Consultant-led Care Research Articles

An analysis into the rise of private healthcare in England by geographical location and time period

Abstract Background Private healthcare is a rapidly growing industry in the UK, particularly for surgical procedures. Across the pandemic period, waiting lists for elective surgical and consultant-led care increased from 4.4 to 7.5 million patients. This study aimed to analyse the trends and geographical variations in privately funded and NHS-funded orthopaedic private procedures across England compared to NHS waiting times. Methods We conducted a longitudinal study using quarterly national data between 2019 and 2023 in England. Descriptive analysis of quarterly orthopaedic surgical volumes per 10,000 people, and quarterly orthopaedic surgery wait times stratified by geographical location and time period was conducted. Results Between 2019 and 2023 there were a total of 1,469,450 procedures across the private sector, comprising 1,030,095 NHS-commissioned private orthopaedic procedures and 439,355 private orthopaedic procedures. The South of England performed a higher total number of private procedures per year compared to the North (63 vs 57/10,000 people); whilst there was almost double the number of privately funded procedures (23 vs 12/10,000), the difference was less amongst NHS-funded procedures (45 vs 40/10,000 respectively). There was a large variation in the number of NHS-funded procedures per 10,000 between regions. The North has consistently shorter waiting times than the South. Conclusions Our findings indicate considerable geographical variation in the use of private healthcare between regions, suggesting a two-tier healthcare system. The founding principles of the NHS, healthcare free at the point of use based on clinical need irrespective of ability to pay, continue to be eroded. Policy makers and politicians urgently need to find solutions to ensure all members of society can access the same high quality health care. Key messages • Private healthcare utilization in the UK for orthopaedic procedures, has increased significantly, contributing to an emerging two-tier healthcare system. • There are large geographical disparities in access to healthcare services, with he South of England performing more private proceeds with longer NHS waiting times compared to the North.

Nurse-Led Care Versus Consultant-Led Usual Care in Patients with Thyroid Cancer: A Longitudinal Interventional Study

Background: The prognosis of thyroid cancer treatment is unsatisfactory in the presence of different independent parameters, such as older age, which may worsen the quality of life and mental health of patients. It is necessary to improve the quality of life and mental health of patients with thyroid cancer. Objectives: This study evaluated the nurse-led care impact as psycho-oncological support on anxiety and quality of life of patients with a history of thyroid cancer, comparing it to a consultant-led usual care and a non-care. Methods: Patients received half an hour of nurse-led care (NC cohort, n = 105), or consultant-led usual care (UC cohort, n = 125), or did not receive healthcare professional-led care (PO cohort, n = 135) at the institute during treatment and a follow-up period of 12 months. The EORTC QLQ-C30 Chinese version was used to assess the quality of life. Anxiety and depression were evaluated, using the Hospital Anxiety and Depression Scale. Results: Before the healthcare professional-led care, the quality of life scale score was 35 (36 - 33) and all patients had definitive anxiety and depression (scale score ≥ 11). After 12 months of the healthcare professional-led care, patients in the NC cohort showed improved quality of life and decreased anxiety and depression as compared to them before the healthcare professional-led care conditions and those of patients in the UC and PO cohorts after 12 months of the healthcare professional-led care (P < 0.001 for all). A higher number of patients survived in the NC cohort than in the UC (P = 0.0327) and PO (P = 0.0014) cohorts. Personal satisfaction of patients was higher in the NC cohort than in the UC and PO cohorts (P < 0.001 for both). Patient satisfaction was higher in the UC cohort than in the PO cohort (P < 0.001). Conclusions: Supportive cancer care after surgery or during follow-up is necessary in patients with thyroid cancer. Nurse-led care had beneficial effects on the quality of life, psychological conditions, survival, and personal satisfaction of patients with thyroid cancer during the follow-up period.

Outcome of induction of labour at 41 weeks with foley catheter in midwifery-led care

ObjectiveAssess the outcome of induction of labour (IOL) with a Foley catheter in pregnancies at 41 weeks in midwifery-led care setting compared to consultant-led care setting. DesignMixed-methods cohort study at a midwifery – hospital partnership in Amsterdam, the Netherlands. Setting and participantsProspectively, women undergoing IOL in midwifery-led care were recruited at a secondary hospital. This group was compared to a retrospective cohort, in which IOL was exclusively performed under consultant-led care. Measurements and findingsWe compared 320 women whose induction started in midwifery-led care to a historical cohort of 320 women induced for the same reason under consultant-led care. Both groups exhibited similar rates of spontaneous vaginal births (64.2 %vs62.5 %). Caesarean section and assisted vaginal birth rates did not significantly differ. Maternal adverse outcomes were comparable, while neonatal adverse outcomes were significantly higher in the midwifery-led care group (8.1 %vs3.8 %; OR 2.27, 95 % CI 1.12–4.58). The use of pain relief was significantly lower in midwife-led care (65.3 %vs75.3 %; OR 0.62, 95 % CI 0.44–0.87). 20.6 % of births occurred in midwife-led care. Key conclusions and implications for practiceIn this single-centre study, spontaneous vaginal birth rates following IOL with a Foley catheter were similar between midwife- and consultant-led care. However, the midwife-led group showed a higher risk of adverse neonatal outcomes, mainly early onset neonatal sepsis, with a minority eventually delivering under midwife-led care. Implications highlight the need for broader research, validation across diverse settings and exploration of patient and healthcare worker perspectives to refine the evolving midwifery-led care model.

ADvAnced PhysioTherapy in MuSculosKeletal Triage: Investigating prognostic factors, healthcare utilisation and clinical outcomes (ADAPT MSK) - a cohort study protocol.

Clinical specialist physiotherapist-led musculoskeletal triage clinics were introduced nationally in Ireland in 2011 to improve patient care and reduce waiting times for secondary care orthopaedics and rheumatology. Evidence has shown them to be effective in reducing waiting lists, however there are currently no data on longitudinal patient outcomes following clinic attendance. The primary aim of this cohort study is to identify predictors of pain and function outcomes up to one year following musculoskeletal triage review. Secondary aims include measuring self-reported use of healthcare resources over the 12-month follow-up period and to explore musculoskeletal phenotypes based on established prognostic factors for musculoskeletal pain. This is a prospective cohort study. ADvAnced PhysioTherapy in MuSculosKeletal Triage (ADAPT MSK) will recruit a cohort of 252 adults through musculoskeletal triage clinics across five secondary care sites in Ireland. The STrengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines will be adhered to for future reporting. Adults (≥ 18 years old) attending physiotherapist-led musculoskeletal triage clinics with musculoskeletal pain, who do not require surgical or consultant-led medical care will be considered for participation. Participant demographics, health literacy, healthcare utilisation, and self-report questionnaires on pain, function, musculoskeletal health, musculoskeletal risk stratification, fear of movement, and psychological distress will be obtained at baseline, with follow-ups at three, six, and 12 months. Primary outcomes are pain intensity and function. Secondary outcomes include musculoskeletal risk stratification status, musculoskeletal health, healthcare utilisation, and work-related factors. Descriptive statistics will be used to profile the participants and predictors of outcome will be assessed using multivariable linear regression. Musculoskeletal phenotypes will be explored using latent class analysis. Results will be disseminated via peer-reviewed journal publication and presentation at national and international conferences. Engagement with a public patient involvement (PPI) panel will explore dissemination strategies for public and service user engagement.

“It could not have been more different.” Comparing experiences of hospital-based birth and homebirth in Ireland: A mixed-methods survey

ProblemInternationally, little is known about the experiences of the minority who have birthed both in hospital and at home. This group are in a unique position to provide experiential evidence regarding perceptions of care under each approach. BackgroundObstetric care within the hospital setting is the hegemonic approach to birth in western cultures. Homebirth is at least as safe as hospital birth for those with low-risk pregnancies, yet access is strictly regulated. AimTo explore how those who have experienced both hospital and homebirth maternity care in Ireland perceived the care received, and experienced birth in each setting. Methods141 participants who birthed both in hospital and at home between 2011 and 2021 completed an online survey. FindingsParticipants’ overall experience scores were significantly higher for homebirth (9.7/10) than hospital birth (5.5/10). In hospital, midwifery-led care scored significantly higher (6.4/10) than consultant-led care (4.9/10). Qualitative data revealed four explanatory themes: 1) Regulation of birth; 2) Continuity of care and/or carer and establishing relationships; 3) Bodily integrity and informed consent; and 4) Lived experiences of labour and birth at home and in hospital. DiscussionHomebirth was perceived far more positively than hospital birth experiences across all aspects of care surveyed. Findings suggest that those who have experienced both models of care have unique perspectives and aspirations about childbirth. ConclusionThis study provides evidence regarding the need for genuine choices for maternity care and reveals the importance of care which is respectful and responsive to divergent ideologies about birth.

EGS P09 An Ambulatory General Surgical Service, Reducing the On-Call Burden and Improving Patient Experience

Abstract Background The management of acute General Surgical patients is dramatically changing with the emergence of Emergency General Surgery departments. The trend is moving towards consultant-led services, and managing patients on ambulatory pathways. This prospective study aims to demonstrate the impact of a consultant-led ambulatory surgical clinic and primary care telephone access on the acute surgical take in a busy tertiary hospital. Methods Data was collected from March 2021-March 2022. Patients were included via the primary care access line, as well as patient attendances either via surgical assessment unit (SAU), or ambulatory surgical clinic (ASC). Their pathways were recorded i.e. admit, discharge, further ambulatory investigation, listed for surgery. Results Consultants took 6,948 calls from primary care from March 2021–22. 43.7% of patients were given an appointment for ASC, 37.3% admitted to SAU, 3.5% directed to ED, and 15.5% given advice or redirected elsewhere. 54.6% of those seen in ASC were discharged without further follow up, the other 45.4% were either admitted, followed up or added to a waiting list. General Surgery patient attendances to SAU fell from an average of 1020 per month between March to October 2021 to 542 attendances November 2021 to present. Conclusions The introduction of a consultant-led ambulatory service has reduced the on-call burden by half. The dramatic reduction in SAU attendances is likely to be the result of developed ambulatory pathways, improved communication with primary care and Consultant Emergency General Surgeons, and autonomy of Junior Surgical Trainees to redirect ED referrals onto refined and supported ambulatory pathways. A Consultant-led primary care access line has reduced ED attendances and allowed for effective streaming of patients. These changes have improved the patient experience significantly, by directing them straight to specialty with same or next day consultant clinics, and reduced waiting times overall. There has been a significant reduction in complaints and consistent improvement in patient feedback.

50 SERVICE EVALUATION COMPARING ACUTE CARE AT HOME FOR OLDER SEOPLE SERVICE AND CONVENTIONAL ACUTE HOSPITAL CARE OF THE ELDERLY WARD

Abstract Background Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness. This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward. Methods Quantitative design, using service evaluation methodology. A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n = 191) and a consultant-led Acute Care at Home Service (n = 314) between April 2018–March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3-and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study. Results Acute Care at Home services are associated with higher readmission and mortality rates at 30 days, 3 and 6 months. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts. Conclusion The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults.

972 EXPLORING THE IMPACT OF FRAILTY FOLLOWING TRAUMA: AN ANALYSIS OF EMERGENCY DEPARTMENT (ED) MANAGEMENT AND LONG TERM OUTCOMES

Abstract Introduction Major trauma represents a large number of hospital presentations in Scotland. 1 We aimed to: -Describe the population of ‘major trauma’ patients presenting to the Emergency Department of QEUH, Glasgow -Compare assessment, management and clinical outcomes in frail versus non-frail patients with trauma. Method This was a retrospective, cohort study. Patients were identified using the Scottish Trauma Audit Group (STAG) database. 2 Patients aged over 18, admitted between 01/11/18 and 31/01/19 were included. STAG data was supplemented by individual case note review. Clinical Frailty Scale (CFS) and Charlson Comorbidity Index (CCI) were calculated. Results 203 patients (173 non-frail, 30 frail) were included. Median age was 58 years (range 19–98). Isolated head injuries were the predominant injury type in frail patients (36.7%) versus polytrauma in non-frail cohort (44.5%). Injury Severity Score (ISS) was similar across both groups (median score: 10v9.5). CCI score correlated well with frailty. Frail patients were less likely to: -Have ambulance pre-alert call (10% v 28%, p = 0.041). -Be managed in ‘Resus’ (17% v 54%, p < 0.05). -Have consultant-led care in ED (6.6% v 36.4%, p = 0.001). -Undergo CT within 60 minutes (10% v 34.7%, p = 0.0095). They were more likely to be admitted under a Medical Team (20% v 2.9%, p < 0.05). Frailty was associated with poorer outcomes: -Mortality 30% v 9.8%: significant difference in unadjusted, 1-year survival curves (Log-rank test p = 0.0026). Frailty carried a hazard-ratio of death of 5.02 (CI:2.13–11.79, p = 0.0002) compared to non-frailty through the first year after trauma. -Longer median Length of Stay: 22 v 8 days. Conclusion We identified poorer clinical outcomes in our frail patient cohort. Despite this, and with similar ISS scores across both groups, our data would suggest a tendency to under-recognise significant trauma in Frail patients.

Impact of suspected late-onset fetal growth restriction on obstetrical interventions and perinatal outcomes at term; a retrospective cohort study

ObjectivesFirst, assess accuracy of late third trimester universal fetal growth screening in high risk nulliparous women with a singleton in vertex presentation at term. Second, assess instrumental delivery rates and perinatal outcomes in this population. Study designSingle centre retrospective cohort study in a teaching hospital, The Netherlands. ResultsIn a cohort of 1902 pregnancies, growth ultrasound after 33 weeks was moderately accurate in detecting children with a birthweight below the 10th centile with a sensitivity of 46.2% and a false positive rate of 4.7%. Induction of labour followed an antenatal suspicion of FGR more often than in the group with normal expected fetal weight (73.4% vs 52.6% OR 2.49 (1.88–3.3)) as could be expected from application of guidelines. The caesarean section rates was lowest in the group with suspected FGR compared to the group with expected normal fetal weight (15.2% vs 22.1% OR 0.63 (0.45–0.9)). There were no differences between both groups in rates of composite severe adverse perinatal outcome (0.7% vs 0.8% OR 0.87 (0.2–3.93)). ConclusionsThe detection of growth restriction using universal screening in term high risk nulliparous women with a singleton in vertex position is moderate. Despite this, caesarean section rates were not increased and perinatal outcomes were similar when compared to that found in the randomized controlled trial on which the recommendation for induction of labour for suspected term FGR is based. This supports universal late third trimester fetal growth screening in pregnancies under consultant-led care in the two tiers Dutch obstetrical system.

Women who decline blood during labour: Review of findings and lessons learnt from 52 years of Confidential Enquiries into maternal mortality in the United Kingdom (1962–2019)

ObjectivePatients who decline blood products because of their religious beliefs pose a unique challenge in the context of obstetric haemorrhage. Four large series assessing maternal outcomes in Jehovah’s Witnesses from USA, UK, Netherlands and Japan estimate that maternal mortality is increased by between 44 and 160-fold. A review of maternal deaths from obstetric haemorrhage was undertaken in mothers who decline blood transfusion, using UK Confidential Enquiries into Maternal Deaths reports (1967–2019) in order to identify common trends and lessons learnt. DesignRetrospective review using 18 triennial Confidential Enquiries in Maternal Deaths reports between 1967 and 2019. ResultsFifteen maternal deaths from haemorrhage were reported in patients who declined blood products for religious beliefs in the 52 years reviewed. Common themes noted included delay in senior escalation, hesitation to perform life-saving hysterectomy and loss of situational awareness. Placental abruptions (3/15) and curettage for secondary postpartum haemorrhage (2/15) especially warrant senior input and cooperation with Jehovah’s Witness Hospital Liaison Committees is recommended. ConclusionsGuidelines from the UK’s Royal College of Obstetricians and Gynaecologists and Royal College of Surgeons highlight the need for collaborative, Montgomery-competent discussions during the antenatal period, as well as the engagement of local Jehovah’s Witness Hospital Liaison committees. Consultant-led care, antenatal optimisation of haemoglobin and techniques to mitigate blood loss at delivery are paramount. We advocate using a lower threshold for hysterectomy than was used in the cases analysed, for example when the haemoglobin level drops below 8–9 g/l in the context of ongoing bleeding. As patients increasingly begin to decline blood products for non-religious reasons, the lessons learnt in the management of Jehovah’s Witnesses are becoming ever more relevant.

National evaluation of trauma teaching for students (NETTS).

Despite the shift towards consultant-led care, many patients with trauma are still seen by junior doctors. Previous research has demonstrated that junior doctors feel unprepared to work in acute care but there is a paucity of recent research in trauma specifically. Thus, a national study is required to investigate the current state of undergraduate trauma teaching and identify specific areas for improvement. Between August and September 2020, a 35-item structured questionnaire was distributed among doctors who graduated from UK medical schools within the last 4 years. The questionnaire retrospectively assessed their experience of trauma teaching at medical school and their confidence to diagnose and manage patients with trauma. 398 responses were recorded from graduates of 39 UK medical schools. With 79.6% reporting only 0-5 hours of bedside trauma teaching and 51.8% reporting less than 20 hours in Accident and Emergency, graduates reported that trauma teaching was deficient compared with other specialties (78.1%). The majority of graduates were not confident in the initial assessment (72.9%) of a patient with trauma and almost all felt that a short course in trauma would be useful (93.7%). 77.4% of students felt that online learning would be beneficial and 92.9% felt that simulation would be useful. There is lack of standardised undergraduate trauma teaching nationally; a formal undergraduate teaching to ensure that new graduates are competent in the management of trauma would be supported by students. It is likely that a blended learning approach, incorporating e-learning with traditional teaching and clinical experience would be well received.

Introduction of a novel telescopic pathway to streamline 2-week-wait suspected head and neck cancer referrals and improve efficiency: A prospective service evaluation.

ObjectivesThis study summarizes the introduction of a novel telescopic pathway, which streamlines 2‐week‐wait suspected head and neck cancer referrals to our unit, describes the logistics of the pathway, and analyzes referral numbers and outcomes. We also discuss wider issues surrounding remote assessment in head and neck cancer.MethodsData were collected prospectively between January and May 2021, capturing all 2‐week‐wait referrals to our unit following the introduction of a telescopic pathway which utilized a nurse‐led clinic for nasendoscopic examination of selected patients and consultant‐led remote assessment using store and forward technology. Information on referral numbers, waiting times and outcomes was recorded.ResultsThree hundred and forty (185 high risk, 155 low risk) patients entered the telescopic pathway with the remaining 74 patients seen on the conventional standard of care pathway. Cancer conversion rates were 17%, <1%, and 5.4% for the high‐risk telescopic, low‐risk telescopic and standard of care pathways respectively. No patients discharged from the telescopic pathway were re‐referred within 3 months. Review capacity for endoscopic examination was higher per consultant on the telescopic pathway versus the standard of care (p = .01).ConclusionA combination of risk stratification and asynchronous telescopic assessment shows promise for the management of suspected head and neck cancer referrals. Potential benefits include consultant‐led care for all patients and enhanced documentation. Digital communication with patients may also assist with adherence to the new NHS 28‐day diagnostic standard for cancer referrals. Ongoing data collection is required to assess how the pathway functions over a longer period.Level of Evidence2c

SP9.1.7 Emergency Laparotomy for Trauma in the United Kingdom and Ireland: a Prospective Multicentre Study

Abstract Aims Trauma patients requiring abdominal surgery have significant morbidity and mortality, but are not included in existing national audits of emergency laparotomy. The aim of this study was to examine processes of care and outcomes among trauma patients undergoing emergency abdominal surgery in the UK and Ireland. Methods A prospective trainee-led multicentre audit was conducted over six months from January 2019 across the national trauma system. Patients undergoing laparotomy or laparoscopy within 24 hours of injury were included. Subgroup analysis was conducted in those requiring major haemorrhage protocol (MHP) activation. Results The study included 363 patients from 34 hospitals (22 major trauma centres). The majority were young males with no co-morbidities who required surgery for control of bleeding (51%) or exploration of penetrating injuries (46%). Over 85% received consultant-led care in the emergency department (318/363) and operating theatre (321/363). The MHP subgroup made up 45% of the cohort but accounted for 97% of deaths and 79% of ICU days, with a mortality rate of 19% and a massive transfusion rate of 32%. Compared to non-MHP patients they had shorter times to theatre (122 vs 218 minutes, p &amp;lt; 0.001), higher rates of advanced prehospital care (60% vs 33%, p &amp;lt; 0.001) and higher rates of consultant-led care (95% vs 85%, p &amp;lt; 0.001). Conclusion The majority of trauma patients requiring emergency abdominal surgery receive consultant-delivered perioperative care which is appropriately tailored to patient risk profile. Despite this, mortality and resource utilization among high-risk patients remains substantial, justifying ongoing performance improvement initiatives and research into novel therapeutics.

250 Determining Timing of Surgery in the COVID-19 Pandemic: Experience from an E.N.T Department in A Hospital Admitting Patients With COVID-19

IntroductionThe COVID-19 Pandemic has led to significant impact on elective services, with over 1.1 million patients waiting over the 18-week target for consultant-led care. Resumption of elective procedures has been left to the discretion of individual units depending on COVID-19 infection rate, access to testing and PPE, and the co-ordination of other services. We present an audit to determine timing of surgery and assess post-operative mortality associated with COVID-19 infection.MethodProspective data collection was undertaken between 5th October 2020 and 1st November 2020, inclusive. With the exclusion of nasal packing and flexible nasoendscopy, all patients operated on within the E.N.T department were reviewed. Inpatient hospital records were reviewed for the 30-day follow-up period.ResultsA total of 98 patients underwent surgical procedures during the audit period. All patients were operated on in a hospital admitting patients with COVID-19. Ninety-five percent of patients were elective, and all-bar-one had a period of isolation and negative SARS-CoV-2 PCR swab prior to operation in a dedicated non-COVID operating theatre. Twenty-eight patients had a peri-operative admission; one patient was advised to isolate on discharge following confirmed COVID-19 contact. Of the total cohort, only one patient died in the 30-day follow-up period; no updated SARS-CoV-2 PCR swab was recorded.ConclusionsWith increasing numbers of elective procedures required, these results provide otolaryngologists with reassurance. We recommend that those awaiting elective surgery should have a negative SARS-CoV-2 PCR swab and period of isolation prior to operation, combined, and be cared for in a dedicated non-COVID setting.

Service evaluation comparing Acute Care at Home for older people service and conventional service within an acute hospital care of elderly ward.

This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward. Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness. Quantitative design, using service evaluation methodology. A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n=191) and a consultant-led Acute Care at Home Service (n=314) between April 2018-March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3- and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study. Acute Care at Home services are associated with higher readmission and mortality rates at 30days, 3 and 6months. Fewer patients die while under Acute Care at Home care. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts. The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. It is likely that the Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults. Acute Care at Home services continue to evolve worldwide. This service evaluation has confirmed that Acute Care at Home services are safe and cost-effective alternatives to traditional older people hospital services. Such services offer patient choice, reduce length of stay and costs and prevent functional decline of older adults. This study accentuates the need to expand Acute Care at Home provision and capacity throughout Northern Ireland.

Paediatric major trauma in the setting of the Irish trauma network

BackgroundThe construction of a new tertiary children's hospital and reconfiguration of its two satellite centres will become the Irish epicentre for all paediatric care including paediatric trauma. Ireland is also currently establishing a national trauma network although further planning of how to manage paediatric trauma in the context of this system is required. This research defines the unknown epidemiology of paediatric major trauma in Ireland to assist strategic planning of a future paediatric major trauma network. MethodsData from 1068 paediatric trauma cases was extracted from a longitudinal series of annual cross-sectional studies collected by the Trauma Audit and Research Network (TARN). All paediatric patients between the ages of 0-16 suffering AIS ≥2 injuries in Ireland between 2014-2018 were included. Demographics, injury patterns, hospital care processes and outcomes were analysed. ResultsChildren were most commonly injured at home (45.1%) or in public places/roads (40.1%). The most frequent mechanisms of trauma were falls <2 m (36.8%) followed by RTAs (24.3%). Limb injuries followed by head injuries were the most often injured body parts. The proportion of head injuries in those aged <1 year is double that of any other age group. Only 21% of patients present directly to a children's hospital and 46% require transfer. Consultant-led emergency care is currently delivered to 41.5% of paediatric major trauma patients, there were 555 (48.2%) patients who required operative intervention and 22.8% who required critical care admission. A significant number of children in Ireland aged 1-5 years die from asphyxia/drowning. The overall mortality rate was 3.8% and was significantly associated with the presence of head injuries (p < 0.001). ConclusionPaediatric Trauma represents a significant childhood burden of mortality and morbidity in Ireland. There are currently several sub-optimal elements of paediatric trauma service delivery that will benefit from the establishment of a trauma network. This research will help guide prevention strategy, policy-making and workforce planning during the establishment of an Irish paediatric trauma network and will act as a benchmark for future comparison studies after the network is implemented.

The Mass Knee Clinic: a new NHS outpatient care model showing clinically led transformation in practice

BackgroundThe Mass Knee Clinic is an innovative, patient-focused and efficient clinic introduced into our hospital in April 2017. The UK Government has mandated referral-to-treatment (RTT) time for patients to be...

How can consultant-led childbirth care at time of delivery be maximised? A modelling study

ObjectiveThe Royal College of Obstetricians and Gynaecologists has advised that consolidation of birth centres, where reasonable, into birth centres of at least 6000 admissions per year should allow constant consultant...

A review of surgical and peri-operative factors to consider in emergency laparotomy care.

Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.

An exploratory cost-effectiveness analysis: Comparison between a midwife-led birth unit and a standard obstetric unit within the same hospital in Belgium

ObjectiveThe objective of this study was to compare midwife-led and consultant-led obstetrical care for women with uncomplicated low-risk pregnancies. We estimated costs and maternal outcomes in both units to achieve a cost-effectiveness ratio. DesignThe cost-analysis was made according to the “intention to treat” concept in order to minimize bias associated with the non-randomization of participants. At the obstetric-led unit, women received care from both midwives and medical staff while those in the alternative structure called ‘Le Cocon’ only received care from midwives. SettingThe obstetric-led unit of the Erasme University-Hospital in Brussels and its alongside midwife-led unit. ParticipantsThe study population included all low-risk pregnant women from 1 March 2014 until 31 October 2015 who were affiliated to the MLOZ (Mutualités Libres-Onafhankelijke Ziekenfondsen; third Belgian statutory health care insurer). InterventionsThe cost calculation involved a bottom-up approach. The health care consumption of each participant was obtained from MLOZ's data. The study included costs occurred the beginning of pregnancy until 3 months post-partum. Clinical data were extracted from the patient medical records. FindingsCompared to the traditional obstetric-led unit, the alternative midwife-led unit was associated with a cost reduction for the national payer (∆ = −€397.39, p = 0.046) and for the patient (∆ = − €44.19, p = 0.016). There were no significant differences in rates of caesarean, instrumental birth and epidural analgesia between MLU and OLU. A sensitivity analysis was performed (Appendix C) but does not change the overall results and conclusions. Key conclusionsDue to the small size of the samples, no statistical differences were found. More analysis is needed to evaluate the cost-effectiveness regarding the use of epidural analgesia, caesarean and instrumental birth rates in the midwife-led unit. Implications for practiceGiven the economical findings, this could contribute to reduce health expenditures for both women (out of pocket) and state (public payer via health care insurers).