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Yvonne Carter

Publications and source records attributed to Yvonne Carter.

12 recordsLinked to original sources
PubMed2005

What's in a care pathway? Towards a cultural cartography of the new NHS.

Maps are increasingly understood as socio-cultural and political constructs, rather than mirrors of nature. Drawing on the insights of cultural cartographers, this paper presents a critical analysis of a specific instance of map-making in health policy, namely the growing use of care pathways in care planning and service delivery. Widely regarded to date as devices for ensuring quality of care, equity of treatment, optimal resource allocation and a rational division of labour between healthcare professionals, they have been seen as helpful--and technically neutral--tools for routing patients through the system. By contrast, we argue that the metaphors are misleading: lived experience and its objectification in pathway maps continually re-create one another, as we explore the slippage between map, map-making and mapping. This paper is based on interviews and observations with a variety of healthcare workers in three areas of south eastern England. We trace the development of a series of pathways-in-process, and show how they configure the patient, highlighting some aspects of their experiences, whilst silencing others. We also analyse the role of pathways in the carving up and surveillance of space round the emergence of the 'hybrid professional', particularly new practitioners such as GP specialists, specialist nurses, extended scope therapists and others. In considering the wider implications of care pathways as part of the contemporary discourse on policy, the paper critiques the rationalist, and sometimes evangelical assumptions underpinning their current popularity. In particular, we suggest that a critical and processual understanding of pathways might contribute to a more informed appreciation of their potential (and their limitations) as mechanisms for healthcare policy implementation.

Critical Pathways↗
PubMed2004

Development and preliminary examination of the predictive validity of the Falls Risk Assessment Tool (FRAT) for use in primary care.

BACKGROUND: There is no validated assessment of an older person's risk of falling that is easily applied in primary care. We aimed to develop a two-part tool for use in primary care or the community. Part 1 includes a rapid assessment of the individual's risk of falling for administration by clinical or non-clinical staff. Part 2 (for clinical staff) includes guidance on further assessment, referral and interventions. We assessed the predictive validity of part 1. METHODS: The tool was developed by an expert panel following the updating of an existing systematic review of community-based prospective studies identifying risk factors for falling and modified in accordance with the feedback from extensive piloting. We assessed predictive validity by a questionnaire survey sent at baseline and 6 months to a random sample of 1000 people aged over 65 in one Primary Care Group area. RESULTS: Five items were included in part 1: history of any fall in the previous year, four or more prescribed medications, diagnosis of stroke or Parkinson's disease, reported problems with balance, inability to rise from a chair without using arms. The presence of three or more risk factors had a positive predictive value for a fall in the next 6 months of 0.57 (95 per cent confidence interval 0.43-0.69). Less than three risk factors had a negative predictive value of 0.86 (0.82-0.89), and a specificity of 0.92 (0.88-0.94). CONCLUSION: The tool may be useful for identifying people who would benefit from further assessment of their risk of falling and appropriate intervention.

Accident Prevention↗
PubMed2002

Limb loss following lower extremity arterial trauma: what can be done proactively?

We performed a retrospective review of patients admitted to two Level I trauma centres over a 15-year period with arterial injuries (excluding primary amputations). Preoperative factors analysed included mechanism of injury, site and type of arterial and venous injury and repair, time to operating room, initial blood pressure, evidence of ipsilateral limb fracture and/or extensive tissue damage, status of preoperative pulses and angiographic data. One hundred and fifty-one arterial injuries were treated (80 penetrating). Overall mortality was 10 (6.6%) and limb loss 16 (10.6%). Only two factors that might possibly be modified by specific interventions were noted. The incidence of limb loss was higher in patients who developed compartment syndrome (41% versus 7% without, P=0.003) and in those who did not receive intra- or immediately postoperative anticoagulation (15% without versus 3% with, P=0.02). Unfortunately, no factor was found that reliably predicted the risk of compartment syndrome. In addition, patients who did not receive peri-operative anticoagulation were more severely injured than those that did were. Despite this, there were no bleeding complications associated with anticoagulation. These findings suggest that the primary interventions that may improve limb salvage include liberal use of fasciotomy (recognising that any patient may require this) as well as early use of anticoagulation.

Adolescent↗
PubMed2002

The impact of positive pressure ventilation on the diagnosis of traumatic diaphragmatic injury.

Initial chest radiography (CXR) has been noted to have limited diagnostic sensitivity to detect acute diaphragmatic injury (ADI). A further confounding variable may be intubation and positive pressure ventilation which may prevent herniation of abdominal organs until weaning is achieved. We sought to determine the impact of positive pressure ventilation on the sensitivity of the initial CXR to identify ADI as well as to document the incidence of late herniation occurring as positive pressure ventilation is weaned. A retrospective chart review of 166 patients over an 8-year period in whom diagnosis of ADI was made on the same admission was performed. Etiology was penetrating trauma in 91 (55%). Eighty-five (51%) patients were intubated and ventilated with positive pressure before the initial chest radiograph. Diagnosis was made within 24 hours in 144 (87%) cases. The ability to correctly identify ADI by CXR was affected by whether or not the patient was intubated (intubated 12% vs nonintubated 27%; P = 0.001), side (right 10% vs left 27%; p = 0.04), and injury size (> 5 cm 81% vs < or = 5 cm 3%, P = 0.02). Late diagnosis was made in 22 cases: eight during surgery, six because of persistent radiographic abnormalities, and six when high levels of ventilator support were decreased with subsequent herniation of stomach above the diaphragm. Two cases were described at autopsy. Diaphragmatic injuries cannot be excluded if patients are intubated. Late diagnosis can be facilitated if chest radiographs are reviewed in sequence as ventilator support is decreased.

Diaphragm↗