Acute National Health Service Hospitals Research Articles

Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation.

Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Three Trusts, one orthopaedic and one older person ward in each. Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. This study is registered as PROSPERO CRD42020184458. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study.

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. This study is registered as ISRCTN10863045. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

The qualities of data: how nurses and their managers act on patient feedback in an English hospital

PurposeTo investigate ethnographically how patient experience data, as a named category in healthcare organisations, is actively “made” through the co-creative interactions of data, people and meanings in English hospitals.Design/methodology/approachThe authors draw on fieldnotes, interview recordings and transcripts produced from 13 months (2016–2017) of ethnographic research on patient experience data work at five acute English National Health Service (NHS) hospitals, including observation, chats, semi-structured interviews and documentary analysis. Research sites were selected based on performance in a national Adult Inpatient Survey, location, size, willingness to participate and research burden. Using an analytical approach inspired by actor–network theory (ANT), the authors examine how data acquired meanings and were made to act by clinical and administrative staff during a type of meeting called a “learning session” at one of the hospital study sites.FindingsThe authors found that the processes of systematisation in healthcare organisations to act on patient feedback to improve to the quality of care, and involving frontline healthcare staff and their senior managers, produced shifting understandings of what counts as “data” and how to make changes in response to it. Their interactions produced multiple definitions of “experience”, “data” and “improvement” which came to co-exist in the same systematised encounter.Originality/valueThe article's distinctive contribution is to analyse how patient experience data gain particular attributes. It suggests that healthcare organisations and researchers should recognise that acting on data in standardised ways will constantly create new definitions and possibilities of such data, escaping organisational and scholarly attempts at mastery.

Prevalence of electronic screening for sepsis in National Health Service acute hospitals in England

Sepsis is a worldwide public health problem. Rapid identification is associated with improved patient outcomes—if followed by timely appropriate treatment.ObjectivesDescribe digital sepsis alerts (DSAs) in use in English National Health...

Microbial diversity and antimicrobial resistance in faecal samples from acute medical patients assessed through metagenomic sequencing.

Antimicrobial resistance (AMR) is a threat to global public health. However, unsatisfactory approaches to directly measuring the AMR burden carried by individuals has hampered efforts to assess interventions aimed at reducing selection for AMR. Metagenomics can provide accurate detection and quantification of AMR genes within an individual person's faecal flora (their gut "resistome"). Using this approach, we aimed to test the hypothesis that differences in antimicrobial use across different hospitals in the United Kingdom will result in observable differences in the resistome of individual patients. Three National Health Service acute Hospital Trusts with markedly different antibiotic use and Clostridioides difficile infection rates collected faecal samples from anonymous patients which were discarded after C. difficile testing over a period of 9 to 15 months. Metagenomic DNA was extracted from these samples and sequenced using an Illumina NovaSeq 6000 platform. The resulting sequencing reads were analysed for taxonomic composition and for the presence of AMR genes. Among 683 faecal metagenomes we found huge variation between individuals in terms of taxonomic diversity (Shannon Index range 0.10-3.99) and carriage of AMR genes (Median 1.50 genes/cell/sample overall). We found no statistically significant differences in diversity (median Shannon index 2.16 (IQR 1.71-2.56), 2.15 (IQR 1.62-2.50) and 2.26 (IQR 1.55-2.51)) or carriage of AMR genes (median 1.37 genes/cell/sample (IQR 0.70-3.24), 1.70 (IQR 0.70-4.52) and 1.43 (IQR 0.55-3.71)) at the three trusts respectively. This was also the case across the sample collection period within the trusts. While we have not demonstrated differences over place or time using metagenomic sequencing of faecal discards, other sampling frameworks may be more suitable to determine whether organisational level differences in antibiotic use are associated with individual-level differences in burden of AMR carriage.

Patient and physiotherapist perceptions of the Getting Recovery Right After Neck Dissection (GRRAND) rehabilitation intervention: a qualitative interview study embedded within a feasibility trial

ObjectiveThe Getting Recovery Right After Neck Dissection (GRRAND) intervention is a physiotherapy programme for patients with head and neck cancer who have undergone neck dissection. The aim of this qualitative...

Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database.

SummaryThe effectiveness of emergency surgery vs. non‐emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non‐emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre‐specified sub‐groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non‐emergency surgery after adjusting for confounding: −0.73 days (−2.10–0.64) for appendicitis; 0.60 (−0.10–1.30) for gallstone disease; −2.66 (−15.7–10.4) for diverticular disease; −0.07 (−2.40–2.25) for hernia; and 3.32 (−3.13–9.76) for intestinal obstruction. For patients with ‘severe frailty’, mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non‐emergency surgery strategies: −21.0 (−27.4 to −14.6) for appendicitis; −5.72 (−11.3 to −0.2) for gallstone disease, −38.9 (−63.3 to −14.6) for diverticular disease; −19.5 (−26.6 to −12.3) for hernia; and − 34.5 (−46.7 to −22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: −0.18 (−1.56–1.20) for appendicitis; 0.93 (0.48–1.39) for gallstone disease; 5.35 (−2.56–13.28) for diverticular disease; 2.26 (0.37–4.15) for hernia; and 18.2 (14.8–22.47) for intestinal obstruction. Emergency surgery and non‐emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non‐emergency surgery strategies for these conditions may be modified by patient factors.

Creating a Real-World Linked Research Platform for Analyzing the Urgent and Emergency Care System.

BackgroundThis article describes the development of a system-based data platform for research developed to provide a detailed picture of the characteristics of the Urgent and Emergency Care system in 1 region of the United Kingdom.Data Set DevelopmentCUREd is an integrated research data platform that describes the urgent and emergency care system in 1 region of the United Kingdom on almost 30 million patient contacts within the system. We describe regulatory approvals required, data acquisition, cleaning, and linkage.Data Set AnalysesThe data platform covers 2011 to 2017 for 14 acute National Health Service (NHS) Hospital Trusts, 1 ambulance service, the national telephone advice service (NHS 111), and 19 emergency departments. We describe 3 analyses undertaken: 1) Analyzing triage patterns from the NHS 111 telephone helpline using routine data linked to other urgent care services, we found that the current triage algorithms have high rates of misclassifying calls. 2) Applying an algorithm to consistently identify avoidable attendances for pediatric patients, we identified 21% of pediatric attendances to the emergency department as avoidable. 3) Using complex systems analysis to examine patterns of frequent attendance in urgent care, we found that frequent attendance is stable over time but varies by individual patient. This implies that frequent attendance is more likely to be a function of the system overall.DiscussionWe describe the processes necessary to produce research-ready data that link care across the components of the urgent and emergency care system. Making the use of routine data commonplace will require partnership between the collectors, owners, and guardians of the data and researchers and technical teams.HighlightsThis article describes the development of a system-level data platform for research using routine patient-level data from the urgent and emergency care system in 1 region of the United Kingdom.The article describes how the data were acquired, cleaned, and linked and the challenges faced when undertaking analysis with the data.The data set has been used to understand patient use of the system, journeys once in the system, and outcomes following its use, for example, patterns of frequent use within urgent care and accuracy of referral decisions within the system.

Has a change in established care pathways during the first wave of the COVID-19 pandemic led to an excess death rate in the fragility fracture population? A longitudinal cohort study of 1846 patients

ObjectiveDuring the first wave of the COVID-19 pandemic, changes to established care pathways and discharge thresholds for patients with fragility fractures were made. This was to increase hospital bed capacity...

The workload of a medical examiner service at an acute National Health Service hospital during the COVID-19 pandemic: The Norfolk & Norwich University Hospital experience.

The COVID-19 pandemic commenced in March 2020. In May 2019, a new Medical Examiner system was introduced to scrutinise deaths of patients dying within acute National Health Service Trusts. The Coronavirus Act 2020 which came into force in March 2020 modified certification of death requirements. Newly formed Medical Examiner Services were advised they could suspend scrutiny during the pandemic. The Norfolk & Norwich University Hospital Medical Examiner Service (NNUH MES) continued to scrutinise patient deaths throughout. This study summarises the workload of the NNUH MES from 1st June 2020 to 31st May 2021 over which period 2856 deaths were recorded and 2687 scrutinised by the Medical Examiners.

The relationship between leader support, staff influence over decision making, work pressure and patient satisfaction: a cross-sectional analysis of NHS datasets in England

ObjectiveTo explore the relationships between leader support, staff influence over decisions, work pressure and patient satisfaction.DesignA cross-sectional study of large National Health Service (NHS) datasets in England in 2010.Setting and...

The impact of management on hospital performance

AbstractThere is a prevailing popular belief that expenditure on management by health‐care providers is wasteful, diverts resources from patient care, and distracts medical and nursing staff from getting on with their jobs. There is little existing evidence to support either this narrative or counter‐claims. We explore the relationship between management and public sector hospital performance using a fixed effects empirical econometric specification on a panel data set consisting of all 129 non‐specialist acute National Health Service (NHS) hospitals in England for the financial years 2012/13 to 2018/19. Measures of managerial input and quality of management practice are constructed from NHS Electronic Staff Records and NHS Staff Survey data. Hospital accounts and Hospital Episode Statistics data are used to construct five measures of financial performance and of timely and high‐quality care. We find no evidence of association either between quantity of management and management quality or directly between quantity of management and any of our measures of hospital performance. However, there is some evidence that higher‐quality management is associated with better performance. NHS managers have limited discretion in performing their managerial functions, being tightly circumscribed by official guidance, targets, and other factors outside their control. Given these constraints, our findings are unsurprising.

Implementation of treatment escalation plans in an old age psychiatry inpatient hospital

A treatment escalation plan (TEP) enables timely and appropriate decision making in the management of deteriorating patients. The COVID-19 pandemic precipitated the widespread use of TEPs in acute care settings...

Capacity planning for acute hospital inpatient care and adult critical care in England: a descriptive study using hospital administrative data

BackgroundAt the beginning of the COVID-19 pandemic in March and April, 2020, there was a focus on accommodating an anticipated surge of patients with COVID-19 in acute hospitals. We aimed to estimate the potential for freeing up capacity in acute hospitals in England. MethodsIn this descriptive study, we used admitted patient and adult critical care records from Hospital Episode Statistics (a database containing details of attendances at National Health Service acute hospitals in England) from 2018/19 to estimate historical numbers of inpatients. Each admission was grouped into emergency, maternity, and elective, with elective split by the presence or absence of cancer in the primary diagnosis. We further stratified the population by age and frailty, which we estimated with an index using International Statistical Classification of Diseases and Related Health Problems (tenth revision) codes in diagnosis fields. We used the (then current) National Institute for Health and Care Excellence (NICE) 2020 guidance on critical care pathways as a framework to examine four scenarios that limited access to beds for specific patient groups. This study was approved by the Secretary of State and the Health Research Authority under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 to hold confidential data and analyse them for research purposes (CAG ref 15/CAG/0005). We have approval to use these data for research into the quality and safety of health care, from the London–South East Ethics Committee (REC ref 20/LO/0611). FindingsBetween April 1, 2018, and March 31, 2019, 8 957 521 adults were admitted (7 372 040 [82·3%] emergency, 295 598 [3·3%] elective with cancer, 850 964 [9·5%] elective without cancer, and 438 919 [4·9%] maternity admissions), and 974 038 critical care episodes were recorded. Our analysis suggested that up to 70% of all acute inpatient beds could be released if only maternity, cancer, and emergency patients younger than 65 years were admitted; if non-frail patients aged 65 years and older were also admitted, 41% of beds could be freed up. Similarly, if only maternity, cancer, and emergency patients younger than 65 years were admitted to critical care beds, that might free up to 56% of adult critical care beds; if non-frail patients aged 65 years and older were also admitted, 30% of critical care beds could be freed up. InterpretationGiven a crisis in health-care capacity, it seemed appropriate to model some difficult options based on NICE guidelines. We identified scope for freeing up total acute and critical care beds by postponing elective non-cancer admissions as a short-term measure during the first wave of COVID-19 (March to June, 2020) in England. The NICE guidelines were criticised by patient groups and have since been updated (NG191). Administrative data can inform planning for future crises albeit with limitations on estimating individual patient need, and deep social and ethical considerations. Our estimates were incorporated into a modelling tool for hospital provision during the pandemic. FundingDr Foster Intelligence.

Examining organisational responses to performance-based financial incentive systems: a case study using NHS staff influenza vaccination rates from 2012/2013 to 2019/2020

ObjectiveFinancial incentives are often applied to motivate desirable performance across organisations in healthcare systems. In the 2016/2017 financial year, the National Health Service (NHS) in England set a national performance-based...

Utility of the FebriDx point-of-care assay in supporting a triage algorithm for medical admissions with possible COVID-19: an observational cohort study

ObjectiveTo evaluate a triage algorithm used to identify and isolate patients with suspected COVID-19 among medical patients needing admission to hospital using simple clinical criteria and the FebriDx assay.DesignRetrospective observational...

Potential impacts of general practitioners working in or alongside emergency departments in England: initial qualitative findings from a national mixed-methods evaluation

ObjectivesTo explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These ‘expectations of impact’ can be used...

PET/MRI, Part 1: Establishing a PET/MRI Facility.

The emergence of PET and MRI as a hybrid modality has generated widespread interest in the technology and techniques. Although adoption and use are unlikely to be as expansive as for PET and CT hybrid systems, PET/MRI is an important modality that requires broad insight for nuclear medicine professions generally and deeper insight for those engaged in PET/MRI practice. This article provides insight into the considerations and challenges associated with establishing a PET/MRI facility. Each clinical site will present unique requisites for establishing a PET/MRI facility, and indeed, each PET/MRI vendor will have specific site requirements. Nonetheless, this article provides general insight into common considerations but should not be considered exhaustive. Here, development of the facility, staffing of the facility, and implications of both radiation and MRI safety are considered from the context of facility design. Given that the nature of PET is well established among the readership of this journal, the article provides an emphasis on MRI factors. This article is the first in a 4-part integrated series sponsored by the PET/MR and Publication Committees of the Society of Nuclear Medicine and Molecular Imaging-Technologist Section. In the subsequent 3 parts, PET/MRI will be explored on the basis of technology principles (part 2), protocols and procedures (part 3), and applications and clinical cases (part 4).

Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study

ObjectiveTo describe outcomes within different ethnic groups of a cohort of hospitalised patients with confirmed COVID-19 infection. To quantify and describe the impact of a number of prognostic factors, including...

Variations in Rates of Discharges to Nursing Homes after Acute Hospitalization for Stroke and the Influence of Service Heterogeneity: An Anglia Stroke Clinical Network Evaluation Study.

Nursing home placement after stroke indicates a poor outcome but numbers placed vary between hospitals. The aim of this study is to determine whether between-hospital variations in new nursing home placements post-stroke are reliant solely on case-mix differences or whether service heterogeneity plays a role. A prospective, multi-center cohort study of acute stroke patients admitted to eight National Health Service acute hospitals within the Anglia Stroke and Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospitals (as a fixed-effect) and rates of new discharges to nursing homes using multiple logistic regression, adjusting for important patient risk factors. Descriptive and graphical data analyses were undertaken to explore the role of hospital characteristics. Of 1335 stroke admissions, 135 (10%) were discharged to a nursing home but rates varied considerably from 6% to 19% between hospitals. The hospital with the highest adjusted odds ratio of nursing home discharges (OR 4.26; 95% CI 1.69 to 10.73), was the only hospital that did not provide rehabilitation beds in the stroke unit. Increasing hospital size appeared to be related to an increased odds of nursing home placement, although attenuated by the number of hospital stroke admissions. Our results highlight the potential influence of hospital characteristics on this important outcome, independently of patient-level factors.