English Hospitals Research Articles

Trends and determinants of clinical staff retention in the English NHS: a double retrospective cohort study

ObjectivesTo investigate how demographic, contractual and organisational factors are related to the retention of hospital workers in the English NHS. The study will specifically examine the trends in age-retention profiles.DesignA...

Hospital corridors as lived spaces: The reconfiguration of social boundaries during the early stages of the Covid pandemic.

This article explores the meanings and uses of a hospital corridor through 98 diary entries produced by the staff of an English specialist hospital during the early stages of the COVID-19 pandemic. Drawing on Lefebvre's (1991, The production of space. Blackwell) threefold theorisation of space, corridors are seen as conceived, perceived and lived spaces, produced through and enabling the reconfiguration and reinterpretation of social interactions. The diaries depict two distinct versions of the central hospital corridor: its 'normal' operation prior to the pandemic when it was perceived as a social and symbolic space for collective sensemaking and the 'COVID-19 empty corridor' described as a haunting place that divided hospital staff along ostensibly new social and moral boundaries that impacted negatively on lived work experiences and staff relationships. The mobilisation of the central hospital corridor in the daily social construction of meaning and experience during a period of organisational and societal crisis suggests that corridors should not be only seen as a material backdrop for work relationships but as social entities that come into being and are maintained and reproduced through the (lack of) performance of social relations.

Impact of the COVID-19 pandemic on hospital episodes for falls and fractures associated with new-onset disability and frailty in England: a national cohort study.

Older people with frailty are at risk of harm from immobility or isolation, yet data about how COVID-19 lockdowns affected them are limited. Falls and fractures are easily measurable adverse outcomes correlated with frailty. We investigated whether English hospital admission rates for falls and fractures varied from the expected trajectory during the COVID-19 pandemic, and how these varied by frailty status. NHS England Hospital Episode Statistics Admitted Patient Care data were analysed for observed versus predicted outcome rates for 24 January 2020 to 31 December 2021. An auto-regressive integrated moving average time-series model was trained using falls and fracture incidence data from 2013 to 2018 and validated using data from 2019. Models included national and age-, sex- and region-stratified forecasts. Outcome measures were hospital admissions for falls, fractures, and falls and fractures combined. Frailty was defined using the Hospital Frailty Risk Score. 144,148,915 pre-pandemic hospital admissions were compared with 42,267,318 admissions after pandemic onset. For the whole population, falls and fracture rates were below predicted for the first period of national lockdown, followed by a rapid return to rates close to predicted. Thereafter, rates followed expected trends. For people living with frailty, however, falls and fractures increased above expected rates during periods of national lockdown and remained elevated throughout the study period. Effects of frailty were independent of age. People living with frailty experienced increased fall and fracture rates above expected during and following periods of national lockdown. These remained persistently elevated throughout the study period.

Risk of multiple sclerosis in individuals with infectious mononucleosis: a national population-based cohort study using hospital records in England, 2003-2023.

Epstein-Barr virus (EBV) is thought to be a necessary causative agent in the development of multiple sclerosis (MS). Infectious mononucleosis (IM), which occurs up to 70% of adolescents and young adults with primary EBV infection, appears to be a further risk factor but few studies have been highly powered enough to explore this association by time since IM diagnosis. The objective was to quantify the risk of MS in individuals with IM compared with the general population, with particular focus on time since IM diagnosis. In this retrospective cohort study using English national Hospital Episode Statistics from 2003 to 2023, patients with a hospital diagnosis of IM were compared with the general population for MS incidence. MS incidence in patients with IM was nearly three times higher than the general population after multivariable adjustment (adjusted hazard ratio = 2.8, 95% confidence interval (CI = 2.3-3.4), driven by strong associations at long time intervals (>5 years) between IM diagnosis and subsequent MS diagnosis. While EBV infection may be a prerequisite for MS, the disease process of IM (i.e. the body's defective immune response to primary EBV infection) seems to be, in addition, implicated over the long term.

A realist evaluation of devices used for the prevention of heel pressure ulcers: An ethnographic study of clinical practice

BackgroundIt is known that heel offloading devices are widely used in clinical practice for the prevention of heel pressure ulcers, even though there is a lack of robust, good quality evidence to inform their use. ObjectiveTo explore how and why heel offloading devices are used (or not used) and reasoning behind their use in population at high risk of developing heel pressure ulcers. MethodsAn ethnographic study was conducted as part of a realist evaluation in three orthopaedic wards in a large English hospital. Twelve observations took place, with 49 h and 35 min of patient care observed. A total of 32 patients were observed and 19 members of the nursing team were interviewed and in-depth interviews with the three ward managers were conducted. ResultsAlthough the focus of the study was on offloading devices, constant low pressure heel specific devices were also observed in use for pressure ulcer prevention, whilst offloading devices were perceived to be for higher risk patients or those already with a heel pressure ulcer. Nursing staff viewed leadership from the ward manager and the influence of the Tissue Viability Nurse Specialists as key mechanisms for the proactive use of devices. ConclusionsThis study informs trial design as it has identified that a controlled clinical trial of both types of heel specific devices is required to inform evidence-based practice. Involving the ward managers and Tissue Viability Nurse Specialists during set up phase for clinical equipoise could improve recruitment.Tweetable abstractHow, for whom, and in what circumstances do devices work to prevent heel pressure ulcers? Observations of clinical practice.

Variation in access to specialist services for neurosurgical procedures in adults with epilepsy in England, a cohort study.

To understand if primary consultation at tertiary epilepsy centres (TEC) in England impacts access to neurosurgical procedures (resective surgery, vagus nerve stimulator [VNS], deep brain stimulator [DBS]). Adults with epilepsy, and with a first neurology outpatient visit (index) between 01/01/2013 and 31/12/2015, were followed using English Hospital Episode Statistics from index date to 31/12/2019. Analyses were stratified by geographic location, learning disability record, and whether the index or follow-up visits were at a TEC. 84,093 people were included, with mean 5.5 years of follow-up. 12.4% of the cohort had learning disability (range 10.1%-17.4% across regions). TEC consultations varied by National Health Service regions and Clinical Commissioning Groups. 37.5% of people (11.2%-75.0% across regions) had their index visit at a TEC; and, of those not initially seen at a TEC, 10.6% (6.5%-17.7%) subsequently attended a tertiary centre. During follow-up, 11.1% people (9.5%-13.2%) visited a neurosurgery department, and 2.3% of those (0.9%-5.0%) then underwent a neurosurgical procedure, mainly VNS implantation. Median time from index date to first visit at a neurosurgery centre was 7 months (range 6-8 months across regions) and 40 months to procedure (36.5-49 months, 37.0 months in people with index visit at a TEC and 49.0 months otherwise). People with learning disability were less likely to have resective surgery (<0.5% versus 1.0% in those without) and more likely to undergo VNS implantation (5.8% versus 0.8%). Although clinically recommended for suitable individuals, neurosurgical procedures in epilepsy remain uncommon even after consultation at a TEC. Geographical variation in access to TECs was present.

Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study

ObjectiveTo describe the COVID-19 pandemic’s impact on acute appendicitis management on children and young people (CYP).DesignRetrospective cohort study.SettingAll English National Health Service hospitals.PatientsAcute appendicitis admissions (all, simple, complex) by CYP...

Gaston Labat, the Mayo Clinic, and the Introduction of Regional Anesthesia to the United States

Abstract Throughout the nineteenth century, transatlantic medical research and training was largely dominated by Western European hospitals. Americans trained in German, Austrian, French, and British medical schools and hospitals, and then returned to work in relatively subpar hospitals and medical schools in the U.S. This relationship was reversed after wwi, with European doctors seeking transition to a comparatively well-funded and respected medical community in the U.S. Recruited in 1920 from a French hospital system to the Mayo Clinic in Rochester, Minnesota, the young surgeon Gaston Labat (1897–1934) became a pioneer in the development of regional anesthesiology and pain management practices in America, establishing the Mayo Clinic as a leader in this nascent field. Published in the U.S. in 1922, Labat’s textbook Regional Anesthesia was based upon his earlier years of work in Paris and came to define the field over the subsequent decades. Labat moved to Bellevue Hospital in New York City, and in 1923 founded the American Society of Regional Anesthesia (asra). The asra acted as an engine of transformation in the professionalization of the field of anesthesia in the U.S. and formed part of the organized response to the opioid crises that emerged in the early twentieth century. Labat’s story serves as a window into this period of transition in global medical leadership and the introduction of regional anesthesiology and acute pain management, based upon European medical practice.

1971 Five years of the National Audit of Inpatient Falls

Abstract Introduction There are around 250,000 inpatient falls in English hospitals each year. Inpatient falls are associated with poor outcomes. Evidence suggests multifactorial assessment and intervention is the most effective way to prevent inpatient falls. There are National Institute of Health and Care Excellence (NICE) quality standards for safe post fall management. National audit supports improvement in the quality and safety of clinical care. Methods The National Audit of Inpatient Falls (NAIF) began collecting continuous data from all femoral fractures (as identified on the National Hip Fracture Database) in England and Wales from 2019. Prospective documentation review collects data on multifactorial falls risk assessment (MFRA) prior to the femoral fracture as well as immediate post fall management and presents performance indicators related to NICE guidelines/quality standards. Results There are around 2000 inpatient femoral fractures each year. Those with an inpatient fracture have double the 30-day mortality of those who fracture elsewhere, highlighting the vulnerability of this group of patients. There has been improvement in most aspects of MFRA and the proportion of patients checked for injury before moving from the floor has increased from 69 to 77%, use of flat lifting equipment from 22 to 29% and medical assessment within 30mins of the fall from 52 to 60%. Conclusion There have been steady improvements in guideline compliant inpatient fall-prevention and post-fall management, but there is more to do. The programme also produces improvement resources and activities and will be expanding the range injuries covered in the next 2 years.

Interactions that support older inpatients with cognitive impairments to engage with falls prevention in hospitals: An ethnographic study.

To explore the nature of interactions that enable older inpatients with cognitive impairments to engage with hospital staff on falls prevention. Ethnographic study. Ethnographic observations on orthopaedic and older person wards in English hospitals (251.25 h) and semi-structured qualitative interviews with 50 staff, 28 patients and three carers. Findings were analysed using a framework approach. Interactions were often informal and personalised. Staff qualities that supported engagement in falls prevention included the ability to empathise and negotiate, taking patient perspectives into account. Although registered nurses had limited time for this, families/carers and other staff, including engagement workers, did so and passed information to nurses. Some older inpatients with cognitive impairments engaged with staff on falls prevention. Engagement enabled them to express their needs and collaborate, to an extent, on falls prevention activities. To support this, we recommend wider adoption in hospitals of engagement workers and developing the relational skills that underpin engagement in training programmes for patient-facing staff. Interactions that support cognitively impaired inpatients to engage in falls prevention can involve not only nurses, but also families/carers and non-nursing staff, with potential to reduce pressures on busy nurses and improve patient safety. The paper adheres to EQUATOR guidelines, Standards for Reporting Qualitative Research. Patient/public contributors were involved in study design, evaluation and data analysis. They co-authored this manuscript.

The effectiveness and efficiency of asymptomatic SARS-CoV-2 testing strategies for patient and healthcare workers within acute NHS hospitals during an omicron-like period

BackgroundAsymptomatic SARS-CoV-2 testing of hospitalised patients began in April-2020, with twice weekly healthcare worker (HCW) testing introduced in November-2020. Guidance recommending asymptomatic testing was withdrawn in August-2022. Assessing the impact of this decision from data alone is challenging due to concurrent changes in infection prevention and control practices, community transmission rates, and a reduction in ascertainment rate from reduced testing. Computational modelling is an effective tool for estimating the impact of this change.MethodsUsing a computational model of SARS-CoV-2 transmission in an English hospital we estimate the effectiveness of several asymptomatic testing strategies, namely; (1) Symptomatic testing of patients and HCWs, (2) testing of all patients on admission with/without repeat testing on days 3 and 5–7, and (3) symptomatic testing plus twice weekly asymptomatic HCW testing with 70% compliance. We estimate the number of patient and HCW infections, HCW absences, number of tests, and tests per case averted or absence avoided, with differing community prevalence rates over a 12-week period.ResultsTesting asymptomatic patients on admission reduces the rate of nosocomial SARS-CoV-2 infection by 8.1–21.5%. Additional testing at days 3 and 5–7 post admission does not significantly reduce infection rates. Twice weekly asymptomatic HCW testing can reduce the proportion of HCWs infected by 1.0-4.4% and monthly absences by 0.4–0.8%. Testing asymptomatic patients repeatedly requires up to 5.5 million patient tests over the period, and twice weekly asymptomatic HCW testing increases the total tests to almost 30 million. The most efficient patient testing strategy (in terms of tests required to prevent a single patient infection) was testing asymptomatic patients on admission across all prevalence levels. The least efficient was repeated testing of patients with twice weekly asymptomatic HCW testing in a low prevalence scenario, and in all other prevalence levels symptomatic patient testing with regular HCW testing was least efficient.ConclusionsTesting patients on admission can reduce the rate of nosocomial SARS-CoV-2 infection but there is little benefit of additional post-admission testing. Asymptomatic HCW testing has little incremental benefit for reducing patient cases at low prevalence but has a potential role at higher prevalence or with low community transmission. A full health-economic evaluation is required to determine the cost-effectiveness of these strategies.

Recognize your audience: Stakeholders' coaptation work to improve political representation in innovation programs

AbstractManagers often exclude some stakeholders from innovation programs, believing they would be “dangerous” for the purpose and pace of new product/service development. The exclusion of “dangerous” stakeholders, however, has negative implications on innovation, as it prevents access to key knowledge and connections. Our study investigates how “dangerous” stakeholders can overturn their exclusion, and gain key decision‐making responsibilities. Theoretically, we import the “general theory of political representation” from Rehfeld (2006) to derive insight into agency of five actors: selection agents, strategic constellation and representatives (on the side of innovators), represented and “audience” (on the side of stakeholders). Empirically, we undertake a 4‐year longitudinal case study of a digital innovation program in an English public hospital. Our study highlighted that only an elite “audience” of clinical leads enacted a strategy of “coaptation work” to overturn their exclusion from the innovation program, and ascend to a role of selection agents. Through “coaptation work,” the clinical leads used their privileged access to clinical resources to first create fractures within the community of innovators, and then embed clinical stakeholders in key decision‐making roles to heal them. Our results challenge established “hub‐and‐spoke” interpretations of innovation programs, and emphasize the importance of political representation work to understand how stakeholders exert their influence.

“That's not a proper ethnography”: a hybrid “propportune” ethnography to study nurses' perceptions of organisational culture in a British hospital

PurposeThis paper revolves around the central question: is it possible to do “proper ethnography” without complete participant observation? The authors draw upon a student's experiences of negotiating National Health Service (NHS) ethical approval requirements and access into the student's research field, a British NHS hospital and having to adapt data collection methods for the student's doctoral research. The authors examine some of the positional (insider/outsider, native gone academic), methodological (long-term/interrupted, overt/covert) and contextual challenges that threatened the student's ethnographic study.Design/methodology/approachThe paper draws on reflexive vignettes written during the student's doctorate, capturing significant moments and issues within the student's research.FindingsThe authors highlight the temporal, practical, ethical and emotional challenges faced in attempting an ethnography of nursing culture within a highly regulated research environment. Having revealed the student's experience of researching this specific culture and finding ways to overcome these challenges, the authors conclude that the contemporary ethnographer needs to be increasingly flexible, opportunistic and somewhat covert.Research limitations/implicationsThe authors argue that it is possible to do “proper” and “good” ethnography without complete participant observation – it is not the method, the observation, that is the essence of ethnography, but whether the researcher achieves real understanding through thick descriptions of the culture that explain “what is really going on here”.Practical implicationsThe authors hope to assist doctoral students engage in “good” ethnographic research within (potentially) risk-averse host organisations, such as the NHS, whilst being located in neo-liberal performative academic organisations (Foster, 2017; McCann et al., 2020). The authors wish to contribute to the journal to ensure good ethnography is accessible and achievable to (particularly) doctoral researchers who have to navigate complex challenges exacerbated by pressures in both the host and home cultures. The authors wish to see doctoral researchers survive and thrive in producing good organisational ethnographies to ensure such research is published (Watson 2012), cognisant of the pressures and targets to publish in top-ranked journals (Jones et al. 2020).Originality/valueHaving identified key challenges, the authors demonstrate how these can be addressed to ensure ethnography remains accessible to and achievable for, doctoral researchers, particularly in healthcare organisations. The authors conclude that understanding can be attained in what they propose as a hybrid form of “propportune” ethnography that blends the aim of the essence of “proper” anthropological approaches with the “opportunism” of contemporary data collection solutions.

Evaluating pooled testing for asymptomatic screening of healthcare workers in hospitals

BackgroundThere is evidence that during the COVID pandemic, a number of patient and HCW infections were nosocomial. Various measures were put in place to try to reduce these infections including developing asymptomatic PCR (polymerase chain reaction) testing schemes for healthcare workers. Regularly testing all healthcare workers requires many tests while reducing this number by only testing some healthcare workers can result in undetected cases. An efficient way to test as many individuals as possible with a limited testing capacity is to consider pooling multiple samples to be analysed with a single test (known as pooled testing).MethodsTwo different pooled testing schemes for the asymptomatic testing are evaluated using an individual-based model representing the transmission of SARS-CoV-2 in a ‘typical’ English hospital. We adapt the modelling to reflect two scenarios: a) a retrospective look at earlier SARS-CoV-2 variants under lockdown or social restrictions, and b) transitioning back to ‘normal life’ without lockdown and with the omicron variant. The two pooled testing schemes analysed differ in the population that is eligible for testing. In the ‘ward’ testing scheme only healthcare workers who work on a single ward are eligible and in the ‘full’ testing scheme all healthcare workers are eligible including those that move across wards. Both pooled schemes are compared against the baseline scheme which tests only symptomatic healthcare workers.ResultsIncluding a pooled asymptomatic testing scheme is found to have a modest (albeit statistically significant) effect, reducing the total number of nosocomial healthcare worker infections by about 2%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\%$$\\end{document} in both the lockdown and non-lockdown setting. However, this reduction must be balanced with the increase in cost and healthcare worker isolations. Both ward and full testing reduce HCW infections similarly but the cost for ward testing is much less. We also consider the use of lateral flow devices (LFDs) for follow-up testing. Considering LFDs reduces cost and time but LFDs have a different error profile to PCR tests.ConclusionsWhether a PCR-only or PCR and LFD ward testing scheme is chosen depends on the metrics of most interest to policy makers, the virus prevalence and whether there is a lockdown.

The Dutiful Daughters of the British Empire: Psychosocial Topology of The British Hospital in Smyrna

Scholarship on the accounts of the Western travellers about the Ottoman Empire focuses on some commonly known writers only, and Ismeer, or Smyrna, and its British hospital in 1855, by a lady [M. Nicol] remains neglected. It is a diary written by a lady-nurse, Martha Nicol, who worked in the British hospital in Smyrna, during the Crimean War. She is tightly bound in with the imperial ideology and by reconceptualising the space in the hospital, the lady-nurses help the British soldiers achieve a sense of continuity between their home back in England and the host culture about which they know very little. By playing a formative role to transpose this hospital to a homely space in a foreign territory, the lady-nurses function as psychic and cultural stabilisers. This essay aims to decipher how the hospital space functions as an ideological heterotopia of deviance, and how the lady-nurses contribute to its power to inspire the idea of “at-homeness” in the soldiers and retain the ideological structuring mechanisms in this distant location by exploring the textual evidence in the book. This essay will also explore how power and ideology are contextualised in the psychosocial topology of the hospital.

COVID-19, deaths at home and end-of-life cancer care

During the COVID-19 pandemic there was a period of high excess deaths from cancer at home as opposed to in hospitals or in care homes. In this paper we aim to explore whether healthcare utilisation trajectories of cancer patients in the final months of life during the COVID-19 pandemic reveal any potential unmet healthcare need. We use English hospital records linked to data on all deaths in and out of hospital which identifies the cause and location of death.Our analysis shows that during the periods of peak COVID-19 caseload, patients dying of cancer experienced up to 42% less hospital treatment in their final month of life compared to historical controls. We find reductions in end-of-life hospital care for cancer patients dying in hospitals, care homes/hospices and at home, however the effect is amplified by the shift to more patients dying at home. Through the first year of the pandemic in England, we estimate the number of inpatient bed-days for end-of-life cancer patients in their final month reduced by approximately 282,282, or 25%.For outpatient appointments in the final month of life we find a reduction in face-to-face appointments and an increase in remote appointments which persists through the pandemic year and is not confined only to the periods of peak COVID-19 caseload.Our results suggest reductions in care provision during the COVID-19 pandemic may have led to unmet need, and future emergency reorganisations of health care systems must ensure consistent care provision for vulnerable groups such as cancer patients.

Types, predictors, and consequences of medicines related problems (MRPs) in frail older adults admitted to hospital from primary care - A retrospective cohort study

IntroductionMedicines related problems (MRPs) can be common in frail older people due to age-compromised body systems and a propensity to be on multiple drugs concurrently. This group of people can also succumb to a rapid deterioration in health. Thus, it is important to investigate MRPs in frail older people. The objectives of the study were to evaluate prevalence of MRPs, types of MRPs, risk factors and deterioration that can be associated with MRPs in frail older people admitted to an English teaching hospital from primary care. MethodsIncluded in the sample were frail older adults, aged 65 years and over, admitted from primary care. Data was retrieved from the hospital's electronic patient record system, anonymised, and reviewed for MRPs. MRPs which were retrospectively identified at admission were coded with the WHO-ICD10,2016 (World Health Organisation-International Classification of Diseases version 10, 2016). Descriptive and inferential statistics were performed on the data using SPSS Version 25. Primary outcome was the prevalence of MRPs in frail older patients. Secondary outcome was the association of deterioration indicated as fall, delirium, or NEWs ≥3 with presence of MRPs. ResultsAmong the 507 frail older people (≥4 on Rockwood scale) that met criteria for inclusion, 262 (51.8%) were patients with MRPs and 244 (48.2%) without. The Median age of sample as a whole was 85 years (IQR = 80–89). Prevalence of MRPs was 33.28%. Types of MRPs were adverse drug reaction (ADR-20%), non-compliance (9.1%), unintentional poisoning (3.3%) and inappropriate polypharmacy (0.8%). In logistic regression, potentially inappropriate medicines (PIM), social support, number of comorbidities and winter were significant predictors of MRPs. Risk of deteriorating with delirium was two times higher in patients with MRPs than in patients without MRPs, RR 2.613 (95% CI, 1.049 to 6.510). ConclusionMRPs and risks of deterioration associated with MRPs in frail older people can be reduced. This is because factors associated with MRPs can be modified.

Model-based evaluation of admission screening strategies for the detection and control of carbapenemase-producing Enterobacterales in the English hospital setting

BackgroundGlobally, detections of carbapenemase-producing Enterobacterales (CPE) colonisations and infections are increasing. The spread of these highly resistant bacteria poses a serious threat to public health. However, understanding of CPE transmission and evidence on effectiveness of control measures is severely lacking. This paper provides evidence to inform effective admission screening protocols, which could be important in controlling nosocomial CPE transmission.MethodsCPE transmission within an English hospital setting was simulated with a data-driven individual-based mathematical model. This model was used to evaluate the ability of the 2016 England CPE screening recommendations, and of potential alternative protocols, to identify patients with CPE-colonisation on admission (including those colonised during previous stays or from elsewhere). The model included nosocomial transmission from colonised and infected patients, as well as environmental contamination. Model parameters were estimated using primary data where possible, including estimation of transmission using detailed epidemiological data within a Bayesian framework. Separate models were parameterised to represent hospitals in English areas with low and high CPE risk (based on prevalence).ResultsThe proportion of truly colonised admissions which met the 2016 screening criteria was 43% in low-prevalence and 54% in high-prevalence areas respectively. Selection of CPE carriers for screening was improved in low-prevalence areas by adding readmission as a screening criterion, which doubled how many colonised admissions were selected. A minority of CPE carriers were confirmed as CPE positive during their hospital stay (10 and 14% in low- and high-prevalence areas); switching to a faster screening test pathway with a single-swab test (rather than three swab regimen) increased the overall positive predictive value with negligible reduction in negative predictive value.ConclusionsUsing a novel within-hospital CPE transmission model, this study assesses CPE admission screening protocols, across the range of CPE prevalence observed in England. It identifies protocol changes—adding readmissions to screening criteria and a single-swab test pathway—which could detect similar numbers of CPE carriers (or twice as many in low CPE prevalence areas), but faster, and hence with lower demand on pre-emptive infection-control resources. Study findings can inform interventions to control this emerging threat, although further work is required to understand within-hospital transmission sources.

Effect of ondansetron in maternal hypotension during cesarean delivery: an observational study

Background: Spinal anesthesia is the most common anesthetic technique for cesarean delivery. Thus, hypotension is associated with a reduction in uteroplacental flow which may induce fetal morbidity. Activation of the Bezold Jarisch reflex (mediated by 5HT3 receptors) can worsen hypotension and decrease cardiac output. We studied the effect of ondansetron administration before spinal anesthesia on the trajectory of blood pressure during cesarean delivery. Methods: We conducted a retrospective chart review of all cesarean deliveries that occurred between April 1st 2020 and April 1st 2021 and included 85 pregnant women (43 with ondansetron and 42 in the control group). Data were obtained from the electronic medical record database of the British Hospital of Buenos Aires. Socio- demographic, obstetric, anesthetic and perioperative characteristics of patients were assessed. Results: There were no significant differences in the trajectories of the change from baseline of mean arterial blood pressure between ondansetron and control group (0.14% (95% CI: 0.06 to 0.21) per minute). This also applied to heart rate (-0.10% per minute (95% CI: -0.19 to 0.01). The need of any infusion (phenylephrine or atropine) comparing ondansetron to the reference group was 1.12 (95% CI: 0.68, 1.85). There were eight events of shivering (16.3%) in the ondansetron exposed group and four events of shivering (8.5%) in the reference group. APGAR values showed no clinical difference between groups. Conclusions: In this single-center cohort study, we did not observe an effect of routine administration of ondansetron before spinal anesthesia in cesarean section on improving arterial blood pressure or heart rate throughout the procedure.

Ordering medication for hospital inpatients in England: pharmacy staff decision on the type and duration of supply

Abstract Introduction In the last few decades, hospital pharmacies have introduced new medication supply systems to increase safety and cost-efficiency1. Hospitals currently use a mixture of inpatient supply types, including ward stock, “one-stop” dispensing (OSD) and non-OSD patient labelled dispensing. A mixed supply model has become the dominant system in the UK1 despite some criticism2 and has been introduced in other countries3. There is no current guidance for deciding the type and duration of inpatient supply, and little known about how pharmacy staff make this decision. Aim To explore how pharmacy staff decide on type and duration of medication supply for hospital inpatients in an English teaching hospital organisation. Methods A list of 19 factors was developed through discussions with pharmacy staff. These were arranged into four categories: medication, patient, treatment, and miscellaneous. An online survey was designed using Qualtrics. This explored staff perceptions of the importance of each factor when making decisions, separately for type and duration of supply, using a 5 point Likert scale ranging from 1 (”not at all”) to 5 (“a great deal”). A free-text box was available to add any additional factors. All pharmacy staff responsible for ordering patient-specific medication were invited to take part. Demographics were collected, participation was voluntary and all response data anonymous. Responses were subjected to descriptive statistical analysis using Microsoft Excel. A pre-selected subset of factors were compared using Mann-Whitney U tests. The study was approved as a service evaluation in the organisation concerned; therefore ethical approval was not necessary. Results There were 47 pharmacist and 10 medicines management pharmacy technician (MMPT) responses (response rate 32% for each group). For decisions both about supply type and duration, 14 factors were considered important (median score 4 or 5) with “patient on dosette box” and “duration of treatment” rated 5. Others with a median of 4 included “high risk patient”, “medication route/formulation”, “day of the week” and “drug history completed”. Only one factor, “nurse skill set on ward”, was considered unimportant (median score 2). The remainder were considered moderately important (median score 3). Statistical analysis suggested that some factors were significantly more important in certain groups. The factor “medication screened by a pharmacist” appeared less important to pharmacists versus MMPTs (p=0.0002) and less important to staff employed at the trust for longer than 10 years versus those employed less than this (p=0.0011). Discussion/Conclusion Results of this study provide valuable insight into the factors pharmacy staff consider when deciding on the type and duration of inpatient medication supply. To our knowledge, no previous studies have explored the factors influencing this kind of decision-making. Limitations include a small sample size, and that we focussed on which factors were more or less important rather than how they were used to guide decisions. We conducted some sub-group analysis, but the project was not powered to demonstrate statistical significance. This could now be addressed with the results of this survey enabling a power calculation. Further work using semi-structured interviews is currently underway to further explore how the factors influence decision making.