Acute District General Hospital Research Articles

Have outcomes of trauma in centenarians changed in the last 15 years?

BackgroundCentenarians are an often forgotten and under-reported group. Trauma in this population is a substantial cause of morbidity and mortality. 15 years ago, a small observational study examined the outcomes of trauma in centenarians in a single trauma unit, concluding that age alone should not be a determinant of treatment. Following implementation of national standards of care for trauma patients in older adults, this study re-examined outcomes in centenarians admitted secondary to trauma to assess if outcomes have changed. Materials and MethodsWe performed a retrospective cohort study examining patients aged over 100 years who had been admitted with trauma to an acute district general hospital and trauma unit. Patients were admitted from January 2020 to January 2022. Outcomes investigated included duration of hospital stay, complications, and mortality at three timepoints (inpatient, 30 days, 12 months). We compared this cohort to the cohort 15 years ago to assess for changes in outcomes. Results29 patients met our eligibility criteria in this cohort. Common presenting injuries included hip fracture (13), pelvic ring fractures (8) and head injuries (8). There was significantly higher inpatient mortality within our cohort between patients who underwent operative versus non-operative treatment, but no significant difference in duration of hospital stay. There was no significant change in duration of hospital stay, inpatient mortality, or mortality at 30 days and 12 months between this cohort and 15 years ago. ConclusionsOutcomes of centenarians admitted secondary to trauma have been maintained but not improved in the last 15 years in our centre. Following this we must consider if more must be done to improve outcomes in this underreported but growing patient demographic.

1149 Bringing Recycling to the Operating Department - a Sustainability Project in a DGH in London

Abstract Aim The Lancet Commissions report of 2015 suggested that tackling climate change could be the greatest global health opportunity of the 21st century. Both the Royal College of Surgeons of England and the Royal College of Anaesthetists have committed to sustainability task forces and have published guidance on improving care through small, sustainable practices including recycling waste. Method We conducted a theatre staff survey on SurveyMonkey in an operating department in an acute district general hospital without any recycling facilities on the attitudes towards recycling, and how this could be implemented. Results We received 103 responses, including a broad spectrum of the multi-disciplinary team including surgeons, anaesthetists, scrub nurses, operating department practitioners and healthcare assistants. Results showed that little to no recycling occurred (59%), 48% of respondents were not familiar with which material can be recycled, and 96% were agreeable to improving access to recycling in theatres. Two main areas identified as barriers to recycling were inadequate access to recycling bins and inadequate information on what can and what cannot be recycled. In terms of implementation, 75% of respondents indicated that posters around the department would be most useful in raising awareness and providing information on recyclable materials. Conclusions Currently, we are in conversation with the Trust and the waste management company to identify a list of recyclable materials and to incorporate recycling bins as part of the waste management pathway.

Impact of radiographer immediate reporting of X-rays of the chest from general practice on the lung cancer pathway (radioX): a randomised controlled trial

The National Optimal Lung Cancer Pathway recommends rapid progression from abnormal chest X-rays (CXRs) to CT. The impact of the more rapid reporting on the whole pathway is unknown. The...

Safety culture, error reporting and medical innovation: comparing a survey taken during COVID-19 to the 2019 national staff survey

Background/Aims Times of crisis can lead to great innovations. Since the outbreak of COVID-19, rapid changes have been made in the NHS, warranting safety evaluation. This study assessed changes in safety culture, professionalism and staff morale during COVID-19, compared to the year before the crisis. Methods A survey of 205 staff at an acute district general hospital was carried out during summer 2020. Questions were taken directly from the 2019 National Staff Survey, the results of which were used as a baseline. Novel questions were also added to the 2020 survey to explore staff morale, professionalism and innovation. Datix reports made from March-June 2020 were also compared to those made during the same period in 2019. Results Reporting of errors using traditional methods decreased following the outbreak of COVID-19, with the number of staff stating that they would report an error they witnessed decreasing from 95% before March 2020 to 87%. The number of Datix reports made decreased from 2805 before the crisis to 1798 during. However, 81% of staff reported greater psychological safety during the pandemic, compared to 69% in the 2019 survey. Respondents cited several facilitators of innovation, with desire to improve patient care scoring the highest. Conclusions The health service has the capacity for incredible innovation and agility with the correct mindset. Innovations need to be documented for organisational learning. Error reporting and learning systems that are appropriate for times of extreme pressure and crisis need to be developed.

EP.WE.617A clinical audit analysing the completion of junior clerking at the Surgical Admissions Unit at an acute District General Hospital, as impacted by short-staffing due to CoViD-19

Abstract Aims The quality of junior clerking is essential to patient safety and care; it provides information vital to the management of surgical patients. This audit aimed to evaluate the completion of the General Admission Document (GAD) on the Surgical Admissions Unit to identify the impact of staff absences secondary to CoViD-19. Methods Admissions to the unit over a 5-day period (n = 92) were evaluated against a checklist of the 26 items included on the GAD utilised by the trust, and daily handover sheets were used to identify staff absences. Mean completion was measured alongside thematic analysis of free-text remarks. Results Handover sheets identified staff absences on 3 days. The overall mean completion of the GAD was 50.88% (95%CI: 46.65, 55.11, p < 0.05). This was not significantly (p = 0.074) impacted by staffing; mean completion was 48.47% (95%CI: 42.75, 54.20, p < 0.05) on days with junior doctor absences, and 54.98% (95%CI: 49.14, 60.82, p < 0.05) without. The major theme identified was deferring to the ‘senior review’ section of the GAD, suggesting a lack of awareness among juniors regarding the importance of a full junior clerking. Conclusions Staff shortages secondary to CoViD-19 absences did not significantly impact the quality of junior clerking. However, the baseline completion of the GAD was noted to be poor regardless. Therefore, a teaching session during induction of the next cohort of doctors could be a sensible intervention to reiterate the importance of a full clerking.

884 Improving the Analgesia Prescribing Compliance to NICE Guidelines (NG118) In Suspected Renal Colic Patients Using a Proforma

Abstract Aim To improve analgesia prescribing for patients admitted with suspected renal colic in line with NICE guidelines (NG118) in an acute district general hospital using a proforma. Method In the first cycle, a retrospective review of 16 patients who presented with renal colic to the emergency department or surgical assessment unit was performed and the analgesia prescribing was recorded. A unique analgesia prescribing proforma was then developed using NICE guidelines (NG118) including the use of NSAIDS as first-line when there are no contra-indications, intravenous paracetamol, opioid analgesics and omitting antispasmodics. Following implementation of the proforma, a prospective review of 18 patients were included in the second cycle and the prescribing compliance were compared. Results Study included 34 patients who presented with suspected renal colic over a 3-month period. In the first cycle, 19% of patients had appropriate analgesia prescribed which were compliant with NICE guidelines. In cycle 2, 89% of patients had appropriate analgesia prescribed. In particular, the inappropriate prescription of antispasmodics has improved significantly (38 % in cycle 1 vs 0 % in cycle 2). Conclusions A proforma can serve as a useful ‘checklist’ for analgesia prescribing and improve the symptomatic relief for patients presenting with suspected renal colic in line with NICE quality standards.

Incidence and Risk Factors for Surgical Site Infection following Emergency Cesarean Section: A Retrospective Case-Control Study.

To assess the incidence, risk, and associated factors that contribute to an acquired surgical site infection (SSI) after emergency cesarean section (CS). This retrospective case-control study was conducted in an acute district general hospital in England with 206 patients (101 SSI patients and 105 non-SSI patients) who had an emergency CS in 2017. Grade of surgeon, smoking status, preoperative vaginal swab status (positive or negative), diabetes status, age, body mass index, membrane rupture to delivery interval, and length of surgery were recorded. Risk factors were identified using simple and multiple logistic regression. Body mass index was significantly associated with SSI (odds ratio, 1.17; 95% confidence interval, 1.11 to 1.24; P < .001). Further, substantive nonsignificant associations were recorded between SSI and patient age and vaginal swab status. Body mass index was the only significant risk factor for the development of an SSI after emergency CS, possibly because of the impact of excessive adipose tissue on the immune system and reduced effectiveness of antibiotics. Diabetes status, patient age, and preoperative vaginal swab status were not significantly associated with SSI. Improved guidelines and strategies for managing at-risk patients would enable clinicians to reduce the risk of SSI development. The importance of wound management including frequent wound cleaning, appropriate dressings, dressing changes, and education is highlighted. Future research on larger samples should be conducted to validate these findings.

100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance

Abstract Introduction Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&amp;E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge. Method 4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services. Results From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers. Conclusions Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.

90 Socio-Demographic and Medical Factors in A Multi-Ethnic Cohort of COVID Deaths

Abstract Introduction Whilst most patients during the COVID pandemic made an uneventful recovery,there was a significant minority in whom the disease was severe and unfortunately fatal. This survey aims to examine and evaluate risk factors for those patients who died of COVID and to identify any markers for improvement in the management of such patients during future COVID surges. Methods Medical records of all patients who died within a multi-ethnic, inner city acute district general hospital over a 6-week period in 2020 were examined. Data collected included demographic details, medical comorbidities, and type of ward where they received care. Multivariable analysis using stepwise backward logistic regression was conducted to examine independent risk factors for these patients. Results Of 275 deaths,204 were related to COVID. Compared to non-COVID deaths(n = 71), there were no age differences. There were significantly more deaths in males (58%vs39%,P &amp;lt; 0.001)) and in Black African and South Asian groups. 18% of COVID deaths were those who were not frail (Frailty Rockwood Scale 1–3) whereas there were no non-COVID deaths in this group(P &amp;lt; 0.001). 69% of COVID deaths occurred in general medical wards whereas 19% in critical care units (90% and 7% for non-COVID deaths,p &amp;lt; 0.001). COVID patients died more quickly compared to non-COVID patients (length of stay mean, 11vs21,p &amp;lt; 0.001). Medical factors prevalent in &amp;gt;20% of COVID deaths included Diabetes, Hypertension, Chronic Heart Disease, Chronic Kidney Disease,and Dementia. Multivariable analyses showed males (OR 1.9), age &amp;gt; 70(OR 2.0), frailty (OR 2.3) were independent risk factors for COVID deaths. Discussion Compared to non-COVID deaths,COVID deaths were more common in previously well individuals,males,Black African and South Asian ethnicity, but multivariable analyses showed males, age &amp;gt; 70 and frailty were independent risk factors for COVID deaths. This survey indicates that greater psychological support may be required for healthcare workers on general medical wards who looked after greater proportion of COVID deaths.

Patient experiences of alcohol specialist nurse interventions in a general hospital, and onwards care pathways.

To provide insight into patient experiences of a general hospital-based alcohol specialist nurse intervention during alcohol detoxification, experiences of alcohol specialist nurse hospital-based follow-up appointments (Pathway A) as well as the experiences of patients who did not have access to this additional help post detoxification (Pathway B). A longitudinal qualitative study. A thematic analysis of semi-structured interviews (2016-2017) with 24 patient participants (N=12 in each pathway; purposive selection) 1-4weeks post-detoxification and at 3 and 6months, to identify patient experiences of these interventions. Participants gave accounts of how 'empathic' and 'straight talking' interactions with alcohol specialist nurses during detoxification helped them to 'open up' and orient towards change. After detoxification follow-up, outpatient appointments in the hospital setting were seen as supporting change in early recovery and engagement with a wider range of services. Those with no access to nurse follow-up described experiencing a 'void' in available help. Participants in both groups described barriers to engagement with community alcohol services, peer groups and access to help for mild-moderate mental health problems. Patient accounts indicate alcohol specialist nurse interventions during and after unplanned detoxification in a hospital setting can help orient patients towards change and support early recovery. Providing alcohol specialist nurse interventions in general hospitals offers one route to initiating recovery in alcohol-dependent patients. This has potential to improve the lives of those affected and to reduce related demands on hospital services, but further research is needed.

'I want to change the perception of pharmacy' — a day in the life of a community hospital pharmacist

For many of us, 2020 was a life-changing year in our lives and careers as pharmacists. It was in my case — in March 2020, I was redeployed from a busy acute district general hospital to work as a full-time clinical pharmacist at Ysbyty Cwm Rhondda, a peripheral community hospital in the South Wales Valleys. […]

Awareness About Sharps Disposal Leads to Significant Improvement in Healthcare Safety: an Audit of Compliance in the National Health Service During the COVID-19 Pandemic.

Needle-stick injuries (NSIs) pose serious health risks and can transmit blood-borne diseases (BBDs), such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus from the patient to the staff member. The purpose of this study was evaluation of appropriate and safe disposal of sharps within a 730-bed acute district general hospital (DGH) in the UK. One hundred sharps containers were audited in November 2019 to assess whether they complied with the health and safety regulations across surgical, medical, and acute wards. Meetings with the appropriate staff members were organised and posters placed throughout the hospital to raise awareness. One hundred twenty-five sharps containers were re-audited in July 2020, in the midst of the COVID-19 pandemic to ascertain if there was an improvement. In November 2019, a total of 56% of sharps containers were overfilled and hence were non-compliant with safety regulations. A re-audit performed in July 2020 found only 17% of sharps containers to be overfilled, which was a significant improvement (p = 0.0064) in practice. We noted that the overall compliance improved from being 44% in 2019 to 82.64 in the year 2020. This audit showed a significant improvement in the compliance of sharps bin containers in a DGH, signifying the increased awareness. It is necessary to audit sharps management regularly to accurately assess practice and prevent exposure to BBDs.

Analysis of activities undertaken by ward-based clinical pharmacy technicians during patient hospital journey

IntroductionPrevious studies recognise insufficient time as an obstacle to pharmacists expanding their clinical-based activities and services. For such a reason, the role of well-trained ward-based clinical pharmacy technicians (CPTs) is...

Cognitive impairment is independently associated with mortality, extended hospital stays and early readmission of older people with emergency hospital admissions: A retrospective cohort study

BackgroundOlder adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population. ObjectivesTo determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes. DesignRetrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases. SettingLarge, acute district general hospital in England. Participants21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment. MethodsMultivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk. ResultsTwenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17–1.55] with dementia; Odds Ratio 1.78 [1.52–2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48–1.86]; Odds Ratio 1.67 [1.46–1.90]); readmission (Odds Ratio 1.21 [1.04–1.40]; Odds Ratio 1.47 [1.25–1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76–0.83]; sub-hazard ratio 0.66 [0.63–0.69]). ConclusionsCognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population.

Better safe than sorry? Frequent attendance in a hospital emergency department: an exploratory study.

Pain accounts for the majority of attendances to the Emergency Department (ED), with insufficient alleviation of symptoms resulting in repeated attendance. People who frequently attend the ED are typically considered to be psychologically and socially vulnerable in addition to experiencing health difficulties. This service development study was commissioned to identify the defining characteristics and unmet needs of frequent attenders (FAs) in a UK acute district general hospital ED, with a view to developing strategies to meet the needs of this group. A mixed-methods multi-pronged exploratory approach was used, involving staff interviews, focus groups, business data and case note analysis. Findings reflect an absence of a coherent approach to meeting the needs of FAs in the ED, especially those experiencing pain. FAs to this ED tend to be vulnerable, complex and report significant worry and anxiety. Elevated anxiety on the part of the patient may be contributing to a 'better safe than sorry' culture within the ED and is reported to bear some influence on the clinical decision-making process. It is recommended that a systemic approach is taken to improve the quality and accessibility of individualised care plans, provision of patient education, psychological care and implementation of policies and procedures. Change on an organisational level is likely to improve working culture, staff satisfaction and staff relationships with this vulnerable group of patients. A structured care pathway and supportive changes are likely to lead to economic benefits. Further research should build on findings to implement and test the efficacy of these interventions.

An economic evaluation of introducing a skills mix approach to CT head reporting in clinical practice

BackgroundComputed Tomography (CT) head examinations are a common diagnostic examination in National Health Service (NHS) acute hospital trusts. Current NHS England and Royal College of Radiologist (RCR) reports estimate the year on year increase of examinations to be 10%, with the designated workforce of radiologists disproportionate to the increase in demand of imaging reporting. ObjectiveTo determine an economic evaluation of cost, risk and feasibility of introducing skills mix CT head reporting by radiographers. DesignApplying a PICO framework study to evaluate the patient workflow demand from retrospective audit data of CT head examination attendance (n = 7266) at an acute NHS district general hospital (DGH) to model an example workflow demand over 12 months. Reviewing potential outcome risk data (diagnostic thresholds), and feasibility (workforce capacity) of both interventions. The economic evaluation calculated hourly unit costs for comparison estimation of consultant radiologists and reporting radiographers using Netten et al.'s Ready Reckoner. Report unit costs were calculated utilising the Gishen's Ready Reckoner to estimate the uninterrupted time of reporting a non-complex CT report using RCR, Centre for Workforce Intelligence (CfWI) and Department of Health (DoH) estimates for both interventions. ConclusionsThe economic evaluation of introducing a skills mix reporting service model to the benefit of service delivery with the NHS has shown a potential £299,359–£124,514 per annum cost saving using a generic acute DGH workload model. Research into recorded discrepancy/error audit data for potential detrimental risk to patient outcomes identified a paucity of evidence, and recommends further research is needed.

Optimizing patient care in radiology through team-working: A case study from the United Kingdom

ObjectivesTo investigate how changes in service delivery within the radiology department of an acute district general hospital optimized imaging services for patients and referrers through a strong emphasis on team-working. MethodsData related to service delivery was collected for three consecutive years and interrogated by imaging modality and reporting practitioner (radiologist, reporting radiographer, sonographer) to explore how workload had changed over the cycle. ResultsDepartmental activity demonstrated consistent increases, both overall (13.3%) and for most modalities (MRI 43.7%, CT 22.8%) for the study period (March 2010–March 2013). Overall trend suggested significantly shorter waiting times (CT 0.7 weeks, MRI 1.3 weeks, non-obstetric ultrasound one week; all modalities p = 0.001). Some modality variation in reporting times was apparent, with CT (p = 0.06) and MRI (p = 0.01) decreasing but there was an increase in X-ray reporting times (p = 0.001). Reporting radiographers and sonographers reported the majority of X-ray and non-obstetric ultrasound interpretations (59% and 52%, respectively). A radiographer-led neonatal reporting service was implemented and the urology patient pathway redesigned. Effective team-working produced savings of three full-time consultant radiologist posts. ConclusionRadiologists and radiographers, working together, can deliver an effective service. Innovation, staff development and redesign of patient pathways, have produced significant improvements.

EPA-1223 – An evaluation of the effectiveness of a geriatric liaison psychiatry service in an acute district general hospital in the UK

Background 60% of older people admitted to general hospital will have or develop a mental disorder (Department of Health, 2001). Mental disorder in this population is an independent predictor of poor outcome and is associated with increased mortality, greater length of stay, loss of independent function and higher rates of institutionalisation (The Royal College of Psychiatrists, 2005). Aims & Objectives To examine if the liaison psychiatric intervention has improved the outcome for the patients and to introduce measures to improve quality, safety and efficiency within the service practice in the future Method A total of 128 patients were referred to the geriatric liaison psychiatry service in a 6 months period between from an acute general hospital .50 patients were randomly selected from these referrals. Data's were collected from both the case notes as well as clinical information system using an audit data collection tool. Results Majority (62%) were seen within 24 hours and 82% were seen within 48 hours. The main diagnosis was depression closely followed by dementia. Only a small minority (8%) of the patient needed inpatient psychiatric admission. 50% of the patients were discharged within a week of the Liaison assessment and majority of the cases (70%) patients were able to go back home. Conclusion Identification of mental illness in the acute hospital settings remains low. In spite of dementia being extremely common diagnosis, very few did appear to have been referred to the specialist memory service. Liaison Psychiatry intervention possibly improved outcomes for patients and the services.

An evaluation of the activity of a 7-day, nurse-led specialist palliative care service in an acute district general hospital

This report describes the activity of a new 7-day-per-week, nurse-led palliative care service in an acute district general hospital in the UK. The service is based in a hospital with an integral cancer centre. On the weekends, one clinical nurse specialist (CNS) is present within the hospital, with a consultant providing telephone support. The data for this report was obtained by reviewing the team's clinical database and the patients' individual clinical assessments. During the first year, the CNSs undertook 651 face-to-face weekend consultations. Overall, 25% of the total consultations and 18% of new patient consultations were undertaken on the weekends. The primary reasons for reviewing patients on the weekends were pain (46%), other symptoms (27.5%), and patient on the Liverpool Care Pathway (17%). Overall, 23% of new patients died over the weekend or in the early hours of the Monday morning. This service evaluation provides evidence of the value of having a 7-day-per-week palliative care service in an acute district general hospital.

Exploring factors in non‐use of hospital library resources by healthcare personnel

Purpose – The purpose of this study is to investigate reasons for non‐use of a UK hospital library service and under‐utilisation by some groups of staff. The context is the increasing role of evidence‐based clinical and non‐clinical activity in the health sector and requirements for professional development.Design/methodology/approach – A purposive sample survey of staff groups in an acute services, teaching and district general hospital (DGH) is carried out. Three core themes for non‐use of hospital libraries are identified from the literature and the survey findings are evaluated in accordance with those themes using quantitative and qualitative evidence.Findings – The evaluation demonstrates that the three selected themes of ignorance of service, not having a need and perceived bar on access are based on shortcomings in library promotion and hospital staff members' assumptions about access and benefits.Research limitations/implications – Selection of specific non‐use factors within a larger list from p...