British Teaching Hospital Research Articles

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.

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.

Identification of antibiotic consumption targets for the management of Clostridioides difficile infection in hospitals- a threshold logistic modelling approach

ABSTRACT Background This study aims to demonstrate the utility of a threshold logistic approach to identifying thresholds for specific antibiotic use associated with Clostridioides difficile infection (CDI) in an English teaching hospital. Methods A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-onset, healthcare-associated (HOHA) CDI cases. Results Using a threshold logistic regression approach, an incidence greater than 0.2645 cases/1000 occupied bed-days (OBD; 85th percentile) was determined as the cutoff rate to define a critical (high) incidence rate of HOHA CDI. Fluoroquinolones and piperacillin-tazobactam were found to have thresholds at 84.8 and 54 defined daily doses (DDD)/1000 OBD, respectively. Analysis of data allowed calculating risk scores for HOHA CDI incidence rates exceeding the 85th percentile, i.e. entering critical incidence level. The threshold-logistic model also facilitated performing ‘what-if scenarios’ on future values of fluoroquinolones and piperacillin-tazobactam use to understand how HOHA CDI incidence rates may be affected. Conclusion Using threshold logistic analysis, critical incidence levels and antibiotic use targets to control HOHA CDI were determined. Threshold logistic models can be used to inform and enhance the effective design and implementation of antimicrobial stewardship programs.

P25 An opportunity for antimicrobial stewardship? Assessing the diagnosis and treatment of lower urinary tract infections among inpatients aged 65 and older in a large English teaching hospital

BackgroundBetween 2015 and 2019 the rate of bacteraemias reported in the UK increased by 16.9% along with an increase of 32.5% of resistant organisms associated with bloodstream infections. This increase appears to be driven by a high number of Gram-negative bloodstream infections (GNBSI). There were 312 GNBSI within Leeds Teaching Hospital NHS Trust (LTHT) for the financial year (FY) of 2019–20 and 275 in FY 2020–21. Escherichia coli has been identified as the most common Gram-negative organism associated with bacteraemias. Urinary tract infections (UTIs) have been consistently highlighted as a primary source of E. coli infections, alongside other Gram-negative infections, therefore justifying a review of practice within LTHT regarding diagnosis and treatment of UTI in patients over the age of 65. This quality improvement work aimed to build on the foundations laid by NHS England's Commissioning for Quality and Innovations (CQUIN) scheme 2019–20, which had a focus on the treatment of UTIs in patients over the age of 65. This interventional prospective project was carried out to assess the impact of an antimicrobial stewardship (AMS) pharmacist-led review of patients prescribed antimicrobial treatment for UTIS.ObjectivesTo assess the impact of a pharmacist led clinical review of the diagnosis and treatment of UTIs in patients over the age of 65.StandardsEighty percent compliance was expected in the following standards: (i) patients having symptoms of a UTI documented in their clinical notes; (ii) a urine dipstick is not used as part pf the diagnosis pathway; (iii) have a had a midstream urine sample sent; and (iv) if appropriate, an antibiotic prescribed that complies with NICE/Trust guidelines.MethodsA prospective study of 87 inpatients prescribed antimicrobials for lower UTI (LUTI) was conducted from September 2020 to November 2020. The study aimed to evaluate if LUTI was diagnosed in accordance with PHE guidance, treated as per Trust guidelines and the impact an AMS pharmacist interventions had on treatment. Patients were identified using a daily antimicrobial list; searching and filtering based on indication for antimicrobial prescribed. Online medical notes were reviewed for information relating to the standards, where no information could be found wards were contacted with recommendations or further questions. If a patient was identified as requiring an intervention, for example a change of treatment, this was communicated with the ward team by an appropriate route as well as documenting in the medical notes. Inclusion criteria: >65 years old, prescribed an antibiotic for the treatment of LUTI or catheter associated UTI. Exclusion criteria: <65 years old, complicated UTI, upper UTI, urosepsis.ResultsEighty-seven patients were audited against the criteria: documentation of UTI symptoms = 74%; urine dipstick was not used to diagnose UTI = 69%; urine sample requested = 82%; appropriate antimicrobial was prescribed = 76% (Figures 1 and 2). As a treatment pathway 32% (28 patients) met all four criteria required to accomplish compliance to the diagnosis and treatment of LUTI. Of the 24% of antimicrobial prescriptions deemed inappropriate common themes included: not prescribing appropriate first line antibiotic; no clear indication for antibiotics; resistant to antibiotic prescribed; and inappropriate IV antibiotic prescribing (Figure 3). After an AMS pharmacist contacted the clinical teams to discuss the 24% of inappropriate antimicrobials it resulted in 92% of the antimicrobials being amended to appropriate antimicrobial choices. Increasing appropriate antimicrobials prescribed from 76% to 99%.Figure 1.Graph showing the percentage of datasets meeting the standard.Figure 2.Pie chart showing the percentage of inappropriate versus appropriate antimicrobial prescriptions.Figure 3.Bar chart showing the number of inappropriate antimicrobials and the reasons associated with them being inappropriate.ConclusionsThe results show that whilst most patients met some of the criteria expected to diagnose a LUTI, most did not meet all four. This warrants further quality improvement work to improve the recognition and adherence of the diagnosis and treatment of LUTIs with the aim to embed the processes across all age groups. The interventions of an AMS pharmacist positively impacted the prescribing of antimicrobials in LUTI and appears to be significant, particularly with regards to stopping inappropriate antimicrobials and recommending better treatment choices. These decisions included: promoting oral antibiotics instead of IV; recommending effective treatment based on renal impairment; acting on urine culture sensitivities; and choosing more narrow spectrum antibiotics. This provides a new potential tool for targeted AMS in relation to the treatment of LUTI within a large scale teaching hospital.

Cost comparison study of reusable and disposable rhinolaryngoscopes in a large English teaching hospital.

This study aimed to compare the cost per use of video-rhinolaryngoscopy using reusable and disposable devices in a tertiary referral centre. A cost-comparison study was performed that utilised retrospective cost data and prospective utilisation data to compare the total costs of using reusable video-rhinolaryngoscopes versus a single-use alternative. It was estimated that 4776 and 1821 procedures were performed annually with reusable and disposable video-rhinolaryngoscopes, respectively. The cost per use was £66.61 for reusable devices versus £150.00 for disposable devices. The break-even point (i.e. when cost per use was equal, occurred at 1374 procedures per year). Thereafter, it was cheaper to use reusable devices. Disposable rhinolaryngoscopes may present a cheaper solution to services with low rates of rhinolaryngoscope utilisation. However, for larger services considering replacement of their reusable rhinolaryngoscopes with disposable units, it is likely that the recurring costs will be prohibitive in the medium to long term.

Combining research and design: A mixed methods approach aimed at understanding and optimising inpatient medication storage systems.

BackgroundAlmost every patient admitted to hospital will receive medication during their stay. Medication errors are an important cause of patient morbidity and mortality, as well as an economic burden for healthcare institutions. Research suggests that current methods of storing medication on hospital wards are not fit for purpose, contributing to inefficiency and error.AimTo improve medication storage in inpatient areas, by exploring variation and challenges related to medication storage and designing a prototype solution.MethodsSet in four hospitals in an English teaching hospital trust, the study used a mixed methods approach comprising a quantitative descriptive survey of storage facilities and practices followed by mixed methods observations of medication rounds and interviews with patients, nurses and pharmacy staff. Quantitative data were presented descriptively and qualitative data analysed thematically and using a human-centered design approach.ResultsWe identified wide variation in medication storage facilities and practices across 77 wards. Observations and staff interviews in six wards revealed five problem areas: poor management of multiple storage facilities; lack of visibility and organisation of medication within trolleys; inadequate size of storage; lack of ownership and knowledge of standard practice; and use of key locks. Patients were largely satisfied with receiving their medication. Systematic and consistent physical organisation of medication in medication trolleys, and integrating and implementing principles of best practice, were identified as areas for intervention.Discussion and conclusionVariation in medication storage facilities and practices existed both across the organization and on individual wards. Multiple challenges were identified in how medication was stored, which if addressed may improve the efficiency and safety of medication administration and in turn, staff and patient experience. The use of design principles alongside a research approach resulted in a rapid, iterative process for developing and refining potential solutions to improve inpatient medication storage.

Persistent post-covid symptoms in healthcare workers.

BackgroundRecent reports suggest a higher incidence of COVID-19 infections among healthcare workers (HCW). However, information about the long-term complications affecting this population is lacking.AimsInvestigation of long-term impact of COVID-19 in HCW.MethodsSeropositivity for SARS-CoV-2 antibodies was evaluated for the majority of HCW in an English teaching hospital 2 months following the peak of COVID-19 first wave. A questionnaire investigating the long-term complications was sent through global e-mail to HCW 4 months following the peak of the wave enquiring about the persistent health issues still affecting them at that point.ResultsOut of 3759 subjects tested for SARS-CoV-2 antibodies, 932 were positive (24%). Forty-five per cent of 138 HCW responding to the questionnaire reported persistent symptoms with 32% struggling to cope 3–4 months following the peak of the wave. Moderate-to-severe fatigue stood out as the most disabling symptom (39%) but mild-to-moderate shortness of breath, anxiety and sleep disturbance were almost universal in the subjects still struggling with symptoms. Only 16% consulted their general practitioner (GP) about their symptoms with only 2% taking sick leave after recovering from the acute illness.ConclusionsOur data suggest that about a third of HCW who responded to the survey were still struggling to cope with the symptoms of what is now known as long covid several months after the acute COVID-19 infections. The overwhelming majority of this group seem to be reluctant to neither seek medical advice nor take sick leave.

Disruption and Rapid Recovery of Emergency Ophthalmic Services Amidst the COVID Pandemic: An English Teaching Hospital Experience

Disruption and Rapid Recovery of Emergency Ophthalmic Services Amidst the COVID Pandemic: An English Teaching Hospital Experience

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis

IntroductionMedication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.ObjectivesTo describe...

Influenza-associated mortality in hospital care: a retrospective cohort study of risk factors and impact of oseltamivir in an English teaching hospital, 2016 to 2017.

BackgroundEvidence of an oseltamivir treatment effect on influenza A(H3N2) virus infections in hospitalised patients is incomplete.AimsThis cohort study aimed to evaluate risk factors for death among PCR-confirmed hospitalised cases of seasonal influenza A(H3N2) of all ages and the impact of oseltamivir.MethodsParticipants included all 332 PCR-confirmed influenza A(H3N2) cases diagnosed between 30 August 2016 and 17 March 2017 in an English university teaching Hospital. Oseltamivir treatment effect on odds of inpatient death was assessed by backward stepwise multivariable logistic regression analysis.ResultsThe odds of death were reduced by two thirds (odds ratio (OR): 0.32; 95% confidence interval (CI): 0.11–0.93), in inpatients treated with a standard course of oseltamivir 75 mg two times daily for 5 days – compared with those untreated with oseltamivir, after adjustment for age, sex, current excess alcohol intake, receipt of 2016/17 seasonal influenza vaccine, serum haemoglobin and hospital vs community attribution of acquisition of influenza.ConclusionsOseltamivir treatment given according to National Institutes of Clinical Excellence (NICE); United States Centres for Disease Control and Prevention (CDC); Infectious Diseases Society of America (IDSA) and World Health Organization (WHO) guidelines was shown to be effective in reducing the odds of mortality in inpatients with PCR-confirmed seasonal influenza A(H3N2) after adjustment in a busy routine English hospital setting. Our results highlight the importance of hospitals complying with relevant guidelines for prompt seasonal influenza PCR testing and ensuring standard oseltamivir treatment to all PCR-confirmed cases of seasonal influenza.

What is the impact of introducing inpatient electronic prescribing on prescribing errors? A naturalistic stepped wedge study in an English teaching hospital.

Most studies evaluating the impact of electronic prescribing on prescribing safety have used comparatively weak study designs such as uncontrolled before-and-after studies. This study aimed to apply a more robust naturalistic stepped wedge study design to compare the prevalence and types of prescribing errors for electronic prescribing and paper prescribing. Data were collected weekly during a phased electronic prescribing implementation across 20 wards in a large English hospital. We identified 511 (7.8%) erroneous orders in 6523 paper medication orders, and 312 (6.0%) in 5237 electronic prescribing orders. Logistic regression suggested no statistically significant effect of electronic prescribing use or of study week; patient and ward had significant effects. Errors involving incorrect doses and illegible or incomplete orders were less common with electronic prescribing; those involving duplication, omission, incorrect drug and incorrect formulation were more common. Actions are needed to mitigate these error types; future studies should give more consideration to the effects of patient and ward.

Is there a place for the Mayo Model of Integrated Clinical Care in the English NHS?

Introduction: The English NHS is implementing integrated care models across primary, community and secondary care, and between health and social care systems. These may achieve improvements to quality, safety and cost, but they do not directly address the frequently fragmented and episodic care of patients within hospital settings, particularly those patients with complex co-morbidities. There are examples, however, of hospital-based integrated clinical care models which could address this deficit. Mayo Clinic USA, for example, offers highly integrated, multi-specialty clinical care. We report on two phases of a research project which aims to determine if adoption of something akin to the Mayo Model would be feasible in English NHS hospitals, to the benefit of patients and staff. Methods: Phase 1 used a rapid review to assess recent literature concerning the Mayo Model and links between this and the organisation’s performance and patient outcomes. Phase 2 consisted of semi-structured interviews N=13 conducted with a range of senior clinical and non-clinical staff in a large English NHS teaching hospital. The question schedule addressed general understanding of integrated clinical care, and sought views on barriers and enablers to implementing a Mayo-type integrated care model in English NHS hospitals. Results: Literature concerning the distinctive features of the Mayo Model is limited in scope and largely confined to ‘grey’ sources. We found only two peer-reviewed articles which offer critical analysis of the contribution of the Mayo Model to the performance of the organisation. Analysis of interview data suggests that 1 many NHS hospital physicians and managers are frustrated by the fragmented service offered to multi-morbid patients; 2 the same group sees significant potential in a more holistic, multi-specialty coordinated care model, and understand how in-hospital care could change to meet this vision. Discussion: Despite the paucity of peer-reviewed literature concerning links between the distinctive Mayo Model and performance indicators such as patient outcomes, cost containment and staff and patient satisfaction, there are indications that this model may offer something which is currently absent from in-hospital care in the English NHS. Our interview data shows that clinical and non-clinical hospital staff strongly believe that there is a place for better coordinated, multi-specialty care, particularly in the case of patients who are disadvantaged by repeated journeys between primary and secondary care. Conclusions: Given the urgent need to improve care for non-emergency patients who attend hospitals in the English NHS, we consider it worthwhile to explore the possibility of trialling a Mayo Clinic-style care model in the environment of English NHS hospitals. There are barriers to implementing this approach to in-hospital care, but with appropriate resourcing and support they are not insurmountable. Limitations: The interview data covered a broad range of professional roles, but was confined to one NHS hospital. Future research: We suggest that piloting a Mayo-type care model in one or more English NHS hospitals could be accompanied by a rigorous evaluation of the effects on patient outcomes, the patient experience and staff satisfaction.

Ten thousand steps: a pedometer study of junior dentists in a major British teaching hospital and a district general hospital

Sedentary behaviour is widely associated with deleterious health outcomes that in modern medicine have similar connotations to smoking tobacco and alcohol misuse. The integration of e-portfolio, e-logbook, British National Formulary (BNF) and encrypted emails has made smartphones a necessity for trainees. Smartphones also have the ability to record the amount of exercise taken, which allows activity at work to be monitored. The aim of this study to compare the activity of the same group of dental core trainees when they worked within a large multisite teaching hospital and a smaller district general hospital, to find out if supplementary activity was needed outside work. Data were collected from smartphones. To ensure continuity, data were collected only from those who had calibrated iPhones (n=10). At the teaching hospital six of the trainees walked over 10 000 steps a day while working (mean (SD) 10 004 (639)). At the district hospital none of the trainees walked 10 000 steps. The mean (SD) number of steps completed by all trainees was 6265 (119). Walking at work provides the full quota of recommended daily exercise most of the time for those working in the teaching hospital, but additional exercise is occasionally required. While working at the district hospital they walk less, meaning that they should try to increase their activity outside work. Trainees working in the teaching hospital walk significantly more steps than in the district hospital.

Examining the sources of occupational stress in an emergency department.

Previous work has established that health care staff, in particular emergency department (ED) personnel, experience significant occupational stress but the underlying stressors have not been well quantified. Such data inform interventions that can reduce cases of occupational mental illness, burnout, staff turnover and early retirement associated with cumulative stress. To develop, implement and evaluate a questionnaire examining the origins of occupational stress in the ED. A questionnaire co-designed by an occupational health practitioner and ED management administered to nursing, medical and support staff in the ED of a large English teaching hospital in 2015. The questionnaire assessed participants' demographic characteristics and perceptions of stress across three dimensions (demand-control-support, effort-reward and organizational justice). Work-related stressors in ED staff were compared with those of an unmatched control group from the acute ear, nose and throat (ENT) and neurology directorate. A total of 104 (59%) ED staff returned questionnaires compared to 72 staff (67%) from the acute ENT/neurology directorate. The ED respondents indicated lower levels of job autonomy, management support and involvement in organizational change, but not work demand. High levels of effort-reward imbalance and organizational injustice were reported by both groups. Our findings suggest that internal ED interventions to improve workers' job control, increase support from management and involvement in organizational change may reduce work stress. The high levels of effort-reward imbalance and organizational injustice reported by both groups may indicate that wider interventions beyond the ED are also needed to address these issues.

Excess Mortality Attributable to Clostridium difficile and Risk Factors for Infection in an Historic Cohort of Hospitalised Patients Followed Up in the United Kingdom Death Register.

MethodsWe compared time from hospital admission to death in a probability sample of 100 Clostridium difficile infected cases and a probability sample of 98 non-cases admitted to an English teaching hospital between 2005 and 2007 with follow up in the UK national death register using survival analysis.ResultsClostridium difficile infection was associated with a 50% increased risk of death (Hazard Ratio 1.51 (95% CI: 1.05–2.19 p = 0.03) at between five to eight years in Cox Regression analysis adjusting for age, sex, Charlson comorbidity index, diagnosis of a malignant condition and insertion of a nasogastric tube during admission. Acquisition of Clostridium difficile infection was independently associated with an almost six fold higher odds of being admitted with a diagnosis of infection of any other type (OR 5.79 (2.19, 15.25) p<0.001).ConclusionsOur results strongly support continued priority being given to improve prevention and treatment of Clostridium difficile infection in the English National Health Service particularly in patients admitted with an infection. Our results may be applicable to other health systems.

Excess length of stay and mortality due to Clostridium difficile infection: a multi-state modelling approach

The burden of healthcare-associated infections, such as healthcare-acquired Clostridium difficile (HA-CDI), can be expressed in terms of additional length of stay (LOS) and mortality. However, previous estimates have varied widely. Although some have considered time of infection onset (time-dependent bias), none considered the impact of severity of HA-CDI; this was the primary aim of this study. The daily risk of in-hospital death or discharge was modelled using a Cox proportional hazards model, fitted to data on patients discharged in 2012 from a large English teaching hospital. We treated HA-CDI status as a time-dependent variable and adjusted for confounders. In addition, a multi-state model was developed to provide a clinically intuitive metric of delayed discharge associated with non-severe and severe HA-CDI respectively. Data comprised 157 (including 48 severe) HA-CDI cases among 42,618 patients. HA-CDI reduced the daily discharge rate by nearly one-quarter [hazard ratio (HR): 0.72; 95% confidence interval (CI): 0.61-0.84] and increased the in-hospital death rate by 75% compared with non-HA-CDI patients (HR: 1.75; 95% CI: 1.16-2.62). Whereas overall HA-CDI resulted in a mean excess LOS of about seven days (95% CI: 3.5-10.9), severe cases had an average excess LOS which was twice (∼11.6 days; 95% CI: 3.6-19.6) that of the non-severe cases (about five days; 95% CI: 1.1-9.5). HA-CDI contributes to patients' expected LOS and risk of mortality. However, when quantifying the health and economic burden of hospital-onset of HA-CDI, the heterogeneity in the impact of HA-CDI should be accounted for.

Preparation to care for confused older patients in general hospitals: a study of UK health professionals

Background and Objective: in the UK, two-thirds of patients in general hospitals are older than 70, of whom half have dementia or delirium or both. Our objective was to explore doctors, nurses and allied health professionals' perceptions of their preparation to care for confused older patients on general hospital wards.Methods: using a quota sampling strategy across 11 medical, geriatric and orthopaedic wards in a British teaching hospital, we conducted 60 semi-structured interviews with doctors, nurses and allied healthcare professionals and analysed the data using the Consensual Qualitative Research approach.Results: there was consensus among participants that education, induction and in-service training left them inadequately prepared and under-confident to care for confused older patients. Many doctors reported initial assessments of confused older patients as difficult. They admitted inadequate knowledge of mental health disorders, including the diagnostic features of delirium and dementia. Handling agitation and aggression were considered top priorities for training, particularly for nurses. Multidisciplinary team meetings were highly valued but were reported as too infrequent. Participants valued specialist input but reported difficulties gaining such support. Communication with confused patients was regarded as particularly challenging, both in terms of patients making their needs known, and staff conveying information to patients. Participants reported emotional and behavioural responses including frustration, stress, empathy, avoidance and low job satisfaction.Conclusion: our findings indicate that a revision of training across healthcare professions in the UK is required, and that increased specialist support should be provided, so that the workforce is properly prepared to care for older patients with cognitive problems.

An audit of mental capacity assessment on general medical wards

The Mental Capacity Act (2005) was designed to protect and empower patients with impaired capacity. Despite an estimated 40% of medical inpatients lacking capacity, it is unclear how many patients undergo capacity assessments and treatment under the Act. We audited the number of capacity assessments on the general medical wards of an English-teaching hospital. A total of 95 sets of case notes were reviewed: the mean age was 78.6 years, 57 were female. The most common presenting complaints were feeling ‘unwell’ ( n = 25) and confusion ( n = 24). In all, 52 patients had conditions, such as delirium ( n = 26) and dementia ( n = 15), which often impair capacity. Capacity was assessed in seven (7.4%) patients, all of whom disagreed with the medical team about their treatment. The number of documented assessments fell short of the estimated rate of incapacity, suggesting that some means of improving capacity assessment in busy medical environments is required.

When did the doctors become fomites?

The word ‘fomites’ was introduced early in the 19th century from the Latin fomes, to indicate objects or materials that are likely to carry infection, such as clothes, utensils and furniture. Indeed, the role of the environment as a likely significant contributor to hospital-acquired infections (HAI) was proposed even earlier [1]. In 1873, Louis Pasteur in his lecture to the Academie de Medecine noted that, even after cleaning his hands and using heated sponges, he still had to fear germs surrounding patients’ beds [2]. Today, headlines such as ‘Hospitals criticized over hygiene’ (BBC News, 20th December 2010) are common in the news and instigate a negative general public perception that fomites such as uniforms or stethoscopes represent an infection risk for hospitalized patients. Political interest has obviously been raised. An interesting example is the ‘bare below the elbows’ dress code for physicians that was promised to be introduced by the then Secretary of State for Health, Alan Johnson, in 2007, in all acute trusts in England, despite lack of conclusive evidence that white coats pose a significant threat for the spread of HAI [3]. Clear evidence does exist that pathogenic bacteria can survive for months in the hospital environment and can be isolated on clinical equipment, as well as on general surfaces, especially those close to the patient’s area, such as curtains, beds, lockers and over-bed tables [4,5]. Before contact precautions are implemented, methicillin-resistant Staphylococcus aureus (MRSA) carriers may have already contaminated their environment with MRSA. A recent observational study showed that 18% and 35% of MRSA-colonized patients had contaminated the surrounding environmental surfaces 25 h and 33 h after admission, respectively [6]. Cross-transmission between patients may occur via the hands of healthcare workers after they have touched contaminated environmental surfaces [5,7]. There is also some evidence that cleaning removes pathogenic bacteria from the hospital environment with benefit for the patients, especially in epidemic settings. Rampling et al. [8] documented an outbreak of MRSA in a urology ward, which was resistant to the promotion of hand hygiene and contact isolation; it ended only after doubling the number of ward-cleaning hours. However, conclusive proof of the link between environmental contamination and rate of HAI is still lacking. Wilson et al. [9] sampled six environmental sites around randomly selected patients in intensive care units plus two communal sites during periods when MRSA-colonized patients were isolated or not. Study results showed that, although MRSA-colonized patients frequently contaminated their environment, transmission of MRSA from the environment to the patient was not commonly identified [9]. The risk that personnel equipment (white coat, stethoscope, mobile phones, or pagers) used at point of care might be responsible or co-responsible for cross-transmission of pathogenic bacteria to patients was signalled early in the 1970s for the use of stethoscopes [1]. In 1972, Gerken et al. [1] demonstrated that coagulase-positive staphylococci were isolated from 21% of the stethoscopes in a British teaching hospital. The Centers for Disease Control and Prevention advises stethoscope cleanings between patient examinations and the use of dedicated room equipment for patients carrying a communicable disease and in isolation [10]. However, compliance with those procedures is still very low. Whittington et al. [11] showed that while all the intensive care unit nursing staff reported cleaning stethoscopes at least daily, only one-third of medical staff, cleaned their stethoscope at best every month. To further increase the complexity of the problem recent advances in engineering have brought into hospitals a series of new technologies (smartphones, personal digital assistants, mobile phones) usually worn by the doctors, even when attending patients [12]. Interestingly, a market research study found that 65% of physicians in the USA believe that mobile computing devices pose significant risks for the spreading of pathogenic bacteria in hospitalized patients [13]. A systematic review on bacterial contamination of physicians’ mobile phones showed that 9–25% of mobile devices are contaminated with pathogenic bacteria. Levels of MRSA (0–10%), Acinetobacter species (1–12%) and other pathogens range widely according to the local ecology [14]. Ulger et al. sampled 200 mobile phones and the hands of 200 healthcare workers. In total, 94.5% of phones demonstrated evidence of bacterial contamination with different types of bacteria. MRSA was isolated in 13% of mobile phones and 10% of healthcare workers’ hands. Distributions of the

Audit of Orthopaedic Audits in an English Teaching Hospital: Are We Closing the Loop?

Background:Clinical audit is an important tool to improve patient care and outcomes in health service. A significant proportion of time and economic resources are spent on activities related to clinical audit. Completion of audit cycle is essential to confirm the improvements in healthcare delivery. We aimed this study to evaluate audits carried out within trauma and orthopaedic unit of a teaching hospital over the last 4 years, and establish the proportions which were re-audited as per recommendations.Methods:Data was collected from records of the clinical audit department. All orthopaedic audit projects from 2005 to 2009 were included in this study. The projects were divided in to local, regional and national audits. Data regarding audit lead clinicians, completion and presentation of projects, recommendations and re-audits was recorded.Results:Out of 61 audits commenced during last four years, 19.7% (12) were abandoned, 72.1% (44) were presented and 8.2 % (5) were still ongoing. The audit cycle was completed in only 29% (13) projects.Conclusion:Change of junior doctors every 4~6 months is related to fewer re-audits. Active involvement by supervising consultant, reallocation of the project after one trainee has finished, and full support of audit department may increase the ratio of completion of audit cycles, thereby improving the patient care.