Model of multidisciplinary teamwork in hip fracture care: a qualitative interview study

OBJECTIVES

Hip fractures are common injuries in older age with high mortality requiring multidisciplinary clinical care. Despite guidance, there is considerable variation in hip fracture services and patient outcomes; furthermore, little is known about how successful multidisciplinary working can be enabled. This study aimed to characterise professionals' views about the core components of multidisciplinary teamwork in hip fracture care.

DESIGN

The study comprised qualitative interviews with healthcare professionals delivering hip fracture care. Interviews were audio recorded, transcribed and analysed abductively: material was coded inductively and grouped into higher level concepts informed by theories and frameworks relating to teamwork.

SETTING

Four hospitals in England.

PARTICIPANTS

Participants were 40 healthcare professionals including orthopaedic surgeons, orthogeriatricians, physiotherapists and service managers.

RESULTS

Results identified four components of successful multidisciplinary teamwork: (1) defined roles and responsibilities, (2) information transfer processes, (3) shared goals and (4) collaborative leadership. These were underpinned by a single concept: shared responsibility. Defined roles and responsibilities were promoted through formal care pathways, reinforced through induction and training with clear job plans outlining tasks. Information transfer processes facilitated timely information exchange to appropriate individuals. Well-defined common purpose was hindered by complex interdisciplinary professional relationships, particularly between orthogeriatric and orthopaedic staff, and encouraged through multidisciplinary team meetings and training. Clinical service leads were integral to bridging interdisciplinary boundaries. Mutual trust and respect were based on recognition of the value of different professional groups. Teamwork depended on formal clinical leads with facilitative and motivational roles, and on hospital leadership that created an environment supporting collaboration. Shared responsibility for patients was encouraged by joint orthopaedic and orthogeriatric care models. Staff shared responsibility by assisting colleagues when needed.

CONCLUSIONS

Shared responsibility across the multidisciplinary team is fundamental to delivery of hip fracture care. Findings will inform development of clinical practice recommendations and training to build teamworking competencies.

Engaging and supporting the public on the topic of grief and bereavement: an evaluation of Good Grief Festival

Background

Good Grief Festival was originally planned as a face-to-face festival about grief and bereavement. Due to COVID-19, it was held online over 3 days in October 2020.

Objective

To evaluate the festival's reach and impact.

Design

Pre/post evaluation.

Methods

Pre-festival online surveys assessed reasons for attending and attitudes to bereavement across four items (fear of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was struggling, knowing how to help). Post-festival online surveys evaluated audience experiences and the four attitude items. Free-text responses, analysed using thematic analysis, generated suggestions for improvement and general comments.

Results

Between 5003 and 6438 people attended, with most attending two to five events. Pre-festival survey participants (n = 3785) were mostly women (91%) and White (91%). About 9% were from Black or minoritised ethnic communities. About 14% were age ⩾65 years, 16% age ⩽34 years. Around 75% were members of the public, teachers, students or 'other'; 25% academics, clinicians or bereavement counsellors. A third had been bereaved in the last year; 6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants (n = 685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good and 75% agreed that they felt more confident talking about grief after attending. Higher ratings and confidence were associated with attending more events. Post-festival attitudes were improved across all four items (p < 0.001). Attendees appreciated the festival, particularly valuing the online format, opportunities for connection during lockdown and the diversity and quality of speakers. Suggestions included improving registration, more interactive events and less content.

Conclusion

Good Grief Festival successfully reached a large public audience, with benefit in engagement, confidence and community-building. Evaluation was critical in shaping future events. Findings suggest festivals of this nature can play a central role in increasing death- and grief-literacy within a public health approach.

Integrated therapist and online CBT for depression in primary care (INTERACT): study protocol for a multi-centre randomised controlled trial

BACKGROUND

Cognitive behavioural therapy (CBT) is an effective treatment for depression. Self-directed online CBT interventions have made CBT more accessible at a lower cost. However, adherence is often poor and, in the absence of therapist support, effects are modest and short-term. Delivering CBT online using instant messaging is clinically and cost-effective; however, most existing platforms are limited to instant messaging sessions, without the support of between-session "homework" activities. The INTERACT intervention integrates online CBT materials and 'high-intensity' therapist-led CBT, delivered remotely in real-time. The INTERACT trial will evaluate this novel integration in terms of clinical and cost-effectiveness, and acceptability to therapists and clients.

METHODS

Pragmatic, two parallel-group multi-centre individually randomised controlled trial, with 434 patients recruited from primary care practices in Bristol, London and York. Participants with depression will be identified via General Practitioner record searches and direct referrals.

INCLUSION CRITERIA

aged ≥ 18 years; score ≥ 14 on Beck Depression Inventory (BDI-II); meeting International Classification of Diseases (ICD-10) criteria for depression.

EXCLUSION CRITERIA

alcohol or substance dependency in the past year; bipolar disorder; schizophrenia; psychosis; dementia; currently under psychiatric care for depression (including those referred but not yet seen); cannot complete questionnaires unaided or requires an interpreter; currently receiving CBT/other psychotherapy; received high-intensity CBT in the past four years; participating in another intervention trial; unwilling/unable to receive CBT via computer/laptop/smartphone. Eligible participants will be randomised to integrated CBT or usual care. Integrated CBT utilises the standard Beckian intervention for depression and comprises nine live therapist-led sessions, with (up to) a further three if clinically appropriate. The first session is 60-90 min via videocall, with subsequent 50-min sessions delivered online, using instant messaging. Participants allocated integrated CBT can access integrated online CBT resources (worksheets/information sheets/videos) within and between sessions. Outcome assessments at 3-, 6-, 9- and 12-month post-randomisation. The primary outcome is the Beck Depression Inventory (BDI-II) score at 6 months (as a continuous variable). A nested qualitative study and health economic evaluation will be conducted.

DISCUSSION

If clinically and cost-effective, this model of integrated CBT could be introduced into existing psychological services, increasing access to, and equity of, CBT provision.

TRIAL REGISTRATION

ISRCTN, ISRCTN13112900. Registered on 11/11/2020. Currently recruiting participants. Trial registration data are presented in Table 1.

Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery

BACKGROUND

Hip fractures are devastating injuries, with high health and social care costs. Despite national standards and guidelines, substantial variation persists in hospital delivery of hip fracture care and patient outcomes. This qualitative study aimed to identify organisational processes that can be targeted to reduce variation in service provision and improve patient care.

METHODS

Interviews were conducted with 40 staff delivering hip fracture care in four UK hospitals. Twenty-three anonymised British Orthopaedic Association reports addressing under-performing hip fracture services were analysed. Following Thematic Analysis of both data sources, themes were transposed onto domains both along and across the hip fracture care pathway.

RESULTS

Effective pre-operative care required early alert of patient admission and the availability of staff in emergency departments to undertake assessments, investigations and administer analgesia. Coordinated decision-making between medical and surgical teams regarding surgery was key, with strategies to ensure flexible but efficient trauma lists. Orthogeriatric services were central to effective service delivery, with collaborative working and supervision of junior doctors, specialist nurses and therapists. Information sharing via multidisciplinary meetings was facilitated by joined up information and technology systems. Service provision was improved by embedding hip fracture pathway documents in induction and training and ensuring their consistent use by the whole team. Hospital executive leadership was important in prioritising hip fracture care and advocating service improvement. Nominated specialty leads, who jointly owned the pathway and met regularly, actively steered services and regularly monitored performance, investigating lapses and consistently feeding back to the multidisciplinary team.

CONCLUSION

Findings highlight the importance of representation from all teams and departments involved in the multidisciplinary care pathway, to deliver integrated hip fracture care. Complex, potentially modifiable, barriers and facilitators to care delivery were identified, informing recommendations to improve effective hip fracture care delivery, and assist hospital services when re-designing and implementing service improvements.

Is In-Service Granular Activated Carbon Biologically Active? An Evaluation of Alternative Experimental Methods to Distinguish Adsorption and Biodegradation in GAC

In-service granular activated carbon (GAC) may transform into biological activated carbon (BAC) and remove contaminants through both adsorption and biodegradation, but it is difficult to determine its biodegradative capacity. One approach to understand the GAC biodegradative capacity is to compare the performance between unsterilized and sterilized GAC, but the sterilization methods may not ensure effective microbial inhibition and may affect adsorption. This study identified the ¹⁴C-glucose respiration rate as the best metric to evaluate the effectiveness of three sterilization methods: sodium azide addition, autoclaving, and γ irradiation. The sterilization protocols were refined, including continuously feeding 300 mg/L of sodium azide, three cycles of autoclaving, and 10-12 kGy of γ irradiation. Parallel minicolumn tests were conducted to identify sodium azide addition as the most broadly effective sterilization method with an insignificant effect on adsorption in most cases, except for the adsorption of anionic compounds under certain conditions. Nevertheless, this problem was solved by decreasing the azide dosage as long as it is still sufficient to provide effective microbial inhibition. This study helps to develop an approach that differentiates adsorption and biodegradation in GAC, which could be used by future studies to advance our understanding of BAC filtration.

995 MULTIPLE ORGANISATIONAL FACTORS IMPROVE MULTI-DISCIPLINARY CARE DELIVERY TO PATIENTS WITH HIP FRACTURES: A QUALITATIVE STUDY

Introduction

Hip fractures are devastating injuries which incur high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that facilitate successful delivery of hip fracture services.

Method

Forty qualitative interviews were conducted with healthcare professionals involved in delivering hip fracture care at four English hospitals. Interview data were supplemented with documentary analysis of 23 anonymised British Orthopaedic Association hospital-initiated peer-review reports of services. Data were analysed thematically, with themes transposed onto key components of the care pathway.

Results

We identified multiple aspects of service organisation that facilitated good care delivery. At admission, standardisation of training in nerve block administration impacted care delivery. During hospital stays, service delivery was improved by integrated, shared-care between orthopaedics and orthogeriatrics, and by strategies to improve trauma list efficiency. Adequately staffed orthogeriatric services and the ‘right’ skills and seniority mix were important to holistic care provision. Placing patients on designated hip fracture wards concentrated staff expertise. Collaborative working was achieved through multi-disciplinary team (MDT) meetings between key staff, protocols and care pathways that defined roles and responsibilities, MDT documentation, ‘joined-up’ IT systems within hospitals and with primary care, and shared working spaces such as shared offices and onwards. Trauma and hip fracture coordinators organised care processes and provided a valuable central point of contact within teams. Nominated leads, representing diverse specialties, worked together in MDT planning meetings to develop joint protocols, establish audit priorities, and agree shared goals. Routine, comprehensive monitoring and evaluation of service delivery, with findings shared throughout the MDT, was beneficial.

Conclusion

Our study has characterised potentially modifiable elements of successful hip fracture service delivery. Findings are intended to help services overcome organisational barriers towards delivery of high-quality hip fracture services.

Dental Extractions under General Anesthesia: New Insights from Process Mining

INTRODUCTION

Tooth extraction under general anesthetic (GA) is a global health problem. It is expensive, high risk, and resource intensive, and its prevalence and burden should be reduced where possible. Recent innovation in data analysis techniques now makes it possible to assess the impact of GA policy decisions on public health outcomes. This article describes results from one such technique called process mining, which was applied to dental electronic health record (EHR) data. Treatment pathways preceding extractions under general anesthetic were mined to yield useful insights into waiting times, number of dental visits, treatments, and prescribing behaviors associated with this undesirable outcome.

METHOD

Anonymized data were extracted from a dental EHR covering a population of 231,760 patients aged 0 to 16 y, treated in the Irish public health care system between 2000 and 2014. The data were profiled, assessed for quality, and preprocessed in preparation for analysis. Existing process mining methods were adapted to execute process mining in the context of assessing dental EHR data.

RESULTS

Process models of dental treatment preceding extractions under general anesthetic were generated from the EHR data using process mining tools. A total of 5,563 patients who had 26,115 GA were identified. Of these, 9% received a tooth dressing before extraction with an average lag time of 6 mo between dressing and extraction. In total, 11,867 emergency appointments were attended by the cohort with 2,668 X-rays, 4,370 prescriptions, and over 800 restorations and other treatments carried out prior to tooth extraction.

DISCUSSION AND CONCLUSIONS

Process models generated useful insights, identifying metrics and issues around extractions under general anesthetic and revealing the complexity of dental treatment pathways. The pathways showed high levels of emergency appointments, prescriptions, and additional tooth restorations ultimately unsuccessful in preventing extractions. Supporting earlier publications, the study suggested earlier screening, preventive initiatives, guideline development, and alternative treatments deserve consideration.

KNOWLEDGE TRANSFER STATEMENT

This study generates insights into tooth extractions under general anesthetic using process mining technologies and methods, revealing levels of extraction and associated high levels of prescriptions, emergency appointments, and restorative treatments. These insights can inform dental planners assessing policy decisions for tooth extractions under general anesthetic. The methods used can be combined with costs and patient outcomes to contribute to more effective decision-making.

Measuring outcomes in trials of interventions for people who self-harm: qualitative study of service users' views

BACKGROUND

Patients often have very different ideas from clinicians about what they want treatments to achieve. Their views on what outcomes are important are not always reflected in trials.

AIMS

To elicit the views of people who self-harm on the most commonly used outcome measures and to identify the outcomes that matter to them.

METHOD

We conducted in-depth interviews with 18 people with histories of self-harm, recruited from hospital and community settings. We conducted thematic analysis using a framework approach and used visual mapping to arrive at our final analysis and interpretation.

RESULTS

Participants' accounts contained a number of challenges to the validity and meaningfulness of current trial outcome measures. Five broad issues emerged: (a) relationship between frequency and severity of self-harm; (b) behavioural substitution; (b) self-management skills; (d) the role of self-harm as survival tool and affect regulator, and (e) strategic self-presentation. We show how these affect the visibility and measurability of commonly used outcomes. The outcomes that mattered to participants focused on positive achievements in three domains: (a) general functioning and activities of everyday living; (b) social participation, and (c) engagement with services. Participants conceptualised these as both measures and means of sustained improvement.

CONCLUSIONS

Our findings suggest that current self-harm trial science rests on flawed assumptions about the relationship between mental states and behaviours and about our ability to measure both. Greater understanding of the outcomes that matter to people who self-harm is needed to inform both intervention development and trial design.

Consequences of 'conversations not had': insights into failures in communication affecting delays in hospital discharge for older people living with frailty

OBJECTIVES

Older people living with frailty (OPLWF) are often unable to leave hospital even if they no longer need acute care. The aim of this study was to elicit the views of health care professionals in England on the barriers to effective discharge of OPLWF.

METHODS

We conducted semi-structured interviews with hospital-based doctors and nurses with responsibility for discharging OPLWF from one large urban acute care hospital in England. The data were analysed using the constant comparative method.

RESULTS

We conducted interviews with 17 doctors (12 senior doctors or consultants and 5 doctors in training) and six senior nurses. Some of our findings reflect well-known barriers to hospital discharge including service fragmentation, requiring skilled coordination that was often not available due to high volumes of work, and poor communication between staff from different organizations. Participants' accounts also referred to less frequently documented factors that affect decision making and the organization of patient discharges. These raised uncomfortable emotions and tensions that were often ignored or avoided. One participant referred to 'conversations not had', or failures in communication, because difficult topics about resuscitation, escalation of treatment and end-of-life care for OPLWF were not addressed.

CONCLUSIONS

The consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients' quality of life and care. As the population of older people is rising, this becomes a key priority for all practitioners in health and social care. Evidence to support practitioners, OPLWF and their families is needed to ensure that these vital conversations take place so that care at the end of life is humane and compassionate.

Inside, outside and in-between: The process and impact of co-producing knowledge about autism in a UK Somali community

Background

Co‐production is predicated on equal power‐sharing and responsibility in research partnerships. However, relatively few accounts exist that explore the subjective experience of how co‐researchers achieve such equality, from the perspectives of public contributors and researchers.

Aim

This paper aims to provide a unique insight into the process of co‐production, by weaving personal reflections with principles to evaluate the impact arising from co‐produced knowledge. It is based upon participatory research that was initiated by a ‘lay’ person, on behalf of a community organization, seeking support for Somali families who are affected by autism. The paper explores the evolving partnerships that began with community theatre and qualitative research and leading to extensive dissemination and impact, all of which has been jointly owned and negotiated by the co‐researchers and community organizations.

Discussion

Initially, this paper reflects on the process, drawing on principles defined for co‐production in health research and combining it with the co‐researcher's personal reflections of their experiences as insiders and outsiders, stepping in and out of each other's worlds. The value of reciprocity, flexibility and continuous reflection is illustrated. The latter part of the paper explores the impact of this co‐produced knowledge using a theoretical framework, to assess the specific impacts and its broader transformative potential. It demonstrates how (1) opportunities for all partners to be equitably involved to the maximum degree possible throughout the research process can affect social change and (2) co‐produced research can become a catalyst that is dynamic and complex, achieving multi‐layered impact.

'You are labelled by your children's disability' - A community-based, participatory study of stigma among Somali parents of children with autism living in the United Kingdom

OBJECTIVES

Social stigma is commonly experienced by parents of children with autism. Our aim was to understand the nature of stigma experienced by Somali parents of children with autism in the United Kingdom (UK), and to consider how they coped with or resisted such stigma.

DESIGN

We used a community-based participatory research approach, collaborating with a community organisation of Somali parents. In-depth interviews with simultaneous translation were conducted with 15 Somali parents of children with autism living in Bristol, UK, in 2015. Parents were sampled purposively to capture diversity in children's age, severity of autism and time since diagnosis. Directed thematic analysis used Link and Phelan's model of stigma.

RESULTS

Of the 15 participants, 12 were mothers (mean age 36). The 17 children with autism they cared for were 4-13 years' old, and five were girls. Two main themes with sub-themes were identified: the nature of stigma (labelling and stereotyping; separation; emotional reactions, discrimination and power), and coping and resistance (the power of language; faith as a resource; learning, peer support and community relationships). Children with autism were labelled and stereotyped (e.g. as 'sick', 'naughty', 'different') and parents blamed for not controlling them, leading to social rejection and isolation. Stigma was associated with a poor understanding of autism, a lack of vocabulary related to autism in the Somali community, and prejudice against mental illness and disability. There was evidence of enacted and felt stigma and examples of discrimination. Finding their own language to describe their child's condition and drawing on faith, learning and peer support were important resources in resisting stigma.

CONCLUSIONS

Findings inform support for this community, highlighting the need to raise awareness of autism, enable parents to speak openly, and ensure appropriate professional services and interventions are available.

'DrinkThink' alcohol screening and brief intervention for young people: a qualitative evaluation of training and implementation

Background

Alcohol Screening and Brief Intervention (ASBI) helps reduce risky drinking in adults, but less is known about its effectiveness with young people. This article explores implementation of DrinkThink, an ASBI co-produced with young people, by health, youth and social care professionals trained in its delivery.

Methods

A qualitative evaluation was conducted using focus groups with 33 staff trained to deliver DrinkThink, and eight interviews with trained participants and service managers. These were recorded, transcribed and a thematic analysis undertaken.

Results

DrinkThink was not delivered fully by health, youth or social care agencies. The reasons for this varied by setting but included: the training staff received, a working culture that was ill-suited to the intervention, staff attitudes towards alcohol which prioritized other health problems presented by young people, over alcohol use.

Conclusions

Implementation was limited because staff had not been involved in the design and planning of DrinkThink. Staffs’ perceptions of alcohol problems in young people and the diverse cultures in which they work were subsequently not accounted for in the design. Co-producing youth focused ASBIs with the professionals expected to deliver them, and the young people whom they target, may ensure greater success in integrating them into working practice.

A qualitative study exploring the value of a catheter passport

Many patients leaving hospital with a catheter do not have sufficient information to self-care and can experience physical and psychological difficulties.

AIM

This study aimed to explore how a patient-held catheter passport affects the experiences of patients leaving hospital with a urethral catheter, the hospital nurses who discharge them and the community nurses who provide ongoing care for them.

METHOD

Qualitative methods used included interviews, focus groups and questionnaires, and thematic analysis.

FINDINGS

Three major themes were reported-informing patients, informing nurses; improving catheter care, promoting self-management; and supporting transition.

CONCLUSION

The catheter passport can bridge the existing information gap, improve care, promote self-care and help patients adjust to their catheter, especially if complemented by ongoing input from a nurse or other health professional.

Coming back from the edge: a qualitative study of a professional support unit for junior doctors

BACKGROUND

It is known that many trainee doctors around the world experience work satisfaction but also considerable work stress in the training period. Such stress seems to be linked to multiple factors including workload, level of support and growing cultural inculcation into unwillingness to show any personal or professional weakness. In the United Kingdom, junior doctors are qualified medical practitioners who have gained a degree in Medicine and are now working while training to become a specialist (consultant) or a general practitioner. The period of medical training can be particularly stressful for some UK junior doctors, in common with their counterparts in other countries. UK Postgraduate Medical Deaneries provide support for those who need it via Professional Support Units (PSUs); however little is known about the perceptions and experiences of the doctors who access and utilise this support. This study aimed to generate qualitative insight into how the (PSU) provided by one UK Deanery is experienced by the trainees who accessed it. We aimed to investigate whether such experience intersects with the progressive socialisation of trainee doctors into the notion that doctors do not get ill.

METHODS

Through in-depth telephone interviews with eight female junior doctors, we explored the benefits and problems associated with using a PSU with reference to the formation of trainee doctors' professional identities, and conducted a thematic analysis.

RESULTS

Themes identified illustrate the process of accepting, accessing and benefiting from PSU support. These are: Medical identity intact (it will never happen to me); Denial of disrupted medical identity; Being on the edge: accepting help; Role of PSU in 'recovery' process; Repaired identity / coming back from the edge; Different ways to be a doctor. The gendered sample occurred simply as it was females who responded to study invitations. Whilst we present some related aspects (such as "manning up" as part of keeping going), analyses of this small sample showed that medical identity as a doctor in training was more salient than a gendered experience of help seeking in this study.

CONCLUSIONS

This study highlights the initial reluctance of female junior doctors to seek help from the PSU, as acknowledging their own difficulties spoiled their identity as a competent doctor. However, once engaged with the PSU, the findings exemplify its role in repairing medical identity, by offering different and acceptable ways to be a doctor. We interpret these findings within Goffman's theoretical framework of stigma conferring a spoiled identity on recipients, and how this may then be repaired. Reducing the stigma attached to initial help-seeking among junior doctors is crucial to increase ease of access to the PSU and to improve the experiences of doctors who encounter challenges during their training.

Alcohol screening and brief interventions for adults and young people in health and community-based settings: a qualitative systematic literature review

BACKGROUND

Systematic reviews of alcohol screening and brief interventions (ASBI) highlight the challenges of implementation in healthcare and community-based settings. Fewer reviews have explored this through examination of qualitative literature and fewer still focus on interventions with younger people.

METHODS

This review aims to examine qualitative literature on the facilitators and barriers to implementation of ASBI both for adults and young people in healthcare and community-based settings. Searches using electronic data bases (Medline on Ovid SP, PsychInfo, CINAHL, Web of Science, and EMBASE), Google Scholar and citation searching were conducted, before analysis.

RESULTS

From a total of 239 papers searched and screened, 15 were included in the final review; these were selected based on richness of content and relevance to the review question. Implementation of ASBI is facilitated by increasing knowledge and skills with ongoing follow-up support, and clarity of the intervention. Barriers to implementation include attitudes towards alcohol use, lack of structural and organisational support, unclear role definition as to responsibility in addressing alcohol use, fears of damaging professional/ patient relationships, and competition with other pressing healthcare needs.

CONCLUSIONS

There remain significant barriers to implementation of ASBI among health and community-based professionals. Improving the way health service institutions respond to and co-ordinate alcohol services, including who is most appropriate to address alcohol use, would assist in better implementation of ASBI. Finally, a dearth of qualitative studies looking at alcohol intervention and implementation among young people was noted and suggests a need for further qualitative research.

Using real-time, anonymous staff feedback to improve staff experience and engagement

Improving staff engagement has become a priority for NHS leaders, although efforts in this area vary between organisations. University Hospital Bristol NHS Foundation Trust (UH Bristol) is a tertiary teaching hospital where concerns about staff satisfaction and communication were reflected in the 2014 staff survey. To improve staff engagement, a real-time feedback mechanism to capture staff experience and to facilitate feedback from local leaders, was developed and piloted using the Model for Improvement. Initially piloted in two areas in January 2015, the Staff Participation Engagement and Communication application (SPEaC-app) was gradually rolled out to 23 areas within the trust by November 2016.

The 2015 staff survey revealed significant improvements in staff motivation, satisfaction with level of responsibility and involvement, and perceived support from managers. These improvements cannot be attributed to this new mechanism in their entirety, but local surveys indicated satisfaction with SPEaC-app, the majority reporting that giving feedback about their shift was valuable while fewer staff had noticed changes in their work area as a result of the comments made via SPEaC-app. Between March 2015 and November 2016, 9259 entries were recorded, with an average of 15 entries per day across all areas. Of the entries, 45.7% were positive and nearly 40% were negative, and ‘team working’ was the most frequent theme.

The project has identified the key factors associated with usability of the SPEaC-app, including, access, location, reliability and perceived privacy of the SPEaC-app. The SPEaC-app is valued and used most by staff in areas where feedback from local leaders is regular, rapid and comprehensive, and where staff comments are acted upon, leading to tangible change. This suggests that strong, consistent local management is required in order to embed it in new areas. SPEaC-app has the potential to support local engagement between managers and their service delivery teams, stimulate tangible improvements in service delivery and support the process of change. Longer term data are needed to determine whether SPEaC-app can influence other factors including staff turnover, recruitment and retention.

"It was like walking without knowing where I was going": A Qualitative Study of Autism in a UK Somali Migrant Community

Increasing recognition of autism in Somali migrant communities means that appropriate support services are needed. Attitudes to autism and barriers related to help-seeking in these communities are poorly understood. We aimed to assess what families affected by autism need, and how health, education and social care services can support them. In partnership with the local Somali community the research team conducted 15 in-depth interviews with parents affected by autism. Two themes are reported; 'Perceptions of Autism' and 'Navigating the System'. Our research shows the importance of understanding cultural views of autism and the need to raise awareness, reduce stigma and provide support to encourage families not to delay seeking help for their children.

GPs role identifying young people who self-harm: a mixed methods study

BACKGROUND

Self-harm is common among young people and is evident in increasingly younger age groups. Many young people who self-harm do visit their GP but do not access specialist support. GP's can find it challenging to raise and discuss this sensitive subject with young people during short consultations.

OBJECTIVE

To explore GP's capabilities, motivations and opportunities for discussing self-harm and to identify barriers to and enablers for proactively discussing self-harm with young people.

DESIGN AND SETTING

An exploratory, mixed methods study was designed comprising an online survey and a qualitative interview study with GPs in the South West of England.

METHODS

An online survey was completed by 28 GPs. Ten GPs took part by telephone, in semi-structured interviews. Quantitative data was analysed using descriptive statistical techniques and thematic analysis was used to analyse the qualitative data. Findings from the quantitative and qualitative analysis are synthesized to illustrate GPs' skills, knowledge and perceptions about young people who self-harm.

RESULTS

Experienced GPs may underestimate the prevalence of self-harm in young people, particularly in the 11-14 age range. While consultations with young people and their carers can be challenging, GPs acknowledge that it is their role to provide support for young people who self-harm. GPs would welcome training for themselves and other practice staff in talking to young people and practical information about self-harm.

CONCLUSION

All primary care staff who provide frontline support to young people should receive education and practical training in talking about self-harm.

Exploring experiences of physical activity among people with Alzheimer's disease and their spouse carers: a qualitative study

OBJECTIVES

To improve understanding about the barriers and facilitators to physical activity for people with Alzheimer's disease and their spouse carers, and to consider the development of activity interventions that would be acceptable, sustainable and feasible for both groups.

DESIGN

A qualitative approach, using semi-structured interviews, facilitated exploration of physical activity in a small group of people with Alzheimer's disease and their spouse carers.

SETTING

Participants were recruited from one memory clinic in South West England.

PARTICIPANTS

Potential participants were identified by clinical psychologists at the memory clinic and were given information about participating in the research. Five people with Alzheimer's disease and their spouse carers were subsequently recruited for semi-structured interviews, which took place at the memory clinic. Interviews were audio-recorded and transcribed verbatim.

MAIN OUTCOME MEASURES

Qualitative data were analysed using thematic analysis. Three major themes have been presented.

RESULTS

The findings illustrate the complex interplay between the overarching themes 'self', 'others' and 'couple' that affect physical activity for both people with Alzheimer's disease and their spouse carers, and which are linked to the progression of dementia.

CONCLUSIONS

An individually tailored approach for couples, which values the role of the carer and accounts for the progressive and changing nature of dementia, should be a guiding principle for intervention design.

A phase I, first in man study of weekly IMC-A12, a fully human insulin like growth factor-I receptor IgG1 monoclonal antibody, in patients with advanced solid tumors

3505

Background: IMC-A12 is a fully human IgG1 monoclonal antibody directed against the human insulin like growth factor-I receptor. The safety and maximum tolerated dose (MTD) of IMC-A12 are being evaluated in an on-going a phase I trial. Methods: Patients (pts) with ECOG PS = 2 and advanced refractory solid tumors receive IMC-A12 weekly for 4 infusions per cycle until progression. After cycle one only, there is a two week observation period. Six cohorts of IMC-A12 are planned at 3, 6, 10, 15, 21, 27mg/kg. Sampling for PK and human anti-human antibodies directed against IMC-A12 occurs before and after the first and fourth doses of each cycle. Results: Fifteen pts have been treated, 7 at 3 mg/g, 4 at 6 mg/kg, 3 at 10 mg/kg and 1 at 15 mg/kg. Data is available for the first 11 pts: 7 male, 4 female, median age 56 years (range: 45–70). Treatment related toxicities for the first 11 pts include: grade 1 pruritis, rash, discolored feces; grade 2 anemia, psoriasis, hyperglycemia, infusion-related reaction; grade 3 hyperglycemia. Four of 11 pts have stable disease: 2 at the 3 mg/kg dose remain stable for >9 months (1 male breast cancer,1 hepatocellular cancer) and 2 at the 6 mg/kg dose (1 bladder, 1 endometrial) were stable after cycle 1. One pt with prostate cancer had >25% decline in PSA and stable radiographic disease at time of study discontinuation (week 5) for DLT. Non-compartmental PK analysis reveals a mean t1/2 of 148 and 209 hrs, mean Cmax of 333 and 415 ug/mL, and mean AUC0-Inf of 51317 and 80727 hr*ug/mL at the 3 and 6 mg/kg dose levels, respectively. Target trough levels have been achieved. Conclusions: Weekly administration of IMC-A12 appears to be well tolerated and the MTD has not been reached. The PK profile is consistent with that of other Mab’s. There is early evidence of clinical activity and correlative IGF biomarker data will be available. IMC-A12 will be further evaluated in prostate, breast, and other cancers.

No significant financial relationships to disclose.

A phase I study of IMC-11F8, a fully human anti-epidermal growth factor receptor (EGFR) IgG1 monoclonal antibody in patients with solid tumors. Interim results

3024

Background: This ongoing phase I study is being conducted to determine the safety profile and recommended dose of IMC-11F8, a fully-human IgG1 monoclonal antibody that targets the EGFR. Methods: Patients (pts) with advanced solid tumors who are refractory to or have no available standard therapy are eligible to receive IMC-11F8 intravenously either weekly or every other week for 6 weeks (1 cycle). The initial cohort of patients will receive 100 mg of IMC-11F8. In the absence of a dose-limiting toxicity (DLT), dose escalation will be 200, 400, 600, 800, and 1000 mg in successive cohorts. Prior to the initial cycle, pts receive one IMC-11F8 infusion at their assigned cohort followed by a 2-week pharmacokinetic (PK) period. Pts with stable disease or better after cycle 1 are eligible to receive additional cycles of IMC-11F8. Results: 31 of 40 pts have been enrolled in the 100-, 200-, 400-, 600-, and 800-mg cohorts. Pt characteristics are M/F 20/11, median age 58 years (37 - 76), median ECOG score 1 (0–2). No DLTs have been observed. Only grade 1/2 skin rashes were reported. The most frequent adverse events were nausea, vomiting, fatigue, and headache. No infusion reactions were observed. 2 pts (1 confirmed) have achieved a PR, 1 pt with melanoma in the 200-mg cohort with 39+ weeks of weekly IMC-11F8 treatment and 1 pt with rectal cancer in the 400-mg cohort with 20+ weeks of IMC-11F8 administered every other week. 5 pts in the 200- to 600-mg cohorts have stable disease and have received from 11+ to 35+ weeks of IMC-11F8 treatment. A noncompartmental analysis of 20 pts demonstrated that IMC-11F8 exhibits nonlinear PK. As IMC-11F8 escalated from 100 to 600 mg, T1/2 increased from 67 to 84 hrs, Cmax increased from 30 to 368 μg/mL, AUCinf increased from 1753 to 67295, and CL decreased from 57.0 to 8.9 mL/hr. Conclusions: These interim results indicate that IMC-11F8 is well tolerated in this patient population. Although a maximum tolerated dose has not been established, IMC-11F8 has shown activity at two different dose levels.

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A phase I dose-escalation study of weekly IMC-1121B, a fully human anti-vascular endothelial growth factor receptor 2 (VEGFR2) IgG1 monoclonal antibody (Mab), in patients (pts) with advanced cancer

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Background: Anti-VEGFR2 antibodies are effective in a variety of preclinical leukemia and solid tumor models. IMC-1121B is a fully human anti-VEGFR2 IgG1 Mab. Methods: Cohorts of 3–6 pts (ECOG PS ≤ 2) with advanced cancer and no significant cardiovascular, thrombotic or bleeding disorders received escalating doses of IMC-1121B. A single initial dose with extended PK sampling was followed by 4 x weekly infusions per treatment cycle starting at 2mg/kg. 7 dose levels up to a maximum of 16 mg/kg are planned. Human anti-human antibodies (HAHA) directed against IMC-1121B were assessed at baseline and before each Week 4 dose. Tumor response was assessed every 2 cycles. PD analyses include DCE-MRI, serum VEGF and sVEGFR1/2 levels, and peripheral blood mononucleocyte gene expression profiling at baseline and post-dosing. Results: 12 pts (8 M; 4 F), median age 58 years (range: 36–76), have entered the study: cohort 1 (2mg/kg) n=6, cohort 2 (4mg/kg) n=4 and cohort 3 (6mg/kg) n=2. No toxicities ≥ grade 2, considered definitely or probably related to study drug, have occurred. Toxicities ≥ grade 2 possibly drug-related include anorexia, vomiting, anemia, depression, fatigue, and insomnia. To date, there has been one unconfirmed partial response (melanoma) and 5 pts with stable disease for >3 months (colon: 2, breast, gastric, thyroid). Preliminary non-compartmental PK analysis reveals dose-dependent elimination and non-linear exposure, consistent with saturable clearance mechanism(s): mean t1/2 = 63.62, 93.46, 99.63 hrs, mean Cmax = 43.67, 80.25, 264 ug/mL, and AUC0-Inf = 3860, 9242, 27437 hr*ug/mL, at the 2, 4, and 6 mg/kg dose levels, respectively. Conclusions: Weekly administration of IMC-1121B is well tolerated at doses up to 6mg/kg/week. There is early evidence of a non-linear dose-PK relationship. Dose escalation continues. Updated safety, PK, PD, HAHA, and efficacy data will be presented.

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A reassessment of comparative pregnancy and implantation rates following embryo transfer in recipients vs their infertile donors also trying to conceive in the background of performing salpingectomy for hydrosalpinx

PURPOSE

To compare pregnancy and implantation rates in egg donors trying to conceive vs their recipients in the background of salpingectomy for hydrosalpinx prior to IVF-ET.

METHODS

A retrospective six-year review of all donor egg cycles where the eggs are supplied by an infertile donor trying to conceive herself was carried out. Salpingectomy for hydrosalpinx was performed prior to IVF-ET.

RESULTS

Clinical and delivered pregnancy rates (PRs) following fresh ET were not significantly different in donors vs recipients (60.0%, 45.8% vs 56.8%, 50.8%). Implantation rates were 27.3% vs 32.6%. The respective implantation rates following frozen ET were 13.8% and 14.4%.

CONCLUSIONS

In the background of salpingectomy for hydrosalpinges the much higher PRs in recipients vs donors is no longer seen. The trend for higher implantation rates in recipients (about 20%) following fresh but not frozen transfer could still reflect some adverse effect of the controlled ovarian hyperstimulation regimen in a minority of women.