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Processes of change: qualitative findings At baseline purchase levitra with dapoxetine 40/60 mg without a prescription, GPs and practice staff expressed a willingness to adopt PRISM purchase levitra with dapoxetine 40/60 mg fast delivery, but raised concerns about whether or not it would identify patients not yet known cheap levitra with dapoxetine 40/60mg with mastercard, and about whether or not there were sufficient community-based services to deliver care to patients identified as at high risk, in order to prevent hospital admission. All practices reported that they used PRISM to fulfil their QOF targets, and generally limited their use of PRISM to the small number at highest risk. After the QOF reporting period ended, only two practices reported continuing to regularly use PRISM. Reasons given for not using it included lack of time to work prospectively, inadequate support, limited internet access, and data being out of date and not well integrated with practice records. General practitioners were unsure if using PRISM had any effect on emergency admissions and ED attendances. They felt that PRISM had changed their awareness of patients and focused them on targeting the patients at highest risk, although they were not sure that proactive management could make any difference to emergency admissions in this group. Among health service managers and community health staff, awareness and understanding of PRISM was high, though they expressed similar concerns as practice staff about the availability of services to which practices could refer. Technical performance Using data from 51,600 patients with both an early PRISM score and a sufficient control phase, PRISM showed good technical performance, comparable to existing risk prediction tools (c-statistic of 0. However, it generally underpredicted risk at higher risk levels and overpredicted risk at the lowest risk level. Conclusions: implications for health care – research recommendations Summary of key findings l Our systematic review found that previous research evidence, limited in scope and quality, showed minimal effects of predictive risk stratification tools on emergency admissions. Secondary outcomes: attendances at EDs, GP events and outpatient visits were also slightly higher in the intervention phase; and patients spent more time in hospital in the intervention phase. Mental health quality-of-life scores were not dissimilar between phases. Physical health scores were higher in the intervention phase. Satisfaction scores were lower in the intervention phase. All users reported some change in practice resulting from PRISM. Strengths and weaknesses of the research Our stepped-wedge study design randomised clusters of general practices to receive PRISM tool at intervals over 1 year. Together with linked routine outcome data, this enabled us to conduct a rigorous evaluation of this population-level intervention by monitoring outcomes for nearly 250,000 people. We anonymously linked self-completed questionnaires from a sample stratified to favour higher levels of risk to our routine data outcomes, thus describing effects on quality of life and satisfaction as well as on health service use. Response rates were no higher than expected in this general population and need non-response analysis. This was the first evaluation of the effects of the introduction of a PRISM in normal practice, even though the tools have since been widely introduced across the UK as part of a comprehensive policy for the care of people with chronic conditions. Conclusions Use of anonymised data linkage has enabled us to conduct an experimental study with a randomised design at the population level, and include almost all primary and secondary routine outcomes, as well as self-reported outcomes from a sample of patients. Introduction of PRISM in primary care in a large urban area in Wales was followed by increased emergency admissions, both overall and at each level of risk. We also found increases in each secondary measure of resource use following PRISM implementation. There was evidence of improved quality of life, but satisfaction scores were slightly lower. Despite low reported use of PRISM, we found clinically and operationally important effects of the introduction of the new risk stratification tool alongside contractual incentives (QOF) to target those at the highest risk of emergency admission to hospital. Unexpectedly, most effects were in the opposite direction to those intended. Although we cannot disentangle the effects of introducing PRISM from those of introducing the QOF targets, this has the merit of reflecting practice across the UK, where predictive risk stratification tools for emergency admissions operate alongside incentives to focus on patients at risk. Hence, we believe that our findings from a large population in south-west Wales, mixing urban and semi-urban, are generalisable. In brief, the introduction of PRISM increased emergency episodes, hospital admissions and costs across the population and at each risk level without clear evidence of benefits to patients. Evaluate the alternative approach of delivering different services to different levels of risk, rather than the current focus on the very highest level of risk. Investigate the effects of emergency admission risk stratification tools on vulnerable populations and health inequalities. Conduct a secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by condition type. Explore the acceptability of predictive risk stratification and communication of risk scores to patients and practitioners.

Much of the early management of traumatic brain injury falls upon emergency room staff 40/60 mg levitra with dapoxetine with visa, primary care and ambulance services prior to hospital admission trusted levitra with dapoxetine 40/60 mg. Most patients who attend hospital after a traumatic brain injury do not develop life-threatening complications in the acute stage buy 40/60 mg levitra with dapoxetine with mastercard. However, in a small but important subgroup, the outcome is made worse by failure to detect promptly and deal adequately with complications. A traumatic brain injury should be discussed with neurosurgery when a. Persistent coma (GCS <9, no eye opening) after initial resuscitation ii. Confusion persisting for more than 4 hours Brain Injuries | 45 iii. Deterioration in level of consciousness after admission (a sustained decrease of one point in the motor or verbal GCS subscores, or 2 points on the eye opening subscale of the GCS) iv. A CSF leak or other sign of base of skull fracture 2. A fall in serum sodium produces an osmotic gradient across the blood–brain barrier, and aggravates cerebral edema. Avoid hyperglycemia (treat blood glucose >11 mmol/L). Hyperglycemia increases cerebral lactic acidosis, which may aggravate ischemic brain injury. Apply 15–30° head-up tilt with head kept in neutral position; this may improve CPP. Acute stroke The World Stroke Organization declared a public health emergency on World Stroke Day (WSO 2010). There are 15 million people who have a stroke each year. According to the World Health Organization, stroke is the second leading cause of death for people above the age of 60, and the fifth leading cause in people aged 15 to 59. Stroke also happens to children, including newborns. Each year, nearly six million people die from stroke. In fact, stroke is responsible for more deaths annually than those attributed to AIDS, tuberculosis and malaria put together. Stroke is also the leading cause of long-term disability irrespective of age, gender, ethnicity or country. Yet for many healthcare staff it remains an area of therapeutic nihilism and thus uninteresting and neglected (WSO 2010). This 46 | Critical Care in Neurology negative perception is shared by the general public, who often has a poor understanding of the early symptoms and significance of a stroke. Yet within the last few years there have been many important developments in the approach to awareness and caring for stroke patients, for both the acute management and secondary prevention. Clinical research and interest in stroke has increased greatly in the last few years. Each minute of brain ischemia causes the destruction of 1. Ischemic stroke is characterized by one or more focal neurological deficits corresponding to the ischemic brain regions. It requires an immediate decision regarding thrombolytic therapy (tissue plasminogen activator, TPA, in the dosage of 0. Wise control of hypertension is essential, control of hyperglycemia and fever is protective against more destruction of neurons (Mistri 2006). Status epilepticus (SE) Status epilepticus is defined as more than 30 minutes of continuous seizure activity or recurrent seizure activity without an intervening period of consciousness (Manno 2003). In one survey, only 10% of patients who develop seizures in a medical ICU will develop SE. The most common causes of SE are noncompliance with or withdrawal of antiepileptic medications, cerebrovascular disease and alcohol withdrawal. The hypersynchronous neuronal discharge that characterizes a seizure is mediated by an imbalance between excitation and inhibition. The adverse effects of generalized seizures include hypertension, lactic acidosis, hyperthermia, respiratory compromise, pulmonary aspiration or edema, rhabdomyolysis, self-injury and irreversible neurological damage (Bassin 2002). The most common and potentially dangerous forms of status epilepticus are generalized convulsive status epilepticus, non- Brain Injuries | 47 convulsive generalized status epilepticus, refractory status epilepticus and myoclonic status epilepticus. Also, seizures that persist for longer than 5-10 minutes should be treated urgently because of the risk of permanent neurological injury and because seizures become refractory to therapy the longer they persist (Stasiukyniene 2009). General measures for management are shown in Table 4.

Professional groups aimed to address the implementation of the PCAM tool within annual reviews of patients with the LTCs specified generic levitra with dapoxetine 40/60mg without prescription, along with determining any potential barriers to the use of the model and how these could be overcome cheap 40/60mg levitra with dapoxetine visa. As the NPT was used as an analytic framework purchase levitra with dapoxetine 40/60 mg free shipping, the topic guides aimed to identify whether or not, and in what ways, nurses and other practice staff considered the PCAM to differ from existing ways of working; whether or not nurses and GPs could come to a collective agreement on the purpose of the PCAM; how practice staff understood what the PCAM required each of them to do; whether or not nurses and other practice staff constructed a potential value for the PCAM in the context of annual reviews; and whether or not nurses and other practice staff believed that the PCAM was an appropriate part of their work. Practical issues relating to the implementation of the embedded feasibility RCT and the PCAM in general were discussed to allow consideration to be given to how the individual requirements of different practices might be taken into account. This included discussion of what training may be needed to enable the use of the PCAM and how this could be delivered. Topics for discussion included what support patients needed to manage their conditions and whether or not primary care practitioners should play a role in helping them to manage life difficulties that might, potentially, have an impact on their health. The PCAM was then explained to patients and they were invited to discuss whether or not it was acceptable to them and whether or not they considered it useful in relation to their care. Patients were asked how PNs might best raise sensitive or difficult issues with them, and they were also asked about any potential barriers that nurses may experience in using the PCAM. Data analysis Data analysis involved constant comparison of key ideas/themes emerging from multiple staff reviews of focus group transcripts. Carina Hibberd, Eileen Calveley and Patricia Aitchison reviewed and compared patient and staff focus group transcripts as they became available. Data from staff and patient focus groups were organised separately within the database. Only designated members of the research team had access to the database. Carina Hibberd, Patricia Aitchison and Rebekah Pratt conducted initial, independent thematic analyses of focus group transcripts to devise a coding frame that was then discussed in detail by the wider analysis group (CH, PA, RP, EC and MM). Where required, analytical codes were amended at this stage by Rebekah Pratt, and descriptors were created to avoid duplication or lack of clarity in meaning. Rebekah Pratt recoded the entire data set based on the amended codes. For the purposes of this report, the key elements of analysis that are relevant to the acceptability and feasibility of using the PCAM tool in primary care-led annual reviews for LTCs, and for answering questions on the feasibility of a cluster RCT, are presented. The theory-driven NPT analysis will be presented in a future publication. Findings Recruitment of practices Figure 3 shows the number of GP practices contacted and subsequently recruited for focus group participation. Four practices agreed to take part in focus groups following telephone contact by researchers, two practices within NHS FV and two practices within NHS GGC. Our recruitment target for the number of focus groups was met. Recruitment to staff focus groups Sixteen health-care staff participated in the four focus groups. Participating health-care staff included PNs (n = 7), GPs (n = 3), PMs (n = 3), assistant PMs (n = 1) and administrative/reception staff (n = 2). The duration of staff focus group sessions ranged between 47 and 72 minutes. The four staff focus group sessions were held in the GP practice. Practices selected from ISD list [n = 98 (NHS FV 23, NHS GGC 75)] Practices excluded (n = 8) • Moved health board, n = 2 • LINKS, n = 5 • Too few nurses, n = 1 Practices invited by SPCRN [n = 90 (NHS FV 23, NHS GGC 66)] Practices declined (n = 4) Practices to be contacted by research team [n = 86 (NHS FV 20, NHS GGC 65)] Practices declined (n = 8) Practices excluded (n = 1) • Too few nurses, n = 1 Practices not contactable (n = 43) Practices contacted, not required (target achieved) (n = 30) Practices participating [n = 4 (NHS FV 2, NHS GGC 2)] FIGURE 3 The recruitment of practices to the focus group study. ISD, Information Services Division of National Services Scotland; LINKS, National Links Worker Programme (funded by the Scottish Government to make links between people and their communities through their GP practice). This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 19 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. STUDY A: ACCEPTABILITY AND IMPLEMENTATION REQUIREMENTS OF THE PATIENT CENTRED ASSESSMENT METHOD Recruitment to patient focus groups Two of the four participating GP practices agreed to host a patient focus group. A total of 27 patients returned a note of interest, of whom one could not be directly contacted, seven declined or could not attend, two agreed but did not attend and 17 attended and consented. As intended, patient focus groups included a mix of age groups and sex, and reflected the social demographics of participating practices (Table 1). One patient focus group was held in the GP practice, and one patient focus group was held in a local community centre because of limited meeting space in the GP practice. The duration of each patient focus group was 105 minutes. Patient perceptions of living with a chronic illness Participants described the struggle of coming to terms with living with a chronic illness. Some described a tension between rejecting their diagnosis and accepting the limitations of their condition, and how that had an impact on their ability to manage their condition.