Rupa Chilvers -review selection and acquisition of studies, identification of study eligibility, preparation of written report.Geraldine Macdonald -protocol writing, selection of studies, identification of study eligibility, preparation of written report.Alex Hayes -preparation of protocol.

A postal survey of arterial blood sampling practices in 280 intensive care units throughout England and Wales found that very few measures are taken to reduce diagnostic blood loss in adult intensive care patients from arterial sampling. The average volume of blood withdrawn to clear the arterial line before sampling is 3.2 ml; subsequently returned to the patient in only 18.4% of intensive care units. Specific measures to reduce the blood sample size by the routine use of paediatric sample tubes in adult patients occurs in only 9.3% of intensive care units. In paediatric units, the average volume withdrawn was 1.9 ml and this was routinely returned in 67% of units. Some aspects of arterial blood sampling practices identified in this survey may contribute to iatrogenic anaemia in intensive care patients.

BackgroundUK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.Objectives(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.DesignThis was a comprehensive, mixed-methods study.SettingThis study took place in primary care in England.ParticipantsGeneral practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.Main outcome measuresSystematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.ResultsPast research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.LimitationsThe survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.ConclusionsThis research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.Study registrationThis study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Psychiatrists have long recognised that routine clinical practice needs to be shaped and informed by external evidence (Lewis, 1958). Psychiatric researchers were among the first to utilise multi-centre randomised controlled trials (demonstrating the effectiveness of antipsychotics), and psychologists were among the first in the health field to develop techniques of meta-analysis. Social workers, too, point to their tradition with the publication of one of the earliest controlled trials (Lehrman, 1949).

From the single, small and ill-reported, included study, the hostel ward type of facility appeared cheaper and positively effective. Currently, the value of this way of supporting people - which could be considerable - is unclear. Trials are needed. Any 24 hour care 'ward-in-a-house' is likely to be oversubscribed. We argue that the only equitable way of providing care in this way is to draw lots as to who is allocated a place from the eligible group of people with serious mental illness. With follow-up of all eligible for the placements - those who were lucky enough to be allocated a place as well as people in more standard type of care - real-world evaluation could take place. In the UK further randomised control trials are probably impossible, as many of these types of facilities have closed. The broader lesson of this review is to ensure early and rigorous evaluation of fashionable innovations before they are superseded by new approaches.

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SummaryThis study aimed to evaluate whether the application of cricoid pressure at the time of induction of anaesthesia was associated with a lesser incidence of postoperative nausea or vomiting in the immediate postoperative period compared with a group in which no cricoid pressure was applied, in patients undergoing day care gynaecological laparoscopy. One hundred ASA I and II females were randomly allocated to receive cricoid pressure at the time of induction. The peri-operative anaesthetic technique was standardised. The incidence of postoperative nausea and vomiting in the group who received cricoid pressure was 16% in the recovery room compared with 26% in the no cricoid group. When the period was extended to the ®rst 6 h post anaesthesia the incidence was 30% in the cricoid and 44% in the no cricoid group. This difference did not achieve statistical signi®cance in either period (p b 0.05). The results suggest that application of cricoid pressure at the time of induction does not signi®cantly alter the incidence of postoperative nausea and vomiting in the ®rst 6 h of recovery from anaesthesia. Keywords Vomiting; nausea, incidence. Larynx; cricoid pressure. Several factors can in¯uence the incidence of postoperative nausea and vomiting (PONV) after gynaecological surgery. These are age, body weight, type of surgery, anaesthetic agents and anaesthetic techniques [1]. Gastric distension as a result of positive pressure ventilation with a facemask has been suggested as one of the causes of PONV [2].Cricoid pressure, although originally designed to prevent regurgitation in the period between induction of anaesthesia and insertion of a tracheal tube [3], is also effective in preventing in¯ation of the stomach with air in both adults and children [4, 5].The aim of this study was to ®nd out whether cricoid pressure application at the time of induction offered any protection against nausea and vomiting in the immediate recovery period, in day care patients undergoing diagnostic gynaecological laparoscopy. MethodsThe study protocol was approved by the ethics committee of the Aga Khan University Hospital. One hundred patients of ASA status I and II, aged 18±45 years, were enrolled in the study. Exclusion criteria included any previous history of PONV or motion sickness, a dif®cult airway, weight b 80 kg or receipt of concomitant medications that could interfere with the evaluation of the results. All patients were undergoing elective diagnostic gynaecological laparoscopy and informed consent was obtained before enrolment. They were randomly assigned to one of two groups; group C consisted of those patients who had cricoid pressure application at the time of induction of anaesthesia and group NC consisted of those patients in whom no cricoid pressure was applied. Patients were premedicated with midazolam 7.5 mg orally given , 1 h prior to anaesthesia. Pre-oxygenation was with three vital capacity breaths of 100% oxygen. All patients then received pethidine 0.8 mg.kg À1 . Intravenous induction was with thiopental 4±5 m...