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Aims and objectives To explore how older patients with multiple chronic conditions and their family caregivers perceive their engagement and overall care experience throughout the preoperative phase of elective orthopaedic hip or knee joint replacement. Background Patient engagement is a critical component of care necessary for improving patient outcomes. Little is known about how older adults with multiple chronic conditions and their family caregivers engage in preoperative care transitions and the subsequent impact of this experience on postoperative health outcomes. Design Prospective qualitative descriptive design was used. Methods Semi-structured telephone interviews with a convenience sample of older adults coping with multiple chronic conditions and their family caregivers. Interviews were conducted prior to surgery and, again 21 days postsurgery, were audio-recorded and transcribed for qualitative content analysis. The Quality Health Outcomes Model was used to categorise study findings. Results Eleven patients and five family caregivers participated. Guided by the Quality Health Outcomes Model, four major themes were identified. (i) Older adults perceive that joint replacement is about quality of life. (ii) Standardised interventions often fail to address the unique needs of complex older adults. (iii) Family caregivers perceive they are the primary care coordinators. (iv) Postoperative outcomes and resource utilisation vary widely in complex older adults. Conclusion Findings suggest that current preoperative care interventions are often not designed to effectively engage complex older patients and their family caregivers. Coordinated patient-centred preoperative care that reflects the needs and goals of complex older patients and their family caregivers may positively influence perioperative care transitions and outcomes beyond this episode of care. Relevance to clinical practice The current research documents the need for more in-depth knowledge about the relationship between older adults' and their family caregivers' engagement preoperatively and postoperative outcomes and resource utilisation.

Aims National antibiotic practice in cases of suspected early onset neonatal sepsis (EONS) is varied. NICE recommend antibiotic cessation at 36 hours with negative cultures for low-risk asymptomatic babies with negative CRPs. We modelled the impact of switching to a 36 hour culture threshold (from 48 hours) at our unit and extrapolated this nationally. Methods We contacted all 155 neonatal units in England by phone to assess current national antibiotic practice. We retrospectively identified 463 neonates treated for suspected EONS at our level 1 unit. Reviewing investigation results and clinical information, we assessed which babies met NICE criteria to stop antibiotics at 36 hours. We calculated the expected savings in terms of staff time, bed-days and antibiotic doses and extrapolated this nationally. Results 91 units reported using a 36 hour blood culture threshold. 59 units (38%) reported awaiting 48 hour cultures, with 2 35 972 babies born in these units in 2016–17. Five units awaited 24 hour cultures. At our unit, 45.1% of screened babies were found to satisfy NICE Criteria for antibiotic cessation at 36 hours. Despite this, the average antibiotic course in these babies was 56 hours due to the delay in culture availability. Stopping antibiotics at 36 hours in these babies would have saved 502 antibiotic doses over 8 months, with 53.6 nursing hours redirected to other activities. On reviewing clinical information 33% of all screened babies were fit for discharge at 36 hours and were only awaiting cultures; thus 147 families could have returned home at least 12 hours earlier. NICE guidelines suggest 10% of babies are screened for sepsis nationally. Extrapolating our unit’s figures suggests 25 505 antibiotic doses could be saved annually if all units stopped antibiotics according to NICE criteria at 36 hours. 7787 babies could go home earlier to their families, saving 3893.5 bed days and 2838 nursing hours from antibiotic administration. Conclusion A clinical and business case can be made for all units to follow NICE guidelines and stop antibiotics at 36 hours in low-risk asymptomatic babies treated for EONS. Less quantifiable impacts include prevention of antibiotic resistance, gentamicin toxicity and re-cannulation events, as well as improving patient satisfaction and staff morale.

NICE guidelines recommend antibiotics for suspected early onset neonatal sepsis (EONS) be discontinued at 36 hours in asymptomatic newborns with negative blood cultures and reassuring inflammatory markers. Despite this national practice remains varied with five units stopping antibiotics at 24 hours. We assessed whether two negative CRP results ( We retrospectively identified newborns who were screened and treated for suspected EONS over an 8 month period, noting their CRP measurements at 0 and 18–24 hours and blood culture results. Over 8 months, 463 newborns were screened for suspected EONS. There were 16 positive blood cultures (3.5%). Of these, 6 (1.3% overall) grew group-B streptococcus (GBS) within the first 24 hours and all had raised CRPs≥10 mg/L at 18–24 hours (average 57 mg/L, range 40.3–60.2 mg/L). Of the remaining positive blood cultures, 9 were contaminants and one grew a bacillus species which was reported as a likely contaminant although the baby received a 5 day course of antibiotics to cover for possible listeria infection. Of the 303 babies with two negative CRPs, no blood cultures were positive for pathogenic bacteria. Within this group there were 7 grew contaminant blood cultures including the one bacillus species. This baby was symptomatic and would not have met the criteria to stop antibiotics at 24 hours in any case. Of the 16 positive cultures, 15 were reported positive under 24 hours of incubation. The baby with the remaining culture had a raised CRP and would have been treated for 5 days irrespectively. This culture grew a contaminant. We found there were no pathogenic blood cultures among patients with two negative CRP results. The sensitivity of a CRP >10 mg/L for identifying confirmed pathological cultures was 100% in our cohort, with the negative predictive value of two CRP Retrospectively, we found that if we had reviewed the decision to stop antibiotics at 24 hours it would not have changed our decision-making based on a combination of clinical condition, CRP trend and blood culture results for all 463 babies. A clinical argument can be made for identifying a low-risk cohort of babies to stop antibiotics at 24 hours in the absence of adverse clinical or biochemical signs. Joining the five UK units already subject to this policy may provide several clinical benefits but would need careful safeguards to ensure patient safety.

Changes in urinary bladder function and somatic sensation may be mediated, in part, by inflammatory changes in the urinary bladder including the expression of chemokines. Male and female C57BL/6 mice were treated with cyclophosphamide (CYP; 75 mg/kg, 200 mg/kg, i.p.) to induce bladder inflammation (4 h, 48 h, chronic). We characterized the expression of CXC chemokines (CXCL9, CXCL10 and CXCL11) in the urinary bladder and determined the effects of blockade of their common receptor, CXCR3, at the level urinary bladder on bladder function and somatic (hindpaw and pelvic) sensation. qRT-PCR and Enzyme-Linked Immunoassays (ELISAs) were used to determine mRNA and protein expression of CXCL9, CXCL10 and CXCL11 in urothelium and detrusor. In urothelium of female mice treated with CYP, CXCL9 and CXCL10 mRNA significantly (p ≤ 0.01) increased with CYP treatment whereas CXC mRNA expression in the detrusor exhibited both increases and decreases in expression with CYP treatment. CXC mRNA expression urothelium and detrusor of male mice was more variable with both significant (p ≤ 0.01) increases and decreases in expression depending on the specific CXC chemokine and CYP treatment. CXCL9 and CXCL10 protein expression was significantly (p ≤ 0.01) increased in the urinary bladder with 4 h CYP treatment in female mice whereas CXC protein expression in the urinary bladder of male mice did not exhibit an overall change in expression. CXCR3 blockade with intravesical instillation of AMG487 (5 mg/kg) significantly (p ≤ 0.01) increased bladder capacity, reduced voiding frequency and reduced non-voiding contractions in female mice treated with CYP (4 h, 48 h). CXCR3 blockade also reduced (p ≤ 0.01) hindpaw and pelvic sensitivity in female mice treated with CYP (4 h, 48 h). CXC chemokines may be novel targets for treating urinary bladder dysfunction and somatic sensitization resulting from urinary bladder inflammation.

Aims Clinical job aides directly benefit clinical care and assist project evaluation. We describe early experience of their introduction as part of an Emergency Paediatric Care Programme (EPCP). Methods An EPCP working group developed pilot job aides. These included admission, observation and drug charts that were piloted in 11 hospitals. Between May and October 2016 the job aides were reviewed and a survey of local healthcare workers undertaken. Results In the majority of hospitals job aides were limited or inadequately completed. Vital sign charts typically only recorded the temperature. The prescription and administration of drugs were recorded in separate places, and admission information recorded on a brief proforma. Although the job aides received positive endorsement during the EPCP courses there has been some resistance to their use in the wards. A survey of patient notes at one site demonstrated that no staff were using the admission forms or the drug charts adequately. Vital signs charts were more acceptable and 100% were satisfactory. Healthcare workers considered the job aides useful, but cited poor staffing and lack of time as the reason for limited acceptance. Suggestions included: Senior endorsement Training for all staff on how to use the job aides Explanation to nurses how vital signs charts can be used to monitor patient progress and signal when to get help Conclusion Job aides can focus the attention of healthcare workers on key signs and symptoms as taught in EPCP. Ongoing training, familiarisation, mentorship and support from senior colleagues will be key for their successful introduction.

Aims Fluid challenges are a common tool used in A and E to aid decision-making. As they can often prove time-consuming, we aimed to assess whether they impacted on the 4 hour breech target at a busy district general hospital (DGH) paediatric A and E, and whether their use was always indicated. Methods We analysed all 4 hour breeches at a busy DGH paediatric A and E over a 24 day period in December 2016. We attempted to identify those breeches which followed an oral fluid challenge initiated by medical staff and documented in the A and E notes. We then assessed whether this cohort of patients showed the following objective signs of dehydration on presentation (from NICE guidelines): tachycardia, tachypnea, decreased skin turgor and decreased urine output. We conducted a literature search to identify evidence supporting the use of fluid challenges. Results Of 294 breeches, 36 (12.1%) cases involved fluid challenges. Of these, 86% were discharged home. Half of the children who breeched awaiting completion of a fluid challenge had no objective signs of dehydration recorded on presentation. A further third recorded only tachycardia, although many of these were febrile. Of those with no recorded signs of dehydration, 11% were admitted to the paediatric assessment unit for ongoing observation. Of the 5 patients admitted, two had 2 or more signs of dehydration whilst 2 exhibited no characteristic symptoms. Our literature search revealed no high quality evidence for the use of fluid challenges as a reliable diagnostic aid. Conclusion Fluid challenges were implicated in a significant proportion of all paediatric breeches, half of which recorded no core objective signs of dehydration on presentation. We would therefore suggest this cohort did not require a fluid challenge yet accounted for over 6% of all departmental breeches. No strong evidence supports their use. We advocate a more judicious use of fluid challenges limited to the small proportion of children showing objective signs of mild or moderate dehydration at presentation where their use may provide greater decision-making power. This may help reduce breeches at the busiest time of year. A larger scale study would provide with more information to further our conclusions.

Aims Paediatric simulation is an established part of medical student training. However there remain many ways to assess its efficacy. We aimed to assess the efficacy of a simulation programme using video-based clinical vignettes and comparing student responses to established paediatric doctors. Method We created a paediatric simulation programme for 87 fifth year medical students. The programme involved two-hour theory session followed by a two-hour high fidelity simulation in groups of five. Twelve clinical vignettes were created based on the videos from ‘Spotting The Sick Child’ online resource (with permission). The students stated how sick they thought the child was for each scenario on a scale of 1 to 10, where 10 was ‘immediate PICU admission’ and 1 was ‘immediate discharge’. This quiz was carried out pre- and post-course. Twenty post- MRCPCH paediatricians carried out the same quiz. The average of their scores was considered the ‘gold standard’. The deviation between the paediatrician and student scores was calculated both pre- and post-programme. Students also rated their confidence level in assessing and managing the cases before and after the programme. Results Overall, students’ responses were significantly closer to the doctors’ mean post session (p=0.0048). This was particularly pronounced in respiratory distress, dehydration and DKA scenarios. The average value of students’ confidence level for assessing paediatric emergencies pre- and post-simulation were 2.91/5 and 3.58/5, respectively (p Conclusion Video vignettes provided a novel approach to assessing the efficacy of a paediatric simulation programme. Students’ responses more closely correlated with more experienced specialist physicians after the session compared to pre-session. The convergence of the paediatricians’ and students’ scores post-session was validated by the students’ self-reported increased confidence level in assessing and managing the scenarios post-session. This supports the utility of this method for assessing the clinical educational efficacy of paediatric simulation programmes.

Aims An Emergency Paediatric Care Programme in Myanmar provides training in the stabilisation and safe transfer of sick children. The transfer of seriously sick children may be necessary to ensure the appropriate level of care, but is fraught with difficulties. A review of current practice and local challenges was undertaken. Methods In September 2015 a retrospective audit of children admitted with dengue to a Regional Centre was performed to identify reasons for referral. Local healthcare professionals were invited to complete a survey exploring barriers to referral pathways. Results 34% of patients with dengue (n=269) were referred. Only 44% of referrals had a referral letter and 35% did not require tertiary care. Challenges identified included: Late presentation due to families’ preference for traditional medicine, concerns about the quality of public healthcare, medical and transport costs Lack of referral guidelines, human resources and training Transfer of patients who had not first been stabilised Reluctance to acknowledge the potential benefits of transfers Deficiency in ambulances such that patients were transferred by public transport Solutions identified and implemented included: Development of referral guidelines and pathways Training in stabilisation and transfer Development of transfer checklists for emergency equipment and medications Identification of voluntary sector transport vehicles Identification of outpatient tertiary clinic appointments to reduce unnecessary acute referrals Conclusions There is a deficiency in referral pathways between primary, secondary and tertiary healthcare facilities in Myanmar. Development of referral networks and the training of healthcare workers in the stabilisation and transfer of sick children is important to reduce morbidity and mortality.

Aims An Emergency Paediatric Care Programme (EPCP) runs training courses in district hospitals. We describe a strategy to support local leadership and develop teams responsible for devising and fulfilling individual implementation plans. Methods During EPCP courses, participants review the hospital facilities and make recommendations for improvement. A local EPCP Champion (senior clinician) supported by an EPCP Team is responsible for identifying local priorities and developing an Implementation Plan to achieve these. They are asked to consider: layout, infrastructure, staffing, patient safety and infection control, drugs and equipment, staff numbers and training, patient records, clinical guidelines, and morbidity and mortality meetings. Additional support is provided through Global Link Volunteer (GLV) placements in the hospitals. A bi-annual EPCP Champion and Team Conference provides an opportunity to share ideas and experiences, problem solve and discuss quality improvement projects. Results GLVs, EPCP Champions and Teams representing 7 district hospitals reported on their Implementation Plans at the first EPCP Champion and Team Conference in July 2016. A wide range of topics were described including weekly simulation training, new guideline wall charts, well-equipped resuscitation areas, new admission and observation charts, improved infection control through the repair of broken sinks and provision of hand-gel and multi-disciplinary mortality meetings. Feedback was extremely positive with the teams feeling motivated, empowered and rewarded for their efforts. Conclusions Successful training depends on its impact in practice; the EPCP Champions and Team Conference demonstrated that the combined efforts of local EPCP Champions and Teams and GLVs in developing the Implementation Plans had led to valuable quality improvements.

Aims Healthcare in Myanmar is evolving. This includes the use of evidence based quality improvement, a novel concept for many senior clinicians. Royal College of Paediatrics and Child Health (RCPCH) Global Links Volunteers (GLVs) aimed to deliver audit-based quality improvement teaching to 26 senior local paediatricians (consultants and senior registrars) at 3 sites in central Myanmar. We aimed to assess pre-existing knowledge and post-session motivation to affect change. Methods We devised a half-day simulated quality improvement project (QIP), including an interactive lecture along with simulated data collection and analysis. Each participant thus completed a full QIP cycle. Clinicians then discussed QIP ideas to apply to their own hospitals. One month later they completed a questionnaire to assess the impact of the session. Results Of fifteen respondents, 80% had never experienced quality improvement teaching and over half were unaware of QIP activity ever having occurred in their hospitals. Post-session, 66% of respondents reported they had discussed starting a QIP in their hospital, all whom cited specific examples. 87% reported an intention to start a QIP in the near future and 100% reported feeling more confident regarding the process. The participants seemed motivated, with 100% reporting they felt performing QIPs would make tangible improvements to their hospital, and 100% citing the purpose of a QIP as ‘improvement of patient care’. Despite this none of the respondents had actually started a QIP. Post-session, 33% of respondents reported delivering QIP teaching to local colleagues and thereby encouraging wider participation in quality improvement. They appeared to have retained the information delivered, with 100% correctly explaining the steps of the QIP cycle. Conclusions Interactive practical QIP teaching represents a simple and reproducible model to educate and enthuse senior clinicians with limited previous QIP experience. This enthusiasm appeared to remain 4–6 weeks post teaching. Newly-acquired knowledge had also been disseminated to others. While many respondents reported interest in specific QIPs of their own, none had been realised. This signals both the need and opportunity for on-going partnership to put theory into practice, and continue the evolution of a supportive culture of quality improvement across Myanmar, while further work might assess the barriers to achieving this.

Aims and objectives To explore the issues and challenges of care transitions in the preoperative environment. Background Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there. Design Qualitative descriptive design was used. Methods Semistructured interviews were conducted in a 975-bed academic medical centre. Results A total of 30 providers and 10 preoperative patients participated. Themes that arose were as follows: (1) need for clarity of purpose of preoperative care, (2) care coordination, (3) interprofessional boundaries of care and (4) inadequate time and resources. Conclusion Effective transitions in the preoperative environment require that providers bridge scope of practice barriers to promote good teamwork. Preoperative care that is a product of well-informed providers and patients can improve the entire perioperative care process and potentially influence postoperative patient outcomes. Relevance to clinical practice Nurses are well positioned to bridge the gaps within transitions of care and accordingly affect health outcomes.

Single-subject multiple probe designs were employed in two studies with 5 young adults who had a dual diagnosis of mental retardation and mental illness. Our aim was to determine effects of instruction designed to teach visual arts activity skills and promote personal expressiveness on acquisition, maintenance, and generalization of these skills and behaviors associated with these persons' mental health. In Study 1, a 5-second constant time delay procedure was used to teach three chosen art activities. In Study 2, an instructional package was used to promote personally expressive behaviors. After learning the skills in Study 1, participants in Study 2 displayed improvement in occurrence of behaviors associated with mental illness and increases in personally expressive behaviors.

Aims Peer-graded practice examinations can help medical students to achieve higher results in their final exams (1), and peer-led exam revision courses have demonstrated high levels of satisfaction (2,3). Surveys show that the majority of medical students find exam practice provided by recent graduates as useful as consultant teaching (3). Our aim is to present our experience, over a 2 year period, of designing and implementing a practice Objective Structured Skills Examination (OSCE) in paediatrics, run by junior doctors from foundation year one to ST4 level, collating feedback from students and making improvements. Methods 6 medical students have their paediatric placement every 4 weeks. During the 4th week, 5 members of staff run a 90-minute OSCE, consisting of 8 examined stations. 2 history-taking, 2 clinical skills, 2 counselling and 2 data-interpretation stations were designed, reflecting real life clinical situations as well as common exam scenarios. Stations were followed by 90 seconds of immediate individual verbal feedback by examiners who also took up roles of the actors in their scenarios. The OSCE was designed as 2 consecutive cycles of stations and ended with a group question and answer session and feedback forms. Results We have collated written feedback from each student since September, 2012. The majority of students reported finding the OSCE useful exam preparation and something that they would recommend. We then asked the students to complete a further feedback questionnaire 1 year later, once they had completed their paediatric OSCE examination and 100% of respondents replied that the practice examination had been useful preparation for their final exams. Conclusion We can show high levels of satisfaction from participants. The detailed feedback process enabled us to improve the exam, creating a useful revision aid, and an invaluable teaching tool. This process has been easy to implement, using junior doctors available from the rota in an extremely busy Major Acute Trust, without consultant supervision. It has been maintained despite the frequent turnover of junior doctors. We hope to use this model as a template for similar hospitals. References Freeman S, Parks JW. How Accurate is Peer Grading? CBE Life Sci Educ . 2010 Winter;9(4):482–8. Alcamo AM, Davids AR, Way DP, Lynn DJ, Vandre DD. The Impact of a Peer-designed and –led USMLE Step 1 Review Course: Improvement in Preparation and Scores. Acad Med. 2010 Oct; 85 (10 supp) S45–8. Rashid MS, Sobowale, O, Gore D. A Near-Peer teaching programme, designed, developed and delivered exclusively by recent medical graduates for final year medical students sitting the final OSCE. BMJ Med Educ . 2011 Mar 17;11:11.

Aims Peer-graded practice examinations can help medical students to achieve higher results in their final exams, 1 and peer-led exam revision courses have demonstrated high levels of satisfaction. 2,3 Surveys show that the majority of medical students find exam practice provided by recent graduates as useful as consultant teaching. 3 Our aim is to present our experience, over a 2 year period, of designing and implementing a practice Objective Structured Skills Examination (OSCE) in paediatrics, run by junior doctors from foundation year one to ST4 level, collating feedback from students and making improvements. Methods Six medical students have their paediatric placement every four weeks. During the fourth week, five members of staff run a 90-minute OSCE, consisting of 8 examined stations. Two history-taking, two clinical skills, two counselling and two data-interpretation stations were designed, reflecting real life clinical situation as well as common exam scenarios. Stations were followed by 90 seconds of immediate individual verbal feedback by examiners who also took up roles of the actors in their scenarios. The OSCE was designed as two consecutive cycles of stations and ended with a group question and answer session and feedback forms. Results We have collated written feedback from each student since September, 2012. The majority of students reported finding the OSCE useful exam preparation and something that they would recommend. We then asked the students to complete a further feedback questionnaire 1 year later, once they had completed their paediatric OSCE examination and 100% of respondents replied that the practice examination had been useful preparation for their final exams. Conclusion We can show high levels of satisfaction from participants. The detailed feedback process enabled us to improve the exam, creating a useful revision aid, and an invaluable teaching tool. This process has been easy to implement, using junior doctors available from the rota in an extremely busy Major Acute Trust, without consultant supervision. It has been maintained despite the frequent turnover of junior doctors. We hope to use this model as a template for similar hospitals. References Freeman S, Parks JW. How Accurate is Peer Grading? CBE Life Sci Educ 2010 Winter;9(4):482–8. Alcamo AM, Davids AR, Way DP, Lynn DJ, Vandre DD. The Impact of a Peer-designed and –led USMLE Step 1 Review Course: Improvement in Preparation and Scores. Acad Med 2010 Oct;85 (10 supp):S45–8. Rashid MS, Sobowale, O, Gore D. A Near-Peer teaching programme, designed, developed and delivered exclusively by recent medical graduates for final year medical students sitting the final OSCE. BMJ Med Educ 2011 Mar 17;11:11.