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Abstract Background Given the increasing recognition of the value of greater integration of physical and mental health services for children and young people, we aimed to evaluate preferences among parents for the characteristics associated with integrated health service provision for two conditions (eating disorders, functional symptom disorders). Methods Two discrete choice experiments (DCEs) were conducted, using electronic surveys. Participants were adult parents of children and young people. Choice scenarios were based on five attributes for the eating disorders study, and four attributes for the functional symptom disorders study. Results Two hundred parents participated in each DCE. For eating disorders, days missed from school in the last year was the attribute valued most highly, followed by days in hospital in the last year, costs to the NHS, functioning, and interaction with peers with eating disorders. Respondents were willing to trade £531 of costs to the NHS for one less day missed from school. For functional symptom disorders, time to diagnosis was valued most highly, followed by days missed from school while obtaining a diagnosis, reservations about seeing a mental health practitioner, and costs of diagnosis to the NHS. Respondents were willing to trade £4237 of costs to the NHS to wait one month less for a diagnosis. Conclusion Respondents’ preferences were largely consistent with the planned goals of integrating physical and mental health services. Our findings show the factors which ought to be considered when designing new integrated pathways and evaluating them.

High-pressure air injection (HPAI) is an enhanced oil recovery process in which compressed air is injected into deep, light oil reservoirs, with the expectation that the oxygen in the injected air will react with a fraction of the reservoir oil at an elevated temperature to produce carbon dioxide. The different chemical reactions taking place can be grouped into oxygen addition, thermal cracking, oxygen-induced cracking, and bond scission reactions. The latter reactions involve the combustion of a flammable vapor as well as the combustion of solid fuel, commonly known as “coke”. Since stable peak temperatures observed during HPAI experiments are typically below 300 °C, it has been suggested that thermal cracking and combustion of solid fuel may not be important reaction mechanisms for the process. The objective of this work is to assess the validity of that hypothesis. Therefore, this study makes use of different oxidation and combustion HPAI experiments, which were performed on two different light oil reservoir samples. Modeling of those tests indicate that thermal cracking is not an important reaction mechanism during HPAI and can potentially be ignored. The work also suggests that the main fuel consumed by the process is a flammable vapor generated by the chemical reactions. This represents a shift from the original in situ combustion paradigm, which is based on the combustion of coke.

Objective To explore patient and public perceptions of planned improvements to the National Health Service (NHS) total joint arthroplasty (TJA) pathway.Design Three qualitative focus groups undertaken March–May 2018, as part of a mixed-methods evaluation of Getting It Right First Time. Transcripts were subject to framework analysis to identify thematic content between October 2018 and October 2021.Setting Elective TJA surgery in the English NHS.Participants Two focus groups including patients who had undergone TJA in the previous 2 years (group 1: n=5; group 2: n=4) and the other individuals who had not but were aged 60+ (group 3: n=5). Participants were recruited via community groups and patient panels.Results Fourteen individuals took part in the focus groups; all were aged over 60; seven (50%) were female and nine (64%) had undergone TJA surgery. Participants’ perspectives were categorised into themes and mapped onto stages of the TJA pathway. Although perioperative care is often the focus of improvement efforts, participants argued that the patient journey begins before individuals present to primary care. Participants had concerns about other aspects of the pathway, such as obtaining a surgical referral, with prereferral interventions aimed at potentially avoiding the need for surgery (ie, physiotherapy) being perceived as a mechanism to restrict access to secondary care. Patient experience was also conceptualised as a ‘maze’, rather than the logical, sequential process set out in clinical guidelines; exacerbated by a lack of information, knowledge and power imbalances.Conclusion The linear conceptualisation of the TJA pathway is at odds with patient experience. Improvement programmes focused on perioperative care fail to consider patient concerns and priorities. Patients should be directly involved in improvement programmes, to ensure that patient experience is optimised, as well as informing related processes and important outcomes of care.

Objective To describe the implementation and impact of the Getting it Right First Time (GIRFT) national orthopaedic improvement programme at the level of individual National Health Service (NHS) Trusts.Design Qualitative case studies conducted at six NHS Trusts, as part of a mixed-methods evaluation of GIRFT.Setting NHS elective orthopaedic surgery in England.Participants 59 NHS staff.Intervention Improvement bundle, including bespoke routine performance data and improvement recommendations for each organisation, delivered via ‘deep-dive’ visits to NHS Trusts by a senior orthopaedic clinician.Results Although all case study sites had made improvements to care, very few of these were reportedly a direct consequence of GIRFT. A range of factors, operating at three different levels, influenced their ability to implement GIRFT recommendations: at the level of the orthopaedic team (micro—eg, how individuals perceived the intervention); the wider Trust (meso—eg, competition for theatre/bed space) and the health economy more broadly (macro—eg, requirements to form local networks). Some sites used GIRFT evidence to support arguments for change which helped cement and formalise existing plans. However, where GIRFT measures were not a Trust priority because of more immediate demands—for example, financial and bed pressures—it was less likely to influence change.Conclusion Dynamic relationships between the different contextual factors, within and between the three levels, can impact the effectiveness of a large-scale improvement intervention and may account for variations in implementation outcomes in different settings. When designing an intervention, those leading future improvement programmes should consider how it sits in relation to these three contextual levels and the interactions that may occur between them.

Background: In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. Objective: To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. Design: A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality); acceptability (whether or not clinicians want to use it); impact (on outcomes, safety, experience and cost-effectiveness); and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23); a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400; April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650; July 2018 to December 2020). Results: (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability – relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for ‘refresher’ courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability – most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety – clinical leaders monitored and managed potential patient safety issues; clinicians felt strongly that services were safe. Implementation – several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact on safety and quality: we found no evidence of increased times from symptom onset to arrival at services or of stroke clinical interventions reducing in studied areas. We found several significant improvements relative to the rest of England (possibly resulting from other service changes). Limitations: We could not interview patients and carers. Ambulance data had no historic or regional comparators. Stroke audit data were not at patient level. Several safety issues were not collected routinely. Our survey used a convenience sample. Conclusions: Prehospital video triage was perceived as usable, acceptable and safe in both areas. Future research: Qualitative research with patients, carers and other stakeholders and quantitative analysis of patient-level data on care delivery, outcomes and cost-effectiveness, using national controls. Focus on sustainability and roll-out of services. Study registration: This study is registered as PROSPERO CRD42021254209. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 26. See the NIHR Journals Library website for further project information.

Objective To evaluate the impact of the ‘Getting it Right First Time’ (GIRFT) national improvement programme in orthopaedics, which started in 2012.Design Mixed-methods study comprising statistical analysis of linked national datasets (National Joint Registry; Hospital Episode Statistics; Patient-Reported Outcomes); economic analysis and qualitative case studies in six National Health Service (NHS) Trusts.Setting NHS elective orthopaedic surgery in England.Participants 736 088 patients who underwent primary hip or knee replacement at 126 NHS Trusts between 1 April 2009 and 31 March 2018, plus 50 NHS staff.Intervention Improvement bundle including ‘deep dive’ visits by senior clinician to NHS Trusts, informed by bespoke set of routine performance data, to discuss how improvements could be made locally.Main outcome measures Number of procedures conducted by low volume surgeons; use of uncemented hip implants in patients >65; arthroscopy in year prior to knee replacement; hospital length of stay; emergency readmissions within 30 days; revision surgery within 1 year; health-related quality of life and functional status.Results National trends demonstrated substantial improvements beginning prior to GIRFT. Between 2012 and 2018, there were reductions in procedures by low volume surgeons (ORs (95% CI) hips 0.58 (0.53 to 0.63), knees 0.77 (0.72 to 0.83)); uncemented hip prostheses in >65 s (OR 0.56 (0.51 to 0.61)); knee arthroscopies before surgery (OR 0.48 (0.41 to 0.56)) and mean length of stay (hips −0.90 (−1.00 to -0.81), knees −0.74 days (−0.82 to −0.66)). The additional impact of visits was mixed and comprised an overall economic saving of £431 848 between 2012 and 2018, but this was offset by the costs of the visits. Staff reported that GIRFT’s influence ranged from procurement changes to improved regional collaboration.Conclusion Nationally, we found substantial improvements in care, but the specific contribution of GIRFT cannot be reliably estimated due to other concurrent initiatives. Our approach enabled additional analysis of the discrete impact of GIRFT visits.

Worldwide, the known recoverable heavy oil and bitumen reserves make up more than 64% of the total reserves, of which more than 60% are trapped in carbonates. Air injection has immense potential for hydrocarbon recovery from various reservoirs. While most of the successful air-based techniques are performed within carbonate reservoirs containing light oil, theoretically, in situ combustion (ISC) has also shown great potential for recovering heavy oil and bitumen. Carbonates are complex in terms of geology and are often associated with fractures and vugs that affect the fluid flow, pressure propagation and progression of the ISC reactions. This paper describes the first experiment in which the triple-porosity concept was applied to simulate heterogeneity through artificially induced vugs, core matrix and fractures. This approach was used to study the feasibility of the ISC recovery technique for heavy oil (14° API) within a dolomite reservoir using a combustion tube (CT) in an experiment performed at 1740 psig. The combustion front advanced through 78% of the core length prior to the termination of air injection, producing 80% of the initial oil. To differentiate between the various sources of the CO2 gas (a product of carbonate decomposition vs. the combustion reaction) the atomic ratios of (CO2 + CO)/CO = 6 and (CO2 + CO)/N2 = 0.21 were applied. Additionally, partial upgrading of the produced heavy oil was observed.

In the present study, we report a controlled growth of tin oxide and tin oxide: carbon nanoparticles by an integrated method comprising of the gas phase agglomeration, electrical mobility based size selection, and in–flight sintering steps. The effect of in-flight sintering temperature and variation in growth environment (N2, H2 and O2) during nanoparticle formation, morphology and composition has been investigated by carrying out High Resolution Transmission Electron microscopy and X-Ray diffraction studies. The results highlight the novelty of the present technique to grow alloy and core-shell nanoparticles in which the stoichiometery (x) of SnOx and the mode of incorporation of carbon into the tin oxide lattice (alloy or core-shell structure), along with well-defined size can be controlled independently. Detailed Photoluminescence (PL) studies of well sintered monocrystalline SnO, SnOx and SnO2 nanoparticles along with SnOx:C and SnO2:C alloy and C@SnO core-shell nanoparticle has been carried out. The shift in the position and nature of PL peaks due to band edge, Sn interstitials and oxygen vacancy defect level energy states has been understood as a function of stoichiometery and nanoparticle structure (alloy and core-shell). These results suggest the possibility of tailoring the position of these levels by controlling the size, composition and alloying which is potentially important for gas sensing, photoconductivity and photo-electrochemical applications.

Background: The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied., Objective: We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices., Methods: This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note., Results: Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42]., Conclusion: Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation., Competing Interests: The authors declare that they have no conflicts of interest in the research.