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1.  What drives the ‘August effect’? A observational study of the effect of junior doctor changeover on out of hours work 
JRSM Short Reports  2013;4(8):2042533313489823.
To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the ‘August effect’.
Quantitative retrospective observational study of routinely collected data on junior doctor workload.
Two large teaching hospitals in England.
Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals.
Main outcome measures
Number and type of tasks requested by nurses, time to completion of tasks by junior doctors.
There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10−9).
This study suggests that the ‘August effect’ is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.
PMCID: PMC3767064  PMID: 24040495
2.  Clinical utility of diagnostic guidelines and putative biomarkers in lymphangioleiomyomatosis 
Respiratory Research  2012;13(1):34.
Lymphangioleiomyomatosis is a rare disease occurring almost exclusively in women. Diagnosis often requires surgical biopsy and the clinical course varies between patients with no predictors of progression. We evaluated recent diagnostic guidelines, clinical features and serum biomarkers as diagnostic and prognostic tools.
Serum vascular endothelial growth factor-D (VEGF-D), angiotensin converting enzyme (ACE), matrix metalloproteinases (MMP) -2 and -9, clinical phenotype, thoracic and abdominal computerised tomography, lung function and quality of life were examined in a cohort of 58 patients. 32 healthy female controls had serum biomarkers measured.
Serum VEGF-D, ACE and total MMP-2 levels were elevated in patients. VEGF-D was the strongest discriminator between patients and controls (median = 1174 vs. 332 pg/ml p < 0.0001 with an area under the receiver operating characteristic curve of 0.967, 95% CI 0.93-1.01). Application of European Respiratory Society criteria allowed a definite diagnosis without biopsy in 69%. Adding VEGF-D measurement to ERS criteria further reduced the need for biopsy by 10%. VEGF-D was associated with lymphatic involvement (p = 0.017) but not the presence of angiomyolipomas.
Combining ERS criteria and serum VEGF-D reduces the need for lung biopsy in LAM. VEGF-D was associated with lymphatic disease but not lung function.
PMCID: PMC3431996  PMID: 22513045
VEGF-D; Matrix metalloproteinase; Angiotensin converting enzyme; ERS LAM guidelines
3.  Multimodal observational assessment of quality and productivity benefits from the implementation of wireless technology for out of hours working 
BMJ Open  2012;2(2):e000701.
The authors investigated if a wireless system of call handling and task management for out of hours care could replace a standard pager-based system and improve markers of efficiency, patient safety and staff satisfaction.
Prospective assessment using both quantitative and qualitative methods, including interviews with staff, a standard satisfaction questionnaire, independent observation, data extraction from work logs and incident reporting systems and analysis of hospital committee reports.
A large teaching hospital in the UK.
Hospital at night co-ordinators, clinical support workers and junior doctors handling approximately 10 000 tasks requested out of hours per month.
Outcome measures
Length of hospital stay, incidents reported, co-ordinator call logging activity, user satisfaction questionnaire, staff interviews.
Users were more satisfied with the new system (satisfaction score 62/90 vs 82/90, p=0.0080). With the new system over 70 h/week of co-ordinator time was released, and there were fewer untoward incidents related to handover and medical response (OR=0.30, p=0.02). Broad clinical measures (cardiac arrest calls for peri-arrest situations and length of hospital stay) improved significantly in the areas covered by the new system.
The introduction of call handling software and mobile technology over a medical-grade wireless network improved staff satisfaction with the Hospital at Night system. Improvements in efficiency and information flow have been accompanied by a reduction in untoward incidents, length of stay and peri-arrest calls.
Article summary
Article focus
Can an out of hours wireless task requesting and tracking system improve quality and safety in secondary care?
Key messages
The widely adopted Hospital at Night system for out of hours working is inefficient and risks introducing error. We introduced a wireless task requesting and tracking system and showed this change was acceptable and improved qualitative and quantitative markers of efficiency and safety.
Strengths and limitations of this study
The study showed clinically meaningful and statistically significant positive changes using a variety of complementary assessments. The study was observational and within a single acute NHS Trust.
PMCID: PMC3317138  PMID: 22466035
4.  Looking for a bit of co‐action? 
Thorax  2007;62(3):196-197.
MDR, a primary tool for exploratory analyses
PMCID: PMC2117159  PMID: 17329556

Results 1-4 (4)