"Action at a distance":accounting inscriptions and the reporting of episodes of clinical care

This paper reports on an aspect of the implementation of a sophisticated system of Casemix Budgeting within a large public hospital in New Zealand. The paper examines the role of accounting inscription in supporting a system of “remote” management control effected through the Finance function at the hospital. The paper provides detailed description and analysis of part of the casemix technology in use at the research site. The implementation of clinical budgeting through the Transition casemix system will be examined by describing an aspect of the casemix system in detail. The design and use of management reporting is described. Reporting to different levels of management and for differing parts of the organisation are discussed with particular emphasis on the adoption of traditional analysis of costs using standard costing and variance analysis techniques.

A concept-based framework for retrieving evidence to support emergency physician decision making at the point of care

The goal of evidence-based medicine is to uniformly apply evidence gained from scientific research to aspects of clinical practice. In order to achieve this goal, new applications that integrate increasingly disparate health care information resources are required. Access to and provision of evidence must be seamlessly integrated with existing clinical workflow and evidence should be made available where it is most often required - at the point of care. In this paper we address these requirements and outline a concept-based framework that captures the context of a current patient-physician encounter by combining disease and patient-specific information into a logical query mechanism for retrieving relevant evidence from the Cochrane Library. Returned documents are organized by automatically extracting concepts from the evidence-based query to create meaningful clusters of documents which are presented in a manner appropriate for point of care support. The framework is currently being implemented as a prototype software agent that operates within the larger context of a multi-agent application for supporting workflow management of emergency pediatric asthma exacerbations. © 2008 Springer-Verlag Berlin Heidelberg.

Clinical decision support system for point of care use: ontology driven design and software implementation

OBJECTIVES: The objective of this research was to design a clinical decision support system (CDSS) that supports heterogeneous clinical decision problems and runs on multiple computing platforms. Meeting this objective required a novel design to create an extendable and easy to maintain clinical CDSS for point of care support. The proposed solution was evaluated in a proof of concept implementation. METHODS: Based on our earlier research with the design of a mobile CDSS for emergency triage we used ontology-driven design to represent essential components of a CDSS. Models of clinical decision problems were derived from the ontology and they were processed into executable applications during runtime. This allowed scaling applications' functionality to the capabilities of computing platforms. A prototype of the system was implemented using the extended client-server architecture and Web services to distribute the functions of the system and to make it operational in limited connectivity conditions. RESULTS: The proposed design provided a common framework that facilitated development of diversified clinical applications running seamlessly on a variety of computing platforms. It was prototyped for two clinical decision problems and settings (triage of acute pain in the emergency department and postoperative management of radical prostatectomy on the hospital ward) and implemented on two computing platforms-desktop and handheld computers. CONCLUSIONS: The requirement of the CDSS heterogeneity was satisfied with ontology-driven design. Processing of application models described with the help of ontological models allowed having a complex system running on multiple computing platforms with different capabilities. Finally, separation of models and runtime components contributed to improved extensibility and maintainability of the system.

Automatic indexing and retrieval of encounter-specific evidence for point-of-care support

Evidence-based medicine relies on repositories of empirical research evidence that can be used to support clinical decision making for improved patient care. However, retrieving evidence from such repositories at local sites presents many challenges. This paper describes a methodological framework for automatically indexing and retrieving empirical research evidence in the form of the systematic reviews and associated studies from The Cochrane Library, where retrieved documents are specific to a patient-physician encounter and thus can be used to support evidence-based decision making at the point of care. Such an encounter is defined by three pertinent groups of concepts - diagnosis, treatment, and patient, and the framework relies on these three groups to steer indexing and retrieval of reviews and associated studies. An evaluation of the indexing and retrieval components of the proposed framework was performed using documents relevant for the pediatric asthma domain. Precision and recall values for automatic indexing of systematic reviews and associated studies were 0.93 and 0.87, and 0.81 and 0.56, respectively. Moreover, precision and recall for the retrieval of relevant systematic reviews and associated studies were 0.89 and 0.81, and 0.92 and 0.89, respectively. With minor modifications, the proposed methodological framework can be customized for other evidence repositories. © 2010 Elsevier Inc.

The effect of care solutions on the bulk and surface properties of soft contact lenses

Purpose: Soft contact lenses for continuous wear require the use of cleaning regimes which utilise hydrogen peroxide systems or multipurpose cleaning solutions (MPS). The compositions of MPS are becoming increasingly complex and often include disinfectants, cleaning agents, preservatives, wetting agents, demulcents, chelating and buffering agents. Recent research on solution–lens interactions has focused on specific ocular parameters such as corneal staining. However the effect of a solution on the lens, particularly silicone hydrogel lenses, itself has received less attention. The purpose of this work was to establish and understand the effects that care solutions have on selected bulk and surface material properties. Methods: Selected bulk and surface properties of each material (etafilcon A, vifilcon A, balafilcon A, senofilcon A, lotrafilcon A and lotrafilcon B, galyfilcon A) were measured after a 24 h soak in a variety of care solutions. Additionally the lenses were soaked for 24 h in hyperosmolar (680 mOsm L-1) and hyposmolar (170 mOsm L-1) PBS. A bulk property parameter the total diameter (TD) was measured using an Optimec contact lens analyser. The surface property related CoF of soaked lenses was measured on a nano-tribometer with conditions of load 30 mN, at a distance of 20 mm and speed 30 mm/min. Results: In terms of bulk properties, change is related to the EWC of the lens, the higher the EWC of the lens the greater the TD changes. Silicone hydrogel lenses have EWCs of <47% and little or no TD changes were observed; lotrafilcon A exhibited no change irrespective of the cleaning solution. Conventional contact lenses have higher EWCs (58% for etafilcon A and 55% for vifilcon A) and the TD was seen to change to a greater extent, for example the etafilcon A material in ReNu MPS had an increase to 14.45± 0.07 mm from the cited 14.2 mm. Other lenses increased or decreased in TD depending on the solution used. The osmolarity of the solution although important is not the only factor governing change in the TD, for example soaking senofilcon A in hyperosmolar PBS (680 mOsm L-1) for 24 h increased the TD of the lens (+0.25 ± 0.07 mm), however when the same lens type was soaked for 24 h in a MPS with a lower osmolarity there was a similar effect. Biotribology measurements demonstrated that some solution–lens combinations can reduce the CoF by 55%, when compared with biotribology with the native packing solution. An increase in the CoF was observed for other solution–lens combinations. Conclusions: There is a dramatic difference in bulk and surface performance of specific lens materials with particular care solutions. Individual components of the care solutions have effects on the bulk and surface properties of contact lenses. The affects are not as great with the silicone hydrogel as compared with conventional hydrogels.

Fibre optics sensors in tear electrolyte analysis:towards a novel point of care potassium sensor

The diagnosis of ocular disease is increasingly important in optometric practice and there is a need for cost effective point of care assays to assist in that. Although tears are a potentially valuable source of diagnostic information difficulties associated with sample collection and limited sample size together with sample storage and transport have proved major limitations. Progressive developments in electronics and fibre optics together with innovation in sensing technology mean that the construction of inexpensive point of care fibre optic sensing devices is now possible. Tear electrolytes are an obvious family of target analytes, not least to complement the availability of devices that make the routine measurement of tear osmolarity possible in the clinic. In this paper we describe the design, fabrication and calibration of a fibre-optic based electrolyte sensor for the quantification of potassium in tears using the ex vivo contact lens as the sample source. The technology is generic and the same principles can be used in the development of calcium and magnesium sensors. An important objective of this sensor technology development is to provide information at the point of routine optometric examination, which would provide supportive evidence of tear abnormality.

Giving whistleblowers greater protection:improving quality of care

This year, an independent review of whisleblowing in the NHS made recommendations as to how whistleblowers could be given greater protection. The review, chaired by Sir Robert Francis, intended to improve the quality of patient care and safety in the health service. But with many practitioners remaining unregulated, there are unanswered questions as to how reports of mistakes can be properly investigated and the necessary action taken against incompetent or negligent practitioners. Amanda Casey, Chair of the Registration Council for Clinical Physiologists, makes the case for regulation of professionals whose work poses potential risks to patients and can place healthcare managers in an invidious position.

Who speaks up for Inés Fonseca? Representing violence against vulnerable subjects and the ethics of care in fictional narrative about Alzheimer’s disease:Ahora tocad música de baile (2004) by Andrés Barba

This paper studies the Spanish fictional novel by Andrés Barba, Ahora tocad música de baile (2004), one of the first cultural texts dealing entirely with Alzheimer’s disease (AD) to appear in Spain. It argues that the significance of Barba’s fictional novel rests on two important issues: the ethics of representation of violence against vulnerable subjects and the ethics of care. The paper analyses how these two issues allow Barba to create a story in which the verbal and physical abuse to which the person living with Alzheimer’s disease is subjected places the reader, on the one hand, as voyeur/witness of the abuse; and, on the other, as interpreter, and ultimately judge, of the fine line that separates euthanasia, assisted suicide, and murder. The open ending of the novel defers all ethical and moral judgment to the reader. It examines how the novel offers a monolithic perspective about AD, in which care is presented as a burden. In fact, this study shows that the novel’s multi-layered structure and polyphonic nature places the emphasis on stigmas, stereotypes and negative metaphors around AD, as found in contemporary social discourses.

Accounting and the emergence of care pathways in the National Health Service

This paper examines the effects of New Public Management reforms on the information infrastructure underpinning the work of public service professionals. Focussing on the case of the British National Health Service (NHS), the paper argues that hospital accounting reforms played a significant role in the emergence of standardised models of clinical practice. The paper moreover argues that, under the label “care pathways”, such standardised models of clinical practice became embedded in the information infrastructure of the NHS and concludes by discussing their implications for the work of doctors and hospital accountants.

Assessing the motivation of MDs to use computer-based support at the point-of-care in the emergency department

A significant body of research investigates the acceptance of computer-based support (including devices and applications ranging from e-mail to specialized clinical systems, like PACS) among clinicians. Much of this research has focused on measuring the usability of systems using characteristics related to the clarity of interactions and ease of use. We propose that an important attribute of any clinical computer-based support tool is the intrinsic motivation of the end-user (i.e. a clinician) to use the system in practice. In this paper we present the results of a study that investigated factors motivating medical doctors (MDs) to use computer-based support. Our results demonstrate that MDs value computer-based support, find it useful and easy to use, however, uptake is hindered by perceived incompetence, and pressure and tension associated with using technology.

Exploring care relations in later life: disentangling notions of care and choice

The experience of later life varies widely and is often framed in terms of the active lifestyles of the Third Age and the frailty and abjection of the Fourth Age. This thesis sought to understand how the concepts of care and choice are enacted, experienced and interrelated in the context of both informal and formal care in later life and how older people themselves, their families and significant others understand and experience these concepts. The discourse of personalisation that dominates care services has led to an emphasis on individual choice, control and independence so that those in need of care are faced with what has been described as the ‘logic of choice’, a focus on individual responsibility rather than care. Adopting a Feminist Foucauldian theoretical approach and drawing on Tronto’s (1993) ethic of care, this thesis explores the experiences of older people and their informal carers through dialogical narrative analysis. The stories begin with the recognition by individuals that there is a need for care and how this need is met through negotiations with families and significant others. As needs increase the physical and logistical limits of informal care by individuals are reached, often leading to a need to ‘choose’ formal care. Rather than impacting solely on the care recipient, formal care is shown as being an experience that is shared with informal carers. Indeed, the participants depict how informal care continues alongside formal care and how the boundaries between them become blurred. I argue that a binary division between actively making choices and being a passive recipient are not appropriate to understandings of care. By disentangling the notions of care and choice this thesis explores the extent to which these concepts are relevant to the experience of older people in specific care situations.

The professional role of breast cancer nurses in multi-disciplinary breast cancer care teams

Since the 1970s breast cancer services have witnessed considerable changes in the management of patients. One significant change was the introduction of specialist core personnel, including the breast care nurse (BCN). The role of the BCN has been gaining credence rapidly in the British NHS and this service is perhaps the paradigm of care for other services. With the lack of specific evidence of the role of specialist nurses in the breast care team, the current study aims to explore this area by in-depth interviews with core team members, and observations of 16 multi-disciplinary teams in England. The study explores the following themes: Nurses' unique informal management leadership role in ensuring the co-ordination, communication and planning of the team work; nurses' innovatory role in making the bureaucracy respond to patients and their relatives needs; nurses supportive role in the provision of expert advice and guidance to other members of the team; nurses confidence and humour in well-performing teams; and the limitations of the professional role of the breast cancer nurse. This study indicates that there is evidence that the BCN is practicing at an advanced level of practice. However, there is a severe lack of evidence-based description of that advanced practice. Cancer nurses including the BCNs should develop and participate in programmes of research in line with cancer legislation in order to build an evidence base that ultimately supports their unique role. © 2004 Elsevier Ltd. All rights reserved.

The experiences and perceptions of fathers attending the birth and immediate care of their baby

Fathers in the United Kingdom (UK) usually attend the birth and immediate care of their baby. They also have an increasing presence during complicated and preterm childbirth, newborn resuscitation and early neonatal unit(NNU) care. However, there is limited evidence about the effect of these experiences on them. The aim of this study was to gain an understanding of the experiences of fathers encountering these situations. The study consisted of three phases and was undertaken in one National Health Service trust in the UK. Qualitative semi-structured interviews using a phenomenological approach were undertaken with 20 first-time fathers present at the delivery, resuscitation and/or admission of their baby to the NNU. Direct observations were made of 22 normal and complicated deliveries and initial newborn care and qualitative semi-structured interviews using the critical incident approach were undertaken with 37 health care professionals (HCPs). The study generated qualitative and quantitative data that were analysed accordingly. The findings show that most fathers were involved for at least some of the time and often spontaneously initiated their involvement. Their most important need was for information. They were usually more concerned about their partner, irrespective of the baby?s need for resuscitation and NNU care. To facilitate their involvement, fathers needed guidance and support from HCPs, particularly delivery suite midwives. Most HCPs recognised the needs of fathers and ways in which they could be helped to connect with their experience. However, these needs were not always met, usually because of inadequate staffing levels, a lack of resources or a mother-centred philosophy of care. The findings suggest the service often determines the extent to which fathers are involved. It is anticipated that these findings will inform HCP education and training and the development of both policy and health education thereby enhancing the quality of care provision for fathers.