Care Units In England Research Articles

Pseudo-outbreaks of Stenotrophomonas maltophilia on an intensive care unit in England

In June 2014, a cluster of identical S. maltophilia isolates was reported in an adult intensive care unit (ICU) at a district general hospital. An outbreak control team was convened to investigate the cluster and inform control measures. To identify potential risk factors for isolation of S. maltophilia in this setting. We conducted a cohort study of ICU patients for whom a bronchoalveolar lavage (BAL) specimen was submitted between October 2013 and October 2014. Cases were patients with S. maltophilia-positive BAL. We calculated the association between isolation of S. maltophilia and patient characteristics using risk ratios (RRs) with 95% confidence intervals (95% CIs) and univariate logistic regression. Chi-squared or Fisher's exact tests were used. BAL specimens were microbiologically typed using pulse-field gel electrophoresis (PFGE). Eighteen patients met the case definition. Two patients had clinical presentations that warranted antibiotic treatment for S. maltophilia. All cases were exposed to bronchoscopy. PFGE typing revealed clusters of two strain types. We found statistically significant elevated risks of isolating BRISPOSM-4 in patients exposed to bronchoscope A (RR: 13.56; 95% CI: 1.82-100; P < 0.001) and BRISPOSM-3 in patients exposed to bronchoscope B (RR: 16.89; 95% CI: 2.14-133; P < 0.001). S. maltophilia type BRISPOSM-4 was isolated in water used to flush bronchoscope A after decontamination. Two pseudo-outbreaks occurred in which BAL specimens had been contaminated by reusable bronchoscopes. We cannot exclude the potential for colonization of the lower respiratory tract of exposed patients. Introduction of single-use bronchoscopes was an effective control measure.

Data linkage errors in hospital administrative data when applying a pseudonymisation algorithm to paediatric intensive care records.

ObjectivesOur aim was to estimate the rate of data linkage error in Hospital Episode Statistics (HES) by testing the HESID pseudoanonymisation algorithm against a reference standard, in a national registry of paediatric intensive care records.SettingThe Paediatric Intensive Care Audit Network (PICANet) database, covering 33 paediatric intensive care units in England, Scotland and Wales.ParticipantsData from infants and young people aged 0–19 years admitted between 1 January 2004 and 21 February 2014.Primary and secondary outcome measuresPICANet admission records were classified as matches (records belonging to the same patient who had been readmitted) or non-matches (records belonging to different patients) after applying the HESID algorithm to PICANet records. False-match and missed-match rates were calculated by comparing results of the HESID algorithm with the reference standard PICANet ID. The effect of linkage errors on readmission rate was evaluated.ResultsOf 166 406 admissions, 88 596 were true matches (where the same patient had been readmitted). The HESID pseudonymisation algorithm produced few false matches (n=176/77 810; 0.2%) but a larger proportion of missed matches (n=3609/88 596; 4.1%). The true readmission rate was underestimated by 3.8% due to linkage errors. Patients who were younger, male, from Asian/Black/Other ethnic groups (vs White) were more likely to experience a false match. Missed matches were more common for younger patients, for Asian/Black/Other ethnic groups (vs White) and for patients whose records had missing data.ConclusionsThe deterministic algorithm used to link all episodes of hospital care for the same patient in England has a high missed match rate which underestimates the true readmission rate and will produce biased analyses. To reduce linkage error, pseudoanonymisation algorithms need to be validated against good quality reference standards. Pseudonymisation of data ‘at source’ does not itself address errors in patient identifiers and the impact these errors have on data linkage.

Healthcare-associated bloodstream infections in critically ill patients: descriptive cross-sectional database study evaluating concordance with clinical site isolates.

BackgroundHealthcare-associated bloodstream infections are related to both increased antibiotic use and risk of adverse outcomes. An in-depth understanding of their epidemiology is essential to reduce occurrence and to improve outcomes by targeted prevention strategies. The objectives of the study were to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates.MethodsWe conducted a descriptive cross-sectional study in critically ill adults admitted to a tertiary semi-closed intensive care unit in England to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. All nosocomial positive blood cultures over a 4-year study period were identified. Pathogens detected and concordances with clinical site are reported as proportions.ResultsContaminant pathogens accounted for half of the isolates. The most common non-contaminant pathogens cultured were Pseudomonas spp. (8.0%), Enterococcus spp. (7.3%) and Escherichia coli (5.6%). Central venous catheter-linked bloodstream infections represent only 6.0% of the positive blood cultures. Excluding contaminants and central venous line infections, in only 39.5% of the bloodstream infections could a concordant clinical site source be identified, the respiratory and urinary tracts being the most common.ConclusionsClinical practice should focus on a) improving blood culture techniques to reduce detection of contaminant pathogens and b) ensuring paired clinical site cultures are performed alongside all blood cultures to better understand the epidemiology and potential implications of primary and secondary discordant health-care associated bloodstream infections.

Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study

IntroductionResearch has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England.MethodsWe conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital.ResultsThe analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation.ConclusionsWe found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0491-3) contains supplementary material, which is available to authorized users.

Factors associated with non evidence-based prescribing of antipsychotics.

Non evidence-based prescribing of antipsychotics is common in the UK and internationally with high doses and polypharmacy the norm. These practices often remain even after systematic attempts are made to change. We aimed to establish which factors are linked to antipsychotic prescribing quality so we can identify and target patients for interventions to improve quality and allow us to understand further the drivers of non evidence-based prescribing. A cross-sectional survey with a collection of factors potentially affecting antipsychotic prescribing quality outcomes was carried out in eight secondary care units in England. Participants were inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose, polypharmacy, type and route were the main outcome measures. Data were collected for 1198 patients. Higher total dose was associated with greater weight, higher number of previous admissions, longer length of admission, noncompliance with medication and use of an atypical antipsychotic. A lower total dose was associated with clozapine use. Polypharmacy was associated with not being a patient at the South London and Maudsley NHS Trust centre, the subject having a forensic history, a greater number of previous admissions and higher total dose. Younger age, not being detained under a Mental Health Act section, atypical antipsychotic use and oral route were predictors of antipsychotic monotherapy. Atypical antipsychotic use was associated with oral route, higher total dose, being administered only one antipsychotic, having had fewer previous antipsychotics and no anticholinergic use. Use of the oral route was associated with not being sectioned under the Mental Health Act, atypical antipsychotic use, younger age, non-schizophrenia diagnosis, fewer previous admissions and a lower total dose. In patients with chronic illness who are detained, heavier, noncompliant, not taking clozapine and on a depot antipsychotic, prescribers use larger doses and antipsychotic polypharmacy. We found that use of percentage of licensed maximum doses favours typical antipsychotics arbitrarily, and that high doses and polypharmacy are inextricably linked.

Erratum

In the article entitled 'A census of current sedation monitoring practices in adult general intensive care units in England' written by Simon Freilich and Michael Shaw and published in the April 2014 issue of JICS on pages 127–30, the name of one of the authors in reference 10 was misspelt. The author's name should have been spelt 'Reschreiter': it was also incorrectly spelt in the text of the article. This has now been corrected in the online version of this article.

A Census of Current Sedation Monitoring Practices in Adult General Intensive Care Units in England

Under- and over-sedation in intensive care units (ICUs) have potentially deleterious consequences. The Intensive Care Society (ICS) produced guidelines in 2007 to unify sedation management. The aim of the current census was to investigate how sedation practice was subsequently implemented in England. A telephone-based questionnaire to the ‘nurse-in-charge’ was iteratively developed at the host institution until respondent concordance was greater than 80%. Two hundred and four adult general ICUs across England were then contacted. One hundred and sixty units (79%) completed the survey; 82% of responding ICUs had a written sedation policy; all responding ICUs used a sedation scoring system, mainly the Richmond Scale (64%). All responding ICUs assessed and documented sedation levels, with 73% formally assessing this at least two-hourly; 91% of responding ICUs had a formal sedation holding policy; 73% of responding nurses felt there was adequate medical guidance provided on sedation depth; 27% of responding ICUs had bispectral index (BIS) monitors, with 74% of these units using them for monitoring sedated patients receiving neuromuscular blocking agents. Sedation management has improved nationally over the last five years. Written sedation policies, sedation scoring and sedation holding are standard practice. However, some nurses feel they need more guidance on choosing sedation depth, and some units assess sedation depth less frequently than two-hourly. In order to optimise clinical practice, we propose that sedation depth be a goal-directed therapy that is addressed at each patient review.

Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation

Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI. The study is registered with PROSPERO as CRD42012001840. The National Institute for Health Research Health Technology Assessment programme.

The Cardiac Output Monitoring EvaluaTion –UK (COMET-UK) study

The aim of the Cardiac Output Monitoring EvaluaTion-UK (COMET-UK) study was to update reports of cardiac output (CO) monitoring use and to examine whether there is any association between the frequency of CO monitoring use in adult, general intensive care units and patient outcomes. Questionnaires were sent to all intensive care units in England, Wales and Northern Ireland (n=221) asking whether the unit had used CO monitoring in the last two years and, if so, to give details of average frequency of use and which CO monitors were available. The majority of units (n=100, 45.2%) used CO monitoring most days or a few times a week and 33 (14.9%) monitored CO every day (response rate 100%). The most commonly available methods were oesophageal Doppler (n=127, 57.5%), LiDCO (n=96, 43.4%) and PiCCO (n=92, 41.6%). There was no significant difference in risk-adjusted acute hospital mortality (p=0.25) or length of stay (p=0.48) across categories of frequency of use. However for ventilated vs non-ventilated patients and different quartiles of illness severity, there was an association between higher frequency of use and worse outcome among non-ventilated and lowest risk admissions quartiles. The COMET-UK study found that CO monitoring is in common use; however, there was no evidence that more frequent use of CO monitoring was associated with improved outcomes.

Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study

IntroductionResearch has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England.MethodsWe conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital.ResultsThe analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation.ConclusionsWe found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.

Ten years of asthma admissions to adult critical care units in England and Wales

ObjectivesTo describe the patient demographics, outcomes and trends of admissions with acute severe asthma admitted to adult critical care units in England and Wales.Design10-year, retrospective analysis of a national audit...

Characteristics and outcome of children admitted to adult intensive care units in England, Wales and Northern Ireland (1996–2011)

Despite centralisation of paediatric intensive care units (PICU) in the UK, children continue to be admitted to adult intensive care units (AICU). We aimed to analyse trends in the admission of children to AICUs over a 16-year period from 1996, and describe their case mix, outcome and resource use in a recent cohort (2009-2011). We extracted data from consecutive admissions of children (1996-2011) to AICUs from the Intensive Care National Audit and Research Centre Case Mix Programme Database. We studied case mix, outcome and resource use as well as regional, seasonal and temporal variations in admissions of children to AICU. A total of 13,430 children were admitted to AICUs between 1996 and 2011 (representing 1.3% of all admissions). This proportion decreased from 2.8% in 1996 to 0.6% in 2011. Crude mortality fell from 6.7 to 2.8%, and the proportion transferred out to a PICU rose from 18.9 to 51.4%. In recent years (2009-2011), half of the 2,320 admissions of children occurred in just three English Strategic Health Authorities. The median length of unit stay was 7.7 h (IQR 3.8-19.7) for survivors and 11.5 h (IQR 5.0-36.2) for non-survivors. The number of children admitted to AICUs in England, Wales and Northern Ireland has been steadily declining since 1996. In recent years, half of all children admitted to AICUs are transferred to PICU, usually following a short stay. The reasons for regional variation in paediatric admissions to AICUs, and the cause of death in the small number of children who die in AICUs, are unclear.

‘You can’t just hit a button’: an ethnographic study of strategies to repurpose data from advanced clinical information systems for clinical process improvement

BackgroundCurrent policies encourage healthcare institutions to acquire clinical information systems (CIS) so that captured data can be used for secondary purposes, including clinical process improvement. Such policies do not account for the extra work required to repurpose data for uses other than direct clinical care, making their implementation problematic. This paper aims to analyze the strategies employed by clinical units to use data effectively for both direct clinical care and clinical process improvement.MethodsEthnographic methods were employed. A total of 54 contextual interviews with health professionals spanning various disciplines and 18 hours of observation were carried out in 5 intensive care units in England using an advanced CIS. Case studies of how the extra work was achieved in each unit were derived from the data and then compared.ResultsWe found that extra work is required to repurpose CIS data for clinical process improvement. Health professionals must enter data not required for clinical care and manipulation of this data into a machine-readable form is often necessary. Ambiguity over who should be responsible for this extra work hindered CIS data usage for clinical process improvement. We describe 11 strategies employed by units to accommodate this extra work, distributing it across roles. Seven of these motivated data entry by health professionals and four addressed the machine readability of data. Many of the strategies relied heavily on the skill and leadership of local clinical customizers.ConclusionsTo realize the expected clinical process improvements by the use of CIS data, clinical leaders and policy makers need to recognize and support the redistribution of the extra work that is involved in data repurposing. Adequate time, funding, and appropriate motivation are needed to enable units to acquire and deliver the necessary skills in CIS customization.

Eye Care in the Critically Ill: A National Survey and Protocol

Sedated and ventilated critically ill patients often have inadequate eyelid closure and are susceptible to developing exposure keratopathy and microbial keratitis. Preventative measures reduce the risk of complications and visual loss. A telephone survey of all intensive care units in England was performed to elucidate the measures being used and their prevalence. Of 267 units, 217 participated (81%). Of these, 130 (60%) had an eye care protocol and 143 (66%) of all participating units formally assessed eyelid closure. The presence of an eye care protocol did not improve the likelihood of a unit assessing eyelid closure, a key component of the detection of patients at risk of ophthalmic complications; 66% of units with eye care protocols assessed eyelid closure formally, compared to eyelid closure assessment occurring in 65% of units that did not employ an eye care protocol. Most units used at least two protective methods per unit, the most popular being Geliperm application and Lacrilube. Self-reported complication rates in the last year were low, but only 13% of units audited eye-related complications. To improve eye care and replace current protocols, we propose a simple protocol encouraging vigilant eyelid closure assessment, administration of preventative therapy where indicated and referral if there is any corneal opacity or continuous exposure.

‘Matching Michigan’: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England

BackgroundBloodstream infections from central venous catheters (CVC-BSIs) increase morbidity and costs in intensive care units (ICUs). Substantial reductions in CVC-BSI rates have been reported using a combination of technical and...

Simulation-based education (SBE) within postgraduate emergency on-call physiotherapy in the United Kingdom

The application and extent of simulation-based education use within cardiorespiratory physiotherapy postgraduate education (in-house/regional provisions) and emergency oncall services were previously unexplored. This survey aimed to investigate the extent to which simulation-based education is currently utilised by physiotherapy services in the UK. A national postal questionnaire-based survey. All 280 National Health Service Critical/Intensive Care Units in England, Northern Ireland, Scotland and Wales, providing emergency on-call physiotherapy services were included in the survey. Emergency on-call physiotherapy service leads. A self-administered 20-item postal questionnaire survey was designed to establish the extent to which simulation-based education was currently being used within cardio-respiratory physiotherapy post-registration training. A useable response rate of 55% (155/280) was achieved, representing a range of respiratory and emergency on-call service leads. Sixty-one Trusts (39%) currently use simulation within acute respiratory or emergency on-call postgraduate training. The provision of simulation equipment varied with respect to type, fidelity and accessible to the physiotherapy service. Simulation-based education featured in emergency on-call induction, updates, competency assessment, assessment skills, treatment skills and scenarios (75, 92, 39, 28, 82, 48% respectively). Simulation is currently used to teach a wide variety of cardio-respiratory physiotherapy skills relevant to the acute respiratory and on-call environments. Adoption was dependent upon local facilities, needs and training requirements. National inconsistencies in availability, fidelity and accessibility were identified. The evidence base surrounding the current use of simulation-based education within physiotherapy is limited and evidence of transferability to the practice arena remains relatively unknown. Future research is warranted to determine the education outcomes, impact on skill performance, competency, retention and patient safety when integrating SBE within EOC training activities.

Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients

Patients with decompensated liver cirrhosis who are admitted to intensive care units (ICU) are perceived, within the UK, as having a particularly poor prognosis. We performed a descriptive analysis of cirrhosis patients admitted to general critical care units 1995-2008 compared to patients admitted with pre-existing chronic renal failure. Data were obtained from the Intensive Care National Audit and Research Centre Case Mix Programme Database incorporating 192 adult critical care units in England, Wales and Northern Ireland. Cirrhosis accounted for 2.6 % (16,096 patients) of total admissions with mean age 52.5 years and male preponderance (~60 %). Hospital mortality was high (>55 %) although this improved 5 % in recent years, and median length of stay was short (2.5 days). Mortality in cirrhotics with severe sepsis requiring organ support was 65-90 %, compared to 33-39 % in those without. Conversely, patients with chronic renal failure had lower mortality (42 %) despite similar characteristics and higher acute physiology and chronic health evaluation (APACHE) II scores. The APACHE II score under-predicted mortality in cirrhotics. Cirrhosis patients exhibit worse outcomes compared to pre-existing renal failure patients, despite similar characteristics. Survival worsens considerably with organ failure, especially with sepsis. They represent a small number of admissions, albeit increasing over recent years, and, in general, have a short ICU stay. Patients with single organ failure have acceptable survival rates and mortality has improved; although we have no data on those refused ICU admission potentially causing survival bias. Given the extremely high mortality in patients with multi-organ failure, support should be limited/withdrawn in such patients.

Effect of non-clinical inter-hospital critical care unit to unit transfer of critically ill patients: a propensity-matched cohort analysis

IntroductionNo matter how well resourced, individual hospitals cannot expect to meet all peaks in demand for adult general critical care. However, previous analyses suggest that patients transferred for non-clinical reasons have worse outcomes than those who are not transferred, but these studies were underpowered and hampered by residual case-mix differences. The aim of this study was to evaluate the effect of transferring adult general critical care patients to other hospitals for non-clinical reasons.MethodsWe carried out a propensity-matched cohort analysis comparing critical care patients who underwent a non-clinical critical care unit to unit transfer to another hospital with those who were not transferred. The primary outcome measure was mortality at ultimate discharge from acute hospital. Secondary outcomes were mortality at ultimate discharge from critical care, plus length of stay in both critical care and acute hospital.ResultsA total of 308,323 patients were admitted to one of 198 adult general critical care units in England and Wales between January 2008 and September 2011. This included 759 patients who underwent a non-clinical transfer within 48 hours of admission to the unit and 1,518 propensity-matched patients who were not transferred. The relative risk of ultimate acute hospital mortality was 1.01 (95% confidence interval = 0.87 to 1.16) for the non-clinical transfer group, compared with patients who were not transferred but had a similar propensity for transfer. There was no statistically significant difference in ultimate critical care unit mortality. Transferred patients received on average three additional days of critical care (P < 0.001) but the difference in length of acute hospital stay was of only borderline significance (P = 0.05).ConclusionIn our analysis the difference in mortality between non-clinical transferred and nontransferred patients was not statistically significant. Nevertheless, non-clinical transfers received, on average, an additional 3 days of critical care. This has potential ramifications in terms of distress, inconvenience and cost for patients, their families, and the National Health Service. We therefore need further evidence, including qualitative data from family members and cost-effective analyses, to better understand the broader effects of non-clinical transfer.

Survivors of critical illness: victims of our success?

> ‘For many patients the recovery after critical illness is relatively straightforward and it is important not to lose sight of this. What is clear is that tens of thousands of patients leave critical care to go home each year, and it is likely that poor-quality recovery represents a substantial problem. Given the individual impact on patients and ripple effects on families and society in general, poor-quality rehabilitation and impaired recovery from severe illness should be regarded as a major public health issue.’1 From its origins in Copenhagen during the poliomyelitis epidemic of 1952, the critical care unit has grown into a facility central to modern hospital medicine. Changes in medical practice and public expectation are placing increasing demands on critical care services. The Intensive Care National Audit & Research Centre recorded 96 810 admissions from April 2009 to March 2010 to 188 critical care units in England, Wales, and Northern Ireland, of whom 83.1% were discharged alive from critical care and 74.8% from hospital.2 Most patients admitted to critical care stay short periods of time and make complete and uncomplicated recoveries. However, follow-up of critical care survivors and caregivers has consistently shown that many report physical and psychological problems affecting quality-of-life, sometimes years after the admitting insult.3 These long-term effects were often overlooked by all but a few enthusiastic researchers.4 In 2009, the National Institute for Health and Clinical …

What are cancer patients’ experiences and preferences for the provision of written information in the palliative care setting? A focus group study

Background: Whilst there is a wide range of literature pertaining to the need for excellent verbal communication within the palliative care setting, there is a paucity of research designed to identify the written informational needs of such patients. Aim: To identify the experiences and wishes of patients known to a specialist palliative care service in England with regards to written information. We considered both generalizable written information (such as leaflets, books and internet resources) as well as individualized information (for example, copies of letters given to patients). Design: Five focus group discussions were recorded and transcribed for analysis. Setting/participants: The focus groups took place at one specialist palliative care unit in England. Twenty-two patients with cancer over the age of 18 years were recruited. Results: Inductive, realist thematic analysis of the data set was performed. Themes have been broadly categorized into three main areas: (i) patients’ views on the role of written information, (ii) their experiences of written information in different formats, and (iii) their thoughts on what written information they would most value. Conclusions: Written information needs for this patient group vary greatly, sometimes in ways which can be predicted. Using a patient-centred approach to elicit information around an individual’s coping strategies, desire for knowledge and empowerment may be helpful. The data supports a proactive approach to making available (to those who want them) clear, concise and attractive leaflets.