English District General Hospital Research Articles

Loop ileostomy reversal: 5 year experience in an English rural district general hospital

(April 2005-2006). Results: 2010/11 114 patients, 2005/6 133 patients. No change in proportion of emergency presentations 21.2% in 2010/2011 versus 25.6% in 2005/6 (p1⁄40.6044).A significant reduction in stage 45%DukesC/D compared to 64% in historic cohort (p1⁄40.0038).More right sided CRCs presenting 39.5% 2010/ 11 versus 33.8% 2005/6 (p1⁄40.36). Greater proportionpresentedwith anaemia (23.7% versus 14.3%, p1⁄40.0586). Duration of anaemia prior to presentation increased (365 days versus 150 days, p1⁄40.292). Conclusion: Since BCSP introduction there has been a significant decrease in stage of CRC at presentation but no decrease in emergency presentations. There has been a shift towards more right sided tumours which may explain the trend to an increase in those presenting with anaemia.

A study of paediatric and adolescent gynaecology services in a British district general hospital

The Paediatric and Adolescent Gynaecology service (PAG) at Kettering General Hospital is a designated service meeting the needs of children with gynaecological problems. National guidelines reinforce the fact that children should be seen within specific paediatric areas in hospital. We aim to review the role of such a service in the context of a British district general hospital. Retrospective review spanning 15 years. The outpatient/inpatient service of a UK district general hospital. A total of 800 patients were included in the study. We identified patients attending the PAG clinic between 1994 and 2009. Medical notes were reviewed individually. Demographics, referral source, presenting symptoms, examination findings, diagnosis, management, admissions and referrals to tertiary centres. In total, 86% of patients were referred from primary care. The age distribution was bimodal at 4 and 15 years of age: the average age was 10 years. Sixty percent of patients were followed-up, giving a total of 2023 appointments. The commonest presentations were vulvovaginitis (18%), labial adhesions (14%), abdominal pain (7%) and precocious puberty (6%). A total of 15% of patients were admitted, largely for planned procedures, of which vaginoscopy was the most frequent. The PAG service has enabled pathways for care that were previously non-existent, as well as the development of 'best practice'. The British Society for Paediatric and Adolescent Gynaecology has been seeking to develop a network of similar services at secondary and tertiary level throughout the UK. This approach should be encouraged and promoted by those in charge of healthcare policy and provider trusts in general.

Medication errors with electronic prescribing (eP): Two views of the same picture

BackgroundQuantitative prospective methods are widely used to evaluate the impact of new technologies such as electronic prescribing (eP) on medication errors. However, they are labour-intensive and it is not always feasible to obtain pre-intervention data. Our objective was to compare the eP medication error picture obtained with retrospective quantitative and qualitative methods.MethodsThe study was carried out at one English district general hospital approximately two years after implementation of an integrated electronic prescribing, administration and records system. Quantitative: A structured retrospective analysis was carried out of clinical records and medication orders for 75 randomly selected patients admitted to three wards (medicine, surgery and paediatrics) six months after eP implementation. Qualitative: Eight doctors, 6 nurses, 8 pharmacy staff and 4 other staff at senior, middle and junior grades, and 19 adult patients on acute surgical and medical wards were interviewed. Staff interviews explored experiences of developing and working with the system; patient interviews focused on experiences of medicine prescribing and administration on the ward. Interview transcripts were searched systematically for accounts of medication incidents. A classification scheme was developed and applied to the errors identified in the records review.ResultsThe two approaches produced similar pictures of the drug use process. Interviews identified types of error identified in the retrospective notes review plus two eP-specific errors which were not detected by record review. Interview data took less time to collect than record review, and provided rich data on the prescribing process, and reasons for delays or non-administration of medicines, including "once only" orders and "as required" medicines.ConclusionsThe qualitative approach provided more understanding of processes, and some insights into why medication errors can happen. The method is cost-effective and could be used to supplement information from anonymous error reporting schemes.

To Catheterise or Not to Catheterise: A Study in Hip and Knee Primary Arthroplasty

This cross sectional study examines the rate of catheterisation of patients after elective primary hip and knee arthroplasty in an English district general hospital. 50 patients were included in this study, with 19 (37%) being catheterised pre-operatively. Of the remainder, 10 went into retention and had to be catheterised, while the other 21 were managed without a catheter. There was a trend towards more patients requiring catheterisation after axial anaesthetic (42%) compared to non-axial anaesthetic (21%), although this was not significant. We examine the rationale for catheterisation in hip and knee arthroplasty and review the available literature.

Total parenteral nutrition in a busy English district general hospital

Total parenteral nutrition in a busy English district general hospital

Total parenteral nutrition in a busy English district general hospital

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Endoscopic Clearance of Common Bile Duct Stones: What Happens After? Value of Prophylactic Cholecystectomy

Background: Whether cholecystectomy is needed after endoscopic clearance of common bile duct stones has been debated intensely in the past. A recent Cochrane review has concluded that prophylactic cholecystectomy (PChol) post endoscopic bile duct clearance leads to longer survival and fewer complications. Aim & Methods: Our aim was to investigate how commonly prophylactic cholecystectomy is performed post ERCP and whether it influences the outcome in a typical British District General Hospital. A retrospective audit of case notes and electronic records was undertaken to assess how many patients underwent PChol, developed recurrence of stones, cholangitis, cholecystitis or pancreatitis after endoscopic sphincterotomy and bile duct clearance between April 2004 and January 2006.

Parents’ information needs about the treatment of their chronically ill child: A qualitative study

Effective information provision is a prerequisite for partnership between child patients, their parents and health professionals. Objectives To explore the complexity of parents’ information needs and how current information provision is evaluated. Methods Qualitative methodology using semi-structured interviews with 27 parents of 20 families with a chronically ill child, recruited at the paediatric department of a British district general hospital. Results The need for information varied greatly between individuals and over time, and commonly involved diagnosis, management plan and prognosis. However, most parents in this study experienced professional communication and information provision to be inadequate. Information provision appeared to be related to the diagnosis, the level of secondary care involvement and the extent to which parents were required to take responsibility for daily management of the child's condition. Parents’ complex and shifting evaluations and responses point to the double-edged nature of information. Some parents actively sought out information, but resisting information, for fear of its potentially negative impact, was also noted to be a coping strategy. Conclusion Parents of chronically ill children presented with a great variety of information needs, which was not always appreciated by healthcare professionals. Practice implications This study highlights the need for good communication based on professional awareness of how parents understand and experience their child's illness, as well as the importance of sensitively individualising information provision to parents’ needs so as to address their requirements but not to unnecessarily increase their anxiety or insecurity.

Social deprivation and admission for neonatal care

Objective: To determine whether social deprivation is associated with neonatal unit admission. Setting: English district general hospital. Method: Retrospective review of neonatal unit admission records between 1990 and 2002. Results:...

Body Mass Index Extremes in a British Adolescent Gynecology Clinic

Study Objective To identify the prevalence of patients with BMI extremes (BMI > 88% or < 2%) in our Adolescent Gynecology clinic and audit their weight management. Design Retrospective case series. Setting The Adolescent Gynecology Clinic of a British District General Hospital Participants All patients aged 12–17 years when first seen in the Adolescent Gynecology clinic from 1997 to 2003. Interventions Retrospective data collection on biometry and weight management interventions. Main Outcome Measures The percentage of obese (BMI > 98 th percentile for age), overweight (BMI 88 th–98 th percentile) and underweight (BMI < 2 nd percentile) based on published percentile BMI curves for the UK adolescent population, the proportion of patients with extreme BMI that were offered intervention, the types of intervention offered, the proportion of patients whose BMI improved after the intervention, and the number of patients with BMI > 88% among smokers were compared to non-smokers. Results Of the 125 patients 24% were obese, an additional 17% overweight and 1% underweight. The expected figures in the general population are 2%, 10% and 2% respectively ( P < 0.001; test of a single proportion). Weight management intervention was offered to 47% of patients with extreme BMI. The BMI improved in 36% of the patients who were offered and 14% of patients who were not offered intervention ( P = 0.066; χ 2). There was no statistically significant difference between smokers and non-smokers in the proportion of patients with BMI > 88% ( P = 0.93; χ 2). Conclusion There is significantly increased prevalence of obese and overweight women among adolescent gynecological patients. The need for management of the BMI of these patients has not been always been recognized and treatment is not particularly effective. The results indicate a need for defined strategies and additional resources for obesity management.

Antimicrobial resistance of invasive Streptococcus pneumoniae isolates in a British district general hospital: the international connection

Between January 2000 and March 2001, Streptococcus pneumoniae were isolated from the blood of 56 patients admitted to a single district general hospital in the South-East of England. The serotype and antibiotic susceptibility were determined for all isolates and, for those resistant to erythromycin, the presence or absence of the mef(A) and erm(B) genes was determined by PCR. Multi-locus sequence typing, along with PFGE, was undertaken on all isolates resistant to penicillin or erythromycin and a group of antibiotic-susceptible isolates, to identify whether globally distributed pneumococcal clones, as described by the Pneumococcal Molecular Epidemiology Network (PMEN), were present in the study population. Three serotype 9V penicillin-resistant isolates were identified as belonging to the Spain9V-3 clone, while 14 erythromycin-resistant isolates of serotype 14 belonged to the England14-9 clone. A single multi-resistant isolate of serotype 6B, was found to be a single-locus variant of the Spain6B-2 clone. All 14 erythromycin-resistant serotype 14 isolates possessed the mef(A) gene, while the single multi-resistant isolate possessed the erm(B) gene. These findings confirm the wide distribution and clinical impact of PMEN clones, which accounted for all of the penicillin and erythromycin resistance observed amongst invasive isolates in a district general hospital over a 15-month period.

Illumination of x-rays: the usual lights exposed

Aims: Faced with pressure of work and limited resource, doctors frequently use the nearest available light to examine x-ray films. The aim of this study was to examine the relative...

Health system costs of in-hospital cardiac arrest

This paper reports on the health system resources used in the treatment of in-hospital cardiac arrests in a British district general hospital. The resources used in resuscitation attempts were recorded prospectively by observation of a convenience sample of 30 cardiac arrests. The post-resuscitation resource use by survivors was collected through a retrospective record review (n=37) and by following survivor members in the prospective sample (n=6). Financial data were used to translate resource use into costs (1999 prices). There was a non-significant trend for more resources to be used in daytime resuscitations than at night. Survivors had significantly fewer diagnostic tests during resuscitation than those who died (P=0.004). Length of resuscitation attempt was positively and significantly related to resource use (P<0.05). The average variable cost per resuscitation attempt (1999 prices) was £195.66; 76.5% was for staff, and 13.1% for drugs and fluids. Emergency calls were attended by an average of 10.11 staff. The average fixed cost per resuscitation attempt was £928.81; 12% for capital equipment and 73% for staff training. The average post-resuscitation costs attributable to the cardiac arrest of the 29 people surviving more than 24 h after cardio-pulmonary resuscitation (CPR) were estimated to be £1589.72. This is lower than other studies which estimated total costs of post-CPR lengths of stay. Reducing avoidable cardiac arrests would generate in-hospital savings in direct resuscitation care of survivors. Scope for reducing capital and training costs is discussed.

Oral sildenafil (Viagra) in male erectile dysfunction: use, efficacy and safety profile in an unselected cohort presenting to a British district general hospital.

IntroductionSildenafil (Viagra®) is one of the drugs used in the first line therapy of male erectile dysfunction (MED). We have recorded outcomes, adverse events and acceptability of Sildenafil (Viagra) therapy in an unselected group of men presenting with ED to a British district general hospital.MethodsIn this prospective observational study, 147 men with ED were seen since Oct 1999. Study patients were reviewed at 4, 12 and 52 weeks. All the patients filled the International Index of Erectile Function (IIEF) questionnaire and were asked about their willingness to pay (WTP) for treatment.ResultsAll suitable men accepted Viagra as first line therapy. 91% of our patients found sildenafil treatment successful. 80% of these patients were willing to continue with sildenafil therapy. Side effect profile of sildenafil was different in this study with much higher incidence of headache, dyspepsia, flushing and abnormal vision. 92% of men with ED expect to be treated by the NHS. Of those men eligible for treatment in the NHS, 30% qualify under the clinical categories and 18% under the 'distress' category. Only 55% of those with cardiovascular risk factors qualify for NHS treatment.ConclusionsSildenafil is widely accepted as first line therapy among British men with ED and has a success rate of 91%. Nearly half of men with ED qualify for NHS treatment. Nearly half of those with vascular risk factors do not qualify for NHS treatment. Most men with ED could possibly be managed in primary care.

Improving Patient Recruitment to Multicentre Clinical Trials: The Case for Employing a Data Manager in a District General Hospital-Based Oncology Centre

One of the most frequently cited reasons for poor recruitment to multicentre randomized clinical trials is the additional workload placed on clinical staff. We report the effect on patient recruitment of employing a data manager to support clinical staff in an English district general hospital (DGH). In addition, we explore the effect data managers have on the quality of data collected, proxied by the number of queries arising with the trial organizers. We estimate that the cost of employing a data manager on a full-time basis is £502 per patient recruited but may amount to £326 if the appointment is part-time. Data quality is high when full responsibility lies with a data manager but falls when responsibility is shared. Whether the costs of employing a data manager to recruit patients from a DGH are worth incurring depends on the value placed on the speed at which multicentre trials can be completed, how important it is to broaden the research base beyond the traditional setting of teaching hospitals, and the amount of evaluative data required.

Low mortality in ulcerative colitis and Crohn’s disease in three regional centers in England

OBJECTIVES: Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn’s disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. METHODS: Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. RESULTS: Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79–140] for UC and 94 (95% CI: 59–140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99–439; p = 0.02) and 229 (74–535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD ( p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84–793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108–335; p = 0.02) and 164 (95% CI: 82–335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). CONCLUSIONS: Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.

Low mortality in ulcerative colitis and Crohn's disease in three regional centers in England.

Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn's disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79-140] for UC and 94 (95% CI: 59-140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99-439; p = 0.02) and 229 (74-535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD (p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84-793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108-335; p = 0.02) and 164 (95% CI: 82-335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.

Trends in acute admissions: a study of one English district general hospital.

The aim of the study was to determine whether significant daily and hourly variations in acute admissions to hospital were evident over time, and to determine whether significant changes in patient and management characteristics had occurred over time. Time-trend and cross-section analysis of admissions was carried out, for samples between 1986 and 1995, using manual records from the transit ward, Doncaster Royal Infirmary. Mean daily admissions at weekends were significantly lower than those occurring during the working week. During the day, the admission rate peaked at around noon and gradually declined thereafter. Patients arriving during the night tended to be younger and were more likely to be male. Age was a significant predictor of subsequent patient management following arrival. Overall, the number and mean age of arriving patients had increased by the end of the investigation period, although the proportion of patients being sent home from the transit ward did not vary over time.

Patch testing in a British district general hospital.

The results of patch testing in 753 patients attending a dermatology clinic in a British district general hospital over the period 1993-96 are presented. The frequency of positive reactions, and of the relative frequency of common allergens is broadly comparable to series published from specialist contact clinics. This study suggests that nonspecialist dermatology clinics can carry out routine patch testing adequately, although there are likely to be a number of cases which will require review in a specialist clinic or specialist advice.

Surgical outpatient clinics: are we allowing enough time?

Performance management initiatives, such as the UK's Patient's Charter, are creating pressure for patients to be seen earlier at out patient clinics, thus increasing clinic workloads. There is, however, little information about whether this can be absorbed, either by utilizing spare capacity or by more efficient use of time, or whether it is likely to affect patient care adversely. Nine surgical clinics, run by four general surgeons, in an English district general hospital were studied during a typical week. Clinic schedules and numbers invited to attend were extracted from clinic records. An observer recorded the actual time each patient spent with the surgeon to the nearest 5 seconds. Scheduled and actual times of commencement and completion of clinics were also recorded. The number of patients booked to attend each clinic varied from 11 to 82 (mean 37). The median consultation for new patients was 4.3 minutes and for follow-up patients it was 3 minutes. Consultants spent a median 2.7 minutes with patients whereas junior staff spent 4.2 minutes. These aggregate results conceal considerable variation between surgeons, even though the scheduled time available was similar. The median time spent with new patients by one consultant was 1.3 minutes and by another 13.1 minutes. Seven of the nine clinics overran their scheduled time (by up to 55 minutes). All doctors, with one exception, arrived late for the clinics (range 10 minutes early to 30 minutes late). The first patient was invariably seen after the scheduled starting time for the clinic (mean 17 minutes, range 5-50 minutes) and the median interval between a doctor arriving and seeing their first patient was 10.6 minutes. Overall, only 50% of the time spent by doctors at the clinics was with patients. The amount of time spent by patients with surgeons is already so short as to cause concern about both the appropriateness and value of consultations. It is unreasonable to increase workload further. There is a clear need for outpatient clinics to be managed, with regular examination of what is taking place and how long it takes. Only then will it be possible to tailor schedules to the actual requirements of the service.