Acute National Health Service Research Articles

Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus.

This study developed a patient-level audit tool to assess the appropriateness of antibiotic prescribing in acute National Health Service (NHS) hospitals in the UK. A modified Delphi process was used to evaluate variables identified from published literature that could be used to support an assessment of appropriateness of antibiotic use. At a national workshop, 22 infection experts reached a consensus to define appropriate prescribing and agree upon an initial draft audit tool. Following this, a national multidisciplinary panel of 19 infection experts, of whom only one was part of the workshop, was convened to evaluate and validate variables using questionnaires to confirm the relevance of each variable in assessing appropriate prescribing. The initial evidence synthesis of published literature identified 25 variables that could be used to support an assessment of appropriateness of antibiotic use. All the panel members reviewed the variables for the first round of the Delphi; the panel accepted 23 out of 25 variables. Following review by the project team, one of the two rejected variables was rephrased, and the second neutral variable was re-scored. The panel accepted both these variables in round two with a 68% response rate. Accepted variables were used to develop an audit tool to determine the extent of appropriateness of antibiotic prescribing at the individual patient level in acute NHS hospitals through infection expert consensus based on the results of a Delphi process.

Earlier Physical Therapy Input Is Associated With a Reduced Length of Hospital Stay and Reduced Care Needs on Discharge in Frail Older Inpatients: An Observational Study.

Pressures on hospital bed occupancy in the English National Health Service have focused attention on enhanced service delivery models and methods by which physical therapists might contribute to effective cost savings, while retaining a patient-centered approach. Earlier access to physical therapy may lead to better outcomes in frail older inpatients, but this has not been well studied in acute National Health Service hospitals. Our aim was to retrospectively study the associations between early physical therapy input and length of hospital stay (LOS), functional outcomes, and care needs on discharge. This was a retrospective observational study in a large tertiary university National Health Service hospital in the United Kingdom. We analyzed all admission episodes of people admitted to the department of medicine for the elderly wards for more than 3 months in 2016. Patients were categorized into 2 groups: those examined by a physical therapist within 24 hours of admission and those examined after 24 hours of admission.The outcome variables were as follows: LOS (days), functional measures on discharge (Elderly Mobility Scale and walking speed over 6 m), and the requirement of formal care on discharge. Characterization variables on admission were age, gender, existence of a formal care package, preadmission abode, the Clinical Frailty Scale, Charlson Comorbidity Index, the Emergency Department Modified Early Warning Score, C-reactive protein level on admission, and the 4-item version of the Abbreviated Mental Test.The association between the delay to physical therapy input and LOS before discharge home was evaluated using a Cox proportional hazards regression model. There were 1022 hospital episodes during the study period. We excluded 19 who were discharged without being examined by a physical therapist. Of the remaining 1003, 584 (58.2%) were examined within 24 hours of admission (early assessment) and 419 (41.8%) after 24 hours of admission (late assessment).The median (interquartile range) LOS of the early assessment group was 6.7 (3.1-13.7) versus 10.0 (4.2-20.1) days in the late assessment group, P < .001. The early assessment group was less likely to require formal care on discharge: n = 110 (20.3%) versus n = 105 (27.0%), P = .016. No other statistically significant differences were seen between the 2 groups.In the unadjusted Cox proportional hazards model, the hazard ratio for early assessment compared with late assessment was 1.29 (95% confidence interval: 1.12-1.48, P < .001). Early assessment was associated with a 29% higher probability of discharge to usual residence within the first 21 days after admission than the late assessment. Adjustment for possible confounding variables increased the hazard ratio: 1.34 (1.16-1.55), P < .001. Early physical therapy input was associated with a shorter LOS and lower odds of needing care on discharge. This may be due to the beneficial effect of early physical therapy in preventing hospital-related deconditioning in frail older adults. However, causality cannot be inferred and further research is needed to investigate causal mechanisms.

Operating a patient medicines helpline: a survey study exploring current practice in England using the RE-AIM evaluation framework

BackgroundPatient medicines helplines provide a means of accessing medicines-related support following hospital discharge. However, it is unknown how many National Health Service (NHS) Trusts currently provide a helpline, nor how they are operated. Using the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance), we sought to obtain key data concerning the provision and use of patient medicines helplines in NHS Trusts in England. This included the extent to which the delivery of helplines meet with national standards that are endorsed by the Royal Pharmaceutical Society (standards pertaining to helpline access, availability, and promotion).MethodsAn online survey was sent to Medicines Information Pharmacists and Chief Pharmacists at all 226 acute, mental health, specialist, and community NHS Trusts in England in 2017.ResultsAdoption: Fifty-two percent of Trusts reported providing a patient medicines helpline (acute: 67%; specialist: 41%; mental health: 29%; community: 18%). Reach: Helplines were predominantly available for discharged inpatients, outpatients, and carers (98%, 95% and 93% of Trusts, respectively), and to a lesser extent, the local public (22% of Trusts). The median number of enquiries received per week was five. Implementation: For helpline access, 54% of Trusts reported complying with all ‘satisfactory’ standards, and 26% reported complying with all ‘commendable’ standards. For helpline availability, the percentages were 86% and 5%, respectively. For helpline promotion, these percentages were 3% and 40%. One Trust reported complying with all standards. Maintenance: The median number of years that helplines had been operating was six. Effectiveness: main perceived benefits included patients avoiding harm, and improving patients’ medication adherence.ConclusionsPatient medicines helplines are provided by just over half of NHS Trusts in England. However, the proportion of mental health and community Trusts that operate a helpline is less than half of that of the acute Trusts, and there are regional variations in helpline provision. Adherence to the national standards could generally be improved, although the lowest adherence was regarding helpline promotion. Recommendations to increase the use of helplines include increasing the number of promotional methods used, the number of ways to contact the service, and the number of hours that the service is available.

From embracing to managing risks

ObjectiveTo assess developments over time in the capture, curation and use of quality and safety information in managing hospital services.SettingFour acute National Health Service hospitals in England.Participants111.5 hours of observation...

Renal inpatient ward nurse experience and job satisfaction: Aqualitative study.

To examine the experience of registered nurses working in renal inpatients wards at an acute National Health Service (NHS) hospital Trust. Nurse perceptions of their experience particularly in relation to job satisfaction were analysed. Increased understanding of workplace organisation and culture can contribute to improved nurse work experience and better patient care. Worldwide many studies conducted on nurse experience and job satisfaction show that job satisfaction level varies across work settings so analysis of job satisfaction at a local level such as in a ward is important for producing useful analysis and recommendations. Using purposive sampling, semistructured individual interviews were conducted on twelve registered nurses working on renal inpatient wards. The study identified three themes: safe care, organisational culture and work environment. Although staffing was identified as a key element to providing safe care maintaining adequate staffing levels remained a challenge. Whilst there were opportunities for professional development more support is needed for newly qualified nurses. Findings highlighted that renal patients were complex. It is important to maintain adequate staffing levels. Good clinical leadership is required to support and develop the positive experience of nurses. The high turnover of newly qualified nurses is a particular problem and nurse managers need to develop strategies to retain such nurses. Regular audits on staffing levels as part of improving workforce planning and patient safety need to be conducted.

Future priorities of acute hospitals for surgical site infection surveillance in England

Since the launch of the national Surgical Site Infection (SSI) Surveillance Service in 1997, successive expansions of the programme provided hospitals with increasing flexibility in procedures to target through surveillance. Ensuring that the programme continues to meet hospitals' needs remains essential. As a means to inform the future direction of the service, a survey of all acute National Health Service trusts was undertaken to assess and understand priorities for surveillance. A web-based survey was circulated to acute NHS trust infection control teams in England, asking them to identify and rank (i) reasons for undertaking current SSI surveillance, (ii) priority surgical categories for future SSI surveillance, and (iii) reasons for prioritizing these categories. Of the 161 trusts surveyed, 84 (52%) responded. Assessment of quality of care was identified as the most common driver for SSI surveillance activity. Considerable heterogeneity in priority areas was observed, with 24 different surgical categories selected as top priority. Of the procedures undertaken by 15 or more trusts, caesarean section (2.7), hip replacement (2.8) and coronary artery bypass graft (2.9) were highest ranked. All 17 categories in the current surveillance programme were selected as a top priority by one or more trusts. Whereas the majority of hospitals' priorities for SSI surveillance are included in the current programme, the top-ranked priority, caesarean section, is not included. Given the diversity of priority areas, maintaining a comprehensive spectrum of categories in the national programme is essential to assist hospitals in addressing local priorities.

Nurses experiences of using clinical competencies a qualitative study.

Nurses working in haemodialysis units are expected to demonstrate competency and understanding of the technical processes involved in supporting patients undergoing haemodialysis treatment. In 2012 the nursing education team within a large acute National Health Service (NHS) London Hospital Group updated and standardised haemodialysis clinical competencies to assist junior haemodialysis nurses develop their clinical skills and knowledge in delivering nursing care to patients receiving haemodialysis treatment. A qualitative interpretive phenomenological methodology using semi-structured interviews investigated the lived experiences of novice haemodialysis nurses and mentors using these competencies. Nineteen participants including ten novice nurses and nine mentors were recruited from six haemodialysis units within a large acute NHS London Hospital Group. The main findings identified that the haemodialysis clinical competencies were beneficial in developing novice nurses' haemodialysis skills, knowledge and competence. The competencies provided them with a structured framework for assessing competence. Novice nurses experienced stress and anxiety, particularly when they were faced with new and unfamiliar situations. The results obtained concluded the crucial role of expert haemodialysis nurses in mentoring and training novice nurses. The importance of competent skilled nurses in providing care to patients receiving haemodialysis treatment and the value of a competency document were strongly emphasised.

Current strategies to detect, manage and control carbapenemase-producing Enterobacteriaceae in NHS acute hospital trusts in the UK: time for a rethink?

Since 2013, there has been national guidance on controlling carbapenemase-producing Enterobacteriaceae (CPE) in acute National Health Service (NHS) hospital trusts in the UK [1]. However, much has changed in five years, and getting to grips with preventing the spread of CPE has posed many challenges for individual organizations. In this issue, two papers evaluate the toolkit for early detection, management and control of CPE, and, in particular, the role of serial screening to detect CPE carriage.

Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomised controlled trial

ObjectiveFractured neck of femur is a severely painful condition with significant mortality and morbidity. We investigated whether early and continuous use of femoral nerve block can improve pain on movement...

The Patient Experience: Informing Practice through Identification of Meaningful Communication from the Patient's Perspective.

(1) Background: There is limited empirical knowledge concerning aspects of healthcare that contribute to a good patient experience from the patient’s perspective and how patient feedback informs service development. (2) Aim: To examine the issues that influence the effectiveness of communication on patient satisfaction, experience and engagement, in an acute National Health Service (NHS) setting, through identification of the patient’s requirements and expectations. (3) Method: Data was gathered from a large teaching hospital using a Friends and Family Test (FFT) and a communication specific survey. Both surveys captured patient narrative to identify predominant influences to explain the quantitative responses. (4) Results: The key priorities for patients are involvement in their care and receiving the right amount of information to support this. However, the delivery of compassionate care was identified as having the most influence on the likelihood of patients to recommend an acute NHS Trust. (5) Conclusion: The findings support a broader understanding of the constituents of an all-encompassing patient experience from the patient’s perspective. (6) Implications: healthcare organizations need to focus their resources on how to improve patient/provider communication to support patients to be true partners in their care.

A qualitative study of patients’ feedback about Outpatient Parenteral Antimicrobial Therapy (OPAT) services in Northern England: implications for service improvement

ObjectiveOutpatient parenteral antimicrobial therapy (OPAT) provides opportunities for improved cost savings, but in the UK, implementation is patchy and a variety of service models are in use. The slow uptake...

The challenges of training, support and assessment of healthcare support workers: A qualitative study of experiences in three English acute hospitals

BackgroundEver-growing demands on care systems have increased reliance on healthcare support workers. In the UK, their training has been variable, but organisation-wide failures in care have prompted questions about how this crucial section of the workforce should be developed. Their training, support and assessment has become a policy priority. ObjectivesThis paper examines: healthcare support workers’ access to training, support and assessment; perceived gaps in training provision; and barriers and facilitators to implementation of relevant policies in acute care. Design and settingsWe undertook a qualitative study of staff caring for older inpatients at ward, divisional or organisational-level in three acute National Health Service hospitals in England in 2014. Participants58 staff working with older people (30 healthcare support workers and 24 staff managing or working alongside them) and 4 healthcare support worker training leads. MethodsOne-to-one semi-structured interviews included: views and experiences of training and support; translation of training into practice; training, support and assessment policies and difficulties of implementing them. Transcripts were analysed to identify themes. ResultsInduction training was valued, but did not fully prepare healthcare support workers for the realities of the ward. Implementation of hospital policies concerning supervision and formal assessment of competencies varied between and within hospitals, and was subject to availability of appropriate staff and competing demands on staff time. Gaps identified in training provision included: caring for people with cognitive impairment; managing the emotions of patients, families and themselves; and having difficult conversations. Access to ongoing training was affected by: lack of time; infrequent provision; attitudes of ward managers to additional support workforce training, and their need to balance this against patients’ and other staff members’ needs; and the use of e-learning as a default mode of training delivery. ConclusionsWith the current and unprecedented policy focus on training, support and assessment of healthcare support workers, our study suggests improved training would be welcomed by them and their managers. Provision of training, support and assessment could be improved by organisational policy that promotes and protects healthcare support worker training; formalising the provision and availability of on-ward support; and training and IT support provided on a drop-in basis. Challenges in implementation are likely to be faced in all international settings where there is increased reliance on a support workforce. While recent policies in the UK offers scope to overcome some of these challenges there is a risk that some will be exacerbated.

RCR audit of compliance with UK guidelines for the prevention and detection of acute kidney injury in adult patients undergoing iodinated contrast media injections for CT

To determine radiology departmental compliance with current UK guidance on contrast-induced acute kidney injury (CI-AKI) and to provide data on the incidence of clinically significant post-contrast AKI (PC-AKI) in computed tomography (CT) practice. A questionnaire was sent to all UK acute National Health Service (NHS) providers (NHS boards in Scotland, local health boards in Wales, NHS trusts in England and health and social care trusts in Northern Ireland) to assess compliance of provider protocols with current UK guidelines for the prevention, recognition, and management of CI-AKI. Audit data were collected for 40 consecutive fit outpatients and 40 consecutive acutely unwell patients/inpatients from hospitals within each participating provider to assess clinical compliance. Eighty-nine of 172 (52%) health service providers responded, and data on 7,159 contrast-enhanced CT examinations were provided. Compliance with guidelines was poor with wide variation in clinical practice. The observed incidence of clinically significant (requiring treatment or resulting in death) PC-AKI was zero in 3,590 outpatients, although two patients developed AKI due to other causes (sepsis and progressive malignancy). Fourteen out of 3,569 (0.4%) patients in the inpatient group developed clinically significant PC-AKI, and a further 17 patients were identified who met the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI (Electronic Supplementary Material Appendix S1), but did not require active treatment, giving an overall incidence of AKI of 0.9%. In patients at high risk due to impaired renal function prior to the scan, there was no difference in the median serum creatinine (SCr) before and after contrast medium administration in either group. Health service provider protocols and clinical practice demonstrate poor compliance with current UK guidance on CI-AKI. A very low incidence of PC- AKI was demonstrated.

Building and sustaining work engagement – a participatory action intervention to increase work engagement in nursing staff

ABSTRACTThis study evaluated whether a participatory action research intervention with nursing staff on acute care older people National Health Service wards in the United Kingdom was effective for increasing work engagement. Mediation analyses between job resources (social support, influence in decision-making), job demands, work-related needs (autonomy, competence, relatedness), and work engagement explored the presumed psychological mechanisms underlying the intervention. A non-randomized, matched control group, pretest, post-test design involved three intervention and five control wards. A significant decrease in relatedness, and a borderline significant decrease in competence, was observed in the intervention group compared to the control group, with no effect on work engagement (N = 45). Work-related needs mediated between resources and work engagement, supporting the job demands-resources model and self-determination theory as an underlying explanatory theory. Intervention implementation was difficult, highlighting the need for participant and organizational readiness for change, and strong management support. This is the first known study to apply participatory techniques to increase work engagement in nursing staff and explore the underlying explanatory psychological mechanisms, offering a novel means of taking work engagement research forward. Crucially, it highlights the challenges involved in intervention research and the importance of including evaluations of intervention implementation alongside statistical evaluations to avoid erroneous conclusions.

Retrospective observational study of emergency admission, readmission and the ‘weekend effect’

ObjectivesExcess mortality following weekend hospital admission has been observed but not explained. As readmissions have greater age, comorbidity and social deprivation, outcomes following emergency index admission and readmission were examined...

Capacity of English NHS hospitals to monitor quality in infection prevention and control using a new European framework: a multilevel qualitative analysis

Objective(1) To assess the extent to which current English national regulations/policies/guidelines and local hospital practices align with indicators suggested by a European review of effective strategies for infection prevention and...

Mining routinely collected acute data to reveal non-linear relationships between nurse staffing levels and outcomes

ObjectivesNursing is a safety critical activity but not easily quantified. This makes the building of predictive staffing models a challenge. The aim of this study was to determine if relationships...

Radiographer reporting in the UK: is the current scope of practice limiting plain-film reporting capacity?

To update knowledge on individual radiographer contribution to plain-film reporting workloads; to assess whether there is scope to further increase radiographer reporting capacity within this area. Reporting radiographers were invited to complete an online survey. Invitations were posted to every acute National Health Service trust in the UK whilst snowball sampling was employed via a network of colleagues, ex-colleagues and acquaintances. Information was sought regarding the demographics, geographical location and anatomical and referral scope of practice. A total of 259 responses were received. 15.1% and 7.7% of respondents are qualified to report chest and abdomen radiographs, respectively. The mean time spent reporting per week is 14.5 h (range 1-37.5). 23.6% of radiographers report only referrals from emergency departments whilst 50.6% of radiographers have limitations on their practice. The scope of practice of reporting radiographers has increased since previous studies; however, radiographer reporting of chest and abdomen radiographs has failed to progress in line with demand. There remain opportunities to increase radiographer capacity to assist the management of reporting backlogs. This study is the first to examine demographic factors of reporting radiographers across the UK and is one of the largest in-depth studies of UK reporting radiographers, at individual level, to date.

Prospective audit to evaluate the potential of the coronial system to increase solid organ donation

ObjectivesAnecdotal evidence suggests that organ donation from deceased donors referred to the Coroner/Procurator Fiscal (PF) could be increased if all followed best practice. The aim of this prospective audit was...

Hospital patient discharge process: an evaluation

ObjectivesMedication discrepancies for patients after discharge from hospital are well documented. They have been shown to cause unnecessary harm to patients and can result in hospital readmission. To improve patient...