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Objectives Initial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory. Methods In the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure. Results In total, 1083 patients were enrolled with median ISS of 20 (IQR 9–29) and median GCS of 13 (IQR 3–15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74–79%) to 82% (95% CI 80–85%). Sensitivity decreased by 9% (95% CI 7–11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77–0.83), original set 0.80 (95% CI 0.77–0.83). The revised set retains 8.78 mSv (95% CI 6.01–11.56) for 36% of the non-severely injured patients. Conclusions Selection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients. Key Points • Selection criteria for iTBCT can be reduced to 10 clinically useful criteria. • This reduces radiation exposure in 36% of less severely injured patients. • Overall discriminative capacity for selection of severely injured patients remained equal.

Objectives: To conduct a systematic review and narrative synthesis of interventions based on secondary use of data (SUD) from electronic prescribing (EP) and electronic hospital pharmacy (EHP) systems and their effectiveness in secondary care, and to identify factors influencing SUD. Method: The search strategy had four facets: 1. Electronic databases, 2. Medication safety, 3. Hospitals and quality/safety, and 4. SUD. Searches were conducted within EMBASE, Medline, CINAHL, and International Pharmaceutical Abstracts. Empirical SUD intervention studies that aimed to improve medication safety and/or quality, and any studies providing insight into factors affecting SUD were included. Results: We identified nine quantitative studies of SUD interventions and five qualitative studies. SUD interventions were complex and fell into four categories, with ‘provision of feedback’ the most common. While heterogeneous, the majority of quantitative studies reported positive findings in improving medication safety but little detail was provided on the interventions implemented. The five qualitative studies collectively provide an overview of the SUD process, which typically comprised nine steps from data identification to analysis. Factors influencing the SUD process were electronic systems implementation and level of functionality, knowledge and skills of SUD users, organisational context, and policies around data reuse and security. Discussion and Conclusion: The majority of the SUD interventions were successful in improving medication safety, however, what contributes to this success needs further exploration. From synthesis of research evidence in this review, an integrative framework was developed to describe the processes, mechanisms, and barriers for effective SUD.

Background: Abductive Thematic Network Analysis (ATNA) is a qualitative data analysis method, which was first defined by Rambaree and Faxelid (2013). It draws upon the principles of Thematic Analysis (Braun and Clarke, 2006), Thematic Network Analysis (Attride-Stirling, 2001) and Abductive Theory of [for full text, please go to the a.m. URL]

Background: Prehospital feedback is increasingly receiving attention from clinicians, managers and researchers. The effectiveness of feedback in changing professional behaviour and improving clinical performance is strongly evidenced across a range of healthcare settings, but this has not yet been replicated within the prehospital context. Without a firmer evidence base, development in practice relies on isolated initiatives with no clear intervention model or evaluative framework. The aim of this study is to understand how UK ambulance services are currently meeting the challenge of providing prehospital feedback and generate an explanatory programme theory. Methods: This mixed methods study will follow a realist evaluation methodology framework with an explanatory case study research design. A realist approach was selected as it will facilitate development of programme theory by exploring context, mechanisms and outcomes. The study will consist of three phases: a pilot case study, a national survey and three in-depth case studies. Phase 1 and 3 of the study will involve semi-structured qualitative interviews and site visits, whilst phase 2 will consist of a cross-sectional survey sent out to leads of UK prehospital feedback initiatives. This study will draw upon a range of existing theories to aid understanding such as the Consolidated Framework for Implementation Research, Normalisation Process Theory and Clinical Performance Feedback Intervention Theory. Results and Conclusion: The three phases of this study will allow for cyclical development, testing and refinement of programme theory by describing existing prehospital feedback intervention types and variations in implementation, as well as evaluating their causal mechanisms and outcomes. Study findings will facilitate an understanding of the extent and limitations of current initiatives, with a view towards identifying opportunities for intervention.

Background: It is widely recognised that improvement of patient safety requires the engagement of senior leaders. Research to date has reported the impact that patient safety leadership WalkRounds can have onsafety culture. What has not beenreported are the complex social processes that underpin WalkRounds. It is our conjecture that by having a better understanding of these we will begin to answer the question of how best to engage senior leaders in patient safety. Methodology/approach: All 20 organisations participating in Phase 2 of the UK NHS Safer Patients Initiative were involved in this research. Qualitative analysis was performed of 56 interviews, including a clinical lead, an executive and a coordinator in each organisation focusing specifically on WalkRounds. Transcripts were analysed using first an inductive approach and then a thematic analysis. Findings: The research found that although they are a simple concept, WalkRounds reveal much about an organisation, its people and its leadership. Importantly, WalkRounds can help executives to learn about their organisation, their leadership style and their attitudes. The research indicates the need to develop a process beyond WalkRounds that helps executives to understand their organisations and enables them to articulate and deal with difficult managerial concerns. © 2008 Radcliffe Publishing.

AIMS: To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI). METHODS: Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'. RESULTS: Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices. CONCLUSIONS: Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data.

Four off-loading devices used for the treatment of diabetic forefoot ulcers were compared: a custom-molded insole shoe, a cast MABAL shoe, a prefabricated pneumatic walking brace, and a bivalved total contact cast (BTCC). It was anticipated that all devices would significantly reduce forefoot plantar pressure compared with a control shoe. Sixteen healthy volunteers participated. Plantar pressures were evaluated using the Pedar system, while walking speed was determined using an optoelectric timer. Peak pressure (PP) of ten plantar areas and pressure–time integral for the first metatarsal area were analyzed statistically using a repeated measures analysis of variance. Forefoot pressures were significantly reduced compared with the control shoe for all devices (p