions of agreement within±2 breaths per minute and create Bland-Altman plots with limits of agreement between VEP members.

ETHICS AND DISSEMINATION

The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 39315022021) and Edinburgh Medical School Research Ethics Committee (EMREC), Edinburgh, UK (REC Reference: 21-EMREC-040). Dissemination of the study findings will be through conference presentations and publications in peer-reviewed scientific journals.

The burden of respiratory syncytial virus in healthy term-born infants in Europe: a prospective birth cohort study

BACKGROUND

Respiratory syncytial virus (RSV) is a major cause of hospitalisation in infants. The burden of RSV infection in healthy term infants has not yet been established. Accurate health-care burden data in healthy infants are necessary to determine RSV immunisation policy when RSV immunisation becomes available.

METHODS

We performed a multicentre, prospective, observational birth cohort study in healthy term-born infants (≥37 weeks of gestation) in five sites located in different European countries to determine the health-care burden of RSV. The incidence of RSV-associated hospitalisations in the first year of life was determined by parental questionnaires and hospital chart reviews. We performed active RSV surveillance in a nested cohort to determine the incidence of medically attended RSV infections. The study is registered with ClinicalTrials.gov, NCT03627572.

FINDINGS

In total, 9154 infants born between July 1, 2017, and April 1, 2020, were followed up during the first year of life and 993 participated in the nested active surveillance cohort. The incidence of RSV-associated hospitalisations in the total cohort was 1·8% (95% CI 1·6-2·1). There were eight paediatric intensive care unit admissions, corresponding to 5·5% of 145 RSV-associated hospitalisations and 0·09% of the total cohort. Incidence of RSV infection in the active surveillance cohort confirmed by any diagnostic assay was 26·2% (24·0-28·6) and that of medically attended RSV infection was 14·1% (12·3-16·0).

INTERPRETATION

RSV-associated acute respiratory infection causes substantial morbidity, leading to the hospitalisation of one in every 56 healthy term-born infants in high-income settings. Immunisation of pregnant women or healthy term-born infants during their first winter season could have a major effect on the health-care burden caused by RSV infections.

FUNDING

Innovative Medicines Initiative 2 Joint Undertaking, with support from the EU's Horizon 2020 research and innovation programme and European Federation of Pharmaceutical Industries and Associations.

Case-mix and outcome variability in people with diabetic foot complications in England and Scotland

Background

We assessed the difference in survival rates for people with diabetes experiencing LEA in England and Scotland, using large databases held by the Royal College of General Practitioners (RCGP) and the Scottish Diabetes Register (SCI-DC).

Methods

Observational retrospective study of T2D adults 18+ years with LEA between 1/1/2008-1/1/2018 from 1,800 general practices in England (7.4%) and all primary, secondary care units in Scotland. Significance tests were carried out using univariate odds ratios within each database.

Results

On 1/1/2018, N = 127,100 people with T2D were registered alive in RCGP, with N = 1,052 (832 per 100,000) experiencing prior LEA, vs N = 2,200 (783 per 100,000) out of 280,908 in SCI-DC. Among them, England recorded N = 405 patients (72.5%) with prior DFU diagnosis vs N = 993 in Scotland (74.3%), with a median time DFU to LEA of 2.0 vs 2.4 years. The median time spent with LEA was 3.4 years in England vs 3.9 years in Scotland. After including those dying earlier, different univariate patterns were found for England and Scotland. In both networks, increased risk was found for those aged 50+ at first LEA, with prior history of acute myocardial infarction, peripheral arterial disease, ischemic heart disease, cerebrovascular event, higher glomerular filtration rate and major LEA first. In England, reduced risks were found for males (OR = 0.77, 95%CI: 0.64-0.93) and people with retinopathy (0.69; 0.57-0.82), while higher risk were found for hypertension (1.29; 1.09-1.54). In Scotland, lower risks were found for obese (0.59; 0.52-0.66) and those with DFU after LEA (0.74; 0.62-0.89), vs higher rates among those of non-white ethnicity (1.63; 1.19-2.23) and dyalisis (2.31; 1.75-3.07).

Conclusions

Notable differences were found between England and Scotland in terms of characteristics associated with different outcomes following LEA among T2D adults. Multivariate analyses of aggregate patterns are currently ongoing to adjust for potential confounding.

Key messages

• Routine datasets from England and Scotland showed a differential impact of case-mix characteristics on lower extremity amputations among adults with Type 2 diabetes.

• Information available from different clinical networks can be mapped against the available standard sets to compare health care outcomes of people with different complex conditions.

Socioeconomic position, bronchiolitis and asthma in children: counterfactual disparity measures from a national birth cohort study

BACKGROUND

The debated link between severe respiratory syncytial virus (RSV) infection in early life and asthma has yet to be investigated within a social inequity lens. We estimated the magnitude of socioeconomic disparity in childhood asthma which would remain if no child were admitted to hospital for bronchiolitis, commonly due to RSV, during infancy.

METHODS

The cohort, constructed from national administrative health datasets, comprised 83853 children born in Scotland between 1 January 2007 and 31 June 2008. Scottish Index for Multiple Deprivation (SIMD) was used to capture socioeconomic position. Emergency admissions for bronchiolitis before age 1 year were identified from hospital records. Yearly indicators of asthma/wheeze from ages 2 to 9 years were created using dispensing data and hospital admission records.

RESULTS

Using latent class growth analysis, we identified four trajectories of asthma/wheeze: early-transient (2.2% of the cohort), early-persistent (2.0%), intermediate-onset (1.8%) and no asthma/wheeze (94.0%). The estimated marginal risks of chronic asthma (combining early-persistent and intermediate-onset groups) varied by SIMD, with risk differences for the medium and high deprivation groups, relative to the low deprivation group, of 7.0% (95% confidence interval: 3.7-10.3) and 13.0% (9.6-16.4), respectively. Using counterfactual disparity measures, we estimated that the elimination of bronchiolitis requiring hospital admission could reduce these risk differences by 21.2% (4.9-37.5) and 17.9% (10.4-25.4), respectively.

CONCLUSIONS

The majority of disparity in chronic asthma prevalence by deprivation level remains unexplained. Our paper offers a guide to using causal inference methods to study other plausible pathways to inequities in asthma using complex, linked administrative data.

Introducing pulse oximetry for outpatient management of childhood pneumonia: An implementation research adopting a district implementation model in selected rural facilities in Bangladesh

BACKGROUND

Pulse oximetry has potential for identifying hypoxaemic pneumonia and substantially reducing under-five deaths in low- and middle-income countries (LMICs) setting. However, there are few examples of introducing pulse oximetry in resource-constrained paediatric outpatient settings, such as Integrated Management of Childhood Illness (IMCI) services.

METHODS

The National IMCI-programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in routine IMCI services through stakeholder engagement and demonstrated the model in Kushtia district adopting a health system strengthening approach. Between December 2020 and June 2021, two rounds of assessment were conducted based on WHO's implementation research framework and outcome variables, involving 22 IMCI service-providers and 1680 children presenting with cough/difficulty-in-breathing in 12 health facilities. The data collection procedures included structured-observations, re-assessments, interviews, and data-extraction by trained study personnel.

FINDINGS

We observed that IMCI service-providers conducted pulse oximetry assessments on all eligible children in routine outpatient settings, of which 99% of assessments were successful; 85% (95% CI 83,87) in one attempt, and 69% (95% CI 67,71) within one minute. The adherence to standard operating procedure related to pulse oximetry was 92% (95% CI 91,93), and agreement regarding identifying hypoxaemia was 97% (95% CI 96,98). The median performance-time was 36 seconds (IQR 20,75), which was longer among younger children (2-11 months: 44s, IQR 22,78; 12-59 months: 30s, IQR 18,53, p < 0.01) and among those classified as pneumonia/severe-pneumonia than as no-pneumonia (41s, IQR 22,70; 32s, IQR 20,62, p < 0.01). We observed improvements in almost all indicators in round-2. IMCI service-providers and caregivers showed positive attitudes towards using this novel technology for assessing their children.

INTERPRETATION

This implementation research study suggested the adoption, feasibility, fidelity, appropriateness, acceptability, and sustainability of pulse oximetry introduction in routine IMCI services in resource-poor settings. The learning may inform the evidence-based scale-up of pulse oximetry linked with an oxygen delivery system in Bangladesh and other LMICs.

FUNDING

This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research.

The feasibility and effectiveness of a novel online mental health literacy course in supporting university student mental health: a pilot study

BACKGROUND

There is a need for effective universal approaches to promote and support university student mental health that are scalable and sustainable. In this pilot study we assess the feasibility and acceptability of a fully-digitalized, comprehensive mental health literacy course co-created with and tailored to the needs of undergraduate students. We also explore preliminary associations with mental health and positive behaviour change.

METHODS

An accredited online mental health literacy course was developed using state-of-the-art pedagogical principles and a reverse mentorship approach. The course was offered as an interdisciplinary undergraduate elective. Students completed an online survey before and after the 12-week course that collected demographic information and assessed mental health knowledge, emotional self-awareness, mental health, stigma, and health-related behaviors using validated measures. Dependent group t-tests were used to compare pre- and post-course levels of knowledge, mental health, sleep quality and substance use. Mental health outcomes of students who completed the course were compared to an age and sex-matched sample of students not enrolled in the course and who completed the same survey measures over the same academic year. Multivariable linear regression was used to examine the effect of course participation on outcomes at follow-up.

RESULTS

The course had good uptake and was positively reviewed by participants. Specifically, students found the course engaging, relevant, and applicable, and agreed they would recommend it to their peers. Among course participants there was improvement in mental health knowledge (p < 0.001) and emotional self-awareness (p = 0.02) at course completion. Compared to the matched comparison group, taking the course was associated with reduced alcohol (β = - 0.41, p = 0.01) and cannabis use (β = - 0.35, p = 0.03), and improved sleep quality (β = 1.56, p = 0.09) at the end of the term.

CONCLUSIONS

Findings suggest that delivering mental health literacy as an online accredited course may be an acceptable and effective way of promoting university student mental health through improved knowledge, emotional self-awareness, and healthy lifestyle choices. As the course is expanded to larger and more diverse student cohorts we will be able to further examine the short and long-term effectiveness of the course in supporting student mental health and the underlying mechanisms.

Subclinical Doses of Combined Fumonisins and Deoxynivalenol Predispose Clostridium perfringens–Inoculated Broilers to Necrotic Enteritis

Fumonisins (FB) and deoxynivalenol (DON) are mycotoxins which may predispose broiler chickens to necrotic enteritis (NE). The objective of this study was to identify the effects of subclinical doses of combined FB and DON on NE. A total of 480 day-old male broiler chicks were divided into four treatment groups; 1) control group (basal diet + Clostridium perfringens); 2) necrotic enteritis group (basal diet + Eimeria maxima + C. perfringens); 3) FB + DON group (basal diet + 3 mg/kg FB + 4 mg/kg DON + C. perfringens); and 4) FB + DON + NE group (basal diet + 3 mg/kg FB + 4 mg/kg DON + E. maxima + C. perfringens). Birds in NE and FB + DON + NE groups received 2.5 × 10³E. maxima on day 14. All birds were inoculated with C. perfringens on days 19, 20, and 21. On day 35, birds in the NE, FB + DON, and FB + DON + NE groups had 242, 84, and 339 g lower BWG and a 19-, 2-, and 22-point increase in FCR respectively, than in the control group. Subclinical doses of FB + DON increased (p < 0.05) the NE lesion scores compared to the control group on day 21. On day 21, birds in the NE, FB + DON, and FB + DON + NE groups had increased (p < 0.05) serum FITC-D, lower (p < 0.05) jejunal tight junction protein mRNA, and increased (p < 0.05) cecal tonsil IL-1 mRNA compared to control group. On day 21, birds in the NE group had decreased (p < 0.05) villi height to crypt depth ratio compared to the control group and the presence of FB + DON in NE-induced birds further decreased the villi height to crypt depth ratio. Birds in the NE, FB + DON, and FB + DON + NE groups had increased (p < 0.05) C. perfringens, lower (p < 0.05) Lactobacillus loads in the cecal content, and a lower (p < 0.05) CD8⁺: CD4⁺ cell ratio in the cecal tonsils compared to the control group. It can be concluded that subclinical doses of combined FB and DON predispose C. perfringens-inoculated birds to NE, and the presence of FB + DON in NE-induced birds exacerbated the severity of NE.

Accuracy of non-physician health workers in respiratory rate measurement to identify paediatric pneumonia in low- and middle-income countries: A systematic review and meta-analysis

Background

Methods

Results

Conclusions

Success and time implications of SpO2 measurement through pulse oximetry among hospitalised children in rural Bangladesh: Variability by various device-, provider- and patient-related factors

Background

Hypoxaemia is one of the strongest predictors of mortality among children with pneumonia. It can be identified through pulse oximetry instantaneously, which is a non-invasive procedure but can be influenced by factors related to the specific measuring device, health provider and patient. Following WHO's global recommendation in 2014, Bangladesh decided to introduce pulse oximetry in paediatric outpatient services, ie, the Integrated Management of Childhood Illness (IMCI) services in 2019. A national committee updated the existing IMCI implementation package and decided to test it by assessing the pulse oximetry performance of different types of assessors in real-life inpatient settings.

Methods

We adopted an observational design and conducted a technology assessment among children admitted to a rural district hospital. Eleven nurses and seven paramedics received one-day training on pulse oximetry as assessors. Each assessor performed at least 30 pulse oximetry measurements on children with two types of handheld devices. The primary outcome of interest was obtaining a successful measurement of SpO2, defined as observing a stable (±1%) reading for at least 10 seconds. Performance time, ie, time taken to obtain a successful measurement of SpO₂ was considered the secondary outcome of interest. In addition, we used Generalized Estimating Equation to assess the effect of different factors on the pulse oximetry performance.

Results

The assessors obtained successful measurements of SpO₂ in all attempts (n = 1478) except one. The median time taken was 30 (interquartile range (IQR) = 22-42) seconds, and within 60 seconds, 92% of attempts were successful. The odds of obtaining a successful measurement within 60 seconds were 7.3 (95% confidence interval (CI) = 3.7-14.2) times higher with a Masimo device than a Lifebox device. Similarly, assessors aged >25 years were 4.8 (95% CI = 1.2, 18.6) times more likely to obtain a successful measurement within 60 seconds. The odds of obtaining a successful measurement was 2.6 (95% CI = 1.6, 4.2) times higher among children aged 12-59 months compared to 2-11 months.

Conclusions

Our study indicated that assessors could achieve the necessary skills to perform pulse oximetry successfully in real-life inpatient settings through a short training module, with some effect of device-, provider- and patient-related factors. The National IMCI Programme of Bangladesh can use these findings for finalising the national IMCI training modules and implementation package incorporating the recommendation of using pulse oximetry for childhood pneumonia assessment.

Exploring determinants of antimicrobial prescribing behaviour: a qualitative study using the Theoretical Domains Framework

Introduction

Few qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals, and none has made reference to behavioural theories. An understanding of these determinants is required for the successful development and implementation of behaviour change interventions (BCIs) in this area.

Aim

To explore the determinants of clinicians’ antimicrobial prescribing behaviour, using the Theoretical Domains Framework (TDF; a framework of behavioural theories).

Methods

This work was part of a multi-phase explanatory, sequential mixed methods PhD programme of research. This qualitative part involved semi-structured, online (video) interviews via a videoconferencing software programme (Zoom) with clinicians (doctors and pharmacists) based in 12 Hamad Medical Corporation hospitals in Qatar. Clinicians were sampled purposively in strata of gender, profession, years of experience and area of practice. The interview schedule was developed based on a review of published literature (1), previous findings of quantitative research (2) and the TDF to ensure comprehensive coverage of key determinants (including barriers and facilitators) related to clinicians’ antimicrobial prescribing behaviour. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and independently analysed by two research team members using the TDF as an initial coding framework.

Results

Data saturation was achieved after interviewing eight doctors and eight pharmacists from a range of areas of practices and with a variety of experiences. A number of themes, linked to ten TDF domains, were identified as determinants of antimicrobial prescribing behaviour and these determinants were interrelated. In-depth analysis identified several barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. Main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources), gaps in the knowledge in relation to guidelines and appropriate prescribing (knowledge), restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity), uncomfortable antimicrobial prescribing decisions (memory, attention and decision processes), as well as professional hierarchies and poor multidisciplinary teamworking/relationships (social influences). “Sometimes, the barrier would be the ego of senior doctors who refuse our evidence-based recommendation and depend on their clinical judgement or experience” (Pharmacist 470, Cardiology). Key facilitators highlighted included guidelines compliance goals and intentions, and the beliefs of consequences of appropriate or inappropriate prescribing. Further education and training sessions, and some changes to guidelines, including accessibility were also considered essential. “We need to seriously consider getting an antibiotic guidelines app which is downloaded to clinicians’ mobile phones. The mobile app is handy, you can access it anytime even at the patient’s bedside” (Doctor 514, Microbiology).

Conclusion

This qualitative study, using a theoretically based approach, has identified that antimicrobial prescribing in hospitals is a complex process influenced by a broad range of behavioural determinants that described specific barriers and facilitators. The in-depth understanding of this complexity provided by this phase of the research may contribute to the design and development of theoretically based BCIs to improve clinicians’ antimicrobial prescribing. Limitations include data collected with online interviews due to the Covid-19 restrictions. This may have excluded some clinicians who did not feel comfortable with or have access to the technology required.

References

(1) Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. Journal of Antimicrobial Chemotherapy. 2020;75(9):2394-2410.

(2) Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. International Journal of Pharmacy Practice. 2021;29(1):i20-i22.

Views and perceptions on the designated prescribing practitioner role, barriers, and facilitators for its implementation in community pharmacy: a theory-based quantitative study

Introduction

Scottish Government aims to increase numbers of pharmacist independent prescribers (IP) in community to improve healthcare access. This includes utilising qualified IPs as Designated Prescribing Practitioners (DPP) to increase capacity to supervise pharmacists on IP courses.

Aim

To investigate views and perceptions of practice-based stakeholders and identify potential influences on DPP implementation for Scottish community pharmacists (CP)

Methods

A theory-based cross-sectional online survey of stakeholders involved in DPP role implementation (e.g. Directors of Pharmacy, Prescribing Leads, IP qualified CPs) was employed. Participation invites were shared with Scottish health boards and CP organisations via email and social media. Snowball sampling was used so no key individual was omitted. The questionnaire was informed by Royal Pharmaceutical Society (RPS) DPP Framework (1) and Consolidated Framework for Implementation Research (2). It examined views and awareness of DPP role, implementation drivers, and obstacles. The tool was reviewed for credibility and dependability then piloted. Data were analysed descriptively.

Results

Ninety-nine responses were received (NB: Since this was a national survey of multiple stakeholders without a defined sample list, response rate was indeterminate). Two-fifths (n=39, 40.2%) were community pharmacists with majority qualified for more than 10 years (n=76, 76.8%). Only 18 had previous involvement with IP courses. The table shows awareness and views of the role based on RPS framework. Respondents had positive attitudes to DPP implementation with the majority supporting it (72, 73.5%) and believing that its advantages outweigh any disadvantages (74, 75.5%). Facilitators of successful implementation were having clearly defined leadership roles (89, 90.9%), piloting (85, 87.6%), and incentives (65, 88.8%). Drivers for uptake of role included improving patient care (94, 96%) and the profession (91, 92.8%), self-development (91, 92.8%), developing individual pharmacists (89, 90.8%), payment (77, 79.4%), and being recognised by peers/employers (73, 75.2%).

Conclusion

There was positivity regarding DPP role, its acceptability in, and advantages for CP. Resource-related concerns were expressed that need further consideration to ensure effective implementation. This is the first study internationally to explore views on DPP role. Given the Scottish focus, findings may lack generalisability. Future research should focus on theory-based evaluation of structures and processes of implementation.

References

(1) Royal Pharmaceutical Society. Designated Prescribing Practitioner Competency Framework [internet]. London: Royal Pharmaceutical Society; 2019 [Cited 28/09/2021]. Available from: https://www.rpharms.com/resources/frameworks/designated-prescribing-practitioner-competency-framework

(2) Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.

Development and implementation of strategic frameworks for polypharmacy management in healthcare organisations: a scoping review

Introduction

‘Polypharmacy management’ (PM) guidelines exist (1) but there are challenges to implementation and WHO recommends theory-based organisational change strategies to address this (2).

Aim

To identify current evidence base around the development and implementation of strategic frameworks for polypharmacy management in healthcare organisations.

Methods

The Arksey and O’Malley framework and the PRISMA Scoping Reviews extension were used. Databases (Medline, IPA, CINAHL and Business Source Complete) were searched to December 2020. After title and abstract screening full text articles were reviewed. Search, data extraction and eligibility criteria were defined (table). Included studies were charted to collate extracted information and a descriptive narrative approach to data synthesis was taken. All steps involved independent checks by two team members with disagreement mediation by a third.

Results

Initially 702 records were identified after removal of duplicates, 632 of these were excluded after screening leaving 70 papers. A further 63 of these 70 papers were excluded after full text review. The seven papers remaining met the eligibility criteria fully and showed: despite wide availability of polypharmacy guidelines in the West, particularly the UK and European Union, there is limited evidence on the strategic development and implementation of PM frameworks. The main characteristics of strategic approaches used included: Kotter’s eight step process for organisational change, theoretical domains framework to identify individual behavioural determinants, and a community-based medication management intervention. Reported barriers were: lack of data to create a sense of urgency, lack of a national plan for implementation, monitoring and evaluation, poor coordination of care, lack of time for staff, unclear allocation of tasks and responsibilities and lack of training. Organisational level facilitators included: government funding streams and strict regulatory environment, national emphasis on quality and presence of contextual evidence.

Conclusion

Despite PM guidance this review shows limited evidence on development of theory based strategic frameworks for organisational change. Evidence was from Western contexts only. A strength of this work is that it searched internationally but was limited by exclusion of grey literature. Further work is required on theory based strategic organisational change in PM particularly in contexts out with the Western world.

References

(1) Mair A, Fernandez-Llimos F, Alonso A, Harrison C, Hurding S, Kempen T, Kinnear M, Michael N, McIntosh J, Wilson M, the SIMPATHY Consortium. Polypharmacy Management by 2030: a patient safety challenge. 2nd edition. Coimbra: SIMPATHY Consortium; 2017.

(2) World Health Organization. Medication safety in polypharmacy: technical report. Geneva: World Health Organization; 2019.

Healthcare resource utilisation and medical costs for children with interstitial lung diseases (chILD) in Europe

BACKGROUND

No data on healthcare utilisation and associated costs for the many rare entities of children's interstitial lung diseases (chILD) exist. This paper portrays healthcare utilisation structures among individuals with chILD, provides a pan-European estimate of a 3-month interval per-capita costs and delineates crucial cost drivers.

METHODS

Based on longitudinal healthcare resource utilisation pattern of 445 children included in the Kids Lung Register diagnosed with chILD across 10 European countries, we delineated direct medical and non-medical costs of care per 3-month interval. Country-specific utilisation patterns were assessed with a children-tailored modification of the validated FIMA questionnaire and valued by German unit costs. Costs of care and their drivers were subsequently identified via gamma-distributed generalised linear regression models.

RESULTS

During the 3 months prior to inclusion into the registry (baseline), the rate of hospital admissions and inpatient days was high. Unadjusted direct medical per capita costs (€19 818) exceeded indirect (€1 907) and direct non-medical costs (€1 125) by far. Country-specific total costs ranged from €8 713 in Italy to €28 788 in Poland. Highest expenses were caused by the disease categories 'diffuse parenchymal lung disease (DPLD)-diffuse developmental disorders' (€45 536) and 'DPLD-unclear in the non-neonate' (€47 011). During a follow-up time of up to 5 years, direct medical costs dropped, whereas indirect costs and non-medical costs remained stable.

CONCLUSIONS

This is the first prospective, longitudinal study analysing healthcare resource utilisation and costs for chILD across different European countries. Our results indicate that chILD is associated with high utilisation of healthcare services, placing a substantial economic burden on health systems.

Stakeholders' views of supporting asthma management in schools with a school-based asthma programme for primary school children: a qualitative study in Malaysia

OBJECTIVE

The WHO Global School Health Initiative aimed to improve child and community health through health promotion programmes in schools, though most focus on preventing communicable disease. Despite WHO recommendations, no asthma programme is included in the Malaysian national school health service guideline. Therefore, we aimed to explore the views of school staff, healthcare professionals and policy-makers about the challenges of managing asthma in schools and the potential of a school asthma programme for primary school children.

DESIGN

A focus group and individual interview qualitative study using purposive sampling of participants to obtain diverse views. Data collection was guided by piloted semistructured topic guides. The focus groups and interviews were audiorecorded, transcribed verbatim and analysed using inductive thematic analysis. We completed data collection once data saturation was reached.

SETTING

Stakeholders in education and health sectors in Malaysia.

PARTICIPANTS

Fifty-two participants (40 school staff, 9 healthcare professionals and 3 policy-makers) contributed to nine focus groups and eleven individual interviews.

RESULTS

School staff had limited awareness of asthma and what to do in emergencies. There was no guidance on asthma management in government schools, and teachers were unclear about their role in school children's health. These uncertainties led to delays in the treatment of asthma symptoms/attacks, and suggestions that an asthma education programme and a school plan would improve asthma care. Perceived challenges in conducting school health programmes included a busy school schedule and poor parental participation. A tailored asthma programme in partnerships with schools could facilitate the programme's adoption and implementation.

CONCLUSIONS

Identifying and addressing issues and challenges specific to the school and wider community could facilitate the delivery of a school asthma programme in line with the WHO School Health Initiative. Clarity over national policy on the roles and responsibilities of school staff could support implementation and guide appropriate and prompt response to asthma emergencies in schools.

Study Pre-protocol for "BronchStart - The Impact of the COVID-19 Pandemic on the Timing, Age and Severity of Respiratory Syncytial Virus (RSV) Emergency Presentations; a Multi-Centre Prospective Observational Cohort Study"

Background: Bronchiolitis (most frequently caused by respiratory syncytial virus; RSV) is a common winter disease predominantly affecting children under one year of age. It is a common reason for presentations to an emergency department (ED) and frequently results in hospital admission, contributing to paediatric units approaching or exceeding capacity each winter. During the SARS-CoV-2 pandemic, the circulation of RSV was dramatically reduced in the United Kingdom and Ireland. Evidence from the Southern Hemisphere and other European countries suggests that as social distancing restrictions for SARS-CoV-2 are relaxed, RSV infection returns, causing delayed or even summer epidemics, with different age distributions. Study question: The ability to track, anticipate and respond to a surge in RSV cases is critical for planning acute care delivery. There is an urgent need to understand the onset of RSV spread at the earliest opportunity. This will influence service planning, to inform clinicians whether the population at risk is a wider age range than normal, and whether there are changes in disease severity. This information is also needed to inform decision on the timing of passive immunisation of children at higher risk of hospitalisation, intensive care admission or death with RSV infection, which is a public health priority. Methods and likely impact: This multi-centre prospective observational cohort study will use a well-established research network (Paediatric Emergency Research in the UK and Ireland, PERUKI) to report in real time cases of RSV infection in children aged under two years, through the collection of  essential, but non-identifying patient information. Forty-five centres will gather initial data on age, index of multiple deprivation quintile, clinical features on presentation, and co-morbidities. Each case will be followed up at seven days to identify treatment, viral diagnosis and outcome.  Information be released on a weekly basis and used to support clinical decision making.

An innovative General Practice based Pharmacy Longitudinal Clerkship: using theory to characterise its development, implementation and initial evaluation

BACKGROUND

Longitudinal Integrated Clerkships exist in undergraduate medicine courses. A pilot Pharmacy Longitudinal Clerkship (pPLC) was funded to investigate delivery of this model of clinical education for student pharmacists.

OBJECTIVE(S)

To investigate the development, implementation and initial evaluation of a pPLC.

METHODS

The 11-week pPLC was delivered to two students in two GP practices in Scotland. Mixed theory-based methods were used to gather information on the pPLC structures and processes required and qualitative semi-structured Theoretical Domains Framework (TDF) based interviews explored outcomes with key stakeholders. Informed written consent was obtained. Interviews were audio-recorded, transcribed verbatim and analysed thematically. University Ethics approval was granted.

RESULTS

Data were generated on resources and processes required for a pPLC including funds budgeted for and actually spent on staffing, student travel/subsistence and student clinical 'Kit Bags', learning outcomes, curriculum and training timetable, GP Practice/University contracts. Interviews were completed with the two students, three linked GP clinical supervisors and two Regional Tutors involved. The seven themes were identified and mapped to seven TDF domains including: increased levels of student confidence, and increased student enthusiasm for a career in pharmacy, need for definition of the role of the Regional Tutor for the PLC and GP positivity towards the expected outcomes of clerkship model versus traditional placements.

CONCLUSION

Findings are limited by the small number of participants and settings, but evaluation was positive and the work garnered information on requirements for resources and processes. This will inform 'roll out' of the PLC.

Application of Machine Learning to Optimize Management of Children in Hospital with Lower Respiratory Tract Infection

Effective triage can help optimize the use of limited healthcare resources for managing paediatric patients with lower respiratory tract infection (LRTI), the primary cause of death worldwide for under 5 years old children. However, triage decisions do not consider medium to long term needs of hospitalized children. In this study, we aim to leverage data-driven methods using objective measures to predict the type of hospital stay (short or long). We used vital signs (heart rate, oxygen saturation, breathing rate, and temperature) recorded from 12,881 children admitted to paediatric intensive care units in China. We generated multiple features from each vital sign, and then used regularized logistic regression with 10-fold cross validation to test the generalizability of our models. We investigated the minimum number of recording days needed to provide a reliable estimate. We assessed model performance with Area Under the Curve (AUC) using Receiver Operating Characteristic. Our results show that each vital sign independently helps predict hospital stay and the AUC increases further when vital signs are combined. In addition, early prediction of the type of stay of a patient admitted for LRTI using vital signs is possible, even with using only one day of recordings. There is now a need to apply these predictive models to other populations to assess the generalizability of the proposed methods.

Indirect effects of the COVID-19 pandemic on paediatric healthcare use and severe disease: a retrospective national cohort study

OBJECTIVES

To determine the indirect consequences of the COVID-19 pandemic on paediatric healthcare utilisation and severe disease at a national level following lockdown on 23 March 2020.

DESIGN

National retrospective cohort study.

SETTING

Emergency childhood primary and secondary care providers across Scotland; two national paediatric intensive care units (PICUs); statutory death records.

PARTICIPANTS

273 455 unscheduled primary care attendances; 462 437 emergency department attendances; 54 076 emergency hospital admissions; 413 PICU unplanned emergency admissions requiring invasive mechanical ventilation; and 415 deaths during the lockdown study period and equivalent dates in previous years.

MAIN OUTCOME MEASURES

Rates of emergency care consultations, attendances and admissions; clinical severity scores on presentation to PICU; rates and causes of childhood death. For all data sets, rates during the lockdown period were compared with mean or aggregated rates for the equivalent dates in 2016-2019.

RESULTS

The rates of emergency presentations to primary and secondary care fell during lockdown in comparison to previous years. Emergency PICU admissions for children requiring invasive mechanical ventilation also fell as a proportion of cases for the entire population, with an OR of 0.52 for likelihood of admission during lockdown (95% CI 0.37 to 0.73), compared with the equivalent period in previous years. Clinical severity scores did not suggest children were presenting with more advanced disease. The greatest reduction in PICU admissions was for diseases of the respiratory system; those for injury, poisoning or other external causes were equivalent to previous years. Mortality during lockdown did not change significantly compared with 2016-2019.

CONCLUSIONS

National lockdown led to a reduction in paediatric emergency care utilisation, without associated evidence of severe harm.

Longitudinal assessment of lung clearance index to monitor disease progression in children and adults with cystic fibrosis

Background

Lung clearance index (LCI) is a valuable research tool in cystic fibrosis (CF) but clinical application has been limited by technical challenges and uncertainty about how to interpret longitudinal change. In order to help inform clinical practice, this study aimed to assess feasibility, repeatability and longitudinal LCI change in children and adults with CF with predominantly mild baseline disease.

Methods

Prospective, 3-year, multicentre, observational study of repeated LCI measurement at time of clinical review in patients with CF >5 years, delivered using a rapid wash-in system.

Results

112 patients completed at least one LCI assessment and 98 (90%) were still under follow-up at study end. The median (IQR) age was 14.7 (8.6–22.2) years and the mean (SD) FEV₁ z-score was −1.2 (1.3). Of 81 subjects with normal FEV₁ (>−2 z-scores), 63% had raised LCI (indicating worse lung function). For repeat stable measurements within 6 months, the mean (limits of agreement) change in LCI was 0.9% (−18.8% to 20.7%). A latent class growth model analysis identified four discrete clusters with high accuracy, differentiated by baseline LCI and FEV₁. Baseline LCI was the strongest factor associated with longitudinal change. The median total test time was under 19 min.

Conclusions

Most patients with CF with well-preserved lung function show stable LCI over time. Cluster behaviours can be identified and baseline LCI is a risk factor for future progression. These results support the use of LCI in clinical practice in identifying patients at risk of lung function decline.

Operational definitions of paediatric asthma used in epidemiological studies: A systematic review

Background

Researchers use different definitions to identify children with asthma in epidemiological surveys. We conducted a systematic review to describe the definitions used in epidemiologic studies for wheeze and asthma in the paediatric population, aimed to inform the development of a uniform definition of paediatric asthma for future epidemiological research.

Methods

We systematically searched terms to identify asthma and/or wheeze among children aged <13 years and published between 1995-2020 across seven databases (MEDLINE, EMBASE, PsycINFO, Global Health, AMED, LILACS and CINAHL). PRISMA guidelines were followed for this review.

Results

We extracted a total of 11 886 records, where 190 met our eligibility criteria and included in the analysis. Among the included studies, 62.1% (n = 118/190) used the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires, predominantly in developing countries (80%, n = 64/80). ‘Wheeze’ was reported in five categories, subdivided by 14 different definitions. “Current wheeze”, defined as caregivers report of wheezing sounds from the chest of the child in the past 12 months and “Wheeze ever”, defined as caregivers’ report of wheezing or whistling in the chest of the child at any previous time, were the most common wheeze category reported in 129 and 95 studies, respectively. Asthma was reported in nine categories using 53 definitions. The most common asthma category was “Asthma ever”, which was reported in 89 studies, based on caregiver statement that the child had asthma in the past.

Conclusion

Definitions of wheeze and asthma for children used in surveys are primarily based on parent-reported clinical features. Studies from developing countries more frequently used the ISAAC definitions to report childhood asthma and wheeze compared to the studies from developed counties. The use of a uniform asthma definition will aid the interpretation of research findings globally.

Study Pre-protocol for "BronchStart - The Impact of the COVID-19 Pandemic on the Timing, Age and Severity of Respiratory Syncytial Virus (RSV) Emergency Presentations; a Multi-Centre Prospective Observational Cohort Study"

Background: Bronchiolitis (most frequently caused by respiratory syncytial virus; RSV) is a common winter disease predominantly affecting children under one year of age. It is a common reason for presentations to an emergency department (ED) and frequently results in hospital admission, contributing to paediatric units approaching or exceeding capacity each winter. During the SARS-CoV-2 pandemic, the circulation of RSV was dramatically reduced in the United Kingdom and Ireland. Evidence from the Southern Hemisphere and other European countries suggests that as social distancing restrictions for SARS-CoV-2 are relaxed, RSV infection returns, causing delayed or even summer epidemics, with different age distributions. Study question: The ability to track, anticipate and respond to a surge in RSV cases is critical for planning acute care delivery. There is an urgent need to understand the onset of RSV spread at the earliest opportunity. This will influence service planning, to inform clinicians whether the population at risk is a wider age range than normal, and whether there are changes in disease severity. This information is also needed to inform decision on the timing of passive immunisation of children at higher risk of hospitalisation, intensive care admission or death with RSV infection, which is a public health priority. Methods and likely impact: This multi-centre prospective observational cohort study will use a well-established research network (Paediatric Emergency Research in the UK and Ireland, PERUKI) to report in real time cases of RSV infection in children aged under two years, through the collection of  essential, but non-identifying patient information. Forty-five centres will gather initial data on age, index of multiple deprivation quintile, clinical features on presentation, and co-morbidities. Each case will be followed up at seven days to identify treatment, viral diagnosis and outcome.  Information be released on a weekly basis and used to support clinical decision making.

Study protocol of the Edinburgh and Lothian Virus Intervention Study in Kids: a randomised controlled trial of hypertonic saline nose drops in children with upper respiratory tract infections (ELVIS Kids)

INTRODUCTION

Edinburgh and Lothians' Viral Intervention Study Kids is a parallel, open-label, randomised controlled trial of hypertonic saline (HS) nose drops (~2.6% sodium chloride) vs standard care in children <7 years of age with symptoms of an upper respiratory tract infection (URTI).

METHODS AND ANALYSIS

Children are recruited prior to URTI or within 48 hours of developing URTI symptoms by advertising in areas such as local schools/nurseries, health centres/hospitals, recreational facilities, public events, workplaces, local/social media. Willing parents/guardians, of children <7 years of age will be asked to contact the research team at their local site. Children will be randomised to either a control arm (standard symptomatic care), or intervention arm (three drops/nostril of HS, at least four times a day, until 24 hours after asymptomatic or a maximum of 28 days). All participants are requested to provide a nasal swab at the start of the study (intervention arm: before HS drops) and then daily for four more days. Parent/guardian complete a validated daily diary, an end of illness diary, a satisfaction questionnaire and a wheeze questionnaire (day 28). The parent/guardian of a child in the intervention arm is taught to prepare HS nose drops. Parent/guardian of children asymptomatic at recruitment are requested to inform the research team within 48 hours of their child developing an URTI and follow the instructions already provided. The day 28 questionnaire determines if the child experienced a wheeze following illness. Participation in the study ends on day 28.

ETHICS AND DISSEMINATION

The study has been approved by the West of Scotland Research Ethics Service (18/WS/0080). It is cosponsored by Academic and Clinical Central Office for Research and Development-a partnership between the University of Edinburgh and National Health Service Lothian Health Board. The findings will be disseminated through peer-reviewed publications, conference presentations and via the study website.

TRIAL REGISTRATION NUMBER

NCT03463694.

School-based self-management interventions for asthma among primary school children: a systematic review

A Cochrane review of school-based asthma interventions (combining all ages) found improved health outcomes. Self-management skills, however, vary according to age. We assessed effectiveness of primary school-based self-management interventions and identified components associated with successful programmes in children aged 6-12 years. We updated the Cochrane search (March 2020) and included the Global Health database. Two reviewers screened, assessed risk-of-bias and extracted data. We included 23 studies (10,682 participants); four at low risk-of-bias. Twelve studies reported at least one positive result for an outcome of interest. All 12 positive studies reported parental involvement in the intervention, compared to two-thirds of ineffective studies. In 10 of the 12 positive studies, parental involvement was substantial (e.g. attending sessions; phone/video communication) rather than being provided with written information. School-based self-management intervention can improve health outcomes and substantial parental involvement in school-based programmes seemed important for positive outcomes among primary school children.

Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar

Introduction

A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing.

Aim

To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar.

Methods

This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC.

Results

In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all &gt;0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress.

Conclusion

A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques.

References

1. Talkhan H, Stewart D, McIntosh T, Ziglam H Palli Valapila, A; Moza Sulaiman H, Diab M, Cunningham S. The use of theory in the development and evalu​ation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother. 2020;75(9):2394–2410, Available from https://doi.org/10.1093/jac/dkaa154 [Accessed 12 Oct 2020].

2. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, Crone MR. Measuring determinants of implementation behaviour: psychometric properties of a questionnaire based on the Theoretical Domains Framework. Implement. Sci. 2014;9(1):33.

A qualitative exploration of pharmacist prescribing for patients with Chronic Kidney Disease in the United Kingdom

Introduction

Chronic Kidney Disease (CKD) has a high risk of mortality, frequent hospitalisation and reduced life expectancy. Clinical pharmacy services have potential to contribute significantly to the multidisciplinary team. In the UK Government policies prioritise development of pharmacist prescribing and the GPhC highlight changing health services that increasingly use pharmacist prescribers.

Aim

To explore the development, implementation and evaluation of pharmacist prescribing for patients with Chronic Kidney Disease (CKD) in the UK.

Method

This phase of a doctoral research programme used a phenomenological qualitative semi-structured interview approach. It involved 48 pharmacist prescriber members of the UK Renal Pharmacy Group (UKRPG) who had agreed to further research after an online survey. The development of the theory based semi-structured interview tool followed a rigorous iterative process using findings from a systematic review in the first phase [1] and results from a survey in the second phase.[2] The tool was designed using the Consolidated Framework for Implementation Research (CFIR) and reviewed independently for face and content validity by an expert panel. Think aloud testing and piloting completed the development process. A date / time for an audio-recorded telephone interview was arranged following receipt of signed consent. All interviews were transcribed verbatim naturalistically. NVivo® 11 was used for data management and analysis. Interview data were analysed thematically, guided by the CFIR, initially by two team members independently. The Francis method of checking for data saturation was used. Ethical approval was granted by RGU School of Pharmacy & Life Sciences Ethics committee.

Results

Fourteen pharmacists of the 48 agreed to participate. Demographic details included: 11 female, 7 had &gt;16 year experience in profession, all had secondary care as main practice setting and 8 had &gt; 11years as a prescriber. The interviewees were generally very positive about their prescribing practice and they articulated that they were prescribing in a variety of settings. They used mainly independent prescribing in both inpatient and/or outpatient settings and prescribing in clinic settings for CKD associated anaemia / epoetin clinics. CFIR helped identify themes related to facilitators and barriers to advancing prescribing practice (Table 1). There was enthusiasm for the future development of prescribing practice including further establishment of clinics and taking responsibility for groups of patients. Interviewees indicated awareness of systems for evaluating their prescribing activity.

Conclusion

This work provides valuable information relating to the current status of and needs for the development of pharmacist prescribing practice in the UK. It fills a gap shown from previous work [1] around availability of information on structures, process and monitoring of outcomes of this specific growing aspect of clinical pharmacy practice. Main strengths include consideration of aspects of trustworthiness throughout the research process aided by theoretical underpinning with CFIR and the focus on specialist pharmacist prescribers. Major limitations include low number of participants with consequent potential for recruitment and social desirability biases and lack of transferability of findings. Further ‘deep dive’ case study work will help explore the practice of leading edge advanced and consultant level practitioners to learn even more about practice development.

References

1. Al Raiisi F, Stewart D, Fernandez-Llimos F, Salgado TM, Fahmy Mohamed M, Cunningham S. 2019. Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review. Int J Clin Pharm. 2019 41(3):630–666. doi: 10.1007/s11096-019-00816-4.

2. Al Raiisi F, Stewart D, Ashley C, Fahmy M, Alnaamani H, Cunningham S. A theoretically based cross-sectional survey on the behaviors and experiences of clinical pharmacists caring for patients with chronic kidney disease. Res Social Adm Pharm. 2020 May. In press, https://doi.org/10.1016/j.sapharm.2020.05.005

Exploration of inter-professional learning in experiential Learning for student pharmacists in Scotland: A qualitative study

Introduction

Additional Cost of Teaching for Pharmacy (ACTp) funding from Scottish Government supports the development of experiential learning (EL) placements for student pharmacists [1]. Interprofessional learning (IPL) has been built into initial education for many healthcare professionals [2]. In 2019, a National Pharmacy EL Stakeholder event recommended exploring the further development of IPL within EL for the MPharm.

Aim

To scope existing IPL in EL and explore the feasibility for further development within the MPharm in Scotland

Methods

Online qualitative interviews were conducted with key stakeholders from Schools of Pharmacy, NHS Education for Scotland, EL sites, and Scottish health boards. All were involved in the development/delivery of these activities. The interview schedule was developed by the research team, reviewed for face and content validity, piloted prior to use, and modified based on early interviews. All interviews were audio-recorded, transcribed, and independently thematically analysed by two researchers. Interviews continued until data saturation and good representation from all settings were achieved. All ethical approvals were sought prior to the interviews.

Results

Twenty interviews were conducted with three key themes emerging; (1)current IPL within EL activities, (2)future developments, and (3)perceptions of enablers and barriers to developing/delivering IPL within EL. There were limited examples of existing IPL within EL activities including: a pilot pharmacy longitudinal clerkship and hospital-based pharmacy/medical student IPL week. Some stakeholders indicated that current IPL involves mainly campus-based activities but other EL based initiatives were planned but not yet implemented. Respondents indicated that future developments should be carefully planned in collaboration with other stakeholders and tailored to students’ stage of study to ensure their success. There was significant support for incorporating IPL within EL initiatives as part of the MPharm course to complement traditional ways of teaching.

“I think if we don't do it, we're missing a big trick… Doing something in a classroom or doing something within a small tutorial is a very false way of learning, whereas in practice, where they're going to end up working together, it seems ideal.”

Many enablers were highlighted mainly relating to the expected benefits of such activities on students, facilitators, patients, and the healthcare system. Logistics and planning difficulties were perceived to be barriers to implementation of IPL within EL.

“We've tried to do it, it was with the medical school and they were receptive to it, but the logistics just didn't work out… when you've got two very different timetables to try and bring together, it is very, very difficult to do.”

Conclusion

Pharmacy stakeholders highlighted that the majority of IPL currently undertaken in Scotland is not based in EL settings but they supported developing it. Enablers and barriers articulated highlight the need for careful planning of these activities. A strength of this study is it involved a broad range of key stakeholders from across Scotland ensuring representativeness of views and ideas. A limitation may be that, given the Scottish focus, findings may lack direct transferability to other countries. Future research should focus on designing a framework for developing and implementing IPL within EL in Scotland.

References

1. NHS Education for Scotland, 2020. Experiential learning for student pharmacists in Scotland. [online]. Edinburgh: NHS Education for Scotland. Available from: https://www.nes.scot.nhs.uk/our-work/experiential-learning-for-student-pharmacists-in-scotland/ [Accessed 07/10/2020].

2. Barr H. Interprofessional Education-The Genesis of Global Movement. 2015. https://www.caipe.org/resources/publications/barr-h-2015-interprofessional-education-genesis-global-movement. [Accessed 4 Aug 2020]

The international literature underpinning collaborative practice within practice based experiential learning for the initial education of student pharmacists: a scoping review

Introduction

Interprofessional team working within healthcare [1] enables the use of complementary areas of expertise. Collaborative practice (CP) builds on this and enhances recognition and respect for such expertise which facilitates professional synergy. Development of CP needs to be built into initial education programmes and there is global progress. [2] Further, a WHO Framework highlighted the importance of courses developing CP in experiential learning (EL) environments. [1] There is need to develop both CP and EL within pharmacy courses to meet governmental and regulatory aspirations around the clinical and prescribing roles of pharmacists.

Aim

The aim of this part of a scoping review was to describe the different characteristics of the international literature around the development, implementation and evaluation of CP within practice based EL for initial education of student pharmacists.

Methods

The six-stage Arksey and O’Malley framework and the PRISMA extension for Scoping Reviews for reporting were followed. Eligibility criteria were defined (Table 1) and electronic searches of relevant databases (Medline, IPA, CINAHL and Google Scholar) conducted from inception to April 2020. MeSH terms and other relevant subject headings and text words were used. First stage involved screening titles / abstracts and second stage involved review of full text articles. A charting tool was developed and used to extract data on: country, study design, methods of evaluation, sector of practice, stage of students, professional groups involved, monitoring and assessment and scope for development. Findings were presented as a descriptive narrative summary. All steps involved independent checks by two of the review team.

Results

Twenty-eight papers were included with most from the USA (16 papers), with the remainder from Australia (5 papers), UK (5 Papers), Canada and the Netherlands (1 paper each). The majority of papers described quantitative methods using a wide variety of published (some validated) scales (20 scales including RIPLS, SPICE, CPAT) and a number of bespoke survey tools. The main focus was at ‘Kirkpatrick model of educational evaluation’ level 3 – with 13 papers focussing on changes to professional behaviours. Papers focussed on either hospital (12 papers) or primary care initiatives (12 papers) with the remaining four describing cross-sectoral settings. Only 6 papers stated that they focussed on specific healthcare specialities and the remainder were in general medical facilities. The nature of initiatives and activities varied with a predominance of focus to include later years of study. Only 3 papers included only pharmacy and medicine students.. Detailed information was lacking on methods of student assessment: some reported this involved reflection, with limited reporting of tools to assess competencies. A wide array of further research proposals was articulated.

Conclusion

This scoping review highlights the range of work already carried out. The diversity highlights the need for consideration of commonality in the nature of activity and tools to evaluate outcomes to ensure transferability to practice. There are many challenges influencing further development and implementation of CP. Facilitating matters by using the evidence base to add to existing placements without restructuring curricula across courses / institutions has been proposed by some authors.

References

1. Framework [Framework for Action on Interprofessional Education & Collaborative Practice (WHO/HRH/HPN/10.3). World Health Organization 2010, Geneva 27, Switzerland, Available at http://www.who.int/hrh/nursing_midwifery/en/ [Accessed 4 Aug 2020]

2. Barr H. Interprofessional Education-The Genesis of Global Movement. 2015. https://www.caipe.org/resources/publications/barr-h-2015-interprofessional-education-genesis-global-movement. [Accessed 4 Aug 2020]