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Background and objectiveCare for older patients in the ED is an increasingly important issue with the ageing society. To better assess the quality of care in this patient group, we assessed predictors for three outcomes related to ED care: being seen and discharged within 4 hours of ED arrival; being admitted from ED to hospital and reattending the ED within 30 days. We also used these outcomes to identify better-performing EDs.MethodsThe CUREd Research Database was used for a retrospective observational study of all 1 039 251 attendances by 368 754 patients aged 75+ years in 18 type 1 EDs in the Yorkshire and the Humber region of England between April 2012 and March 2017. We estimated multilevel logit models, accounting for patients’ characteristics and contact with emergency services prior to ED arrival, time variables and the ED itself.ResultsPatients in the oldest category (95+ years vs 75–80 years) were more likely to have a long ED wait (OR=1.13 (95% CI=1.10 to 1.15)), hospital admission (OR=1.26 (95% CI=1.23 to 1.29)) and ED reattendance (OR=1.09 (95% CI=1.06 to 1.12)). Those who had previously attended (3+ vs 0 previous attendances) were more likely to have long wait (OR=1.07 (95% CI=1.06 to 1.08)), hospital admission (OR=1.10 (95% CI=1.09 to 1.12)) and ED attendance (OR=3.13 (95% CI=3.09 to 3.17)). Those who attended out of hours (vs not out of hours) were more likely to have a long ED wait (OR=1.33 (95% CI=1.32 to 1.34)), be admitted to hospital (OR=1.19 (95% CI=1.18 to 1.21)) and have ED reattendance (OR=1.07 (95% CI=1.05 to 1.08)). Those living in less deprived decile (vs most deprived decile) were less likely to have any of these three outcomes: OR=0.93 (95% CI=0.92 to 0.95), 0.92 (95% CI=0.90 to 0.94), 0.86 (95% CI=0.84 to 0.88). These characteristics were not strongly associated with long waits for those who arrived by ambulance. Emergency call handler designation was the strongest predictor of long ED waits and hospital admission: compared with those who did not arrive by ambulance; ORs for these outcomes were 1.18 (95% CI=1.16 to 1.20) and 1.85 (95% CI=1.81 to 1.89) for those designated less urgent; 1.37 (95% CI=1.33 to 1.40) and 2.13 (95% CI=2.07 to 2.18) for urgent attendees; 1.26 (95% CI=1.23 to 1.28) and 2.40 (95% CI=2.36 to 2.45) for emergency attendees; and 1.37 (95% CI=1.28 to 1.45) and 2.42 (95% CI=2.26 to 2.59) for those with life-threatening conditions. We identified two EDs whose patients were less likely to have a long ED, hospital admission or ED reattendance than other EDs in the region.ConclusionsAge, previous attendance and attending out of hours were all associated with an increased likelihood of exceeding 4 hours in the ED, hospital admission and reattendance among patients over 75 years. These differences were less pronounced among those arriving by ambulance. Emergency call handler designation could be used to identify those at the highest risk of long ED waits, hospital admission and ED reattendance.

BackgroundLittle is known about how frailty impacts on older people’s experiences of emergency care, despite patient experience being essential to providing person-centred care. This qualitative study reports on the experiences of older people with frailty in the ED and their and their carers’ preferences for emergency care.MethodsOlder people (aged 75+ years) who were at least mildly frail and/or their carers, with current or recent experience of emergency care, were recruited from three EDs in England between January and June 2019. Data were collected via semi-structured in-depth interviews which explored participants’ views on their recent experience of emergency care and their priorities and preferred outcomes. Interviews were audio-recorded, transcribed verbatim and analysed following the principles of the Framework approach.ResultsForty participants were interviewed: 24 patients and 16 carers who, between them, described ED attendances for 28 patients across the three sites. Often informed by previous negative experiences, there was a strong desire to avoid conveyance to EDs, and a sense of helplessness or acquiescence to attend. Although staff attitudes were on the whole seen as positive, the ED experience was dominated by negative experiences relating to very basic issues such as a lack of help with eating, drinking, toileting and discomfort from long waits on hard trolleys. Participants reported that communication and involvement in decision making could be improved, including involving next of kin, who were viewed as critical to supporting vulnerable older people during sometimes very protracted waits.ConclusionFrailty reflects a vulnerability and a need for support in basic activities of daily living, which EDs in this study, and perhaps more widely, are not set up to provide. Changes at the levels of clinical practice and service design are required to deliver even the most basic care for older people with frailty in the ED environment.

Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.

Research highlights how coexisting institutional logics can sometimes offer opportunities for agency to enterprising actors in organizational fields. But macro- and micro-level studies using this framework diverge in their approach to understanding the consequences of institutional complexity for actor autonomy, and correspondingly in the opportunities they identify for agents to resist, reinterpret or make judicious use of institutional prescriptions. This paper seeks to bridge this gap, through a longitudinal, comparative case study of the trajectories of four ostensibly similar change initiatives in the same complex organizational field. It studies the influence of three dominant institutional logics (professional, market and corporate) in these divergent trajectories, elucidating the role of mediating influences, operating below the level of the field but above that of the actor, that worked to constrain or facilitate agency. The consequence for actors was a divergent realization of the relationship between the three logics, with very different consequences for their ability to advance their interests. Our findings offer an improved understanding of when and how institutional complexity facilitates autonomy, and suggests mediating influences at the level of the organization and the relationship it instantiates between carriers of logics, neglected by macro- and micro-level studies, that merit further attention.

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Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as ‘magic bullets’ that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process. This article considers these challenges and proposes four key ways in which QI might itself be improved.

Mindfulness is defined as a non-judgemental awareness and accepting of present-moment experience. With intentional attendance to one's ongoing stream of thoughts, sensations and emotions as they arise, it allows the individual to react with less impulsivity and flexibility. However, empirical findings of mindfulness to date have largely been confined to outcome studies using clinical populations. This cross-sectional study examined the relationships between mindfulness, self-esteem, resiliency and mental health symptoms (anxiety, stress, depression and cognitive inflexibility) in a sample of 106 healthy adolescents. Participants completed a set of questionnaires. First, we found moderate effect size for anxiety, depression and self-esteem and large effect size for cognitive inflexibility. These results, when compared with clinical samples, demonstrated similar trends found in a healthy adolescent sample. Second, predictive value of mindfulness was examined and we found significant contribution of mindfulness to mental and psychological health.

Non-suicidal self-injury (NSSI) refers to socially unacceptable behavior causing intentional and direct injury to one’s own body tissue without conscious suicidal intent. Recent literature has highlighted the importance of examining the interaction between intrapersonal (e.g. coping, psychopathology) and interpersonal risk factors (e.g. psychopathology in family, family abuse, parenting), for enhancing our understanding of NSSI. The present study adds to this by investigating the association between NSSI, adolescent depressive feelings, and perceived family functioning. A sample of 358 adolescents was assessed by means of self-report measures for (1) NSSI behavior (NSSI-AT), (2) depressive symptoms (CDI-NL), and (3) perceived family functioning (FAD-NL). The prevalence rate of NSSI was 14.29%. Data suggest that general dysfunction of the family as a whole, poor affective involvement, and excessive behavioral control uniquely distinguished between adolescents engaging in NSSI and adolescents not engaging in NSSI. The association between family functioning and NSSI was partially mediated by depressive symptoms. The implications of the findings for further research, prevention, and intervention of NSSI are discussed.

Burn injury is one of the most traumatic injuries a child or adolescent can experience. When a burn injury occurs, the child can suffer pain, uncertainty, fear, and trauma from acute treatment to rehabilitation and reintegration. He or she can also experience long-term psychosocial and psychological difficulties. The objective of the study was to compare health-related quality of life (HRQoL), psychopathology, and self-concept of children who have suffered a burn injury with a matched sample of healthy controls. Sixty-six children and adolescents with a burn injury, who were aged between 8 to 17 years, and a caregiver were recruited from six burn centers in Australia and New Zealand. Participants completed the Paediatric Quality of Life Inventory, the Strengths and Difficulties Questionnaire, and the Piers-Harris Self-Concept Scale (P-H SCS). Scores were compared with published normative data. As scarring and appearance are a distinct issue, the Paediatric Quality of Life Inventory cancer module perceived physical appearance subscale was also included. Pediatric burn survivors and their caregivers reported significantly higher emotional and behavioral problems and lower HRQoL, but no significant differences in self-concept compared with healthy counterparts. Pediatric burn survivors also reported significantly poorer perceived physical appearance than the matched pediatric cancer sample. Burned children reported lowered quality of life, particularly related to scarring and appearance; however, they reported normative self-concept. This may be because of self-concept being a psychological trait, whereas HRQoL is influenced by societal norms and expectations. Psychosocial support is necessary to build positive coping strategies and manage the unpleasant social experiences that may reduce quality of life.

Food supplementation can potentially provide additional energy and/or liberate time usually devoted to foraging, enabling birds to invest more in activities, such as nest construction, that provide long-term fitness benefits. Although nest construction can represent large temporal and energetic investments in a breeding attempt, few studies have investigated how it is influenced by food supplementation. We studied the effects of food supplementation on nest construction by Blue Tits (Cyanistes caeruleus) and Great Tits (Parus major). We found that food supplementation advanced nest construction and egg laying in both species. Food supplementation also resulted in truncation of the nest construction period of Blue Tits, but not Great Tits. The duration of the nest-lining period was not influenced by food supplementation in either species. Unexpectedly, food supplementation resulted in significantly shallower nests in Blue Tits but not in Great Tits. We conclude that food availability can constrain nest construction behaviour and that these constraints can be released by the provision of supplementary foods prior to and throughout nest construction.

AbstractNon-suicidal self-injury (NSSI) and under-age alcohol use are dysfunctional coping behaviors used to alleviate negative feelings. However, little is known regarding what mechanisms lead to engagement in NSSI as opposed to alcohol use, or what might infl uence co-occurrence of these behaviors. A total of 2,590 secondary school students (aged 12–17) from fi ve Australian states completed self-report questionnaires measuring NSSI, alcohol use and a range of sociodemographic and psychosocial factors. The fi ndings suggest that adolescent engagement in NSSI is associated with more internal factors, such as psychological distress, poor coping and problem-solving skills, whereas alcohol use is associated with age and gender, as well as more external factors, such as social support and coping by turning to others. Co-morbidity between alcohol use and NSSI is associated with a combination of these factors. Implications of these fi ndings will be discussed with regard to prevention and early intervention initiatives.

The creation of new roles commonly threatens the power and status of elite professionals through the substitution of their labour. In this paper we examine the institutional work carried out by elite professionals to maintain their professional dominance when threatened. Drawing on 11 case sites from the English National Health Service (NHS) where new nursing or medical roles have been introduced, threatening the power and status of specialist doctors, we observed the following. First, the professional elite respond through institutional work to supplant threat of substitution with the opportunity for them to delegate routine tasks to other actors and maintain existing resource and control arrangements over the delivery of services in a way that enhances elite professionals’ status. Second, other professionals outside the professional elite, but relatively powerful within their own professional group, are co-opted by the professional elite to engage in institutional work to maintain existing arrangements. Our work extends Lawrence and Suddaby’s typology of institutional work in three ways. First, we reveal how different types of institutional work interact, and how different types of institutional work cross categories of creating or maintaining institutions. Second, we show how an actor’s social position or status, both intra-professionally as well as inter-professionally, in the institutional field frame the institutional work they engage in. Third, the institutional work of ‘theorizing’ by professional elites appears particularly significant, specifically the focus of the institutional work to invoke the concept of ‘risk’ associated with any change in service delivery, which maintains the model of medical professionalism.

Data is not necessarily Information. Information is not necessarily Knowledge, Knowledge is not necessarily Wisdom And none of the above is Action

Data is not necessarily Information. Information is not necessarily Knowledge, Knowledge is not necessarily Wisdom And none of the above is Action

Masked boobies Sula dactylatra, like many other species of Sulidae, do not construct elaborate nests. However, their nest sites produce a characteristic ‘nest signature’. We found that these nest signatures could apparently be seen in freely available satellite images (Google EarthTM) of the main island of Ascension in the south Atlantic. We verified that this was the case by comparing nest signatures detected on these satellite images with field reports of occupied nests. We found that the locations of these nest signatures determined from satellite images agreed closely with the coordinates of actual nests on the ground. We used this information to determine the position and size of a previously unreported masked booby colony on the island. Thus, we show that the presence and abundance of some species can be estimated using freely available satellite imagery if a suitable signature in the satellite image can be found. Regularly updated satellite imagery of target sites could also be used for population monitoring. While this would be expensive, initial evaluation of the technique for particular species or populations can be achieved using freely available images. We encourage wildlife managers to view their study sites on Google EarthTMfor evidence of their target species.