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Here are cheap kamagra online uk the most important news, trends and analysis that investors need to start their trading day:1. Stock futures rise after June jobs reportTraders work on the floor cheap kamagra online uk of the New York Stock Exchange on Nov. 4th.

2020.NYSEU.S. Stock futures rose Friday morning after the release of the better-than-expected June jobs report. All major Street indexes finished in the green Thursday, as Wall Street kicked off the second half of 2021 on a positive note after a strong first six months.

The S&P 500 advanced 0.5% to 4,319.94, setting its sixth consecutive record high. The Dow Jones Industrial Average added 131 points, finishing the session at 34,633.53. The 30-stock Dow has risen for three sessions in a row and sits at its highest level since June 4.

The tech-heavy Nasdaq on Thursday rose 0.13% to 14,522.38. The major averages are all positive for the week and on pace for their second straight weekly gain.2. U.S.

Added 850,000 jobs in JuneA company advertises a help wanted sign on April 09, 2021 in Pawtucket, Rhode Island.Spencer Platt | Getty ImagesNonfarm payrolls rose by 850,000 in June, the Labor Department said Friday. The figure is better than the 706,000 jobs that economists had expected, according Dow Jones estimates. However, the unemployment rate ticked up to 5.9%, while projections called for it to decline to 5.6%.

Average hourly earnings rose 0.33% in June and 3.6% on a year-over-year basis. Both figures are in line with estimates. The Labor Department's jobs reports for April and May missed Wall Street's expectations, as businesses across industries indicated they were having challenges filling open positions.3.

Robinhood files for highly anticipated initial public offeringPavlo Gonchar | LightRocket | Getty ImagesIn its highly anticipated IPO filing Thursday, Robinhood Markets revealed it has 18 million retail clients and more than $80 billion in customer assets. The free stock trading pioneer said it was profitable in 2020, posting $7.45 million in net income on net revenue of $959 million, as its number of funded accounts more than doubled that year. In 2019, Robinhood lost $107 million on $278 million in net revenue.Robinhood ended the first three months of this year with a loss of $1.4 billion, which is connected to the emergency fundraising it completed during the height of the Reddit-fueled GameStop frenzy in January.

Revenue in the quarter jumped 309% to $522 million, compared with $128 million in the first quarter of 2020. About 38% of Robinhood's revenue comes from options trading accounts. Equities account for 25% of revenue, while crypto represents 17%.The company, which was founded in 2013, is looking to raise $100 million in its IPO.

It intends to list on the Nasdaq and trade under the ticker "HOOD."4. Virgin Galactic plans to launch Richard Branson to space on July 11Sir Richard Branson stands on the floor of the New York Stock Exchange (NYSE) ahead of Virgin Galactic (SPCE) trading in New York, U.S., October 28, 2019.Richard Branson Virgin Galactic IPO NYSESpace tourism company Virgin Galactic scheduled its next test spaceflight for July 11, and company founder Sir Richard Branson intends to be onboard. The timing is particularly noteworthy, as the U.K.

Billionaire aims to beat Jeff Bezos to space. The Amazon founder and world's wealthiest person is scheduled to launch on July 20 with his own company, Blue Origin. Shares of Virgin Galactic soared about 30% in premarket trading to around $56 apiece.

The scheduled launch will be Virgin Galactic's fourth test spaceflight to date. Branson started Virgin Galactic in 2004, and the company began trading on the New York Stock Exchange in October 2019.5. Toyota outsells GM in U.S.

For first time in a quarterA Toyota Tundra pickup truck is seen at a car dealership in San Jose, California.Yichuan Cao | NurPhoto | Getty ImagesToyota Motor sold more vehicles in the U.S. Than General Motors in the second quarter, marking the first time the Japanese automaker has done so in a three-month reporting period. On Thursday, Toyota said it sold 688,813 vehicles in America from April through June, narrowly edging out GM's 688,236 vehicles.

Toyota's results topped analyst expectations. GM's came up short. Toyota may become the bestselling automaker in the U.S., depending on where Ford's results come in.

GM's crosstown rival reports the figure Friday morning, and analysts forecast second-quarter U.S. Sales of 645,000 vehicles. The last time GM was not America's top-selling automaker for a quarter was the third quarter of 1998, when Ford outsold them, according to Edmunds.The automotive industry has been managing through a shortage of semiconductors, disrupting production schedules at a time when consumer demand for new vehicles has been strong.

Toyota and other Japanese automakers have so far managed the chip crunch better than U.S. Rivals.Correction. The Nasdaq on Thursday closed at 14,522.38.

An earlier version misstated the figure.— Follow all the market action like a pro on CNBC Pro. Get the latest on the kamagra with CNBC's erectile dysfunction coverage.Two women in face masks walk along a shopping area on April 19, 2021 in Dubai, United Arab Emirates.Francois Nel | Getty Images News | Getty ImagesVaccination campaigns in several Middle East nations raced ahead of the rest of the world at the beginning of 2021.Israel, the United Arab Emirates and Bahrain topped the list when it came to doses administered per 100 people at the start of the year.Six months later, all three are still among the top 10 most vaccinated countries — but charts show their erectile dysfunction treatment trends have varied greatly.As of June 29, 57.8% of Bahrain's population were fully vaccinated and 59.7% of Israel's residents received both doses of the erectile dysfunction treatment, according to Our World in Data. The UAE's data on fully vaccinated individuals was last updated on April 20, when the figure stood at 38.8%.IsraelIsrael's new daily cases plummeted as its vaccination program ploughed on, and data showed that s remained largely in the low double-digits for more than a month since the end of April.

That was so until a resurgence emerged in late June.Caseloads are a fraction of previous peaks, but have risen rapidly in recent days.The highly contagious delta variant is responsible for about half the new cases, according to Nadav Davidovitch, chair of the Israeli Association of Public Health Physicians.Still, simulations predict that even with "widespread transmission," there will only be several hundred severe cases, he told CNBC via video call. "Not like it used to be in the third wave," he added, referring to the spike that began late last year.UAEThe United Arab Emirates ranks number one in terms of total doses administered per 100 people, according to Our World in Data. But new s in the country have stubbornly hovered around 2,000 per day.Cases have fallen from the record highs reported in January, and temporarily dipped to the mid-1,000 level in May, but have otherwise mostly stayed around the same region.Still, the cases now remain higher than the average daily cases of about 1,200 reported in the fourth quarter of 2020.The UAE's National Emergency Crisis and Disaster Management Authority in May announced that it would be offering a third dose of China's Sinopharm treatment.

It came amid questions over the efficacy of the treatment as there were reports of s in individuals who had received two shots.The country later said those inoculated with Sinopharm's treatment can receive the Pfizer-BioNTech shot as a booster, Reuters reported.Bahrains in Bahrain hit record highs in late May even though vaccinations were well underway in the country.According to Our World in Data, the kingdom reported 3,273 new cases on May 29.At that point, more than 911,000 people in Bahrain had already received at least one dose of a erectile dysfunction treatment. It has a population of around 1.76 million people.New daily cases have since fallen to the hundreds.Bahrain is also offering third doses of Sinopharm's treatment. Booster shots of the Pfizer-BioNTech treatment are available to more vulnerable groups such as those above the age of 50, three months after they receive a second dose of Sinopharm.Deaths attributed to erectile dysfunction treatments are not the only indicator of a country's erectile dysfunction situation, and vaccinations are not the only factor at play.Besides inoculation, a country's demographics and erectile dysfunction treatment restrictions also play a part in the severity of illness and how quickly the kamagra spreads.Deaths in Israel and the UAE have fallen and stayed low, while daily new erectile dysfunction treatment-related deaths per million in Bahrain went as high as 17 in June.Are erectile dysfunction treatment spikes a concern?.

The outbreaks in the Middle East countries are not worrying, said Paul Tambyah, president of the Asia Pacific Society of Clinical Microbiology and ."I do not think that we should be too concerned," he told CNBC in an email. "The majority, or at least a significant proportion of cases have reportedly been in those who have not been vaccinated.""The main concern is that it does not look like we can get away without vaccinating a very significant proportion of the population," he said.I think that as long as the kamagra is circulating globally and borders remain open, there will be occasional outbreaks of the kamagra even in highly vaccinated populations.Paul TambyahAsia Pacific Society of Clinical Microbiology and kamagra clusters expectedHigh vaccination rates will not rule out clusters of cases in future, medical experts said."I think that as long as the kamagra is circulating globally and borders remain open, there will be occasional outbreaks of the kamagra even in highly vaccinated populations," said Tambyah.Davidovitch said "localized outbreaks" among children who are not vaccinated will probably continue.He said it's "hard to tell" if a reliance on Chinese treatments — as seen in the UAE and Bahrain — may be linked to dramatic spikes in erectile dysfunction treatment cases.Tambyah noted that Israel, which has used mainly Pfizer treatments, is seeing a resurgence in cases as well.He said there are no scientific publications comparing traditional treatments developed by China against treatments that rely on messenger RNA technology, which instructs the body to produce a harmless piece of the kamagra that helps trigger an immune response."I think that, unfortunately, higher vaccination rates are required," Tambyah said..

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Members of Zonta Club of Alpena/Tri-County recently presented a check to Ann Diamond, fund development director, MidMichigan what do you need to buy kamagra Health Foundation, representing a $5,000 pledge to the future patient tower of MidMichigan Medical Center – Alpena. Pictured are, back row, left what do you need to buy kamagra to right. Kristen Marsh, Sue Latuszek, JoAnn Kamyszek, Barb Rigg, Cathy Macfalda and Betty DuRocher. Front row, what do you need to buy kamagra left to right. Ann Diamond, Pam Werth, Julie Rouleau, President of Alpena Tri-County Zonta, and LisaVanHorn.

Not pictured what do you need to buy kamagra. Ann Weir, Peggy Donakowski, Ann Cosbitt and Dr. Lorie Vorraro.Zonta Club of Alpena/Tri-County what do you need to buy kamagra recently held their October meeting at the 19th Hole in Alpena. At the event, club members presented Ann Diamond, fund development director, MidMichigan Health Foundation, with a $5,000 pledge to the new patient tower project underway at MidMichigan Medical Center – Alpena.“We are thrilled to have Zonta Club of Alpena/Tri-County supporting this project,” said Diamond. €œZontians worldwide help advance the needs of women, and what do you need to buy kamagra the new Women’s Health Unit in Alpena’s patient tower is a project that fits their mission beautifully.

We are so thankful for what do you need to buy kamagra their continued support.”The patient tower has an entirely new Women’s Health Unit that includes a private operating room for C-sections and eight new labor, delivery, recovery and post-partum suites. The unit was designed to allow parents and babies to stay together throughout all stages of labor, delivery, recovery and post-partum care. Each area what do you need to buy kamagra of the unit is beautifully decorated and outfitted with state-of-the-art equipment. The C-section suite is just steps away from the private rooms in this secure unit. The Women’s what do you need to buy kamagra Health Unit will be located on the second floor of the new patient tower and includes private rooms overlooking the Thunder Bay River.“Zonta gives you the chance to be a part of something much larger than yourself,” said Julie Rouleau, president of Zonta Club of Alpena/Tri-County.

€œZonta allows you to give yourself to others, to actively participate in the selection of service projects to help your community, and to improve the legal, political, economic, educational, health and professional status of women worldwide. We are pleased to be able to what do you need to buy kamagra partner with our hospital in this important project and challenge other service organizations in our area to do the same.”In addition to the Women’s Health Unit, the three-story 99,000 square foot patient tower will offer 60 new private patient rooms in total, with 14 private intensive and critical care rooms, a new Surgical Department including five new operating rooms and 19 private pre- and post-operative rooms. The tower is expected to open in spring 2022.“The Alpena Tri-County Zonta Club has a long history of support for the Medical Center,” says Diamond. €œWhen we updated the Women’s Health Unit in 2005 they were at the forefront of providing funding for the what do you need to buy kamagra Mother’s Room that has impacted thousands of families in our community. We are pleased that Zonta Club of Alpena/Tri-County is once what do you need to buy kamagra again a partner in providing excellent health care for the residents of Northeast Michigan.

They are a small group that works very hard for our community. We are appreciative of all they do and sincerely thank them for their support of the Medical Center.”Businesses or service clubs interested in supporting MidMichigan Medical Center – Alpena may contact Diamond at (989) 356-7738 or ann.diamond@midmichigan.org.With a commitment to keeping care close to home for patients of all ages, the youngest what do you need to buy kamagra of these will benefit with the addition of a Special Care Nursery coming to MidMichigan Medical Center – Midland. The Medical Center received Certificate of Need approval from the state to move forward with plans to open a Level II Special Care Nursery in early 2022.“Giving birth is a stressful situation even when all goes smoothly. With the addition of a Level II Special Care what do you need to buy kamagra Nursery, we can now provide an even higher level of care for babies that are born prematurely or require additional treatment, such as low oxygen levels or antibiotics,” said Tonia VanWieren, R.N., B.S.N., system nursing director, maternal, child and women’s health. €œFor Mom and Dad, this means their newest family member can be treated closer to home, rather than being moved to another facility.”When an infant is too sick or not quite strong enough to go home with their mother following birth, MidMichigan Medical Center – Midland will place the infant in the four-bed Special Care Nursery.

Here, infants receive 24-hour pediatric care and what do you need to buy kamagra monitoring from a highly trained neonatologist, MidMichigan Specialty Care Nursery nurses and by neonatal nurse practitioners from Spectrum Health Helen DeVos Children’s Hospital.In addition to around-the-clock care for infants unable to go home right away, MidMichigan also provides support and education for Mom and families, including breastfeeding. Over time, MidMichigan has plans to continue to build its pediatric program and increase its capacity to manage even more complex cases while maintaining its family-centered approach to care.“We have been delivering babies in Midland since our Medical Center opened its doors more than 75 years ago,” said VanWieren. €œEach delivery is a privilege, and we pride ourselves on providing all what do you need to buy kamagra the technology and care needed for a safe birth plus the comfortable amenities of home. Each birth is special and it’s our goal to meet the needs of our families by offering a full range of pediatric services.”In addition to Midland, MidMichigan Medical Centers in Alpena, Gratiot and West Branch also have Maternity Centers, which feature:All-private LDRP birthing suites where Mom and her support person may stay throughout all stages of Labor, Delivery, Recovery and Postpartum careEquipment and lighting needed for baby's birth, including centralized fetal monitoring and other technologiesHugs® infant tracking security system with mom-baby matchingA state-of-the art birthing bed that can be moved into many comfortable positionsEntertainment system for music, television or videosAn in-room refrigeratorRoom service for regular meals plus a supply of healthy refreshments for in-between timesA separate sleeping space for Mom’s support personDedicated operating room on the unit for planned or emergency c-sectionsA waiting room where visitors can make themselves comfortableThose interested in more information about the maternity services at MidMichigan Health can visit www.midmichigan.org/maternity..

Members of Zonta Club of Alpena/Tri-County recently presented a check to Ann Diamond, fund development director, MidMichigan cheap kamagra online uk Health Foundation, representing a $5,000 pledge to the future patient tower of MidMichigan Medical http://www.ec-griesheim-pres-molsheim.ac-strasbourg.fr/mardi-25-juin-2019/ Center – Alpena. Pictured are, cheap kamagra online uk back row, left to right. Kristen Marsh, Sue Latuszek, JoAnn Kamyszek, Barb Rigg, Cathy Macfalda and Betty DuRocher. Front row, cheap kamagra online uk left to right. Ann Diamond, Pam Werth, Julie Rouleau, President of Alpena Tri-County Zonta, and LisaVanHorn.

Not pictured cheap kamagra online uk. Ann Weir, Peggy Donakowski, Ann Cosbitt and Dr. Lorie Vorraro.Zonta Club of cheap kamagra online uk Alpena/Tri-County recently held their October meeting at the 19th Hole in Alpena. At the event, club members presented Ann Diamond, fund development director, MidMichigan Health Foundation, with a $5,000 pledge to the new patient tower project underway at MidMichigan Medical Center – Alpena.“We are thrilled to have Zonta Club of Alpena/Tri-County supporting this project,” said Diamond. €œZontians worldwide help advance the needs of women, and the new Women’s Health Unit in Alpena’s patient tower is a project that cheap kamagra online uk fits their mission beautifully.

We are so thankful for their continued support.”The patient cheap kamagra online uk tower has an entirely new Women’s Health Unit that includes a private operating room for C-sections and eight new labor, delivery, recovery and post-partum suites. The unit was designed to allow parents and babies to stay together throughout all stages of labor, delivery, recovery and post-partum care. Each area of the unit is beautifully decorated and outfitted with state-of-the-art cheap kamagra online uk equipment. The C-section suite is just steps away from the private rooms in this secure unit. The Women’s Health Unit will be located on the second floor of the new patient tower and includes private rooms overlooking the Thunder Bay River.“Zonta gives you the chance cheap kamagra online uk to be a part of something much larger than yourself,” said Julie http://www.ec-neuwiller-saverne.ac-strasbourg.fr/informations-ecole/reglement-interieur/ Rouleau, president of Zonta Club of Alpena/Tri-County.

€œZonta allows you to give yourself to others, to actively participate in the selection of service projects to help your community, and to improve the legal, political, economic, educational, health and professional status of women worldwide. We are pleased to be able to partner with our hospital in this important project and challenge other service organizations in our area to do the same.”In cheap kamagra online uk addition to the Women’s Health Unit, the three-story 99,000 square foot patient tower will offer 60 new private patient rooms in total, with 14 private intensive and critical care rooms, a new Surgical Department including five new operating rooms and 19 private pre- and post-operative rooms. The tower is expected to open in spring 2022.“The Alpena Tri-County Zonta Club has a long history of support for the Medical Center,” says Diamond. €œWhen we updated the Women’s cheap kamagra online uk Health Unit in 2005 they were at the forefront of providing funding for the Mother’s Room that has impacted thousands of families in our community. We are pleased that Zonta Club of Alpena/Tri-County is once again a partner cheap kamagra online uk in providing excellent health care for the residents of Northeast Michigan.

They are a small group that works very hard for our community. We are appreciative of all they do and sincerely thank them for their support of the Medical Center.”Businesses or cheap kamagra online uk service clubs interested in supporting MidMichigan Medical Center – Alpena may contact Diamond at (989) 356-7738 or ann.diamond@midmichigan.org.With a commitment to keeping care close to home for patients of all ages, the youngest of these will benefit with the addition of a Special Care Nursery coming to MidMichigan Medical Center – Midland. The Medical Center received Certificate of Need approval from the state to move forward with plans to open a Level II Special Care Nursery in early 2022.“Giving birth is a stressful situation even when all goes smoothly. With the addition of a Level II Special Care Nursery, we can now provide an even higher level of care for babies that are born prematurely or require additional treatment, such as low oxygen levels or antibiotics,” said Tonia VanWieren, R.N., B.S.N., system nursing director, cheap kamagra online uk maternal, child and women’s health. €œFor Mom and Dad, this means their newest family member can be treated closer to home, rather than being moved to another facility.”When an infant is too sick or not quite strong enough to go home with their mother following birth, MidMichigan Medical Center – Midland will place the infant in the four-bed Special Care Nursery.

Here, infants receive 24-hour pediatric care and monitoring from a highly trained neonatologist, MidMichigan Specialty Care Nursery nurses and by neonatal nurse practitioners from Spectrum Health Helen DeVos Children’s Hospital.In addition to around-the-clock care for infants unable to go home right away, MidMichigan also provides support and education for cheap kamagra online uk Mom and families, including breastfeeding. Over time, MidMichigan has plans to continue to build its pediatric program and increase its capacity to manage even more complex cases while maintaining its family-centered approach to care.“We have been delivering babies in Midland since our Medical Center opened its doors more than 75 years ago,” said VanWieren. €œEach delivery is a privilege, and we pride ourselves on providing cheap kamagra online uk all the technology and care needed for a safe birth plus the comfortable amenities of home. Each birth is special and it’s our goal to meet the needs of our families by offering a full range of pediatric services.”In addition to Midland, MidMichigan Medical Centers in Alpena, Gratiot and West Branch also have Maternity Centers, which feature:All-private LDRP birthing suites where Mom and her support person may stay throughout all stages of Labor, Delivery, Recovery and Postpartum careEquipment and lighting needed for baby's birth, including centralized fetal monitoring and other technologiesHugs® infant tracking security system with mom-baby matchingA state-of-the art birthing bed that can be moved into many comfortable positionsEntertainment system for music, television or videosAn in-room refrigeratorRoom service for regular meals plus a supply of healthy refreshments for in-between timesA separate sleeping space for Mom’s support personDedicated operating room on the unit for planned or emergency c-sectionsA waiting room where visitors can make themselves comfortableThose interested in more information about the maternity services at MidMichigan Health can visit www.midmichigan.org/maternity..

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MDEL Bulletin, June 24 2021, from the Medical Devices Compliance Program On this page Fees for Medical Device Establishment Licences (MDELs) We issue Medical http://www.onprodny.com/buy-generic-cipro/ Device cheap kamagra online uk Establishment Licences (MDELs) to. class I manufacturers importers or distributors of all device classes for human use in Canada The MDEL fee is a flat fee, regardless of when we receive your initial application. The same fee cheap kamagra online uk applies to applications for.

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However, to help meet the demand for medical devices during the erectile dysfunction treatment kamagra, we have been reviewing and processing MDEL applications before collecting the fees. As a result, some MDEL holders still haven't paid the fees for their 2020 initial MDEL application, despite multiple reminders. Authority to withhold services in case of non-payment As cheap kamagra online uk stated in the Food and Drug Act, Health Canada has the authority to withhold services, approvals, rights and/or privileges, if the fee for an MDEL application is not paid.

Non-payment of fees 30.64. The Minister may withdraw or withhold a service, the use of a facility, a regulatory process or approval or a product, right or privilege under this Act from any person who fails to pay the fee fixed for it under subsection 30.61(1). For more information, please refer cheap kamagra online uk to.

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In line with the Compliance and Enforcement Policy (POL-0001), Health Canada monitors activities for compliance. If your MDEL has been cancelled, you may be subject to compliance and enforcement actions if you conduct non-compliant activities. If you have questions about a MDEL or the application process, please contact the Medical Device Establishment cheap kamagra online uk Licensing Unit at hc.mdel.questions.leim.sc@canada.ca.

If you have questions about invoicing and fees for an MDEL application, please contact the Cost Recovery Invoicing Unit at hc.criu-ufrc.sc@canada.ca. Related linksMDEL Bulletin, June 15, 2021, from the Medical Devices Compliance Program On this page Rapid antigen tests and the workplace screening program There are currently various technologies to detect SARS CoV-2, the kamagra that causes erectile dysfunction treatment. Antigen-based testing devices detect specific proteins on the cheap kamagra online uk surface of the kamagra and typically provide results in less than 1 hour.

While some rapid antigen detection tests (RADTs) have been approved for people without symptoms, most RADTs are indicated for use on people with symptoms and are to be conducted by laboratory personnel, healthcare professionals or trained operators. Health Canada has authorized several RADTs under two interim orders. The indications cheap kamagra online uk and conditions of use of authorized products may change over time as manufacturers continue to collect data.

Screening asymptomatic individuals for SARS CoV-2 is proving to be effective in high-risk settings where social distancing and other measures are not feasible. Through the workplace screening program, Canada is supplying RADTs to eligible workplaces across the country. The program will help companies detect early cases of erectile dysfunction treatment, cheap kamagra online uk for people who are asymptomatic.

This program is being administered in collaboration with the provinces and territories. Interim enforcement approach In the interest of public health, Health Canada is placing less priority on enforcing off-label distribution of RADTs under the following circumstances. This enforcement discretion will be in effect until cheap kamagra online uk December 31, 2021.

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In this issue of BMJ Quality and Safety, Jorro-Barón and colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to buy kamagra with free samples evaluate the implementation of the I-PASS handover system among six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to the authors, prior to the intervention there were complaints that handovers were ‘…lengthy, disorganized, …participants experienced problems with interruptions, distractions, and … senior professionals had buy kamagra with free samples problems accepting dissent’.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative.

Notably, however, on the primary outcome there were no differences between control and intervention buy kamagra with free samples groups regarding preventable adverse events per 1000 days of hospitalisation (control 60.4 (37.5–97.4) vs intervention 60.4 (33.2–109.9), p=0.998, risk ratio. 1.0 (0.74–1.34)). Regarding balancing measures, there was buy kamagra with free samples no observed difference in the ‘full-shift’ handover duration (control 35.7 min (29.6–41.8).

Intervention 34.7 min (26.5–42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77–8.81). Control 5.96 buy kamagra with free samples min (4.69–7.23). P=0.001).

From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved. However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare.

In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23 658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patient’s care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by ‘cross-covering’, ‘float’ or ‘moonlighting’ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers.

The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8–11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12–16. Admissions to a surgery unit17. Management of trauma patients18–20.

ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23–28. And end-of-rotation resident transitions.29–31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites.

A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications.

It is based on adult educational principles and simple to use. It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34–40. And extensive training materials are available to assist programmes in implementation.39 41–45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handover—illness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver.

The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format. The last two I-PASS elements—situational awareness/contingency planning and synthesis—have not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed.

Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power. It is essential to establishing a shared mental model of the current state and any potential concerns.

However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Children’s Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators. Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9.

P<0.001). A commentary by Horwitz46 noted that this was ‘…by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scale’, while also noting limitations including its uncontrolled, ‘before and after’ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10 740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents.

Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable. Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5 min.

P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions. Greater provider satisfaction with handover organisation and information conveyed.

Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47–50 In a mentored implementation study conducted in 2015–2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Children’s Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-Barrón and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?.

With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patient’s clinical outcome. In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted.

Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible. At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements.

The current study of Jorro-Barón and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept. PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ‘non-standardized’ handovers.Study design. The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design.

Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

€˜Last-minute’, early morning order writing decreased, and handover duration increased but not significantly (+5.5 min. 95% CI 0.34 to 9.39. P=0.30).

As in the current study of Jorro-Barón and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation. The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation. However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52–57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition.

For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53–57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods. Clusters per sequence.

And cluster-period sizes.55 56 Concerns include recruitment and selection biases. Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent).

Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52–56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants.

For example, in the handover intervention of Jorro-Barón and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition. This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast.

Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?. From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients.

A new tool—I-PASS—has been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?.

For the reasons discussed above, I think not. In his classic 2008 article,60 ‘The Science of Improvement’, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change.

Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial. His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as children’s hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?.

The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent intervention—essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences.

Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick.

The evidence for effectiveness is overwhelming and the need for action is urgent—all that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1–3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or ‘triggers’), including a projected survival of less than 1 year,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7–12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinician–machine collaboration may even outperform both.13 Second, algorithm-based ‘nudges’ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care.

Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &. Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21% risk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians.

Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree. And 15 (23%) did not respond.

Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly ‘situational challenges’ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients.

The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et al’s work adds to our understanding of critical perceptions regarding end users’ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care. For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed clinicians’ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et al’s work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study.

For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants. Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of clinicians’ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patient’s prognosis.9 21 The brevity of the interviews in Saunders et al’s study (mean.

12 min) could suggest all relevant themes may not have emerged in the data analysis. Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders. In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to ‘focus on the present’, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential.

An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether clinicians’ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patient’s acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patient–provider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et al’s findings cannot be extrapolated to outpatient care. This is particularly relevant as many ‘off-the-shelf’ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et al’s work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an ‘opt-out’ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions.

For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors. Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectiveness–implementation trial design to test the effectiveness of an exercise intervention for breast cancer. This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectiveness–implementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field.

In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

In this issue of BMJ Quality and Safety, Jorro-Barón and colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to evaluate the implementation of the I-PASS handover system among cheap kamagra online uk six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to the authors, prior to the cheap kamagra online uk intervention there were complaints that handovers were ‘…lengthy, disorganized, …participants experienced problems with interruptions, distractions, and … senior professionals had problems accepting dissent’.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative. Notably, however, on the primary outcome there cheap kamagra online uk were no differences between control and intervention groups regarding preventable adverse events per 1000 days of hospitalisation (control 60.4 (37.5–97.4) vs intervention 60.4 (33.2–109.9), p=0.998, risk ratio.

1.0 (0.74–1.34)). Regarding balancing measures, there was cheap kamagra online uk no observed difference in the ‘full-shift’ handover duration (control 35.7 min (29.6–41.8). Intervention 34.7 min (26.5–42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77–8.81). Control 5.96 min (4.69–7.23) cheap kamagra online uk.

P=0.001). From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved. However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare.

In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23 658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patient’s care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by ‘cross-covering’, ‘float’ or ‘moonlighting’ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers. The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8–11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12–16.

Admissions to a surgery unit17. Management of trauma patients18–20. ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23–28.

And end-of-rotation resident transitions.29–31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites. A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications.

It is based on adult educational principles and simple to use. It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34–40. And extensive training materials are available to assist programmes in implementation.39 41–45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handover—illness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver. The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format.

The last two I-PASS elements—situational awareness/contingency planning and synthesis—have not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed. Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power.

It is essential to establishing a shared mental model of the current state and any potential concerns. However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Children’s Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators. Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9.

P<0.001). A commentary by Horwitz46 noted that this was ‘…by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scale’, while also noting limitations including its uncontrolled, ‘before and after’ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10 740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents. Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable.

Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5 min. P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions.

Greater provider satisfaction with handover organisation and information conveyed. Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47–50 In a mentored implementation study conducted in 2015–2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Children’s Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-Barrón and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?.

With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patient’s clinical outcome. In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted. Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible.

At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements. The current study of Jorro-Barón and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept. PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ‘non-standardized’ handovers.Study design.

The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design. Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

€˜Last-minute’, early morning order writing decreased, and handover duration increased but not significantly (+5.5 min. 95% CI 0.34 to 9.39. P=0.30). As in the current study of Jorro-Barón and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation.

The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation. However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52–57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition. For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53–57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods.

Clusters per sequence. And cluster-period sizes.55 56 Concerns include recruitment and selection biases. Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent).

Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52–56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants. For example, in the handover intervention of Jorro-Barón and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition.

This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast. Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?.

From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients. A new tool—I-PASS—has been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?.

For the reasons discussed above, I think not. In his classic 2008 article,60 ‘The Science of Improvement’, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change. Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial.

His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as children’s hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?. The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent intervention—essentially a process of social change.

The effectiveness of these systems is sensitive to an array of influences. Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick.

The evidence for effectiveness is overwhelming and the need for action is urgent—all that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1–3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or ‘triggers’), including a projected survival of less than 1 year,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7–12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinician–machine collaboration may even outperform both.13 Second, algorithm-based ‘nudges’ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care. Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &.

Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21% risk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians. Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree.

And 15 (23%) did not respond. Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly ‘situational challenges’ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients.

The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et al’s work adds to our understanding of critical perceptions regarding end users’ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care. For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed clinicians’ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et al’s work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study. For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants.

Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of clinicians’ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patient’s prognosis.9 21 The brevity of the interviews in Saunders et al’s study (mean. 12 min) could suggest all relevant themes may not have emerged in the data analysis. Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders.

In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to ‘focus on the present’, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential. An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether clinicians’ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patient’s acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patient–provider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et al’s findings cannot be extrapolated to outpatient care. This is particularly relevant as many ‘off-the-shelf’ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et al’s work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an ‘opt-out’ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions. For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors.

Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectiveness–implementation trial design to test the effectiveness of an exercise intervention for breast cancer. This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectiveness–implementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field. In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

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See full-page version New cases of erectile dysfunction treatment declined in rural counties last week, but rural areas continue to account for a disproportionate share buy kamagra uk of new s and erectile dysfunction treatment-related deaths. New s in rural counties fell by 11% in the week ending Saturday, October 16 -- from about 141,000 two weeks to 125,000 cases last week. Metropolitan counties had a slightly bigger decline of buy kamagra uk 12%. erectile dysfunction treatment-related deaths in rural counties fell by 6.1% last week, from 2,655 to 2,492. Metropolitan counties buy kamagra uk had a much sharper decline of 14.4%.

As the delta-variant surge cools, rural counties, on average, have continued to have rates about 80% higher than metropolitan areas. The gap is worse for erectile dysfunction treatment-related deaths. Last week’s rural death rate of 5.4 per 100,000 was twice the metropolitan buy kamagra uk rate of 2.7 per 100,000. The graph below compares the percentage of the nation’s erectile dysfunction treatment-related deaths that have occurred in rural counties to the share of the U.S. Population that buy kamagra uk is rural.

Last week, rural counties, which contain 14% of the U.S. Population, accounted for 25% of the erectile dysfunction treatment-related deaths. Red-Zone Counties buy kamagra uk Like this story?. Sign up for our newsletter. The number of rural counties in the red zone (defined as have a weekly rate of 100 or more cases per 100,000 residents) feel by 78 last week, continuing a three-week decline.States that were first buy kamagra uk to experience the delta-variant surge are now the ones shedding red-zone counties at the fastest rate.

Missouri, which was the launching pad for the summer surge, dropped 19 counties from the rural red-zone list last week. Mississippi dropped 14, and Arkansas dropped nine.Only nine states had more rural red-zone counties last week than two weeks ago. Gains were buy kamagra uk concentrated in the northern interior. South Dakota added five counties to its rural red-zone list. North Dakota and Montana added three.Alaska, which had nation’s worst rural last week, added three county-equivalents to the red-zone list last week.Texas, which had been shedding red-zone counties, added five rural counties buy kamagra uk last week.

Statewide Rates Alaska’s rural rate climbed about 10% last week, to 782 per 100,000. The state’s metropolitan rate was even higher – 879 per 100,000.Several northern states had some of the nation’s highest rural rates last week. North Dakota was second, buy kamagra uk behind Alaska. Montana and Wyoming were fourth and fifth respectively. Idaho was ninth.Great Lakes states that avoided the delta variant surge for months now have some of the buy kamagra uk nation’s highest rural rates.

Minnesota and Michigan had the sixth and seventh highest rates respectively. Another hotspot is Central and Northern Appalachia. West Virginia had the nation’s third highest rural rate, while Pennsylvania had the eighth highest.Several Southern and Midwestern states that were at the epicenter of buy kamagra uk the first stages of the delta-variant surge now have some of the lowest rural rates. These include Florida, Georgia, Louisiana, Missouri, Mississippi and Arkansas. Black-Zone Counties National improvement in the rural rate is reflected in the buy kamagra uk decline of “black-zone” counties.

These are counties with very high rates – over 500 new cases per 100,000 residents in a single week. Rural black-zone counties declined from 312 two weeks ago to 224 last week. You Might Also LikeStart Preamble Centers for Disease Control and Prevention (CDC), Department of Health and buy kamagra uk Human Services (HHS). Notice of meeting and request for comment. In accordance with the Federal Advisory Committee Act, the Centers for Disease Control and Prevention (CDC) announces the following meeting buy kamagra uk of the Advisory Committee on Immunization Practices (ACIP).

This meeting is open to the public. Time will be available for buy kamagra uk public comment. The meeting will be webcast live via the World Wide Web. For more information on ACIP please visit the ACIP website. Http://www.cdc.gov/​treatments/​acip/​index.html.

The meeting will be held on November 2-3, 2021, from 10:00 a.m. To 5:00 p.m., EDT (times subject to change). The public may submit written comments from October 22, 2021 through November 3, 2021. You may submit comments identified by Docket No. CDC-2021-0112 by any of the following methods.

• Federal eRulemaking Portal. Https://www.regulations.gov. Follow the instructions for submitting comments. • Mail. Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H24-8, Atlanta, Georgia 30329-4027, Attn.

ACIP Meeting. Instructions. All submissions received must include the Agency name and Docket Number. All relevant comments received in conformance with the https://www.regulations.gov suitability policy will be posted without change to https://www.regulations.gov, including any personal information provided. For access to the docket to read background documents or comments received, go to https://www.regulations.gov.

Written public comments submitted up to 72 hours prior to the ACIP meeting will be provided to ACIP members before the meeting. Start Further Info Stephanie Thomas, ACIP Committee Management Specialist, Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, 1600 Clifton Road NE, MS-H24-8, Atlanta, Georgia 30329-4027. Telephone. (404) 639-8367. Email.

ACIP@cdc.gov. End Further Info End Preamble Start Supplemental Information In accordance with 41 CFR 102-3.150(b), less than 15 calendar days' notice is being given for this meeting due to the exceptional circumstances of the erectile dysfunction treatment kamagra and rapidly evolving erectile dysfunction treatment development and regulatory processes. The Secretary of Health and Human Services has determined that erectile dysfunction treatment is a Public Health Emergency. A notice of this ACIP meeting has also been posted on CDC's ACIP website at. Http://www.cdc.gov/​treatments/​acip/​index.html.

In addition, CDC has sent notice of this ACIP meeting by email to those who subscribe to receive email updates about ACIP. Purpose. The committee is charged with advising the Director, CDC, on the Start Printed Page 58664 use of immunizing agents. In addition, under 42 U.S.C. 1396s, the committee is mandated to establish and periodically review and, as appropriate, revise the list of treatments for administration to treatment-eligible children through the treatments for Children program, along with schedules regarding dosing interval, dosage, and contraindications to administration of treatments.

Further, under provisions of the Affordable Care Act, section 2713 of the Public Health Service Act, immunization recommendations of the ACIP that have been approved by the CDC Director and appear on CDC immunization schedules must be covered by applicable health plans. Matters To Be Considered. The agenda will include discussions on adult immunization schedule, child/adolescent immunization schedule, Ebola treatment, hepatitis treatments, Orthopoxkamagraes treatment and erectile dysfunction treatments. Recommendation votes on adult immunization schedule, child/adolescent immunization schedule, hepatitis treatment, Orthopoxkamagraes treatment, Ebola treatment and erectile dysfunction treatments are scheduled. No treatments for Children votes are scheduled.

Agenda items are subject to change as priorities dictate. For more information on the meeting agenda visit https://www.cdc.gov/​treatments/​acip/​meetings/​meetings-info.html. Public Participation Interested persons or organizations are invited to participate by submitting written views, recommendations, and data. Please note that comments received, including attachments and other supporting materials, are part of the public record and are subject to public disclosure. Comments will be posted on https://www.regulations.gov.

Therefore, do not include any information in your comment or supporting materials that you consider confidential or inappropriate for public disclosure. If you include your name, contact information, or other information that identifies you in the body of your comments, that information will be on public display. CDC will review all submissions and may choose to redact, or withhold, submissions containing private or proprietary information such as Social Security numbers, medical information, inappropriate language, or duplicate/near duplicate examples of a mass-mail campaign. CDC will carefully consider all comments submitted into the docket. Written Public Comment.

The docket will be opened to receive written comments on October 22, 2021. Written comments must be received on or before November 3, 2021. Oral Public Comment. This meeting will include time for members of the public to make an oral comment. Oral public comment will occur before any scheduled votes including all votes relevant to the ACIP's Affordable Care Act and treatments for Children Program roles.

Priority will be given to individuals who submit a request to make an oral public comment before the meeting according to the procedures below. Procedure for Oral Public Comment. All persons interested in making an oral public comment at the November 2-3, 2021 ACIP meeting must submit a request at http://www.cdc.gov/​treatments/​acip/​meetings/​ no later than 11:59 p.m., EDT, October 31, 2021, according to the instructions provided. If the number of persons requesting to speak is greater than can be reasonably accommodated during the scheduled time, CDC will conduct a lottery to determine the speakers for the scheduled public comment session. CDC staff will notify individuals regarding their request to speak by email by November 1, 2021.

To accommodate the significant interest in participation in the oral public comment session of ACIP meetings, each speaker will be limited to 3 minutes, and each speaker may only speak once per meeting. The Director, Strategic Business Initiatives Unit, Office of the Chief Operating Officer, Centers for Disease Control and Prevention, has been delegated the authority to sign Federal Register notices pertaining to announcements of meetings and other committee management activities, for both the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry. Start Signature Kalwant Smagh, Director, Strategic Business Initiatives Unit, Office of the Chief Operating Officer, Centers for Disease Control and Prevention. End Signature End Supplemental Information [FR Doc. 2021-23222 Filed 10-20-21.

See full-page version New cases of erectile dysfunction treatment declined in rural counties last week, but rural areas kamagra oral jelly online shop continue to account for cheap kamagra online uk a disproportionate share of new s and erectile dysfunction treatment-related deaths. New s in rural counties fell by 11% in the week ending Saturday, October 16 -- from about 141,000 two weeks to 125,000 cases last week. Metropolitan counties had a slightly bigger cheap kamagra online uk decline of 12%. erectile dysfunction treatment-related deaths in rural counties fell by 6.1% last week, from 2,655 to 2,492. Metropolitan counties had a cheap kamagra online uk much sharper decline of 14.4%.

As the delta-variant surge cools, rural counties, on average, have continued to have rates about 80% higher than metropolitan areas. The gap is worse for erectile dysfunction treatment-related deaths. Last week’s rural death rate of cheap kamagra online uk 5.4 per 100,000 was twice the metropolitan rate of 2.7 per 100,000. The graph below compares the percentage of the nation’s erectile dysfunction treatment-related deaths that have occurred in rural counties to the share of the U.S. Population that is cheap kamagra online uk rural.

Last week, rural counties, which contain 14% of the U.S. Population, accounted for 25% of the erectile dysfunction treatment-related deaths. Red-Zone Counties Like this story? cheap kamagra online uk. Sign up for our newsletter. The number of rural counties in the red zone (defined as have a weekly rate of 100 or more cases per 100,000 residents) feel by 78 last week, continuing a three-week decline.States that were first to experience the delta-variant surge are now the ones shedding red-zone counties at the fastest rate cheap kamagra online uk.

Missouri, which was the launching pad for the summer surge, dropped 19 counties from the rural red-zone list last week. Mississippi dropped 14, and Arkansas dropped nine.Only nine states had more rural red-zone counties last week than two weeks ago. Gains were concentrated in the northern interior cheap kamagra online uk. South Dakota added five counties to its rural red-zone list. North Dakota and Montana added three.Alaska, which had nation’s worst rural last week, added three county-equivalents to cheap kamagra online uk the red-zone list last week.Texas, which had been shedding red-zone counties, added five rural counties last week.

Statewide Rates Alaska’s rural rate climbed about 10% last week, to 782 per 100,000. The state’s metropolitan rate was even higher – 879 per 100,000.Several northern states had some of the nation’s highest rural rates last week. North Dakota was second, behind Alaska cheap kamagra online uk. Montana and Wyoming were fourth and fifth respectively. Idaho was ninth.Great Lakes states that avoided the delta variant surge for months now have some of the nation’s highest rural cheap kamagra online uk rates.

Minnesota and Michigan had the sixth and seventh highest rates respectively. Another hotspot is Central and Northern Appalachia. West Virginia had the nation’s third highest rural rate, while Pennsylvania had the eighth highest.Several Southern and Midwestern states that were at the epicenter of the first cheap kamagra online uk stages of the delta-variant surge now have some of the lowest rural rates. These include Florida, Georgia, Louisiana, Missouri, Mississippi and Arkansas. Black-Zone Counties National improvement in the rural rate is reflected in cheap kamagra online uk the decline of “black-zone” counties.

These are counties with very high rates – over 500 new cases per 100,000 residents in a single week. Rural black-zone counties declined from 312 two weeks ago to 224 last week. You Might Also LikeStart Preamble cheap kamagra online uk Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS). Notice of meeting and request for comment. In accordance with the Federal cheap kamagra online uk Advisory Committee Act, the Centers for Disease Control and Prevention (CDC) announces the following meeting of the Advisory Committee on Immunization Practices (ACIP).

This meeting is open to the public. Time will be available for public cheap kamagra online uk comment. The meeting will be webcast live via the World Wide Web. For more information on ACIP please visit the ACIP website. Http://www.cdc.gov/​treatments/​acip/​index.html.

The meeting will be held on November 2-3, 2021, from 10:00 a.m. To 5:00 p.m., EDT (times subject to change). The public may submit written comments from October 22, 2021 through November 3, 2021. You may submit comments identified by Docket No. CDC-2021-0112 by any of the following methods.

• Federal eRulemaking Portal. Https://www.regulations.gov. Follow the instructions for submitting comments. • Mail. Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H24-8, Atlanta, Georgia 30329-4027, Attn.

ACIP Meeting. Instructions. All submissions received must include the Agency name and Docket Number. All relevant comments received in conformance with the https://www.regulations.gov suitability policy will be posted without change to https://www.regulations.gov, including any personal information provided. For access to the docket to read background documents or comments received, go to https://www.regulations.gov.

Written public comments submitted up to 72 hours prior to the ACIP meeting will be provided to ACIP members before the meeting. Start Further Info Stephanie Thomas, ACIP Committee Management Specialist, Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, 1600 Clifton Road NE, MS-H24-8, Atlanta, Georgia 30329-4027. Telephone. (404) 639-8367. Email.

ACIP@cdc.gov. End Further Info End Preamble Start Supplemental Information In accordance with 41 CFR 102-3.150(b), less than 15 calendar days' notice is being given for this meeting due to the exceptional circumstances of the erectile dysfunction treatment kamagra and rapidly evolving erectile dysfunction treatment development and regulatory processes. The Secretary of Health and Human Services has determined that erectile dysfunction treatment is a Public Health Emergency. A notice of this ACIP meeting has also been posted on CDC's ACIP website at. Http://www.cdc.gov/​treatments/​acip/​index.html.

In addition, CDC has sent notice of this ACIP meeting by email to those who subscribe to receive email updates about ACIP. Purpose. The committee is charged with advising the Director, CDC, on the Start Printed Page 58664 use of immunizing agents. In addition, under 42 U.S.C. 1396s, the committee is mandated to establish and periodically review and, as appropriate, revise the list of treatments for administration to treatment-eligible children through the treatments for Children program, along with schedules regarding dosing interval, dosage, and contraindications to administration of treatments.

Further, under provisions of the Affordable Care Act, section 2713 of the Public Health Service Act, immunization recommendations of the ACIP that have been approved by the CDC Director and appear on CDC immunization schedules must be covered by applicable health plans. Matters To Be Considered. The agenda will include discussions on adult immunization schedule, child/adolescent immunization schedule, Ebola treatment, hepatitis treatments, Orthopoxkamagraes treatment and erectile dysfunction treatments. Recommendation votes on adult immunization schedule, child/adolescent immunization schedule, hepatitis treatment, Orthopoxkamagraes treatment, Ebola treatment and erectile dysfunction treatments are scheduled. No treatments for Children votes are scheduled.

Agenda items are subject to change as priorities dictate. For more information on the meeting agenda visit https://www.cdc.gov/​treatments/​acip/​meetings/​meetings-info.html. Public Participation Interested persons or organizations are invited to participate by submitting written views, recommendations, and data. Please note that comments received, including attachments and other supporting materials, are part of the public record and are subject to public disclosure. Comments will be posted on https://www.regulations.gov.

Therefore, do not include any information in your comment or supporting materials that you consider confidential or inappropriate for public disclosure. If you include your name, contact information, or other information that identifies you in the body of your comments, that information will be on public display. CDC will review all submissions and may choose to redact, or withhold, submissions containing private or proprietary information such as Social Security numbers, medical information, inappropriate language, or duplicate/near duplicate examples of a mass-mail campaign. CDC will carefully consider all comments submitted into the docket. Written Public Comment.

The docket will be opened to receive written comments on October 22, 2021. Written comments must be received on or before November 3, 2021. Oral Public Comment. This meeting will include time for members of the public to make an oral comment. Oral public comment will occur before any scheduled votes including all votes relevant to the ACIP's Affordable Care Act and treatments for Children Program roles.

Priority will be given to individuals who submit a request to make an oral public comment before the meeting according to the procedures below. Procedure for Oral Public Comment. All persons interested in making an oral public comment at the November 2-3, 2021 ACIP meeting must submit a request at http://www.cdc.gov/​treatments/​acip/​meetings/​ no later than 11:59 p.m., EDT, October 31, 2021, according to the instructions provided. If the number of persons requesting to speak is greater than can be reasonably accommodated during the scheduled time, CDC will conduct a lottery to determine the speakers for the scheduled public comment session. CDC staff will notify individuals regarding their request to speak by email by November 1, 2021.

To accommodate the significant interest in participation in the oral public comment session of ACIP meetings, each speaker will be limited to 3 minutes, and each speaker may only speak once per meeting. The Director, Strategic Business Initiatives Unit, Office of the Chief Operating Officer, Centers for Disease Control and Prevention, has been delegated the authority to sign Federal Register notices pertaining to announcements of meetings and other committee management activities, for both the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry. Start Signature Kalwant Smagh, Director, Strategic Business Initiatives Unit, Office of the Chief Operating Officer, Centers for Disease Control and Prevention. End Signature End Supplemental Information [FR Doc. 2021-23222 Filed 10-20-21.

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Guidelines aim super kamagra pills to align clinical care with best practice. However, simply publishing a guideline rarely triggers behavioural changes to match guideline recommendations.1–3 We thus transform guideline recommendations into actionable tasks by introducing interventions that promote behavioural changes meant to produce guideline-concordant care. Unfortunately, not much has changed in the 25 years since Oxman and colleagues concluded that we have no ‘magic bullets’ when it comes to changing clinician behaviour.4 In fact, far from magic bullets, interventions aimed at increasing the degree to which patients receive care recommended in guidelines (eg, educational interventions, reminders, audit and feedback, financial incentives, computerised decision support) typically produce disappointingly small improvements in care.5–10Much improvement work aims to ‘make the right thing to do the easy thing to do.’ Yet, design solutions which hardwire the desired actions super kamagra pills remain few and far between. Further, improvement interventions which ‘softwire’ such actions—not guaranteeing that they occur, but at least increasing the likelihood that clinicians will deliver the care recommended in guidelines—mostly produce small improvements.5–9 Until this situation changes, we need to acknowledge the persistent reality that guidelines themselves represent a main strategy for promoting care consistent with current evidence, which means their design should promote the desired actions.11 12In this respect, guidelines constitute a type of clinical decision support. And, like all decision support interventions, guidelines require.

(1) user testing to assess if the content is understood super kamagra pills as intended and (2) empirical testing to assess if the decision support provided by the guideline does in fact promote the desired behaviours. While the processes for developing guidelines have received substantial attention over the years,13–18 surprisingly little attention has been paid to empirically answering basic questions about the finished product. Do users understand guidelines super kamagra pills as intended?. And, what version of a given guideline engenders the desired behaviours by clinicians?. In this issue of BMJ Quality and Safety, Jones et al19 address this gap by using simulation to compare the frequency of medication errors when clinicians administer an intravenous medication using an existing guideline in the UK’s National Health Service (NHS) versus a revised and user-tested version of the guideline that more clearly promotes the desired actions.

Their findings demonstrate that changes to guideline design (through addition of actionable decision supports) based on user feedback does in fact super kamagra pills trigger changes in behaviour that can improve safety. This is an exciting use of simulation, which we believe should encourage further studies in this vein.Ensuring end users understand and use guidelines as intendedJones and colleagues’ approach affords an opportunity to reflect on the benefits of user testing and simulation of guidelines. The design and evaluation of their revised guidelines provides an excellent example of a careful stepwise progression in super kamagra pills the development and evaluation of a guideline as a type of decision support for clinicians. First, in a prior study,20 they user tested the original NHS guidelines to improve retrieval and comprehension of information. The authors produced a revised guideline, which included reformatted sections as well as increased support for key calculations, such as for infusion rates.

The authors again user tested the revised guideline, successfully showing higher rates super kamagra pills of comprehension. Note that user testing refers to a specific approach focused on comprehension rather than behaviour21 and is distinct from usability testing. Second, in the current study, Jones et al evaluated whether nurse and midwife end users exhibited the desired behavioural changes when super kamagra pills given the revised guidelines (with addition of actionable decision supports), compared with a control group working with the current version of the guidelines used in practice. As a result, Jones and colleagues verify that end users (1) understand the content in the guideline and (2) actually change their behaviour in response to using it.Simulation can play a particularly useful role in this context, as it can help identify problems with users’ comprehension of the guideline and also empirically assess what behavioural changes occur in response to design changes in the guidelines. The level of methodological control and qualitative detail that simulation provides is difficult to feasibly replicate with real-world pilot studies, and therefore simulation fills a critical gap.Jones et al report successful changes in behaviour due to the revised guidelines in which they added actionable decision supports.

For example, their earlier user testing found that super kamagra pills participants using the initial guidelines did not account for displacement volume when reconstituting the powdered drug, leading to dosing errors. A second error with the initial guidelines involved participants using the shortest infusion rate provided (eg, guidelines state ‘1 to 3 hours’), without realising that the shortest rate is not appropriate for certain doses (eg, 1 hour is appropriate for smaller doses, but larger doses should not be infused over 1 hour because the drug would then be administered faster than the maximum allowable infusion rate of 3 mg/kg/hour). These two issues were addressed in the revised guidelines by providing key determinants for ‘action’ such as calculation formulas that account for displacement volume and infusion duration, thereby more carefully guiding end users to avoid these dose and rate errors. These changes to the guideline triggered specific behaviours (eg, calculations that account for all variables) that did not occur with the super kamagra pills initial guidelines. Therefore, the simulation testing demonstrated the value of providing determinants for action, such as specific calculation formulas to support end users, by showing a clear reduction in dose and rate errors when using the revised guidelines compared with the initial guidelines.The authors also report that other types of medication-specific errors remained unaffected by the revised guidelines (eg, incorrect technique and flush errors)—the changes made did not facilitate the desired actions.

The initial guidelines indicate ‘DO NOT SHAKE’ super kamagra pills in capital letters, and there is a section specific to ‘Flushing’. In contrast, the revised guidelines do not capitalise the warning about shaking the vial, but embed the warning with a numbered sequence in the medication preparation section, aiming to increase the likelihood of reading it at the appropriate time. The revised guidelines do not have a section specific to flushing, but embed the flushing instructions as an unnumbered step in the administration section. Thus, the value of embedding technique and flushing information within the context of use was super kamagra pills not validated in the simulation testing (ie, no significant differences in the rates of these errors), highlighting precisely the pivotal role that simulation can play in assessing whether attempts to improve usability result in actual behavioural changes.Finally, simulation can identify potential unintended consequences of a guideline. For instance, Jones and colleagues observed an increase in errors (although not statistically significant) that were not medication specific (eg, non-aseptic technique such as hand washing, swabbing vials with an alcohol wipe).

Given that the revised guidelines were specific to the medication tested, it is unusual that super kamagra pills we see a tendency toward a worsening effect on generic medication preparation skills. Again, this finding was not significant, but we highlight this to remind ourselves of the very real possibility that some interventions might introduce new and unexpected errors in response to changing workflow and practice6. Simulations offer an opportunity to spot these risks in advance.Now that Jones et al have seen how the revised guidelines change behaviour, they are optimally positioned to move forward. On one hand, they have the option of revising the guidelines further in attempts to address these resistant errors, and on the other, they can consider designing other super kamagra pills interventions to be implemented in parallel with their user-tested guidance. At first glance, the errors that were resistant to change appear to be mechanical tasks that end users might think of as applying uniformly to multiple medications (eg, flush errors, non-aseptic technique).

Therefore, a second intervention that has a super kamagra pills more general scope (rather than drug specific) might be pursued. Regardless of what they decide to pursue, we applaud their measured approach and highlight that the key takeaway is that their next steps are supported with clearer evidence of what to expect when the guidelines are released—certainly a helpful piece of information to guide decisions as to whether broad implementation of guidelines is justified.Caveats and conclusionSimulation is not a panacea—it is not able to assess longitudinal adherence, and there are limitations to how realistically clinicians behave when observed for a few sample procedures when under the scrutiny of observers. Further, studies where interventions are implemented to assess whether they move the needle on the outcomes we care about (eg, adverse events, length of stay, patient mortality) are needed and should continue. However, having end users physically perform clinical tasks with the intervention in super kamagra pills representative environments represents an important strategy to assess the degree to which guidelines and other decision support interventions in fact promote the desired behaviours and to spot problems in advance of implementation. Such simulation testing is not currently a routine step in intervention design.

We hope it becomes a more common phenomenon, with more improvement work following the example of the approach so effectively demonstrated by Jones and colleagues..

Guidelines aim to align clinical care with cheap kamagra online uk best practice try this site. However, simply publishing a guideline rarely triggers behavioural changes to match guideline recommendations.1–3 We thus transform guideline recommendations into actionable tasks by introducing interventions that promote behavioural changes meant to produce guideline-concordant care. Unfortunately, not much has changed in the 25 years since Oxman and colleagues concluded that we have no ‘magic cheap kamagra online uk bullets’ when it comes to changing clinician behaviour.4 In fact, far from magic bullets, interventions aimed at increasing the degree to which patients receive care recommended in guidelines (eg, educational interventions, reminders, audit and feedback, financial incentives, computerised decision support) typically produce disappointingly small improvements in care.5–10Much improvement work aims to ‘make the right thing to do the easy thing to do.’ Yet, design solutions which hardwire the desired actions remain few and far between. Further, improvement interventions which ‘softwire’ such actions—not guaranteeing that they occur, but at least increasing the likelihood that clinicians will deliver the care recommended in guidelines—mostly produce small improvements.5–9 Until this situation changes, we need to acknowledge the persistent reality that guidelines themselves represent a main strategy for promoting care consistent with current evidence, which means their design should promote the desired actions.11 12In this respect, guidelines constitute a type of clinical decision support. And, like all decision support interventions, guidelines require.

(1) user testing to assess if the content is understood as intended and (2) empirical testing to assess if the decision support provided by the guideline cheap kamagra online uk does in fact promote the desired behaviours. While the processes for developing guidelines have received substantial attention over the years,13–18 surprisingly little attention has been paid to empirically answering basic questions about the finished product. Do users understand guidelines as cheap kamagra online uk intended?. And, what version of a given guideline engenders the desired behaviours by clinicians?. In this issue of BMJ Quality and Safety, Jones et al19 address this gap by using simulation to compare the frequency of medication errors when clinicians administer an intravenous medication using an existing guideline in the UK’s National Health Service (NHS) versus a revised and user-tested version of the guideline that more clearly promotes the desired actions.

Their findings demonstrate that changes to guideline design (through addition of cheap kamagra online uk actionable decision supports) based on user feedback does in fact trigger changes in behaviour that can improve safety. This is an exciting use of simulation, which we believe should encourage further studies in this vein.Ensuring end users understand and use guidelines as intendedJones and colleagues’ approach affords an opportunity to reflect on the benefits of user testing and simulation of guidelines. The design and evaluation of their revised guidelines provides an excellent example of a careful stepwise progression in the development and evaluation of a guideline as a type of cheap kamagra online uk decision support for clinicians. First, in a prior study,20 they user tested the original NHS guidelines to improve retrieval and comprehension of information. The authors produced a revised guideline, which included reformatted sections as well as increased support for key calculations, such as for infusion rates.

The authors again cheap kamagra online uk user tested the revised guideline, successfully showing higher rates of comprehension. Note that user testing refers to a specific approach focused on comprehension rather than behaviour21 and is distinct from usability testing. Second, in the current study, Jones et al evaluated whether nurse and midwife end users exhibited the desired cheap kamagra online uk behavioural changes when given the revised guidelines (with addition of actionable decision supports), compared with a control group working with the current version of the guidelines used in practice. As a result, Jones and colleagues verify that end users (1) understand the content in the guideline and (2) actually change their behaviour in response to using it.Simulation can play a particularly useful role in this context, as it can help identify problems with users’ comprehension of the guideline and also empirically assess what behavioural changes occur in response to design changes in the guidelines. The level of methodological control and qualitative detail that simulation provides is difficult to feasibly replicate with real-world pilot studies, and therefore simulation fills a critical gap.Jones et al report successful changes in behaviour due to the revised guidelines in which they added actionable decision supports.

For example, their earlier user testing found that participants using the cheap kamagra online uk initial guidelines did not account http://robertflannagan.com/?p=33 for displacement volume when reconstituting the powdered drug, leading to dosing errors. A second error with the initial guidelines involved participants using the shortest infusion rate provided (eg, guidelines state ‘1 to 3 hours’), without realising that the shortest rate is not appropriate for certain doses (eg, 1 hour is appropriate for smaller doses, but larger doses should not be infused over 1 hour because the drug would then be administered faster than the maximum allowable infusion rate of 3 mg/kg/hour). These two issues were addressed in the revised guidelines by providing key determinants for ‘action’ such as calculation formulas that account for displacement volume and infusion duration, thereby more carefully guiding end users to avoid these dose and rate errors. These changes to the guideline triggered specific behaviours (eg, calculations that account cheap kamagra online uk for all variables) that did not occur with the initial guidelines. Therefore, the simulation testing demonstrated the value of providing determinants for action, such as specific calculation formulas to support end users, by showing a clear reduction in dose and rate errors when using the revised guidelines compared with the initial guidelines.The authors also report that other types of medication-specific errors remained unaffected by the revised guidelines (eg, incorrect technique and flush errors)—the changes made did not facilitate the desired actions.

The initial guidelines indicate ‘DO NOT SHAKE’ in capital letters, and there is cheap kamagra online uk a section specific to ‘Flushing’. In contrast, the revised guidelines do not capitalise the warning about shaking the vial, but embed the warning with a numbered sequence in the medication preparation section, aiming to increase the likelihood of reading it at the appropriate time. The revised guidelines do not have a section specific to flushing, but embed the flushing instructions as an unnumbered step in the administration section. Thus, the value of embedding technique and flushing information within the context of use was not validated in the simulation testing (ie, no significant differences in the rates of these errors), highlighting precisely the pivotal role that simulation can play in assessing whether attempts to improve usability result in actual behavioural changes.Finally, simulation can identify potential cheap kamagra online uk unintended consequences of a guideline. For instance, Jones and colleagues observed an increase in errors (although not statistically significant) that were not medication specific (eg, non-aseptic technique such as hand washing, swabbing vials with an alcohol wipe).

Given that the revised guidelines cheap kamagra online uk were specific to the medication tested, it is unusual that we see a tendency toward a worsening effect on generic medication preparation skills. Again, this finding was not significant, but we highlight this to remind ourselves of the very real possibility that some interventions might introduce new and unexpected errors in response to changing workflow and practice6. Simulations offer an opportunity to spot these risks in advance.Now that Jones et al have seen how the revised guidelines change behaviour, they are optimally positioned to move forward. On one hand, they have the option of revising the guidelines further in attempts to address these resistant errors, and on the other, they cheap kamagra online uk can consider designing other interventions to be implemented in parallel with their user-tested guidance. At first glance, the errors that were resistant to change appear to be mechanical tasks that end users might think of as applying uniformly to multiple medications (eg, flush errors, non-aseptic technique).

Therefore, a second intervention that cheap kamagra online uk has a more general scope (rather than drug specific) might be pursued. Regardless of what they decide to pursue, we applaud their measured approach and highlight that the key takeaway is that their next steps are supported with clearer evidence of what to expect when the guidelines are released—certainly a helpful piece of information to guide decisions as to whether broad implementation of guidelines is justified.Caveats and conclusionSimulation is not a panacea—it is not able to assess longitudinal adherence, and there are limitations to how realistically clinicians behave when observed for a few sample procedures when under the scrutiny of observers. Further, studies where interventions are implemented to assess whether they move the needle on the outcomes we care about (eg, adverse events, length of stay, patient mortality) are needed and should continue. However, having end users physically perform cheap kamagra online uk clinical tasks with the intervention in representative environments represents an important strategy to assess the degree to which guidelines and other decision support interventions in fact promote the desired behaviours and to spot problems in advance of implementation. Such simulation testing is not currently a routine step in intervention design.

We hope it becomes a more common phenomenon, with more improvement work following the example of the approach so effectively demonstrated by Jones and colleagues..