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BackgroundCentral venous catheters are inserted ubiquitously in critical care and have roles in drug administration, fluid management and renal replacement therapy. They are also associated with numerous complications. The true number of central venous catheters inserted per year and the proportion of them associated with complications are unknown in the UK.MethodsWe performed a prospective audit at five hospitals, as a feasibility pilot for a larger, nationwide audit. Using a novel secure online data collection platform, developed earlier and adapted for this project, all central venous catheters inserted for patients admitted to the Intensive Care Units were documented at five pilot sites across the UK.ResultsA total of 117 data collection forms were submitted. Users found the electronic data collection system easy to use. All data fields were ready for analysis immediately after data input. Out of the 117 central venous catheters, 17 were haemodialysis catheters and five pulmonary artery introducers. Experienced practitioners (at least three years’ experience) inserted 85% of the central venous catheters. The site of insertion was the internal jugular vein for 80%, femoral for 12% and subclavian for 8% of central venous catheters. Most central venous catheters were inserted in ICU (49%) or theatres (42%). Ultrasound was used for 109 (93%) of central venous catheter insertions and its use was not associated with fewer complications. In 15 cases venopuncture was attempted more than once (all with ultrasound) and this was associated with significantly increased risk of complications. There were eight immediate complications (6.8%): five related to venopuncture and inability to pass a guidewire, two carotid artery punctures and one associated with significant arrhythmia.ConclusionThis study demonstrates the ease and feasibility of collecting detailed descriptive data on central line insertion and its immediate complications in the UK over two weeks. In our proposed nationwide audit, organisation-level data on local policies and standard operating procedures is required to complete the picture on this important aspect of intensive care practice.

Our aim was to prospectively determine the predictive capabilities of SEPSIS-1 and SEPSIS-3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24-h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS-1 definition, 212 patients had sepsis. When using the SEPSIS-3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quickSOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS-1 criteria had a sensitivity (95%CI) of 65% (54-75%) and specificity of 47% (41-53%); SEPSIS-3 criteria had a sensitivity of 86% (76-92%) and specificity of 32% (27-38%). SEPSIS-3 and SEPSIS-1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5-5.6) and 1.6 (1.3-2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63-0.76)), followed by NEWS (0.58 (0.51-0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49-0.61)) and quickSOFA score (0.56 (0.49-0.64)) could not predict outcome. The SEPSIS-3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis-induced organ dysfunction.

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross’ theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross’ theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students’ awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.

Data on sepsis prevalence on the general wards is lacking on the UK and in the developed world. We conducted a multicentre, prospective, observational study of the prevalence of patients with sepsis or severe sepsis on the general wards and Emergency Departments (ED) in Wales. During the 24-hour study period all patients with NEWS≥3 were screened for presence of 2 or more SIRS criteria. To be eligible for inclusion, patients had to have a high clinical suspicion of an infection, together with a systemic inflammatory response (sepsis) and evidence of acute organ dysfunction and/or shock (severe sepsis). There were 5317 in-patients in the 24-hour study period. Data were returned on 1198 digital data collection forms on patients with NEWS≥3 of which 87 were removed, leaving 1111 for analysis. 146 patients had sepsis and 144 patients had severe sepsis. Combined prevalence of sepsis and severe sepsis was 5.5% amongst all in-patients. Patients with sepsis had significantly higher NEWS scores (3 IQR 3–4 for non-sepsis and 4 IQR 3–6 for sepsis patients, respectively). Common organ dysfunctions in severe sepsis were hypoxia (47%), hypoperfusion (40%) and acute kidney injury (25%). Mortality at 90 days was 31% with a median (IQR) hospital free stay of 78 (36–85) days. Screening for sepsis, referral to Critical Care and completion of Sepsis 6 bundle was low: 26%, 16% and 12% in the sepsis group. Multivariable logistic regression analysis identified higher National Early Warning Score, diabetes, COPD, heart failure, malignancy and current or previous smoking habits as independent variables suggesting the diagnosis of sepsis. We observed that sepsis is more prevalent in the general ward and ED than previously suggested before and that screening and effective treatment for sepsis and severe sepsis is far from being operationalized in this environment, leading to high 90 days mortality.

Objective To develop a secure, efficient, and easy-to-use data collection platform to measure the prevalence of sepsis in Wales over 24 hours. Materials and Methods Open Data Kit was used on Android devices with Google App Engine and a digital data collection form. Results A total of 184 students participated in the study using 59 devices across 16 hospitals, 1198 datasets were submitted, and 97% of participants found the Open Data Kit form easy to use. Discussion We successfully demonstrated that by combining a reliable Android device, a free open-source data collection framework, a scalable cloud-based server, and a team of 184 medical students, we can deliver a low-cost, highly reliable platform that requires little training or maintenance, providing results immediately on completion of data collection. Conclusion Our platform allowed us to measure, for the first time, the prevalence of sepsis in Wales over 24 hours.

10.1080/15487760590953894-F0001 Phyllis Solomon Professor of social work in psychiatry at the University of Pennsylvania, Phyllis Solomon earned a B.A. in sociology from Russell Sage College, and b...

This study expands on earlier research by our group that has shown that contact with people with mental illness has significant effects on changing stigmatizing attitudes. Two factors that affect contact are examined in this study: the medium through which contact is experienced, and the level of stereotype disconfirmation engendered in contact. One hundred sixty-four individuals were randomly assigned to one of five conditions. Three of the conditions allowed us to examine the effects of medium: no stigma-control, in vivo contact with moderate disconfirmation, and videotaped contact with moderate disconfirmation. Along with the moderate disconfirmation videotape, two additional videotaped conditions —little or no disconfirmation and high disconfirmations—defined the three groups for our second set of hypotheses on disconfirmation. Research participants completed the Social Distance Scale prior to being assigned to condition and immediately upon completion. In terms of the medium of contact, resu...

Bruce G. Link's research broadly addresses the study of how and under what conditions economic inequalities become translated into health disparities. Under this bearing, Dr. Link has examined ment...

Two stigmatizing attitudes related to dangerousness and personal responsibility may undermine the opportunities of persons with serious mental illness. This study set out to examine path models that explain how these attitudes lead to discriminatory behavior and to assess the impact of antistigma programs on components of personal responsibility and dangerousness models. Two hundred thirteen persons were randomly assigned to one of five antistigma conditions: education on personal responsibility, education on dangerousness, contact with a person with serious mental illness where personal responsibility is discussed, contact where dangerousness is discussed, or no change. Persons completed an attribution questionnaire (AQ) representing personal responsibility and dangerousness path models at pretest, posttest, and 1-week followup. They also completed tasks that represented helping behavior. Goodness of fit indexes from linear structural modeling were mixed for both models but suggested that fear of dangerousness was a key attitude leading to discriminatory behavior. Results also showed that subjects who had contact with persons with serious mental illness experienced greater changes than subjects in the education or control groups did on measures of attribution and helping behavior.

This study examined the effects of familiarity with and social distance from persons who have serious mental illness on stigmatizing attitudes about mental illness.A total of 208 community college students completed three written measures about familiarity, perception of dangerousness, fear, and social distance. Path analysis with manifest-variable structural modeling techniques was used to test a version of a model in which familiarity influences the perception of dangerousness, which in turn influences fear, which influences social distance from persons with serious mental illness.Most of the participants reported experience with mental illness. Scores on the three written measures largely supported the path model. Correlations between the perception of dangerousness and fear as well as between fear and social distance were particularly strong.Approaches to social change that increase the public's familiarity with serious mental illness will decrease stigma. Further studies are warranted that focus on how contact between members of the general public and persons who have serious mental illness may be facilitated.

The effects of three strategies for changing stigmatizing attitudes--education (which replaces myths about mental illness with accurate conceptions), contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders), and protest (which seeks to suppress stigmatizing attitudes about mental illness)--were examined on attributions about schizophrenia and other severe mental illnesses. One hundred and fifty-two students at a community college were randomly assigned to one of the three strategies or a control condition. They completed a questionnaire about attributions toward six groups--depression, psychosis, cocaine addiction, mental retardation, cancer, and AIDS--prior to and after completing the assigned condition. As expected, results showed that education had no effect on attributions about physical disabilities but led to improved attributions in all four psychiatric groups. Contact produced positive changes that exceeded education effects in attributions about targeted psychiatric disabilities: depression and psychosis. Protest yielded no significant changes in attributions about any group. This study also examined the effects of these strategies on processing information about mental illness.

Work and housing opportunities of persons with psychosis, substance abuse disorder, and other mental illnesses are significantly hampered by societal stigma. Earlier research by Weiner and colleagues (1988) examined stigmatizing attitudes associated with general health disabilities in terms of attributions about the controllability and stability of these disabilities. The relevance of this model for describing attributions about four psychiatric disorders is examined in this study. One hundred and fifty two adults rated four psychiatric groups (cocaine addiction, depression, psychosis, and mental retardation) and two physical health groups (cancer and AIDS) on six items corresponding with controllability and stability attributions. Findings from a factor analysis supported the distinction between controllability and stability factors. Results also suggested that mental health disabilities were rated more negatively on these factors than physical disabilities. Participants clearly discriminated among mental health disabilities, with cocaine addiction rated most negative in terms of controllability and mental retardation rated most negative in terms of stability. Attribution analyses provide useful information for changing the community's reactions to persons with mental illness. © 2000 John Wiley & Sons, Inc.

Having lived with a bipolar disorder for nearly 20 years, I discuss my personal struggles with the discrimination, blame, and guilt frequently associated with having a mental illness. I have experienced failed aspirations, feelings of self-depreciation, depression, and denial—all associated with stigma. Stigma has contributed to loss of jobs, loss of status in the community, and loss of health insurance. I have found that one way to cope with stigma is to fully disclose my illness to family, friends, and my employer. I have also found satisfaction in opposing stigma through mental health advocacy.

The exhibiting of fine art created by persons living with mental illness has become widespread in recent years, with several associations collecting and showing pieces at national venues, including the National Alliance for the Mentally Ill, The National Mental Health Association, National Artists for Mental Health, and the Very Special Arts Gallery. Some researchers who have examined the works of scores of eminent artists, writers and musicians have found a positive relationship between affective disorders and creative genius. The first author of this paper, who describes his work with a consumer art show in Illinois, questions whether this apparent abundance of creative aptitude translates from elite populations of artists to the general population of persons with mental illness. Experts in the field differ as to whether there is any greater incidence of talent among the general population of artists who are mentally ill and the general population of artists.

Learning Objectives: The placement of central venous catheters (CVCs) is common in modern critical care practice. Whilst infectious complications have been reduced in the last decade, mechanical complications of central venous cannulation remain a significant cause of morbidity and mortality. In the UK this burden has not been quantified before. This feasibility pilot of the Intensive Care National Audit Project assessed the data collection tool and the immediate complication rates in five different hospital settings. Methods: Using a recently developed electronic data collection system, all CVCs inserted to patients admitted to the ICU in 5 hospitals (2 university hospitals and 3 major teaching hospitals) were documented over a two-week period. Indication, insertion site, experience of the operator, use of ultrasound (U/S), use of CXR, number of skin punctures and immediate complications were recorded in an anonymised database. Results: 117 data collection forms were submitted. Users found the electronic data collection system easy to use. All data fields were ready for analysis immediately after inputting the data. Out of the 117 CVCs, 17 were haemodialysis lines and 5 PA sheets. 85% of the CVCs were inserted by experienced practitioners (at least 3 years experience). 95 (80%) of the CVCs were inserted in the internal jugular, 14 in the femoral and 9 in the subclavian veins, respectively. U/S was used for 109 (93%) of CVC insertions and its use was not associated with fewer complications. In 15 cases venopuncture was attempted more than once (all with U/S) and this was associated with significantly increased risk of complications. There were 12 immediate complications (10.5%), 5 related to inability to pass a guidewire, 2 carotid punctures, 3 inadequate positioning of the tip of the CVC and 1 significant arrhythmia. Conclusions: Our feasibility pilot showed that our proposed data collection tool is appropriate for the planned national survey. The 10% complication rate in the hands of experienced practitioners is alarming. Potential long-term morbidity from these will be determined during the national study.

Learning Objectives: The incidence of sepsis on the general wards is unknown in Wales, whilst sepsis accounts for 30% of all admissions to the ICUs. The introduction of the National Early Warning Score and the Sepsis Screening Tool makes it possible to estimate the true incidence. We performed a feasibility pilot study to estimate the incidence of sepsis and severe sepsis on the general wards. Methods: 1 day point prevalence study conducted in 4 hospitals (2 tertiary centres and 2 university affiliated general hospitals) on all general and obstetric wards using an anonymised pro-forma data collection sheet. Information was obtained by medical students who were trained in recognising the signs of sepsis. All patients with NEWS 3 or above were screened. Sepsis and severe sepsis was defined according to SSC criteria. Demographics, co-morbidities and significant drug therapy data was collected along with data on severity of sepsis, organ dysfunction and applied treatment. Results: 393 patients scored 3 or above on the NEWS. 16% of patients (n=62) had clinical signs of sepsis and 7.9% of patients (n=29) had severe sepsis with at least one organ dysfunction. Sepsis patients were similar age: 71 (61-84) years and NEWS 4 (3-6) compared to the non-sepsis patients. M/F ratio was 60/40. 23% of the patients had at least one significant co-morbidities. Out of the 62 sepsis patients only 4 had received the complete Sepsis 6 bundle. Critical Care input was obtained only in 5 patients with severe sepsis. Conclusions: The prevalence of sepsis and severe sepsis is high on the general wards and the problem is highly unrecognised. The lack of critical care referral of severe sepsis patients highlights the educational problem on ward level. Despite national effort, the delivery of the simple and effective Sepsis 6 treatment is lacking. The feasibility pilot showed that the research model employing the medical students as data collectors is workable and we are preparing to launch a nation-wide survey to get a true reflection about the size of the problem in different areas of the country.

The purpose of this study was to evaluate the treatment that patients receive when they are hospitalized for orofacial infections. Results indicated that dental consultations were not always obtained by medical personnel prior to the diagnosis and treatment of patients and that the antibiotic therapy employed did not always involve the recognized drug of choice.

This deliverable aims to define the target population of the DECI Project, by giving the general definitions and boundaries that will be used during the Project, as well as specifying the variables and tests that will be used to analyze the target population in the different pilot sites and, then, subdivide it into various clusters. In particular, the DECI Minimum Data Set (MDS) is defined representing the minimum set of instruments (tests, scales, questionnaires, etc) needed for describing the target population during the pilot phase. MDS is used to standardize the data that each clinical Partner will collect during the pilot phase in order to allow comparisons across the test sites. Finally, the last paragraph includes a preliminary analysis of the target population in the four pilot sites.