scholarly journals Point-of-care blood tests during home visits by out-of-hours primary care clinicians; a mixed methods evaluation of a service improvement

BMJ Open ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. e033428
Author(s):  
Gail Hayward ◽  
Sharon Dixon ◽  
Sophie Garland ◽  
Margaret Glogowska ◽  
Helen Hunt ◽  
...  
Keyword(s):  
Primary Care ◽  
Mixed Methods ◽  
Point Of Care ◽  
Home Visits ◽  
Total Carbon ◽  
Secondary Outcome ◽  
Service Improvement ◽  
Team Approach ◽  
Out Of Hours ◽  
Blood Tests

ObjectivesWe aimed to evaluate test usage and patient and clinician experience following the introduction of point-of-care (POC) blood tests into a primary care out-of-hours service.DesignA mixed methods service evaluation comprising quantitative records of the clinical contexts of tests taken and qualitative interviews with clinicians. Research permissions and governance were obtained for patient interviews.SettingOut-of-hours primary care.ParticipantsAll patients requiring home visits from the service during the implementation period.InterventionsThe i-STAT POC blood test platform was introduced to two bases providing home visits for a period of 8 months. Venous blood samples were used and two cartridges were available. The CHEM8 cartridge measures sodium, potassium, chloride, total carbon dioxide (TCO2), anion gap, ionised calcium, glucose, urea, creatinine, haematocrit and haemoglobin. The CG4 cartridge measures lactate, pH, PaO2 and PCO2, TCO2, bicarbonate, base excess and oxygen saturation.Primary and secondary outcome measuresThe proportion of home visits where tests were taken, the clinical contexts of those tests, the extent to which clinicians felt the tests had influenced their decisions, time taken to perform the test and problems encountered. Clinician and patient experiences of using POC tests.Resultsi-STAT POC tests were infrequently used, with successful tests taken at just 47 contacts over 8 months of implementation. The patients interviewed felt that testing had been beneficial for their care. Clinician interviews suggested barriers to POC tests, including practical challenges, concerns about time, doubt over whether they would improve clinical decision making and concern about increased medicolegal risk. Suggestions for improving adoption included sharing learning, adopting a whole team approach and developing protocols for usage.ConclusionsPOC tests were not successfully adopted by an out-of-hours home visiting service in Oxfordshire. While some clinicians felt they could not add value, in other cases they resulted in improved patient experience. Adoption could be promoted by improving technical, team and education factors.

scholarly journals Clinician perspectives on having point of care tests made available to them during out of hours home visiting

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
S. Dixon ◽  
M. Glogowska ◽  
S. Garland ◽  
H. Hunt ◽  
D. Lasserson ◽  
...  
Keyword(s):  
Decision Making ◽  
Nurse Practitioners ◽  
Home Visiting ◽  
Clinical Decision Making ◽  
Point Of Care ◽  
Home Visits ◽  
Service Improvement ◽  
Improvement Project ◽  
Out Of Hours ◽  
Clinical Scenarios

Abstract Background Little is known about clinicians’ perspectives on the use of point of care (POC) tests in assessment of acute illness during primary care out of hours (OOH) care. During a service improvement project, POC tests (including creatinine, electrolytes, haemoglobin and lactate) were made available to clinicians undertaking OOH home visits, with the clinicians allowed absolute discretion about when and whether they used them. Method To explore clinicians’ perspectives on having POC tests available during OOH home visits, we undertook a qualitative study with clinicians working in Oxfordshire OOH home visiting teams. We conducted 19 Semi-structured interviews with clinicians working in OOH, including those who had and had not used the POC tests available to them. To explore evolving perspectives over time, including experience and exposure to POC tests, we offered clinicians the opportunity to be interviewed twice throughout the study period. Our sample included 7 GPs (4 interviewed once, 3 interviewed twice - earlier and later during the study), 6 emergency practitioners (EPs) including advanced nurse practitioners and paramedics, 1 Healthcare Assistant, and 2 ambulatory care physicians. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Results The clinicians reflected on their decision-making to use (or not use) POC tests, including considering which clinical scenarios were “appropriate” and balancing the resources and time taken to do POC tests against what were perceived as likely benefits. The challenges of using the equipment in patients’ homes was a potential barrier, though could become easier with familiarity and experience. Clinicians who had used POC tests described benefits, including planning onward care trajectories, and facilitating communication, both between professionals and with patients and their families. Conclusion Clinicians described a discriminatory approach to using POC tests, considering carefully in which situations they were likely to add value to clinical decision-making.

scholarly journals Is an opportunistic primary care-based intervention for non-responders to bowel screening feasible and acceptable? A mixed-methods feasibility study in Scotland

BMJ Open ◽  
2017 ◽  
Vol 7 (10) ◽  
pp. e016307 ◽  
Author(s):  
Natalia Calanzani ◽  
Debbie Cavers ◽  
Gabriele Vojt ◽  
Sheina Orbell ◽  
Robert J C Steele ◽  
...  
Keyword(s):  
Primary Care ◽  
Mixed Methods ◽  
Feasibility Study ◽  
Occult Blood ◽  
Secondary Outcome ◽  
Structured Interviews ◽  
Framework Analysis ◽  
Test Kit ◽  
General Practices ◽  
Primary Care Professionals

ObjectivesWe aimed to test whether a brief, opportunistic intervention in general practice was a feasible and acceptable way to engage with bowel screening non-responders.DesignThis was a feasibility study testing an intervention which comprised a brief conversation during routine consultation, provision of a patient leaflet and instructions to request a replacement faecal occult blood test kit. A mixed-methods approach to evaluation was adopted. Data were collected from proformas completed after each intervention, from the Bowel Screening Centre database and from questionnaires. Semi-structured interviews were carried out. We used descriptive statistics, content and framework analysis to determine intervention feasibility and acceptability.ParticipantsBowel screening non-responders (as defined by the Scottish Bowel Screening Centre) and primary care professionals working in five general practices in Lothian, Scotland.Primary and secondary outcome measuresSeveral predefined feasibility parameters were assessed, including numbers of patients engaging in conversation, requesting a replacement kit and returning it, and willingness of primary care professionals to deliver the intervention.ResultsThe intervention was offered to 258 patients in five general practices: 220 (87.0%) engaged with the intervention, 60 (23.3%) requested a new kit, 22 (8.5%) kits were completed and returned. Interviews and questionnaires suggest that the intervention was feasible, acceptable and consistent with an existing health prevention agenda. Reported challenges referred to work-related pressures, time constraints and practice priorities.ConclusionsThis intervention was acceptable and resulted in a modest increase in non-responders participating in bowel screening, although outlined challenges may affect sustained implementation. The strategy is also aligned with the increasing role of primary care in promoting bowel screening.

scholarly journals Provider perspectives on general practice in Henan, China: a mixed-methods study

BMJ Open ◽  
2020 ◽  
Vol 10 (2) ◽  
pp. e036240
Author(s):  
Jiming Zhu ◽  
Proochista Ariana
Keyword(s):  
Public Health ◽  
Primary Care ◽  
General Practice ◽  
Mixed Methods ◽  
Central Government ◽  
Point Of Care ◽  
Primary Care System ◽  
Common People ◽  
Provider Perspectives ◽  
Care System

ObjectiveSince 2011 China’s central government has committed to establishing a new ‘general practitioner’ (GP)-centred primary care system. To this end there have been great efforts to train an additional 300 000 GPs by 2020. This paper examines the perspective of practitioners in Henan, China, regarding general practice.DesignA mixed-methods approach using focus group discussions (FGD), and structured questionnaires.Setting/participantsSeven FGDs and responses to 1887 questionnaires included medical students, primary care doctors and GP residents in Henan.ResultsThe three surveyed medical groups have some awareness of the attributes of general practice (eg, comprehensiveness, first contact and coordination), but often misinterpret what being a GP entails. Five themes were identified through the FGDs and tested quantitatively for their prevalence with structured questionnaires. First, the GPs’ role as a comprehensive care provider was (mis)interpreted as an ‘all-round doctor’. Second, the GP’s responsibility as the first point of care was understood in two conflicting ways: private personal doctors of the rich and the powerful or village doctors for common people. Third, referral was understood as simply guiding patients to appropriate departments within the hospital while the gatekeeping role was interpreted to involve GPs being peoples’ health protectors rather than being also gatekeepers of specialty services. Traditional Chinese medicine now further complicates the understanding of GPs. And lastly, the GPs’ main responsibility was considered to be public health work.ConclusionThe misunderstandings of the roles and responsibilities of GPs render problematic the policy foundation of China’s GP-centred primary care system. Pursuing the quantity of GPs on its own is meaningless, since the number needed depends on the delineated role of GPs. Top priority is to establish clarity about the GP role, which requires reforming the health delivery system to address issues with fragmented care, strategically taking into account the development of GPs with work delegation and substitution and providing more clarity on the distinction between general practice and public health.

C-reactive protein point-of-care testing in acutely ill children: a mixed methods study in primary care

2016 ◽  
Vol 101 (4) ◽  
pp. 382-386 ◽  
Author(s):  
Ann Van den Bruel ◽  
Caroline Jones ◽  
Matthew Thompson ◽  
David Mant
Keyword(s):  
Primary Care ◽  
Mixed Methods ◽  
Qualitative Study ◽  
Point Of Care ◽  
Mixed Methods Study ◽  
Contributory Factor ◽  
Antibiotic Prescribing ◽  
Point Of Care Testing ◽  
C Reactive Protein ◽  
Reactive Protein

BackgroundPoint-of-care C-reactive protein (CRP) testing of adults with acute respiratory infection in primary care reduces antibiotic prescribing by 22%. The acceptability and impact of CRP testing in children is unknownObjectiveTo determine the acceptability and impact of CRP testing in acutely ill children.DesignMixed methods study comprising an observational cohort with a nested randomised controlled trial and embedded qualitative study.Subjects and settingChildren presenting with an acute illness to general practice out-of-hours services; children with a temperature ≥38°C were randomised in the nested trial; parents and clinical staff were invited to the qualitative study.Main outcomesInformed consent rates; parental and staff views on testing.ResultsConsent to involvement in the study was obtained for 200/297 children (67.3%, 95% CI 61.7% to 72.6%); the finger-prick test might have been a contributory factor for 63 of the 97 children declining participation but it was cited as a definite factor in only 10 cases. None of the parents or staff raised concerns about the acceptability of testing, describing the pain caused as minor and transient. General practitioner views on the utility of the CRP test were inconsistent.ConclusionsCRP point-of-care testing in children is feasible in primary care and is likely to be acceptable. However, it will not reduce antibiotic prescribing and hospital referrals until general practitioners accept its diagnostic value in children.Trial registration numberISRCTN 69736109.

scholarly journals Frequencies and patterns of microbiology test requests from primary care in Oxfordshire, UK, 2008–2018: a retrospective cohort study of electronic health records to inform point-of-care testing

BMJ Open ◽  
2021 ◽  
Vol 11 (11) ◽  
pp. e048527
Author(s):  
JM Ordóñez-Mena ◽  
Thomas R Fanshawe ◽  
Dona Foster ◽  
Monique Andersson ◽  
Sarah Oakley ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Urine Culture ◽  
Point Of Care ◽  
Temporal Trends ◽  
Secondary Outcome ◽  
Point Of Care Test ◽  
Primary Care Practices

ObjectivesTo inform point-of-care test (POCT) development, we quantified the primary care demand for laboratory microbiology tests by describing their frequencies overall, frequencies of positives, most common organisms identified, temporal trends in testing and patterns of cotesting on the same and subsequent dates.DesignRetrospective cohort study.SettingPrimary care practices in Oxfordshire.Participants393 905 patients (65% female; 49% aged 18–49).Primary and secondary outcome measuresThe frequencies of all microbiology tests requested between 2008 and 2018 were quantified. Patterns of cotesting were investigated with heat maps. All analyses were done overall, by sex and age categories.Results1 596 752 microbiology tests were requested. Urine culture±microscopy was the most common of all tests (n=673 612, 42%), was mainly requested without other tests and was the most common test requested in follow-up within 7 and 14 days. Of all urine cultures, 180 047 (27%) were positive and 172 651 (26%) showed mixed growth, and Escherichia coli was the most prevalent organism (132 277, 73% of positive urine cultures). Antenatal urine cultures and blood tests in pregnancy (hepatitis B, HIV and syphilis) formed a common test combination, consistent with their use in antenatal screening.ConclusionsThe greatest burden of microbiology testing in primary care is attributable to urine culture ± microscopy; genital and routine antenatal urine and blood testing are also significant contributors. Further research should focus on the feasibility and impact of POCTs for these specimen types.

scholarly journals Treatment of patients with a pituitary adenoma: one clinican's experience

2004 ◽  
Vol 16 (4) ◽  
pp. 1-6 ◽  
Author(s):  
Mary Lee Vance
Keyword(s):  
Primary Care ◽  
Pituitary Adenoma ◽  
Cushing Syndrome ◽  
Hormone Secretion ◽  
Primary Treatment ◽  
Care Physician ◽  
Pituitary Hormone ◽  
Team Approach ◽  
Blood Tests ◽  
Pituitary Lesion

The diagnosis and treatment of a patient with a pituitary adenoma or another type of pituitary lesion requires a team approach involving the neurosurgeon, endocrinologist, primary care physician, and, in some patients, an ophthalmologist and radiation therapist. The diagnosis of excessive pituitary hormone secretion and/or loss of pituitary function is based on biochemical findings and can usually be confirmed by performing blood tests, except for patients with suspected Cushing syndrome. The primary treatment of pituitary adenomas is resection, except in patients with a prolactin-producing tumor, who are most successfully treated medically with a dopamine agonist. In this article the author reviews the principles of diagnosis and treatments and offers recommendations for ideal patient care.

scholarly journals Consultations for gastroenteritis in general practice and out-of-hours services in Norway 2006–15

2019 ◽  
Vol 36 (5) ◽  
pp. 614-620
Author(s):  
Knut Erik Emberland ◽  
Knut-Arne Wensaas ◽  
Sverre Litleskare ◽  
Guri Rortveit
Keyword(s):  
Primary Care ◽  
General Practice ◽  
Young Adults ◽  
Young Children ◽  
Health Care Services ◽  
Point Of Care ◽  
Outcome Variable ◽  
Gastrointestinal Infections ◽  
Out Of Hours ◽  
Children And Young Adults

Abstract Background Most of the patients with gastroenteritis seeking health care services are managed in primary care; yet, little is known about these consultations. Syndromic-based surveillance of gastrointestinal infections is used in several countries, including Norway. Aim To investigate the extent of, and explore characteristics associated with, consultations for gastroenteritis in primary care and to compare consultations in daytime general practice and out-of-hours (OOH) services in Norway. Design and Setting Registry-based study using reimbursement claims data from all consultations in general practice and OOH services in Norway over the 10-year period, 2006–15. Methods The main outcome variable was whether the consultation took place in general practice or OOH services. Possible associations with patient age and sex, time and use of point-of-care C-reactive protein (CRP) testing and sickness certificate issuing were investigated. Results Gastroenteritis consultations (n = 1 281 048) represented 0.9% of all consultations in primary care (n = 140 199 637), of which 84.4% were conducted in general practice and 15.6% in OOH services. Young children and young adults dominated among the patients. Point-of-care CRP testing was used in 36.1% of the consultations. Sickness certificates were issued in 43.6% of consultations with patients in working age. Age-specific time variations in consultation frequencies peaking in winter months were observed. Conclusions The proportion of gastroenteritis consultations was higher in the OOH services when compared with daytime general practice. Young children and young adults dominated among the patients. The seasonal variation in consultation frequency is similar to that shown for gastroenteritis caused by norovirus.

scholarly journals Funding and policy incentives to encourage implementation of point-of-care C-reactive protein testing for lower respiratory tract infection in NHS primary care: a mixed-methods evaluation

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e024558 ◽  
Author(s):  
Matthew Johnson ◽  
Liz Cross ◽  
Nick Sandison ◽  
Jamie Stevenson ◽  
Thomas Monks ◽  
...  
Keyword(s):  
Primary Care ◽  
Mixed Methods ◽  
Tract Infection ◽  
Respiratory Tract ◽  
Respiratory Tract Infection ◽  
Lower Respiratory Tract ◽  
Point Of Care ◽  
Implementation Study ◽  
C Reactive Protein ◽  
Reactive Protein

ObjectivesUtilisation of point-of-care C-reactive protein testing for lower respiratory tract infection has been limited in UK primary care, with costs and funding suggested as important barriers. We aimed to use existing National Health Service funding and policy mechanisms to alleviate these barriers and engage with clinicians and healthcare commissioners to encourage implementation.DesignA mixed-methods study design was adopted, including a qualitative survey to identify clinicians’ and commissioners’ perceived benefits, barriers and enablers post-implementation, and quantitative analysis of results from a real-world implementation study.InterventionsWe developed a funding specification to underpin local reimbursement of general practices for test delivery based on an item of service payment. We also created training and administrative materials to facilitate implementation by reducing organisational burden. The implementation study provided intervention sites with a testing device and supplies, training and practical assistance.ResultsDespite engagement with several groups, implementation and uptake of our funding specification were limited. Survey respondents confirmed costs and funding as important barriers in addition to physical and operational constraints and cited training and the value of a local champion as enablers.ConclusionsAlthough survey respondents highlighted the clinical benefits, funding remains a barrier to implementation in UK primary care and appears not to be alleviated by the existing financial incentives available to commissioners. The potential to meet incentive targets using lower cost methods, a lack of policy consistency or competing financial pressures and commissioning programmes may be important determinants of local priorities. An implementation champion could help to catalyse support and overcome operational barriers at the local level, but widespread implementation is likely to require national policy change. Successful implementation may reproduce antibiotic prescribing reductions observed in research studies.

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