Teaching District General Hospital Research Articles

A cross-sectional study of hospital pharmacists communicating medication changes at discharge

Abstract Introduction Medication discrepancies can happen at transitions of care and there are recognised problems with the content of discharge letters.1 We introduced a discharge medication reconciliation process that was shown to improve the quality of medication information in discharge summaries.2 This involves pharmacists recording any changes to patient’s medication in the electronic prescribing system during the inpatient stay and summarising these changes on discharge in a discharge medication reconciliation (DMR) note. Though this is part of routine clinical pharmacy practice we have not directly quantified these notes in comparison to standards for the clinical structure and content of patient records,3 nor have we examined which medication classes are commented upon by our pharmacists. Aim To characterise the type of medication changes that pharmacists describe and the classes of medication that warrants such attention. Methods A retrospective study of a purposive sample of 100 patient episodes where a DMR note was recorded at a 750-bed teaching district general hospital in England. We classified the text of the DMR note using the four categories (added, amended, on hold, and discontinued) in the eDischarge Summary Standard,3 plus four further categories. The actual medication named was categorised according to the main BNF therapeutic chapters. Data were collated and analysed using Microsoft Excel. As this project falls under the definition of a service evaluation, according to UK NHS Research Ethics Committees, formal ethical approval was not required. This project was registered on the hospital’s clinical audit database. Results Data were extracted for 100 discharges from early 2023. The mean age was 70 years (range 12 to 96), and 40% were male. In total, 352 medicines were named in the DMR notes with 184 (52%) recorded as added, 41 (12%) amended, 32 (9%) on hold, and 42 (12%) discontinued. For 32 (9%) instances the DMR note specifically referred to continuation of medication; in 12 (3%) instances to monitoring required; and 22 (6%) instances fell into other category. For 33 (33%) of episodes there was a note indicating that no changes had been made to other pre-admission medication during the hospital stay. Of the medication attracting a DMR note, the main chapters were cardiovascular 162 (46%), gastrointestinal 45 (13%), central nervous system 40 (11%), and 28 (8%) each for infection and for blood and nutrition. Discussion/Conclusion For this sample of patients who undergo a DMR process, the pharmacy team clarified medication changes at a mean rate of 3.5 changes per patient. Addition of medication was the most common event. The most frequent class of medication attracting a DMR note may be a reflection of the cardiovascular morbidities of patients as well as perceived adverse effects as 27/32 ‘on hold’ notes were for cardiovascular medication. Limitations of this study include the patient sample being collected in one hospital, hence results may not be generalizable. There was no attempt to ascertain if the DMR notes added value to primary care medicines reconciliation process.

Navigating ACL Injuries Amid the COVID-19 Pandemic: A Retrospective Analysis.

Introduction In the United Kingdom, musculoskeletal injuries represent a substantial proportion of primary care appointments, and within this category, acute knee injuries are prominent in accident and emergency department cases. Notably, diagnosing anterior cruciate ligament (ACL) injuries is a recognized challenge, often leading to extended diagnostic delays. The COVID-19 pandemic has significantly affected the management of musculoskeletal disorders, driven by reduced surgical capacities, creating a backlog of patients awaiting necessary surgical interventions. Delayed ACL reconstruction poses risks of prolonged knee instability and secondary injuries. To address these concerns, this study evaluates the impact of COVID-19 on the timeline from ACL injury diagnosis to MRI and surgical intervention, with a specific focus on an internal acute knee clinic pathway designed to expedite the evaluation, diagnosis, and management of soft tissue knee injuries. Methods In this cross-sectional study, we retrospectively reviewed all the patients who underwent primary ACL reconstruction from January 2019 to November 2022 in a district general teaching hospital (DGH). Besides demographic data of the patients, we recorded the dates of injury, primary presentation, first knee specialist review, knee MRI, and ACL reconstruction surgery, as well as the injury-to-surgery, injury-to-MRI, and MRI-to-surgery periods. Patients were divided based on the date of operation to pre- and post-COVID, and outcomes were compared to see the possible effects of COVID-19. Data were analyzed using a quantitative and qualitative test with a P < 0.05 significance level. Results Our cohort included 97 patients, and the mean age of patients was 30.6 years (17-53 years). The median time of injury-to-MRI was 46.5 days during the pre-COVID period, which decreased to 44 days in the post-COVID period (P = 0.596). The median time of injury-to-surgery was 287.5 days during the pre-COVID period, which increased to 289 days in the post-COVID period (P = 0.019). The median MRI-to-surgery duration was 200 days during the pre-COVID period, which increased to 225 days in the post-COVID period (P = 0.006). Around 35% of patients had an MRI prior to getting evaluated by a specialist. Conclusion The COVID-19 pandemic had a significant impact on the management of ACL injuries, with delays in elective knee clinics and surgery potentially leading to delays in the diagnosis and management of such injuries. However, our study showed that the delay from ACL injury to subsequent surgery actually reduced post-pandemic due to hospital-based acute knee pathway, which is particularly important in the context of associated meniscal injury that can worsen while patients wait for surgery.

ChroniSense National Early Warning Score Study: Comparison Study of a Wearable Wrist Device to Measure Vital Signs in Patients Who Are Hospitalized.

Wearable devices could be used to continuously monitor vital signs in patients who are hospitalized, but they require validation. This study aimed to evaluate the clinical validity of the prototype of a semiautomated wearable wrist device (ChroniSense Polso) to measure vital signs and provide National Early Warning Scores (NEWSs). Vital signs and NEWSs measured using the wearable device were compared with standard, nurse-lead manual measurements. We enrolled adult patients (aged ≥18 years) who required vital sign measurements at least every 6 hours in a UK teaching district general hospital. Wearable device measurements were not used for clinical decision-making. The primary outcome was the agreement on the individual National Early Warning parameter scores and vital sign measurements: respiratory rate, oxygen saturation, body temperature, systolic blood pressure, and heart rate. Secondary outcomes were the agreement on the total NEWS, incidence of adverse events, and user acceptance. To compare the wearable device measurements with the standard measurements, we analyzed vital sign measurements by limits of agreement (Bland-Altman analysis) and conducted κ agreement analyses for NEWSs. A user experience survey was conducted with questions about comfort of the wrist device, safety, preference, and use. We included 132 participants in the study, with a mean age of 62 (SD 15.81) years; most of them were men (102/132, 77.3%). The highest weighted κ values were found for heart rate (0.69, 95% CI 0.57-0.81 for all 385 measurements) and systolic blood pressure (0.39, 95% CI 0.30-0.47 for all 339 measurements). Weighted κ values were low for respiration rate (0.03, 95% CI -0.001 to 0.05 for all 445 measurements), temperature (0, 95% CI 0-0 for all 231 measurements), and oxygen saturation (-0.11, 95% CI -0.20 to -0.02 for all 187 measurements). Weighted κ using Cicchetti-Allison weights showed κ of 0.20 (95% CI 0.03-0.38) when using all 56 total NEWSs. The user acceptance survey found that approximately half (45/91, 49%) of the participants found it comfortable to wear the device and liked its appearance. Most (85/92, 92%) of them said that they would wear the device during their next hospital visit, and many (74/92, 80%) said that they would recommend it to others. This study shows the promising use of a prototype wearable device to measure vital signs in a hospital setting. Agreement between the standard measurements and wearable device measurements was acceptable for systolic blood pressure and heart rate, but needed to be improved for respiration rate, temperature, and oxygen saturation. Future studies need to improve the clinical validity of this wearable device. Large studies are required to assess clinical outcomes and cost-effectiveness of wearable devices for vital sign measurement. RR2-10.1136/bmjopen-2018-028219.

A review of adherence to nice criteria for initiation and continuation of treatment of dupilumab in atopic dermatitis

Abstract Introduction Atopic dermatitis is a chronic, recurrently flaring, generalised skin condition that can be life-limiting, debilitating and isolating. A typical treatment pathway involves emollients and topical corticosteroids (first line), topical calcineurin inhibitors (second line), phototherapy (third line) and systemic immunosuppressant therapies (fourth line. Dupilumab is recommended by NICE1 as an option for treating moderate to severe atopic dermatitis in adults, only if the disease has not responded to at least one other systemic therapy, such as ciclosporin, methotrexate, azathioprine and mycophenolate mofetil, or these are contraindicated or not tolerated, and the company provides dupilumab according to the commercial arrangement. Dupilumab should be stopped at 16 weeks if the atopic dermatitis has not responded adequately i.e. at least a 50% reduction in the Eczema Area and Severity Index score (EASI, ranges from 0 to 72, with higher scores indicating greater severity) from when treatment started and at least a 4-point reduction in the Dermatology Life Quality Index (DLQI) from when treatment started. Aim To ascertain whether dupilumab (a payments by results excluded drug, commissioned by integrated care systems) was used in a teaching district general hospital according to the stated criteria within the NICE technology appraisal. Methods Patients prescribed and supplied with dupilumab for more than 16 weeks were identified and Dermatology letters were scrutinised by a pharmacy team member. Ethical review was not required as this was a service evaluation. Results Eighty-eight patients had received dupilumab and the records of 30 (mean age 44, range 18-73, 18 male) were reviewed. Most entries were from when NICE first approved dupilumab, though some were chosen from late 2021/early 2022. All but one had been on at least one prior systemic therapy. This one patient was admitted urgently with severe dermatitis and so was referred for dupilumab as it is quicker acting than immunosuppressant therapy and no need to wait for blood tests. One patient did not have a starting EASI score (under a tertiary hospital). Twenty-nine of the 30 patients experienced both the required 50% or more reduction in EASI score at the review meeting and the at least a 4-point reduction in DLQI. The one patient who did not respond had treatment ceased. At approximately week 16, for all patients the ASI score changed from a mean of 29.7 (range 3-66.7) to 3.6 (range 0-27.9), and DLQI from a mean of 18.9 (range 7-30) to 4.4 (range 0-28). Discussion/Conclusion This study found that all but one of 30 patients had been on prior systemic therapy, and all but one patient met the NICE criteria at the review period (treatment then ceased). This was a sample of approximately one-third of the patients who had received dupilumab. Acknowledging that the dupilumab NHS price is about £16,000 per patient per year, these reassuring results of NICE compliance have been shared with Dermatology. We recognise the limitations of a single centre, very small-scale study. We do not report prolonged follow up of patients in relation to any improvement in their atopic dermatitis other than what we observed documented in Dermatology letters at commencement and review of treatment.

Effectiveness of a junior-led near-peer simulated patient teaching programme on knowledge retention and provision of junior doctor teaching opportunities

Transition from medical student to foundation doctor can be a daunting process. There is growing interest for research into ‘how prepared medical graduates are for practice’, with a systematic review showing graduates feel unprepared for prescribing, clinical reasoning/diagnosis, and emergency management [1]. Following reports by medical students describing the benefits from simulation programmes for preparation to practice [2], a group of doctors established a junior-led near-peer simulated patient teaching programme at a district general teaching hospital to supplement the medical education programme. With qualitative evaluation demonstrating positive reception from teachers and students, this study aimed to quantitatively evaluate the effectiveness of the programme on improving the knowledge of medical students/junior doctors and providing junior doctors with opportunities to gain teaching experience. Nine simulation teaching sessions were run between 7/1/22 – 31/3/22, with a total of 22 medical students and 17 Near-Peer Teachers (NPTs) [3] involved. Knowledge tests were completed by medical students and NPTs before and after each simulation session, as well as feedback forms enquiring about confidence in managing different cases (choosing from the options of: very confident; confident; mildly anxious; anxious). NPTs were also asked to report on their confidence in teaching cases and whether they wanted feedback by a supervising clinician in the form of ‘Developing the Clinical Teacher’ assessment; a mandatory task for foundation year trainees. The difference in examination scores and confidence rankings before and after the sessions were calculated for students and teachers, allowing for quantification of improvement following simulation sessions. Medical students demonstrated an average improvement in test score of 13% from a simulation teaching session, whilst NPTs had an average test score increase of 5%. 86% of students reported an improvement in confidence of managing cases related to their scenarios after the teaching session. 75% of NPTs reported an improvement in confidence of both managing and teaching scenarios. Almost half (46%) of foundation year doctors completed mandatory ‘Developing the Clinical Teacher’ assessment through this initiative. A junior-led simulated patient teaching programme improves both medical student and NPT knowledge of managing clinical on-call scenarios. This programme also contributed to foundation year trainees achieving the mandatory teaching assessments. Such programmes benefit both students and teachers demonstrating the potential for junior-led programmes to supplement student teaching and doctor training programmes. 1. Monrouxe L, Grundy L, Mann M, John Z, Panagoulas E, Bullock A, Mattick K. How prepared are UK medical graduates for practice? A rapid review of the literature 2009–2014. BMJ Open. 2017;7(1):e013656. 2. Manalayil J, Muston A, Ball A, Chevalier D. 1HR ON-CALL – Using Simulated ON-CALL to Underpin Experiential Learning in Final Year Medical Students. Journal of European CME. 2020;9(1):1832749. 3. Aba Alkhail B. Near-peer-assisted learning (NPAL) in undergraduate medical students and their perception of having medical interns as their near peer teacher. Medical Teacher. 2015;37(sup1):S33-S39.

Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey.

This national postal survey aimed to examine Canadian emergency physicians' practice patterns with respect to drug treatment and perspectives on peripheral nerve blocks. The treatment of primary headache disorders in the emergency department is variable. We surveyed 500 emergency physicians listed in the Canadian Medical Directory according to a modified Dillman's method: an initial invitation was followed by up to four reminders to nonresponders. Physicians were asked questions regarding their frequency of medication administration and perspectives toward peripheral nerve blocks. Of 500 mailed surveys, 468 were delivered and 179 physicians responded (response rate = 38.2%). The majority of physicians were men (92/144, 63.9%); 80.6% (116/144) had been in practice for greater than or equal to 10years with 50.7% (75/148) in a community or district general teaching hospital. Commonly used pharmacotherapies for primary headaches were intravenous dopamine receptor antagonists (69%), co-administration of ketorolac and a dopamine receptor antagonist (54.2%), intravenous fluid boluses (54%), nonsteroidal anti-inflammatory drugs (NSAIDs) alone (53.5%), and acetaminophen (51.4%). Only 80 of 144 physicians (55.6%) reported previous experience with peripheral nerve blocks (95% confidence interval [CI] = 48%-65%). The majority (68/80, 85.0%) agreed peripheral nerve blocks are safe and 55.1% (43/78) agreed they are effective. The vast majority (118/140, 84.3%) would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial (95% CI = 78%-90%). NSAIDs alone, as well as dopamine receptor antagonists with or without ketorolac are commonly used for primary headache in Canadian emergency departments. A large proportion of physicians have never used a peripheral nerve block in their practice; among those who have experience with peripheral nerve blocks, the majority find them safe and effective. The majority of respondents would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial.

Seizures and emergency department: characteristics and factors of repeat adult attendees.

To identify risk factors and characteristics for the repeated attendance at an emergency department (ED) following a seizure. A retrospective cohort study was conducted using non-identifiable data of individuals attending ED at least twice between 2015 and 2018, following a seizure. Data were drawn from the patient administration system of an English rural medium-sized teaching district general hospital emergency department (ED), serving a population of 566,000 people. It was analysed for bio-psycho-social features associated with repeat attendances. Of 3522 seizure-related attendances in the four years, 450 people were identified to be repeaters attending on two or more occasions (range 2-12). Just over a quarter (27%) were 18-29years old. Higher likelihood of re-attendance was associated with social deprivation and no fixed abode. Mental illness was a significant co-morbidity influencing repeat attendances. Nearly half (47%) had no recorded anti-seizure medication (ASM). Three fifth (60%) were on general medication and a quarter (25%) on psychotropics. Nearly a quarter (22%) had alcohol and recreational drug concerns. Just over a quarter (28%) had no previous epilepsy diagnosis. Nearly a fifth (n = 85, 19%) died during the study period. People who present repeatedly with seizures at ED are at significant risk of death over a four-year period and require pro-active clinical follow-up. People who are homeless or from socially deprived areas are over-represented in this group, as are those with alcohol problems, co-morbid mental health conditions and compliance issues. This suggests enhanced targeted intervention for this cohort is needed.

Exploring pharmacist involvement in the discharge medicines reconciliation process and information transfer to primary care: an observational study.

Background Medication errors can occur because of incomplete or poorly communicated information at the transition from hospital to community. Following an audit in 2016, a project was undertaken to determine if pharmacists could improve the quality of medication information in discharge summaries by introducing a discharge medication reconciliation process. Pharmacists recorded any changes to the patient's medication in the electronic prescribing system during their inpatient stay and summarised these changes on discharge. Objective To compare medication information in discharge summaries with recognised standards for the clinical structure and content of patient records, and to assess the impact of the pharmacist process on compliance with certain elements of these standards. Setting A 750 bed teaching district general hospital in England. Method A retrospective observational study examining all patient discharge summaries over a 1week period for compliance to national standards. Main outcome measure The main outcome measures were compliance with standards for medication started, stopped or changed in hospital and any differences between extent of recording this information by doctors and pharmacists. Results Data were collected and analysed for 243 patients, of whom 94 (38.7%) attracted a discharge medicines reconciliation process by a pharmacist. Discharge summaries were compliant with basic standards for changed medication in 42% of patients or 51.4% with the input of a pharmacist. This increase of 9.4% was statistically significant (p = 0.0365). At an enhanced level, pharmacists increased compliance from 39.1 to 46.5%, this did not represent a significant increase (p = 0.0989). Conclusion Pharmacists undertaking a discharge medication reconciliation process significantly improves the quality of discharge summaries.

Surgical Fluid Prescribing: When Are the Last Orders?

IntroductionInappropriate fluid prescriptions result in excess morbidity and mortality in surgical patients. The majority of prescriptions are done by foundation year one doctors (FY1s) despite repeated evidence of poor knowledge and prescription habits among them when it comes to prescribing fluids.Materials and methodsThis was a retrospective observational study conducted at a 798-bed district general teaching hospital. Data for one year from an out-of-hours (OOHs) electronic task record system was extracted. An analysis was performed on all surgical ‘Fluid Reviews’ jobs recorded in the period from August 1, 2018, to August 7, 2019.ResultsDuring the 371-day study period, 1,283 requests for fluid reviews were made. Of these, 1,228 (95.7%) were assigned to the FY1 and 1,185 (92.3%) were requested by nurses. There was a mean of 3.5 ±2.1 requests per day. A bimodal distribution of requests was noted with peaks at 1900 and 2400. There was no discernible variation between different days of the week.ConclusionFluid reviews were most frequently requested by nursing staff at times that coincide with their handover and the commencement of a new fluid chart at midnight. Reducing the number of inappropriate requests for fluid reviews may reduce the opportunity for inappropriate fluid prescribing. Improvements could be achieved through interventions in the ward rounds and by encouraging a multidisciplinary approach to education on fluid prescribing. Reducing the number of fluid prescriptions OOHs promotes continuity of care and education through patient follow-ups.

Using targeted education to improve acute hospital nurses’ knowledge and attitudes regarding pain assessment and management

The assessment and management of pain in acute hospitals has been shown to be suboptimal in literature dating back to the 1950s. Inadequate pain management is thought to be partly due to knowledge gaps and suboptimal attitudes among healthcare professionals regarding pain assessment and management. The literature focuses on measuring and comparing knowledge scores, but it is necessary to understand where the knowledge gaps are and how to fill them. This article presents the findings of an evaluation project conducted across the acute sector of a district general teaching hospital. The project aimed to improve knowledge and attitudes, among nurses, regarding pain assessment and management with a targeted educational intervention.

Airway management in the critically ill patient - How can we improve?

Introduction The NAP4 demonstrated adverse airway outcomes are associated with poor airway assessment and poor planning. 25% of major airway events occur in the Intensive Care Unit (ICU) or emergency department (ED), and the outcome of these events are more likely to lead to permanent harm or death compared with the operating theatre. This study set out to review documentation of intubations in ICU patients, including the pre-procedure planning taking place to identify areas for improvement. Methods Single institution retrospective review of documentation of endotracheal intubations performed by ICU staff (on either ICU or a ward/ED) over a six week period in an English district general teaching hospital. Criteria assessed were: use of a pre-intubation checklist, documentation of name and grade of intubator, airway assessment, time of intubation, drugs and doses given, number of attempts at intubation, use of cricoid pressure, laryngoscopy grade, ETT size + length at teeth, type of laryngoscope used, monitoring used (including etCO2), ventilator settings and any complications. Results In the 6 week study period, there were 15 intubation episodes identified and reviewed (12 on ICU, 3 in ED). See attached table for full results. Discussion The lowest performing domain was airway assessment (0%). The explanation for this is likely in part due to the acutely unwell nature of ICU patients making airway assessment more challenging than in an elective setting. Another particularly low scoring domain was the use of a pre-procedure checklist (33%). Considering the NAP findings associating adverse airway events with poor airway assessment and planning, these are concerning findings, and unlikely to be isolated to this hospital. We suggested education to promote the routine use of a pre-intubation checklist that incorporates an airway assessment and procedural plan.

ChroniSense National Early Warning Score Study (CHESS): a wearable wrist device to measure vital signs in hospitalised patients—protocol and study design

IntroductionThe National Early Warning Score is used as standard clinical practice in the UK as a track and trigger system to monitor hospitalised patients. Currently, nurses are tasked to take...

Accuracy of pharmacist electronic discharge medicines review information transmitted to primary care at discharge.

Background The poor quality of discharge summaries following admission to hospital, especially in relation to information on medication changes, is well documented. Hospital pharmacists can record changes to medications in the electronic discharge note to improve the quality of this information for primary care. Objective To audit the pharmacist-completed notes describing changes to admission medication, and to identify improvement opportunities. Setting 750-bed teaching district general hospital in England. Methods An evaluation of pharmacist written notes was conducted at a 750-bed teaching district general hospital in England. A sample of notes was analysed in three consecutive years, 2016-2018. Analyses were performed using descriptive statistics. Main outcome measure The number of discrepancies in the note compared to the discharge summary medication list. Results Notes were analysed for 125, 120 and 120 patients in 2016-2018 respectively. We saw an overall improvement in the accuracy of our notes from 12% of patients having an inaccurate note in 2016 to 4.2% in 2017 and 5.8% in 2018. The percentage of discharge medicines affected by these discrepancies reduced from 1.7% (2016) to 0.6% (2017) and 0.9% (2018). Conclusion Discrepancies were due to changes in the patient's medicines journey not being fully captured and documented. The overall reduction of discrepancies over the three consecutive audits was felt to be largely due to formalisation of the discharge medicines reconciliation process and reminding staff on how to complete a note. We are planning to utilise informatics surveillance tools along with system developments to sustain this elimination of out of date notes being transmitted to primary care.

Patients’ perspective of physician associates in an acute medical unit within an English district general teaching hospital – a pilot survey study

Physician associates (PAs) are valuable members of the -medical team. However, few data are available concerning their role and contributions in acute settings from the perspective of patients. The current study explored patients' acceptance of the role of PAs in the NHS. A questionnaire was distributed to 100 patients who were under care of PAs in the acute -medical unit (AMU) of George Eliot Hospital. The questionnaire explored previous exposure to PAs, satisfaction in PA's attitude and knowledge, PA value to NHS and overall satisfaction in PA profession. Fifty women (58.1%) and 36 men (41.9%) with a mean age of 74.75 ± 10 years participated in the study. Most of the survey responders stated that the attitudes, professionalism and medical knowledge of PAs were good or very good and nearly all of respondents were satisfied or very satisfied with the role of PAs in the NHS. This pilot questionnaire survey study in the AMU of an English district general teaching hospital showed that most study participants valued the role of PAs in the NHS.

A UK hospital survey to explore healthcare professional views and attitudes to patients incorrectly labelled as penicillin allergic: an antibiotic stewardship patient safety project

ObjectivesTo ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic...

Fatal pulmonary embolism following elective total knee replacement using aspirin in multi-modal prophylaxis — A 12 year study

BackgroundThe National Institute for Health and Clinical Excellence (NICE) has issued guidelines on which thromboprophylaxis regimens are suitable following lower limb arthroplasty. Aspirin is not a recommended agent despite being accepted in orthopaedic guidelines elsewhere. We assessed the incidence of fatal pulmonary embolism (PE) and all-cause mortality following elective primary total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching district general hospital. MethodsWe utilised a prospective audit database to identify those that had died within 42 and 90days postoperatively. Data from April 2000 to 2012 were analysed for 42 and 90day mortality rates. There were a total of 8277 elective primary TKR performed over the 12year period. The multi-modal prophylaxis regimen used unless contraindicated for all patients included 75mg aspirin once daily for four weeks. Case note review ascertained the causes of death. Where a patient had been referred to the coroner, they were contacted for post mortem results. ResultsThe mortality rates at 42 and 90days were 0.36 and 0.46%. There was one fatal PE within 42days of surgery (0.01%) who was taking enoxaparin because of aspirin intolerance. Two fatal PE’s occurred at 48 and 57days post-operatively (0.02%). The leading cause of death was myocardial infarction (0.13%). ConclusionsFatal PE following elective TKR with a multi-modal prophylaxis regime is a very rare cause of mortality.

An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial

Objective To investigate whether an early rehabilitation intervention initiated during acute admission for exacerbations of chronic respiratory disease reduces the risk of readmission over 12 months and ameliorates the negative...

Acute oncology and palliative care: two sides of the same coin?

The aim of the acute oncology service is to provide a systematic approach to dealing with cancer related emergencies in order to optimise the care of patients presenting to hospital...

PTH-066 Specialist nurse-led percutaneous endoscopic gastrostomy insertion and patient assessment in modern-day practice

Introduction PEG feeding improves prognosis and general state of health when patients cannot maintain adequate nutrition. Some hospitals now have nutrition teams who review percutaneous endoscopic gastrostomy (PEG) requests. The PEG Clinical Nurse Specialist (CNS) can provide information/advice/counselling for patients and relatives on PEG feeding, aftercare and follow-up as well as being an integral part of the Upper GI multidisciplinary team. Methods Aims: To assess the role of the Specialist nurse lead PEG service in an associate teaching district general hospital (DGH). We retrospectively assessed 178 PEG referrals to the service over the period 2006–2008 in our DGH. All PEG referrals are assessed by a CNS who recommends appropriateness of PEG insertion or deflects inappropriate referrals. Data were obtained from the CNS records along with endoscopy software and from patient9s clinical data. Results 178 PEGs inserted in the period 2006–2008. Of these referrals, 44 (25%) were declined due to ill health and deemed as inappropriate (eg, advanced severe dementia). Of these 44 patients following assessment, 6 (13%) started eating and drinking within 48 h, 3 (6.8%) died within 24 h, 4 (9%) died within 72 h. 144 PEGs were inserted one failed due to difficulty in positioning. 38 (26.5%) were inserted by the CNS, and 105 (73.5%) were performed by 11 doctors in the same period. 11 (7.6%) of these were performed as day-case procedures. The nurse specialist requested a second opinion and consultant review for only six patients (3.3%). The CNS assessed and followed up all the 144 patients prior to PEG insertion and provided aftercare. PEG referrals required 60 min on average per patient assessment by the CNS, furthermore the actual PEG insertion average time was 30 min/patient. There were 2 (1%) complications due to minor bleeding from the skin incision. There were 14.6% (21 patients) deaths recorded at 30 days post insertion. Conclusion In our experience, specialist nurse led PEG service prevented inappropriate PEG insertion in 25% of all referrals and reduced significant clinical commitment for doctors with only requiring advice from consultant in 3%, saving 250 h of clinical assessment and review time. This service also helped reduce waiting times for patient assessment and improved the quality of the service offered by increasing continuity of care and closer liaison with dietician, ward nurses along with patients and their relatives. Our complication/mortality rates compared favourably at 1% and 15%, respectively, to the BSG announcement in 2006 suggesting that minor complications are around 15% and mortality up to 28%. For a modern day PEG service from our data, we recommend a Nurse Lead PEG assessment/insertion and follow-up service in all hospitals not offering this.

Changes in Outcome during Implementation of a Fast-Track Colonic Surgery Project in a University-Affiliated General Teaching Hospital

Background and Aims: The aim of this study was to investigate whether changes can be accomplished rapidly after implementing a fast-track colonic surgery project at a university-affiliated general teaching hospital. Methods: In 2004 and 2005 all colonic surgery patients were recorded for a number of pre-, per- and postoperative care elements. In 2006, during the implementation of a fast-track program, changes were recorded. Results: Before the implementation of the fast-track regime at our hospital, 97% of the patients (n = 89/92) received mechanical bowel preparation, in contrast to 3% (n = 1/36) afterwards (p < 0.0001). The application of thoracic epidural analgesia rose from 46% (n = 42/92) in 2004 and 2005 to 94% (n = 34/36) in 2006 (p < 0.0001). The use of nasogastric tubes postoperatively almost disappeared. 77% (n = 28/36) enjoyed a small meal on the 1st day after operation, compared to 0% (n = 0/92) in 2004 and 2005 (p < 0.0001). Median hospital stay was 6 (range 3–27) nights in 2006 compared to 9 (range 3–25) nights in 2005 and 9.5 (range 7–64) nights in 2004 (p < 0.005). Conclusion: These preliminary results show that also at a district general teaching hospital advantages can be reached rapidly and safely by implementing fast-track surgery; especially a faster recovery.