Job crafting as retention strategy: An ethnographic account of the challenges faced in crafting new nursing roles in care practice

Nursing shortages in the global north are soaring. Of particular concern is the high turnover among bachelor-trained nurses. Nurses tend to leave the profession shortly after graduating, often citing a lack of appreciation and voice in clinical and organisational decision-making. Healthcare organisations seek to increase the sustainability of the nursing workforce by enhancing nursing roles and nurses' organisational positions. In the Netherlands, hospitals have introduced pilots in which nurses craft new roles. We followed two pilots ethnographically and examined how nurses and managers shaped new nursing roles and made sense of their (expected) impact on workforce resilience. Informed by the literature on professional ecologies and job crafting, we show how managers and nurses defined new roles by differentiating between training levels and the uptake of care-related organisational responsibilities beyond the traditional nursing role. We also show how, when embedding such new roles, nurses needed to negotiate specific challenges associated with everyday nursing practice, manifested in distinct modes of organising, work rhythms, embodied expertise, socio-material arrangements, interprofessional relationships, and conventions about what is considered important in nursing. We argue that our in-depth case study provides a relational and socio-material understanding of the organisational politics implicated in organising care work in the face of workforce shortages.

Why is hospital discharge so difficult? Reconsidering patient trajectories in theory and practice: Insights from an ethnographic study of transitions in hip fracture care

This paper combines translational mobilisation theory and assemblage thinking to elaborate the patient trajectory concept. Deploying ethnographic research on transitions in hip fracture care in Wales (2014-2016), it describes and explains the structures and logics that condition transition interfaces, how transition infrastructures enact patients and with what effects. Comparative analysis of transition in three distinctive assemblages offers new insights into the challenges of hospital discharge and opportunities for research and improvement.

"It's not just about the numbers": Inside the black box of nurses' professional judgement in nurse staffing systems in England and Wales: Insights from a qualitative cross-case comparative study

BACKGROUND

Whether implicit or explicit, professional judgement is a central component of the many nurse staffing systems implemented in high-income countries to inform workforce planning and staff deployment. Whilst a substantial body of research has evaluated the technical and operational elements of nurse staffing systems, no studies have systematically examined the role of professional judgement and its contribution to decision-making.

OBJECTIVE

To explore nurses' use of professional judgement in nurse staffing systems in England and Wales.

METHODS

A cross-case comparative design centred on adult in-patient services in three University Health Boards in Wales and three National Health Service Trusts in England. Data generation was undertaken between January 2021 and March 2023 through stakeholder interviews, observations of staffing meetings, and analysis of documents and artefacts. Observations were undertaken in clinical areas but limited to three cases by COVID-19 restrictions. Analysis was informed by translational mobilisation theory.

FINDINGS

Two kinds of professional judgement were deployed in the nurse staffing systems: the judgement of clinical nurses and the judgement of senior nurse managers. The research highlighted the reflexive relationship between professional judgement and data, and the circumstances in which organisations placed trust in people and when they placed trust in numbers. Nurses' professional judgement was central to the generation of data, its interpretation and contextualisation. Healthcare organisations relied on the professional judgements of clinical nurses and senior nurse managers in making operational decisions to mitigate risk, where real-world understanding of the status of the organisation was privileged over formal data. Professional judgement had attenuated authority for the purposes of workforce planning, where data was a master actor. Nurses expressed concerns that strategic decision-making prioritised safety and efficiency, and formal measurement systems did not capture important aspects of care quality or staff wellbeing, which made it difficult to articulate their professional judgement.

CONCLUSIONS

The implementation of staffing systems is resource intensive. Given limited evidence on which to recommend any specific methodology, the priority for future research is to optimise existing systems. If nurses are to deploy their professional judgement to proactively influence the conditions for care, as well as responding to the challenges of risk mitigation, there is a need for robust systems of nursing measurement aligned with agreed standards of care and a vocabulary through which these judgements can be articulated.

TWEETABLE ABSTRACT

Health systems depend on nurses' professional judgement for operational staffing decisions, but data is privileged over professional judgement for workforce planning.

Paediatric early warning systems: not a simple answer to a complex question

Paediatric early warning systems (PEWS) to reduce in-hospital mortality have been a laudable endeavour. Evaluation of their impact has rarely examined the internal validity of the components of PEWS in achieving desired outcomes. We highlight the assumptions made regarding the mode of action of PEWS and, as PEWS become more commonplace, this paper asks whether we really understand their function, process and outcome.

Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme: the PUMA mixed methods study

Background

Paediatric mortality rates in the United Kingdom are amongst the highest in Europe. Clinically missed deterioration is a contributory factor. Evidence to support any single intervention to address this problem is limited, but a cumulative body of research highlights the need for a systems approach.

Methods

An evidence-based, theoretically informed, paediatric early warning system improvement programme (PUMA Programme) was developed and implemented in two general hospitals (no onsite Paediatric Intensive Care Unit) and two tertiary hospitals (with onsite Paediatric Intensive Care Unit) in the United Kingdom. Designed to harness local expertise to implement contextually appropriate improvement initiatives, the PUMA Programme includes a propositional model of a paediatric early warning system, system assessment tools, guidance to support improvement initiatives and structured facilitation and support.

Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome was a composite metric (adverse events), representing the number of children monthly that experienced one of the following: mortality, cardiac arrest, respiratory arrest, unplanned admission to Paediatric Intensive Care Unit, or unplanned admission to Higher Dependency Unit. System changes were assessed qualitatively through observations of clinical practice and interviews with staff and parents. A qualitative evaluation of implementation processes was undertaken.

Results

All sites assessed their paediatric early warning systems and identified areas for improvement. All made contextually appropriate system changes, despite implementation challenges. There was a decline in the adverse event rate trend in three sites; in one site where system wide changes were organisationally supported, the decline was significant (ß = -0.09 (95% CI: − 0.15, − 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes.

Conclusions

System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07314-2.

Evidence of free tropospheric and long-range transport of microplastic at Pic du Midi Observatory

The emerging threat of atmospheric microplastic pollution has prompted researchers to study areas previously considered beyond the reach of plastic. Investigating the range of atmospheric microplastic transport is key to understanding the global extent of this problem. While atmospheric microplastics have been discovered in the planetary boundary layer, their occurrence in the free troposphere is relatively unexplored. Confronting this is important because their presence in the free troposphere would facilitate transport over greater distances and thus the potential to reach more distal and remote parts of the planet. Here we show evidence of 0.09-0.66 microplastics particles/m³ over 4 summer months from the Pic du Midi Observatory at 2877 meters above sea level. These results exhibit true free tropospheric transport of microplastic, and high altitude microplastic particles <50 µm (aerodynamic diameter). Analysis of air/particle history modelling shows intercontinental and trans-oceanic transport of microplastics illustrating the potential for global aerosol microplastic transport.

Temporal Archive of Atmospheric Microplastic Deposition Presented in Ombrotrophic Peat

Ombrotrophic peatland-fed solely from atmospheric deposition of nutrients and precipitation-provide unique archives of atmospheric pollution and have been used to illustrate trends and changes in atmospheric trace element composition from the recent decadal to the Holocene period. With the acknowledgment of atmosphere plastic pollution, analysis of ombrotrophic peat presents an opportunity to characterize the historical atmospheric microplastic pollution prevalence. Ombrotrophic peatland is often located in comparatively pristine mountainous and boreal areas, acting as sentinels of environmental change. In this paired site study, a Sphagnum ombrotrophic peat record is used for the first time to identify the trend of atmospheric microplastic pollution. This high altitude, remote location ombrotrophic peat archive pilot study identifies microplastic presence in the atmospheric pollution record, increasing from <5(±1) particles/m²/day in the 1960s to 178(±72) particles/m²/day in 2015-2020 in a trend similar to the European plastic production and waste management. Compared to this catchment's lake sediment archive, the ombrotrophic peat core appears to be effective in collecting and representing atmospheric microplastic deposition in this remote catchment, collecting microplastic particles that are predominantly ≤20 μm. This study suggests that peat records may be a useful tool in assessing the past quantities and trends of atmospheric microplastic.

Internal jugular vein ultrasound in patients with chronic congestive heart failure

Background

Bedside assessment of intravascular volume in patients with chronic congestive heart failure (CHF) is often difficult. Under- and over-diuresis are common causes of morbidity and readmissions in these patients.

Purpose

We hypothesized that ultrasound assessment of the internal jugular vein would be easier and more reproducible than clinically assessing jugular venous pressure (JVP). Our goal was to create a bedside test that would be simpler to learn than inferior vena cava (IVC) assessment and easier to perform in obese patients.

Methods

Adults with HF (n=53, 52% men, mean age 65 years, mean BMI 29.6 kg/m2, mean LVEF 44%) scheduled for right heart catheterization (RHC) had an ultrasound of their right internal jugular (RIJ) vein performed immediately prior. Cross-sectional area of RIJ was measured during normal breathing with patients at 90 and 45 degrees recumbency and was indexed by height (RIJI). JVP was also assessed clinically. Results were compared to right atrial pressure (RAP) measured by RHC. Operators were blinded to RHC results and vice versa.

Results

JVP was correctly assessed clinically in only 43%. RIJI at 90 and 45 degrees were significantly larger in patients with elevated RAP compared to euvolemic patients (Table). At 90 degrees, RIJI of &gt;15 predicted a RAP of &gt;10 mmHg with 68% sensitivity and 72% specificity. At 45 degrees, RIJI of &gt;10 predicted a RAP of &gt;10 mmHg with 94% sensitivity and a negative predictive value of 80% (Table). Simply being able to see the RIJ at 90 degrees (n=34) had an 82.4% positive predictive value for elevated RAP. IVC data could not be obtained on 23% of patients due to body habitus or inability to lay flat.

Conclusion

Ultrasonographic RIJI is more accurate than clinical assessment in patients with CHF and can be accurately performed even in obese patients. It requires only a basic linear ultrasound probe and was easily performed by clinicians at various stages of training with reproducible results. With the increased availability of bedside ultrasound in clinical practice, it is a feasible method of evaluating chronic CHF patients.

Funding Acknowledgement

Type of funding sources: None.

1191 The Use of CT Urography to Diagnose Upper Tract Urothelial Carcinomas (UTUC); Managing Surgical Resources During The COVID-19 Pandemic

Introduction

Upper tract urothelial carcinomas (UTUC) account for 5-10% of urothelial malignancies. Rapid diagnosis is essential as 60% are invasive at diagnosis and confer poor prognoses. European Association of Urology (EAU) guidelines recommend CT urography (CTU) for initial diagnosis and staging of UTUCs. Diagnostic ureteroscopy (URS) is used second line where diagnosis is unclear. The COVID-19 pandemic has limited theatre access and may delay diagnosis of suspected UTUC. Our aim was to evaluate specific CTU findings in predicting UTUC to aid prompt diagnosis and risk stratification in a tertiary centre.

Method

A retrospective analysis was performed on 122 patients who underwent CTU with diagnostic URS over two years from 2018-2019 for possible UTUC. Data including demographics, imaging and histology were collected from our electronic database.

Results

57 patients had confirmed UTUC, all had CT changes. CTU had an overall positive predictive value (PPV) of 45%. CT findings were divided into: hydronephrosis; filling defect/lesion; urothelial thickening; normal; or other. The PPV was highest for filling defects/lesions at 60%, hydronephrosis was 38%, urothelial thickening was 30%, and other was 33%. Of those with high-grade histology, 61% had evidence of filling defects/lesions and 24% had hydronephrosis.

Conclusions

A specific CTU finding of filling defect/lesion in combination with cytology can aid diagnosis and risk stratification of UTUC. This may enable us to reduce use of diagnostic URS, as well as associated risks of intravesical seeding, necessary in the COVID-19 pandemic. With other CTU findings of hydronephrosis or urothelial thickening, a diagnostic URS may be required.

1054 A Simple Intervention to Minimise the Incidence of The Forgotten Ureteric Stent: Updating the Surgical Discharge Summary

Introduction

Ureteric stents are routinely used in ureteric obstruction, however, have considerable morbidity with major complications, such as encrustation, obstruction, urosepsis, and renal failure if left in situ for longer than six months. Despite an electronic stent register, there are still multiple emergency admissions of complications from forgotten stents, as well as those presenting with significant stent symptoms. Often stents are inserted as an emergency procedure with minimal information given on their discharge summary. A discharge template was therefore introduced that could also serve as a patient information leaflet to help minimise the incidence of forgotten stents.

Method

A discharge template was designed based off the trust-endorsed and British Association of Urological Surgeons (BAUS) patient leaflet and distributed amongst the juniors. A total of 28 patients were interviewed via telephone questionnaires – 21 randomly selected pre-intervention and 7 post-intervention from a one-month scale either side of the intervention. The template included: information on stents, common stent symptoms, indications to seek healthcare advice, and contact details to use in the event they are lost to follow-up.

Results

Patients aware that stents should be changed within six months went from 52% to 100%. Awareness of stent symptoms and red-flag symptoms went from 52% to 91%, and 57% to 100% respectively. Those who felt they had sufficient information on the discharge letter to understand their stent increased from 52 to 89%.

Conclusions

Significant improvement in patient understanding of stents and therefore hopefully in appropriate health-seeking behaviour, patient rapport, safety, and improvement in stents removed within target.

Pro-judge study: Nurses' professional judgement in nurse staffing systems

AIMS

Aim of this study is to better understand the role of nurses' professional judgment in nurse staffing systems.

DESIGN

Qualitative comparative case study design of nurse staffing systems in England and Wales.

METHODS

Data will be collected through a variety of sources: individual interviews, observations of relevant meetings and analysis of key documents. Ethical approval for the study was granted in August 2020 from The Healthcare Research Ethics Committee (SREC reference: REC741). Data generation will be informed by science and technology studies and practice theories.

DISCUSSION

Ensuring adequate numbers of nurses are available to care for patients in response to shifting demand is an international policy priority. Emerging evidence on the use of formal workforce planning methodologies across the developed world highlights both the centrality of nurses' professional judgement in nurse staffing methodologies and the urgent need for theoretically informed research to better understand and conceptualise its contribution to decision-making. This study is designed to address this gap in understanding. It takes advantage of nurses' experiences of managing the service and staffing impacts of the Covid-19 pandemic and differences in strategic approaches to nurse staffing systems between England and Wales.

IMPACT

The research will: make visible the knowledge and skills that underpin professional judgement in nurse staffing decisions and provide a conceptual language with which to articulate this; lay the foundations for evidence-based programmes of nurse education and continuing professional development; furnish the evidence to inform the development of nurse-led decision support tools to augment professional judgement; and generate wider insights into the effectiveness of nurse staffing systems in practice.

Patient experience data as enacted: Sociomaterial perspectives and 'singular-multiples' in health care quality improvement research

Over the last three decades, sociomaterial approaches to the study of health care practices have made an important contribution to the sociology of health care. Significant attention has been paid to the role of technology and artefacts in health care and the operation of actor-networks but less space has been given to questions of ontological multiplicity in health care practices. In this paper, we draw upon our study of patient experience data in five acute hospitals in England to illustrate how treating patient experience data as 'singular-multiples' can enable useful insights into patient experience data work in health care organisations. Our data was generated during 12 months of fieldwork at five participating hospitals and included organisational documents, field notes, informal and formal interviews with frontline and managerial staff and patient representatives at the study sites. We use the examples of the Friends and Family Test (FFT) and the National Cancer Patient Experience Survey (NCPES) in England to consider the multiple nature of data as it is enacted in practice and the work data does when coordinated as an entity in the singular. We argue that, and discuss how, the sociomaterial insights we discuss here are relevant to health care quality and improvement research and practice.

Prioritising the mobilisation of emergency medical services: patient making at the healthcare gateway

Purpose

The purpose of this paper is to analyse the socio-material practices through which organisational understanding of patients is accomplished in order to prioritise calls and mobilise emergency medical services at the gateway of the healthcare system.

Design/methodology/approach

The methodology of this paper is an ethnographic study of the co-ordination of collective action in an emergency services control room in the Welsh NHS, with data generation and analysis informed by Translational Mobilisation Theory.

Findings

Mobilisation of emergency medical services entails the translation of callers' undifferentiated problems into response priority categories, which are used by dispatch operators to mobilise crews. A central actor in these processes is the computerised Medical Priority Dispatch System. While designed to enable non-clinically qualified call handlers to triage calls in a standardised way, the system constrains caller–call handler interaction, which negatively impacts the categorisation process. Analysis of these interactional difficulties and associated mitigation strategies highlights opportunities for intervening to support co-ordination at this healthcare boundary.

Originality/value

Orthodox approaches to improving interface management are founded on a conceptualisation of “patients” as immutable actors in care transfer processes. Translational Mobilisation Theory brings into view the multiple versions of the “patient” produced by healthcare systems and offers a framework for analysing the mechanisms of action necessary to create organisational understandings of patients at boundary crossings. While the ambulance control centre is a singular case, the paper illustrates the value of attending to these processes in interface organisation.

Evaluating alcohol intoxication management services: the EDARA mixed-methods study

Background

Front-line health-care services are under increased demand when acute alcohol intoxication is most common, which is in night-time environments. Cities have implemented alcohol intoxication management services to divert the intoxicated away from emergency care.

Objectives

To evaluate the effectiveness, cost-effectiveness and acceptability to patients and staff of alcohol intoxication management services and undertake an ethnographic study capturing front-line staff’s views on the impact of acute alcohol intoxication on their professional lives.

Methods

This was a controlled mixed-methods longitudinal observational study with an ethnographic evaluation in parallel. Six cities with alcohol intoxication management services were compared with six matched control cities to determine effects on key performance indicators (e.g. number of patients in the emergency department and ambulance response times). Surveys captured the impact of alcohol intoxication management services on the quality of care for patients in six alcohol intoxication management services, six emergency departments with local alcohol intoxication management services and six emergency departments without local alcohol intoxication management services. The ethnographic study considered front-line staff perceptions in two cities with alcohol intoxication management services and one city without alcohol intoxication management services.

Results

Alcohol intoxication management services typically operated in cities in which the incidence of acute alcohol intoxication was greatest. The per-session average number of attendances across all alcohol intoxication management services was low (mean 7.3, average minimum 2.8, average maximum 11.8) compared with the average number of emergency department attendances per alcohol intoxication management services session (mean 78.8), and the number of patients diverted away from emergency departments, per session, required for services to be considered cost-neutral was 8.7, falling to 3.5 when ambulance costs were included. Alcohol intoxication management services varied, from volunteer-led first aid to more clinically focused nurse practitioner services, with only the latter providing evidence for diversion from emergency departments. Qualitative and ethnographic data indicated that alcohol intoxication management services are acceptable to practitioners and patients and that they address unmet need. There was evidence that alcohol intoxication management services improve ambulance response times and reduce emergency department attendance. Effects are uncertain owing to the variation in service delivery.

Limitations

The evaluation focused on health service outcomes, yet evidence arose suggesting that alcohol intoxication management services provide broader societal benefits. There was no nationally agreed standard operating procedure for alcohol intoxication management services, undermining the evaluation. Routine health data outcomes exhibited considerable variance, undermining opportunities to provide an accurate appraisal of the heterogenous collection of alcohol intoxication management services.

Conclusions

Alcohol intoxication management services are varied, multipartner endeavours and would benefit from agreed national standards. Alcohol intoxication management services are popular with and benefit front-line staff and serve as a hub facilitating partnership working. They are popular with alcohol intoxication management services patients and capture previously unmet need in night-time environments. However, acute alcohol intoxication in emergency departments remains an issue and opportunities for diversion have not been entirely realised. The nurse-led model was the most expensive service evaluated but was also the most likely to divert patients away from emergency departments, suggesting that greater clinical involvement and alignment with emergency departments is necessary. Alcohol intoxication management services should be regarded as fledgling services that require further work to realise benefit.

Future work

Research could be undertaken to determine if a standardised model of alcohol intoxication management services, based on the nurse practitioner model, can be developed and implemented in different settings. Future evaluations should go beyond the health service and consider outcomes more generally, especially for the police. Future work on the management of acute alcohol intoxication in night-time environments could recognise the partnership between health-care, police and ambulance services and third-sector organisations in managing acute alcohol intoxication.

Trial registration

Current Controlled Trials ISRCTN63096364.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 24. See the NIHR Journals Library website for further project information.

Standardised self-management kits for children with type 1 diabetes: pragmatic randomised trial of effectiveness and cost-effectiveness

OBJECTIVE

To estimate the effectiveness of standardised self-management kits for children with type 1 diabetes.

DESIGN

Pragmatic trial with randomisation ratio of two intervention: one control. Qualitative process evaluation.

SETTING

11 diabetes clinics in England and Wales.

PARTICIPANTS

Between February 2010 and August 2011, we validly randomised 308 children aged 6-18 years; 201 received the intervention.

INTERVENTION

We designed kits to empower children to achieve glycaemic control, notably by recording blood glucose and titrating insulin. The comparator was usual treatment. OUTCOME MEASURES AT 3 AND 6 MONTHS: Primary: Diabetes Pediatric Quality of Life Inventory (PedsQL). Secondary: HbA1c; General PedsQL; EQ-5D; healthcare resource use.

RESULTS

Of the five Diabetes PedsQL dimensions, Worry showed adjusted scores significantly favouring self-management kits at 3 months (mean child-reported difference =+5.87; Standard error[SE]=2.19; 95% confidence interval [CI]) from +1.57 to +10.18; p=0.008); but Treatment Adherence significantly favoured controls at 6 months (mean child-reported difference=-4.68; SE=1.74; 95%CI from -8.10 to -1.25; p=0.008). Intervention children reported significantly worse changes between 3 and 6 months on four of the five Diabetes PedsQL dimensions and on the total score (mean difference=-3.20; SE=1.33; 95% CI from -5.73 to -0.67; p=0.020). There was no evidence of change in HbA1c; only 18% of participants in each group achieved recommended levels at 6 months. No serious adverse reactions attributable to the intervention or its absence were reported.Use of kits was poor. Few children or parents associated blood glucose readings with better glycaemic control. The kits, costing £185, alienated many children and parents.

CONCLUSIONS

Standardised kits showed no evidence of benefit, inhibited diabetes self-management and increased worry. Future research should study relationships between children and professionals, and seek new methods of helping children and parents to manage diabetes.

TRIAL REGISTRATION NUMBER

ISRCTN17551624.

Acceptability, adherence and economic analyses of a new clinical pathway for the identification of non-responders to glaucoma eye drops: a prospective observational study

BACKGROUND/AIMS

Assess whether a new clinical pathway for glaucoma was acceptable to patients and healthcare professionals and whether it provided useful clinical information on non-responsiveness and non-adherence to the treatment of elevated intraocular pressure with latanoprost eye drops.

METHODS

A single arm non-randomised prospective observational study incorporating new glaucoma/ocular hypertension patients. To assess issues of acceptability, qualitative observation and interviews were conducted with patients and healthcare professionals. To determine clinical responsiveness, intraocular pressures were measured before and 4 hours after a clinician-instilled eye drop over two distinct appointments. Adherence data were collected using a Medicine Event Monitoring System. Economic analyses compared the costs between novel and standard care pathways.

RESULTS

Of 72 patients approached, 53 entered the study (74.3%) and 50 completed all procedures (94.3%). Intraocular pressure was reduced more than 15% in 83 out of 92 study eyes by final visit (90.2%). The non-response rate was 5.1% once the effect of low adherence was minimised. For the 1376 drop instillation days under observation, eye drops were instilled as prescribed on 1004 days (73.0%), over-instilled on 137 days (9.9%) and not instilled on 235 days (17.1%). The Cardiff Model of Glaucoma Care involved negligible cost, although acceptance for healthcare professionals showed variation.

CONCLUSIONS

The Cardiff Model of Glaucoma Care offers novel clinical and adherence insights at marginal costs while acceptable to patients. Healthcare professionals felt that 4 hour and 4 week follow-up appointments could cause administrative problems. A streamlined version of the pathway has therefore been developed to facilitate clinical adoption.

TRIAL REGISTRATION NUMBER

ISRCTNID:ISRCTN75888393.

High-resolution imaging of the human incudostapedial joint using synchrotron-radiation phase-contrast imaging

The incudostapedial joint (ISJ) of the middle ear is important for proper transmission of sound energy to the cochlea. Recently, the biomechanics of the ISJ have been investigated using finite-element (FE) modelling, using simplified geometry. The objective of the present study was to investigate the feasibility of synchrotron-radiation phase-contrast imaging (SR-PCI) in visualising the ISJ ultrastructure. Three human cadaveric ISJs were dissected and scanned using SR-PCI at 0.9 µm isotropic voxel size. One of the samples was previously scanned at 9 µm voxel size. The images were visually compared and contrast-to-noise ratios (CNRs) were calculated (of both bone and soft tissues) for quantitative comparisons. The ISJ ultrastructure as well as adjacent bone and soft tissues were clearly visible in images with a 0.9 µm voxel size. The CNRs of the 0.9 µm images were relatively lower than those of the 9 µm scans, while the ratio of bone to soft tissue CNRs were higher, indicating better discernibility of bone from soft tissue in the 0.9 µm scans. This study was the first known attempt to image the ISJ ultrastructure using an SR-PCI scanner at submicron voxel size and results suggest that this method was successful. Future studies are needed to optimise the contrast and test the feasibility of imaging the ISJ in situ. LAY DESCRIPTION: The human middle ear consists of the eardrum, three small bones (the malleus, incus and stapes) and two joints connecting the bones (the incudostapedial joint and the incudomallear joint). The role of the middle ear is to amplify and transfer sound energy to the cochlea, the end organ of hearing. The incudostapedial joint (ISJ) of the middle ear is a synovial joint which is important for proper transmission of sound energy to the cochlea. Similar to other synovial joints it consists of meniscus, fluid and articulating surfaces. Recently, the biomechanics of the ISJ have been investigated using computational models, using grossly simplified geometry. Synchrotron radiation phase contrast imaging (SR-PCI) is a high-resolution imaging technique used to visualise small structures in three dimensions. The objective of the present study was to investigate the feasibility of using SR-PCI in visualising the ISJ ultrastructure. Three human cadaveric ISJs were dissected and scanned using SR-PCI at 0.9 µm isotropic voxel size. One of the samples was previously scanned at 9 µm voxel size. The images were both qualitatively and quantitatively compared. This study was the first known attempt to image the ISJ ultrastructure using an SR-PCI scanner at submicron voxel size and results suggest that this method was successful. Future studies are needed to optimise the contrast and feasibility of imaging the ISJ in situ.

Advances in research on the impacts of anti-submarine sonar on beaked whales

Mass stranding events (MSEs) of beaked whales (BWs) were extremely rare prior to the 1960s but increased markedly after the development of naval mid-frequency active sonar (MFAS). The temporal and spatial associations between atypical BW MSEs and naval exercises were first observed in the Canary Islands, Spain, in the mid-1980s. Further research on BWs stranded in association with naval exercises demonstrated pathological findings consistent with decompression sickness (DCS). A 2004 ban on MFASs around the Canary Islands successfully prevented additional BW MSEs in the region, but atypical MSEs have continued in other places of the world, especially in the Mediterranean Sea, with examined individuals showing DCS. A workshop held in Fuerteventura, Canary Islands, in September 2017 reviewed current knowledge on BW atypical MSEs associated with MFAS. Our review suggests that the effects of MFAS on BWs vary among individuals or populations, and predisposing factors may contribute to individual outcomes. Spatial management specific to BW habitat, such as the MFAS ban in the Canary Islands, has proven to be an effective mitigation tool and mitigation measures should be established in other areas taking into consideration known population-level information.

Chronic Conditions and Behavioural Change Approaches to Medication Adherence: Rethinking Clinical Guidance and Recommendations

Patient adherence to medication is an ongoing concern for clinicians, obfuscating treatment efficacy and resulting in wastage of medicine, reduced clinical benefit, and increased mortality. Despite this, procedural guidance on how clinicians should best engage patients regarding their medicine-taking is limited in the United Kingdom. Adherence for chronic conditions is notably complex, requiring clear education, communication, and behavioural shifts to initiate and sustain daily regimens successfully. This article explores current clinician guidance on assuring patient adherence to medication within the National Health Service, comparing it to that provided for healthcare workers in the field of behavioural change. Outlining the inertia of the former and the progress of the latter, we consider what steps should be taken to address this deficit, including greater focus on patient concerns, as well as knowledge translation for healthcare professionals in future adherence research. Current United Kingdom clinical guidance for assuring patient adherence is largely outdated based on inconclusive evidence for best practice. However, efforts to encourage behavioural change in the public health setting demonstrate evidence-based success. Integrating knowledge generated around adherence behaviour and the practical application of adherence and behavioural change research, as well as funding for longer-term studies with a focus on clinical outcomes, may help to solidify the NICE guidance on adherence and further progress the field. This would require close involvement from patient groups and networks informing ethical aspects of study design and clinical implementation.

Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

OBJECTIVE

To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.

METHODS

A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.

RESULTS

Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.

CONCLUSIONS

There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

Institutionalising emergent organisation in health and social care

Purpose

The purpose of this paper is to argue for the institutionalisation of emergent forms of organisation in health and social care and offer a conceptual framework for this purpose.

Design/methodology/approach

Drawing on ethnographic research on the organising work of nurses and Translational Mobilisation Theory, this paper extends two classic Straussian sociological concepts – illness trajectory and articulation work – to conceptualise emergent organisation as Care Trajectory Management.

Findings

Failures of coordination are well-recognised threats to quality and safety and recent decades have witnessed an explosion of neoliberal technologies and governance arrangements designed to “measure and manage” these risks. Yet in a significant and growing proportion of health and social care provision successful service integration depends not on rational planning, but iterative negotiations and adjustments in response to contingencies. While ubiquitous in health and social care systems, these emergent forms of organisation lack legitimacy, the work involved is relatively invisible and practice is poorly served by prevailing management discourses.

Originality/value

The Care Trajectory Management Framework provides an alternative discourse and logic on which to develop strategies and technologies to support emergent organisational processes in acute and community care contexts.

PP9 Managing alcohol intoxication in the night-time economy: staff and patient perspectives

Background

Alcohol-related harms arising in the Night-Time Economy (NTE) impose a substantial burden on emergency services (ES) especially ambulance services engaged in both street level care and transportation of acutely intoxicated patients to a hospital Emergency Department (ED). Alcohol Intoxication Management Services (AIMS) are intended as an alternative care pathway for intoxicated patients who would normally use emergency services and are often run by ambulance services in partnership with other agencies. Despite growing policy interest in AIMS as an alternative pathway it is not known what their users think of them nor the experiences of frontline staff engaged in and around AIMS.

Methods

As part of a mixed-method study semi-structured interviews were followed by a survey of users recruited from six different AIMS. A parallel ethnographic component used observations and interviews with ambulance staff in two cities with AIMS and one without.

Results

Surveys and interviews found AIMs users retrospectively viewed the decision to take them to AIMS favourably and highly rated the care they received, especially the friendly, non-judgemental atmosphere created between ambulance staff and other agents involved in AIMS. A majority of AIMS survey respondents said they would not have called emergency services (85%) or gone to the ED (75.6%). Ethnographic work showed ambulance personnel considered AIMS to have a positive impact on ES, freeing capacity to attend to other emergencies. Ambulance staff without AIMS worked to avoid conveyance to ED but this could result in extended periods risk assessing individuals at street level, which meant they felt unavailable to address other emergency calls.

Conclusions

AIMS are viewed very positively by their users and the ambulance staff involved. Findings from surveys, interviews and ethnography suggest that AIMS and EDs are managing different patient groups in different ways, and thus may represent complementary rather than competing alternatives care pathways.

Organisational strategies and practices to improve care using patient experience data in acute NHS hospital trusts: an ethnographic study

Background

Although NHS organisations have access to a wealth of patient experience data in various formats (e.g. surveys, complaints and compliments, patient stories and online feedback), not enough attention has been paid to understanding how patient experience data translate into improvements in the quality of care.

Objectives

The main aim was to explore and enhance the organisational strategies and practices through which patient experience data are collected, interpreted and translated into quality improvements in acute NHS hospital trusts in England. The secondary aim was to understand and optimise the involvement and responsibilities of nurses in senior managerial and front-line roles with respect to such data.

Design

The study comprised two phases. Phase 1 consisted of an actor–network theory-informed ethnographic study of the ‘journeys’ of patient experience data in five acute NHS hospital trusts, particularly in cancer and dementia services. Phase 2 comprised a series of Joint Interpretive Forums (one cross-site and one at each trust) bringing together different stakeholders (e.g. members of staff, national policy-makers, patient/carer representatives) to distil generalisable principles to optimise the use of patient experience data.

Setting

Five purposively sampled acute NHS hospital trusts in England.

Results

The analysis points to five key themes: (1) each type of data takes multiple forms and can generate improvements in care at different stages in its complex ‘journey’ through an organisation; (2) where patient experience data participate in interactions (with human and/or non-human actors) characterised by the qualities of autonomy (to act/trigger action), authority (to ensure that action is seen as legitimate) and contextualisation (to act meaningfully in a given situation), quality improvements can take place in response to the data; (3) nurses largely have ultimate responsibility for the way in which data are collected, interpreted and used to improve care, but other professionals also have important roles that could be explored further; (4) formalised quality improvement can confer authority to patient experience data work, but the data also lead to action for improvement in ways that are not formally identified as quality improvement; (5) sense-making exercises with study participants can support organisational learning.

Limitations

Patient experience data practices at trusts performing ‘worse than others’ on the Care Quality Commission scores were not examined. Although attention was paid to the views of patients and carers, the study focused largely on organisational processes and practices. Finally, the processes and practices around other types of data were not examined, such as patient safety and clinical outcomes data, or how these interact with patient experience data.

Conclusions

NHS organisations may find it useful to identify the local roles and processes that bring about autonomy, authority and contextualisation in patient experience data work. The composition and expertise of patient experience teams could better complement the largely invisible nursing work that currently accounts for a large part of the translation of data into care improvements.

Future work

To date, future work has not been planned.

Study registration

NIHR 188882.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

B-50 Frequency of Sports-Related Concussion in Athletes with Neurodevelopmental Conditions

Objective

Research demonstrates that athletes with neurodevelopmental diagnoses may have a higher frequency of lifetime concussions (Iverson et al., 2016; Alosco, Fedor & Gunstad, 2014) possibly due to underlying attention, processing speed, or reaction time difficulties. The present study investigates concussion history and sports-related concussions between athletes with and without a history of neurodevelopmental disorders in a longitudinal, state-wide sample.

Method

Participants included 39,586 high school athletes (Mage = 15.18; 56.2% males) who were assessed pre and post-concussion with ImPACT between 2008 and 2016. There were 36,880 athletes (55.1% males) who did not report neurodevelopmental disorders and served as the control group and 2,706 athletes (71.4% males) in the clinical group who self-reported diagnosis of ADHD (55.6%), Learning Disability (LD;13.6%), Autism (3.2%), ADHD+LD (4.5%), and athletes in special education but no reported diagnosis (SpEd; 22%). Concussion frequency in each group was analyzed using chi-square analysis.

Results

Athletes were more likely to report prior concussions if they had a self-reported neurodevelopmental diagnosis (17%) compared to the control group (9%, χ2(1) = 112.11, p < .001). Odds ratios indicated that athletes with neurodevelopmental conditions were 1.43 times more likely to have a sports-related concussion.

Conclusions

Consistent with past research, results indicate that neurodevelopmental conditions are associated with greater lifetime risk of concussion, including sport-related concussions. Future studies may expand this research by examining underlaying causes of this increased risk in order to develop specific interventions to help reduce rates of concussion for this population.

B-55 Performance of ImPACT Validity Indices for Athletes with Neurodevelopmental Disorders

Objective

Research demonstrates neurodevelopmental diagnoses may increase likelihood of failing scores on ImPACT embedded validity indicators that flag questionable effort. New criteria have been proposed to enhance sensitivity of these indicators although their utility in athletes with neurodevelopmental diagnosis have not been thoroughly examined. This study investigates the effect of neurodevelopmental history on frequency of invalid performance on the standard and three proposed validity indicators.

Methods

Participants included 41,214 high school athletes (Mage = 15.1; 44.2% female; Meducation = 9.1) who completed baseline ImPACT testing. Athletes included these groups: ADHD (3.7%), Learning Disability (LD; 1.5%), Autism (0.2%), ADHD+LD (0.6%), Autism+ADHD/LD (0.1%), athletes with special education history but no diagnosis reported (SpEd; 2.8%), and healthy athletes (91.1%). Odds ratios were calculated to determine differences in invalid performance by both standard and proposed cutoffs.

Results

Neurodevelopmental disorder was associated with increased invalid performance using standard and proposed cutoffs with odds ratios ranging from 1.32 to 3.25. Invalid performance differed significantly across groups for both standard and two sets of proposed criteria (chi square p < .00001). For standard cutoffs, athletes with ADHD, LD, and ADHD/LD were significantly more likely than healthy athletes to have invalid performance. This pattern remained similar across the two sets of proposed criteria.

Conclusions

Results indicate increased incidence of invalid ImPACT performance based on standard and proposed validity indicators in athletes who self-report neurodevelopmental disorders. Findings indicate current and proposed cutoffs may not accurately capture low effort for neurodevelopmental populations. Future research should examine utility of separate cutoff criteria and expanded norms for athletes with neurodevelopmental history.

B-39 Is the Latent Structure of Neurocognitive Domains Invariant Across Males and Females with Schizophrenia?

Objective

Differences between males and females with schizophrenia have been identified for numerous important disorder-related variables including age of onset, severity, and course, among others. Evidence suggests there also may be differences in intellectual functioning and possibly specific cognitive deficits. This study examined differences in the latent structure of cognitive abilities between males and females with schizophrenia.

Method

Participants included 659 males (age X̄ = 38.25, 64.5% Caucasian, education X̄ = 11.69) and 209 females (age X̄ = 40.52, 55.5% Caucasian, education X̄ = 11.72) with schizophrenia who were evaluated with neuropsychological tests as part of a large multicenter randomized control trial of antipsychotic medications (CATIE). Confirmatory factor analysis (CFA) was used to test four competing models based on prior CFA of the CATIE data. Model accuracy was evaluated using Comparative Fit Index (CFI), Root Mean Squared Error of Approximation (RMSEA), and Akaike’s Information Criterion (AIC).

Results

CFAs were completed for each sex using EQS 6.3. Models included one-factor, five-factor, six-factor, and a hierarchical model in which five factors load on a single factor “g”. The six-factor model was the best fitting for both males and females.

Conclusions

The results indicated that a six-factor model of neurocognition is the best fitting model for both males and females. The results also suggest that the latent structure of cognitive abilities is similar for both sexes. This provides a strong basis for uniform interpretation of neuropsychological domains across males and females, although there may be sex-related differences in patterns and severity of deficit in each domain.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

OBJECTIVE

To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.

DESIGN

Systematic review.

DATA SOURCES

British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.

ELIGIBILITY CRITERIA

We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered.

DATA EXTRACTION AND SYNTHESIS

Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.

RESULTS

36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.

CONCLUSION

There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

A prospective, mixed-methods, before and after study to identify the evidence base for the core components of an effective Paediatric Early Warning System and the development of an implementation package containing those core recommendations for use in the UK: Paediatric early warning system - utilisation and mortality avoidance- the PUMA study protocol

BACKGROUND

In hospital, staff need to routinely monitor patients to identify those who are seriously ill, so that they receive timely treatment to improve their condition. A Paediatric Early Warning System is a multi-faceted socio-technical system to detect deterioration in children, which may or may not include a track and trigger tool. It functions to monitor, detect and prompt an urgent response to signs of deterioration, with the aim of preventing morbidity and mortality. The purpose of this study is to develop an evidence-based improvement programme to optimise the effectiveness of Paediatric Early Warning Systems in different inpatient contexts, and to evaluate the feasibility and potential effectiveness of the programme in predicting deterioration and triggering timely interventions.

METHODS

This study will be conducted in two district and two specialist children's hospitals. It deploys an Interrupted Time Series (ITS) design in conjunction with ethnographic cases studies with embedded process evaluation. Informed by Translational Mobilisation Theory and Normalisation Process Theory, the study is underpinned by a functions based approach to improvement. Workstream (1) will develop an evidence-based improvement programme to optimise Paediatric Early Warning System based on systematic reviews. Workstream (2) consists of observation and recording outcomes in current practice in the four sites, implementation of the improvement programme and concurrent process evaluation, and evaluation of the impact of the programme. Outcomes will be mortality and critical events, unplanned admission to Paediatric Intensive Care (PICU) or Paediatric High Dependency Unit (PHDU), cardiac arrest, respiratory arrest, medical emergencies requiring immediate assistance, reviews by PICU staff, and critical deterioration, with qualitative evidence of the impact of the intervention on Paediatric Early Warning System and learning from the implementation process.

DISCUSSION

This paper presents the background, rationale and design for this mixed methods study. This will be the most comprehensive study of Paediatric Early Warning Systems and the first to deploy a functions-based approach to improvement in the UK with the aim to improve paediatric patient safety and reduce mortality. Our findings will inform recommendations about the safety processes for every hospital treating paediatric in-patients across the NHS.

TRIAL REGISTRATION

Sponsor: Cardiff University, 30-36 Newport Road, Cardiff, CF24 0DE Sponsor ref.: SPON1362-14. Funder: National Institute for Health Research, Health Services & Delivery Research Programme (NIHR HS&DR) Funder reference: 12/178/17. Research Ethics Committee reference: 15/SW/0084 [13/04/2015]. PROSPERO reference: CRD42015015326 [23/01/2015].

ISRCTN

94228292 https://doi.org/10.1186/ISRCTN94228292 [date of application 13/05/2015; date of registration: 18/08/2015]. Prospective registration prior to data collection and participant consent commencing in September 2014.

Care trajectory management: A conceptual framework for formalizing emergent organisation in nursing practice

Aim

To offer a new conceptual framework for formalizing nurses’ work in managing emergent organisation in health and social care.

Background

Much health and social care requires continuous oversight and adjustments in response to contingencies. Nurses have an important role in managing these relationships.

Evaluation

A longstanding programme of research on the social organisation of health and social care work provided the foundations for the article.

Key issue

Nurses’ work in managing emergent organisation may be conceptualized as care trajectory management and factors contributing to trajectory complexity are explored.

Conclusions

Care trajectory management is essential for the quality and safety of health and social care but poorly served by existing management frameworks.

Implications for Nursing Management

Care trajectory management offers a conceptual framework for the development of new management structures to support an important but poorly supported element of nursing practice.

Analysing healthcare coordination using translational mobilization

Purpose

The purpose of this paper is to introduce translational mobilization theory (TMT) and explore its application for healthcare quality improvement purposes.

Design/methodology/approach

TMT is a generic sociological theory that explains how projects of collective action are progressed in complex organizational contexts. This paper introduces TMT, outlines its ontological assumptions and core components, and explores its potential value for quality improvement using rescue trajectories as an illustrative case.

Findings

TMT has value for understanding coordination and collaboration in healthcare. Inviting a radical reconceptualization of healthcare organization, its potential applications include: mapping healthcare processes, understanding the role of artifacts in healthcare work, analyzing the relationship between content, context and implementation, program theory development and providing a comparative framework for supporting cross-sector learning.

Originality/value

Poor coordination and collaboration are well-recognized weaknesses in modern healthcare systems and represent important risks to quality and safety. While the organization and delivery of healthcare has been widely studied, and there is an extensive literature on team and inter-professional working, we lack readily accessible theoretical frameworks for analyzing collaborative work practices. TMT addresses this gap in understanding.

Comminuted, Articular Fractures of the Olecranon Process in Horses: 17 Cases (1980 to 1990)

Case records of 17 horses with a radiographic and surgical diagnosis of comminuted, articular fracture of the olecranon process of the ulna were retrieved using a computer-assisted search of hospital records entered between January 1, 1980 and October 31, 1990. The records were reviewed, and case management data summarized. Radiographic images were retrieved, and descriptions of the fractures recorded. Horses were classified as survivors if they were discharged from the hospital. Follow-up information was obtained by examination or phone conversation with the referring veterinarian, owner or trainer.

Twelve horses (71%) survived to be discharged from the hospital. Survivors were significantly younger and weighed less (mean age, 3.9 years; mean body weight 290.2 kg) than non-survivors (mean age, 9.1 years; mean body weight, 412.2 kg). Breed, gender, and duration of clinical signs prior to surgery were not significant to the outcome. Seven horses admitted with open wounds, and two horses suffered sepsis of the surgical site after internal fixation. Of these nine horses, four (44%) were discharged from the hospital. Patients with sepsis of the fracture site, because of open wounds or postoperative infection, had a significantly lower survival rate than horses in which asepsis of the fracture site was maintained.

Follow-up information was available for eight of 12 survivors (mean followup period, 2.6 years). Five (63%) horses were riding or “training sound” at the time of follow-up. Of five horses less than one year of age at the time of surgery, three (60%) were sound at a mean of 1.2 years after surgery. Of three horses four years or older, two (66%) were sound at follow-up 3.7 years after the operation.

Comminuted, articular fractures involving the olecranon process can be managed successfully in horses using a dynamic compression plate applied to the caudal aspect of the ulna. Also, application of a second plate on the lateral aspect of the ulna is possible, when fracture instability has been noted after application of the caudal plate. Age, weight, and sepsis of the fracture site were the most important prognostic indicators in this study.

Historical data, physical examination findings, surgical findings, clinical management data, and follow-up information are reported for 17 horses affected with comminuted, articular fracture of the olecranon process. Twelve (71%) horses survived to be discharged from the hospital. Survivors were significantly younger and of lighter body weight than non-survivors. Horses in which sepsis of the fracture site occurred had a significantly lower survival rate than horses in which aseptic fracture environment was maintained. Of eight horses available for follow-up information, five (63%) were riding or training sound at a mean of 2.6 years after surgery.