Factors affecting the adoption of telehealthcare in the United Kingdom: the policy context and the problem of evidence

The adoption of telehealthcare in the United Kingdom has been slow and fragmented. This paper presents a structural explanation for this by contrasting contending themes in recent UK health policy. It is argued that the conflict between trends towards modernizationand demands for evidence-based practicehave made it difficult for a major policy agency to emerge that can sponsor service development, and so proponents of telehealthcare have been forced to situate their work within the domain of R&D. This has led to a fragmented field of practice characterized by short-term and small-scale projects.

Evaluation of new technologies in health-care systems: what’s the context?

Evaluation is an essential component of the introduction of new technologies, treatment modalities and models of service delivery across the health-care sector. Such work attracts significant levels of public funding, but little attention has been paid to understanding evaluation as more than a set of applied methodological activities. This paper sets out an agenda for a more complex and richer understanding of evaluation as a set of professional and organizational dynamics.

A new paradigm emerges from the study of de novo mutations in the context of neurodevelopmental disease

The study of de novo point mutations (new germline mutations arising from the gametes of the parents) remained largely static until the arrival of next-generation sequencing technologies, which made both whole-exome sequencing (WES) and whole-genome sequencing (WGS) feasible in practical terms. Single nucleotide polymorphism genotyping arrays have been used to identify de novo copy-number variants in a number of common neurodevelopmental conditions such as schizophrenia and autism. By contrast, as point mutations and microlesions occurring de novo are refractory to analysis by these microarray-based methods, little was known about either their frequency or impact upon neurodevelopmental disease, until the advent of WES. De novo point mutations have recently been implicated in schizophrenia, autism and mental retardation through the WES of case-parent trios. Taken together, these findings strengthen the hypothesis that the occurrence of de novo mutations could account for the high prevalence of such diseases that are associated with a marked reduction in fecundity. De novo point mutations are also known to be responsible for many sporadic cases of rare dominant mendelian disorders such as Kabuki syndrome, Schinzel-Giedion syndrome and Bohring-Opitz syndrome. These disorders share a common feature in that they are all characterized by intellectual disability. In summary, recent WES studies of neurodevelopmental and neuropsychiatric disease have provided new insights into the role of de novo mutations in these disorders. Our knowledge of de novo mutations is likely to be further accelerated by WGS. However, the collection of case-parent trios will be a prerequisite for such studies. This review aims to discuss recent developments in the study of de novo mutations made possible by technological advances in DNA sequencing.

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room

BACKGROUND

We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room.

METHODS

We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts.

RESULTS

We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an 'audit point' in care where the patient's intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists' practice than might be expected.

CONCLUSIONS

Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged.

What defines expertise in regional anaesthesia? An observational analysis of practice †

BACKGROUND

Published work on knowledge in regional anaesthesia has focused on competence, for instance by identifying numbers of procedures required to achieve competence, or by defining criteria for successful performance of blocks. We aimed to define expertise in regional anaesthesia and examine how it is acquired.

METHODS

We observed anaesthetists performing 15 regional anaesthetic blocks and analysed the resulting transcripts qualitatively and in detail.

RESULTS

Expertise in regional anaesthesia encompasses technical fluency but also includes non-cognitive skills such as handling of the patient (communicating, anticipating and minimizing discomfort) and recognizing the limits of safe practice (particularly deciding when to stop trying to insert a block). Such elements may be underplayed by the experts who possess them. Focusing on a small number of regional anaesthetic procedures in detail (as is standard with such qualitative analytical approaches) has also allowed us to develop a model for the acquisition of expertise. In this model, trainees learn how to balance theoretical and practical knowledge by reflection on their clinical experiences, an iterative process which leads to the embedding of knowledge in the expert's personal repertoire of individual techniques.

CONCLUSIONS

Expertise in regional anaesthesia extends beyond competence at technical performance; non-cognitive elements are also vital. Further work is needed to test our learning model, and the hypothesis that learning can be enhanced by deliberate promotion of the tacit elements of 'expertise' we have described.

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting

BACKGROUND

This study aimed to explore how critical and acceptable practice are defined in anaesthesia and how this influences the discussion and reporting of adverse incidents. Method. We conducted workplace observations of, and interviews with, anaesthetists and anaesthetic staff. Transcripts were analysed qualitatively for recurrent themes and quantitatively for adverse events in anaesthetic process witnessed. We also observed departmental audit meetings and analysed meeting minutes and report forms.

RESULTS

The educational value of discussing events was well-recognized; 28 events were discussed at departmental meetings, of which 5 (18%) were presented as 'critical incidents'. However, only one incident was reported formally. Our observations of anaesthetic practice revealed 103 minor events during the course of over 50 anaesthetic procedures, but none were acknowledged as offering the potential to improve safety, although some were direct violations of 'acceptable' practice. Formal reporting appears to be constrained by changing boundaries of what might be considered 'critical', by concerns of loss of control over formally reported incidents and by the perception that reporting schemes outside anaesthesia have purposes other than education.

CONCLUSIONS

Despite clear official definitions of criticality in anaesthesia, there is ambiguity in how these are applied in practice. Many educationally useful events fall outside critical incident reporting schemes. Professional expertise in anaesthesia brings its own implicit safety culture but the reluctance to adopt a more explicit 'systems approach' to adverse events may impede further gains in patient safety in anaesthesia.

Making monitoring 'work': human-machine interaction and patient safety in anaesthesia

This study aimed to explore the use of electronic monitoring within the context of anaesthetic practice. We conducted workplace observation of, and interviews with, anaesthetists and other anaesthetic staff in two UK hospitals. Transcripts were analysed inductively for recurrent themes. Whilst formal sources of knowledge in anaesthesia deal with the issue of monitoring in terms of theoretical principles and performance specifications of devices, anaesthetists in practice often 'disbelieve' monitoring information. They call on and integrate other sources of knowledge about the patient, especially from their clinical assessment. The ability to distinguish 'normal' and 'abnormal' findings is vital. Confidence in electronic information varies with experience, as does the degree to which electronic information may be considered 'redundant'. We conclude that electronic monitoring brings new dimensions of understanding but also the potential for new ways of misunderstanding. The tacit knowledge underlying the safe use of monitoring deserves greater acknowledgement in training and practice.

Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia

BACKGROUND

Expert professional practice in any field is known to rely on both explicit (formal) and tacit (personal) forms of knowledge. Current anaesthetic training programmes appear to favour explicit knowledge and measurable competencies. We aimed to describe and explore the way different types of knowledge are learned and used in anaesthetic practice.

METHOD

Qualitative approach using non-participant observation of, and semi-structured interviews with, anaesthetic staff in two English hospitals.

RESULTS

The development of expertise in anaesthesia rests on the ability to reconcile and interpret many sources of knowledge--clinical, social, electronic, and experiential--and formal theoretical learning. Experts have mastered technical skills but are also able to understand the dynamic and uncertain condition of the anaesthetized patient and respond to changes in it. This expertise is acquired by working with colleagues, and, importantly, by working independently, to develop personal routines. Routines mark the successful incorporation of new knowledge but also function as a defence against the inherent uncertainty of anaesthetic practice. The habits seen in experts' routines are preferred ways of working chosen from a larger repertoire of techniques which can also be mobilized as changing circumstances demand.

CONCLUSIONS

Opportunities for developing expertise are linked to the independent development of personal routines. Evidence-based approaches to professional practice may obscure the role played by the interpretation of knowledge. We suggest that the restriction of apprenticeship-style training threatens the acquisition of anaesthetic expertise as defined in this paper.

Dietary patterns and nutrient intakes of toddlers from low-income families in Denver, Colorado

Over a 2-year period, dietary and socioeconomic data were collected from 793 food records of 90 toddlers, aged 1 to 2 years, who were predominantly U.S. Hispanics living in low-income households in Denver, CO. This study was part of a larger investigation designed to assess the efficacy of vitamin and mineral supplements in young children. The toddlers were randomly assigned to one of five treatment groups: multivitamin; multivitamin and iron; multivitamin, iron, and zinc; multivitamin and zinc; or placebo. Three-day food records that were collected from the toddlers at the beginning of the study, at 3 months, and at 6 months were used to assess the dietary and nutrient intakes. Meal patterns were devised on the basis of the frequency of food consumption and common food combinations. Nutrient values were calculated using a diet analyzer program. Nutrient analysis of the toddlers' diets indicated that iron and magnesium were consumed least frequently, whereas more than adequate amounts of protein (193% of the Recommended Dietary Allowance) and sodium (207% of minimum requirements for healthy persons) were consumed. No significant differences in nutrient intakes were observed among the treatment groups, suggesting that the vitamin and mineral supplements had no effect. A difference in energy intake was observed over time with the 6-month and 3-month intakes significantly higher than the initial intakes. There was also a high consumption of carbonated beverages. Despite the low income levels of the families, these toddlers were consuming adequate amounts of food; however, an educational component aimed at reducing the toddlers' high intakes of protein, sodium, and carbonated drinks may help improve the present feeding practices of the mothers.