English Trusts Research Articles

Bed occupancy and hospital mortality

British Journal of Healthcare ManagementVol. 22, No. 7 Money MattersBed occupancy and hospital mortalityRod JonesRod JonesSearch for more papers by this authorRod JonesPublished Online:18 Jul 2016https://doi.org/10.12968/bjhc.2016.22.7.380AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Boyle J, Zeitz K, Hoffman R, Khanna S, Beltrame J et al. (2013) Probability of severe adverse events as a function of hospital occupancy. IEEE J Biomed Health Inform 18(1): 15–20. doi: https://doi.org/10.1109/JBHI.2013.2262053. Crossref, Google ScholarGriffiths P, Ball J, Murrells T et al. (2015) Registered nurse, healthcare support workers, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open 5: e008751. doi: https://doi.org/10.1136/bmjopen-2015-008751 Crossref, Google ScholarHealth and Social Care Information Centre (2016) Summary Hospital-level Mortality Indicator. Available at: www.hscic.gov.uk/SHMI (accessed 15 June 2016) Google ScholarJones R (2011) Hospital bed occupancy demystified and why hospitals of different size and complexity must operate at different average occupancy. BJHCM 17(6): 242–8 Google ScholarJones R (2013) Optimum bed occupancy in psychiatric hospitals. www.priory.com/psychiatry/psychiatric_beds.htm (accessed 15 June 2016) Google ScholarJones R (2015) Recurring outbreaks of an infection apparently targeting immune function, and consequent unprecedented growth in medical admission and costs in the United Kingdom: A review. British Journal of Medicine and Medical Research 6(8): 735–70. doi: https://doi.org/10.9734/BJMMR/2015/14845 Crossref, Google ScholarJones R (2016a) Hospital bed occupancy and deaths (all-cause mortality) in 2015. BJHCM 22(5): 283–5 Google ScholarJones R (2016b) Is cytomegalovirus involved in recurring periods of higher than expected death and medical admissions, occurring as clustered outbreaks in the northern and southern hemispheres? British Journal of Medicine and Medical Research 11(2): 1–31. doi: https://doi.org/10.9734/BJMMR/2016/20062 Crossref, Google ScholarKaier K, Meyer E, Dettenkofer M, Frank U (2010) Epidemiology meets econometrics: using time-series analysis to observe the impact of bed occupancy rates on the spread of multidrug-resistant bacteria. J Hosp Infect 76(2): 108-13. doi: https://doi.org/10.1016/j.jhin.2010.04.010 Crossref, Google ScholarKaier K, Mutters N, Frank U (2012) Bed occupancy rates and hospital-acquired infections – should beds be kept empty? Clin Microbiol Infect 18(10): 941–5. doi: https://doi.org/10.1111/j.1469-0691.2012.03956.x Crossref, Google ScholarKuntz L, Mennicken R, Scholtes S (2014) Stress on the ward: Evidence for safety tipping points in hospitals. Manage Sci 61: 754-771. doi: https://doi.org/10.1287/mnsc.2014.1917 Crossref, Google ScholarNHS England (2016) Bed availability and occupancy data. https://www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-and-occupancy/bed-data-overnight/ (accessed 15 June 2016) Google ScholarOzdemir B, Sinha S, Karthikesalingam A, et al. (2016) Mortality of emergency general surgical patients and associations with hospital structures and processes. Brit J Anaesthesia 116(1): 1–9. doi: https://doi.org/10.1093/bja/aev372 Crossref, Google ScholarPublic Health England (2016) National End of Life Care Intelligence Network. www.endoflifecare-intelligence.org.uk/data_sources/place_of_death (accessed Google ScholarTeitelbaum A, Lahad A, Calfon N, Gun-Usishkin M, Lubin G, Tsur A (2016) Overcrowding in psychiatric wards is associated with increased risk of adverse events. Medical Care 54(3): 296–302. doi: https://doi.org/10.1097/MLR.0000000000000501 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 July 2016Volume 22Issue 7ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 18 July 2016 Published in print 2 July 2016 Information© MA Healthcare LimitedPDF download

The Adaptation, Face, and Content Validation of a Needs Assessment Tool: Progressive Disease for People with Interstitial Lung Disease.

Background: Irrreversible interstitial lung disease (ILD) is associated with high morbidity and mortality. Palliative care needs of patients and caregivers are not routinely assessed; there is no tool to identify needs and triage support in clinical practice.Objective: The study objective was to adapt and face/content validate a palliative needs assessment tool for people with ILD.Methods: The Needs Assessment Tool: Progressive Disease-Cancer (NAT:PD-C) was adapted to reflect the palliative care needs identified from the ILD literature and patient/caregiver interviews. Face and content validity of the NAT:PD-ILD was tested using patient/caregiver focus groups and an expert consensus group. Participants in the study were two English tertiary health care trusts' outpatients clinics. There were four focus groups: two patient (n = 7; n = 4); one caregiver (n = 3); and one clinician (n = 8). There was a single caregiver interview, and an expert consensus group—academics (n = 3), clinicians (n = 9), patients (n = 4), and caregivers (n = 2). Each item in the tool was revised as agreed by the groups. Expert consensus was reached.Results: Overall, the tool reflected participants' experience of ILD. Each domain was considered relevant. Adaptations were needed to represent the burden of ILD: respiratory symptoms (especially cough) and concerns about sexual activity were highlighted. All emphasized assessment of caregiver need as critical, and the role of caregivers in clinical consultations.Conclusions: The NAT:PD-ILD appears to have face and content validity. The inclusion of the family caregiver in the consultation as someone with their own needs as well as a source of information was welcomed. Reliability testing and construct validation of the tool are ongoing.

Quality of Quality Accounts: transparency of public reporting of Never Events in England. A semi-quantitative and qualitative review

To describe the quality of reporting and investigation into surgical Never Events in public reports. Semi-quantitative and qualitative review of published Quality Accounts for three years (2011/2-2013/14). Data on Never Events were compared with previously collated Never Events rates. Quality of reported investigations was assessed using the London Protocol. English National Health Service. All English acute hospital trusts. Quality of Never Event reporting. Quality Accounts were available for all Trusts for all three years, of which 342 referred to years when a surgical Never Event had occurred. A total of 125 of 342 (37%) accounts failed to report any or all Never Events that had occurred; 13/342 (4%) provided full disclosure; 197 (58%) reported that some investigation had taken place. Of these 197, 61 (31%) were limited in scope; 61 (31%) were categorised as detailed reports. Task and Technology factors were the commonest factor (103/211 (49%)) Identified in investigations, followed by Individual factors (48/211 (23%)). Team and Work environment factors were identified in 29/211 (14%) and 23/211 (11%), respectively. Organisational and Management 5/211 (2%) factors were rarely identified, and the Institutional context was never discussed. Reporting of Never Events and their investigations by English NHS Trusts in their Quality Accounts is neither consistently transparent nor adequate. As with clinical error, the true root causes are likely to be organisational rather than individual.

Overseas recruitment under review as demand continues to increase

The reliance the NHS has on foreign workers has been highlighted by a survey of English trusts that shows six out of ten nurses to be recruited next year will come from outside the European Economic Area (EEA).

Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study

ObjectivesTo examine associations between mortality and registered nurse (RN) staffing in English hospital trusts taking account of medical and healthcare support worker (HCSW) staffing.SettingSecondary care provided in acute hospital National...

Investigating healthcare IT innovations: a "conceptual blending" approach.

The purpose of this paper is to better understand how and why adoption and implementation of healthcare IT innovations occur. The authors examine two IT applications, computerised physician order entry (CPOE) and picture archiving and communication systems (PACS) at the meso and micro levels, within the context of the National Programme for IT in the English National Health Service (NHS). To analyse these multi-level dynamics, the authors blend Rogers' diffusion of innovations theory (DoIT) with Webster's sociological critique of technological innovation in medicine and healthcare systems to illuminate a wider range of interacting factors. Qualitative data collected between 2004 and 2006 uses semi-structured, in-depth interviews with 72 stakeholders across four English NHS hospital trusts. Overall, PACS was more successfully implemented (fully or partially in three out of four trusts) than CPOE (implemented in one trust only). Factors such as perceived benefit to users and attributes of the application - in particular speed, ease of use, reliability and flexibility and levels of readiness - were highly relevant but their influence was modulated through interaction with complex structural and relational issues. Results reveal that combining contextual system level theories with DoIT increases understanding of real-life processes underpinning implementation of IT innovations within healthcare. They also highlight important drivers affecting success of implementation, including socio-political factors, the social body of practice and degree of "co-construction" between designers and end-users. The originality of the study partly rests on its methodological innovativeness and its value on critical insights afforded into understanding complex IT implementation programmes.

Neonatal drug withdrawal syndrome: cross-country comparison using hospital administrative data in England, the USA, Western Australia and Ontario, Canada

ObjectivesWe determined trends over time in the prevalence of neonatal drug withdrawal syndrome (NWS) in England compared with that reported in the USA, Western (W) Australia and Ontario, Canada. We...

Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England

The largest outbreak of Ebola virus disease (EVD) is ongoing in West Africa. Air-travel data indicate that outside Africa, the UK is among the countries at greatest risk of importing a case of EVD. Hospitals in England were therefore instructed to prepare for the assessment and early management of suspected cases. However, the response of hospitals across England is undetermined. To evaluate the readiness of acute hospitals in England, and to describe the challenges experienced in preparing for suspected cases of EVD. A cross-sectional study using semi-structured telephone interviews and online surveys of all acute National Health Service (NHS) hospital trusts in England (hospital trusts are the vehicle by which one or more NHS hospitals in a geographical area are managed). In total, 112 hospital trusts completed the survey. All interviewed hospital trusts reported undertaking preparedness activities for suspected cases of EVD, and 97% reported that they were ready to assess suspected cases. Most hospital trusts had considered scenarios in accident & emergency (97%). However, fewer hospital trusts had considered specific obstetric (61%) and paediatric scenarios (79%), the provision of ventilatory and renal support (75%), or resuscitation in the event of cardiorespiratory arrest (56%). Thirty-four hospital trusts reported issues with timely access to category A couriers for sample transportation. Challenges included the choice, use and procurement of personal protective equipment (71%), national guidance interpretation (62%) and resource allocation/management support (38%). English hospital trusts have engaged well with EVD preparedness. Although subsequent national guidance has addressed some issues identified in this study, there remains further scope for improvement, particularly in a practical direction, for acute care services encountering suspected cases of EVD.

Variation in local trust Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies: a review of 48 English healthcare trusts

ObjectivesTo explore Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies from English acute, community and ambulance service Trusts for evidence of consistency and variation in implementation of national guidelines between healthcare...

Developing effective feedback on quality of anaesthetic care: what are its most valuable characteristics from a clinical perspective?

Research suggests that better feedback from quality and safety indicators leads to enhanced capability of clinicians and departments to improve care and change behaviour. The aim of the current study was to investigate the characteristics of feedback perceived by clinicians to be of most value. Data were collected using a survey designed as part of a wider evaluation of a data feedback initiative in anaesthesia. Eighty-nine consultant anaesthetists from two English NHS acute Trusts completed the survey. Multiple linear regression with hierarchical variable entry was used to investigate which characteristics of feedback predict its perceived usefulness for monitoring variation and improving care. The final model demonstrated that the relevance of the quality indicators to the specific service area (β=0.64, p=0.01) and the credibility of the data as coming from a trustworthy, unbiased source (β=0.55, p=0.01) were the significant predictors, having controlled for all other covariates. For clinicians to engage with effective quality monitoring and feedback, the perceived local relevance of indicators and trust in the credibility of the resulting data are paramount.

Antibacterial usage in English NHS hospitals as part of a national Antimicrobial Stewardship Programme

Antimicrobial resistance (AMR) has become a global problem for health care services, with fewer antimicrobials entering the market and some pathogenic organisms becoming resistant to commonly used antimicrobials. Antimicrobial stewardship (AS), including evidence-based standard setting, education and communication, and audits of practice, has become a key method of preventing the rise in the rise in AMR. Data on antibiotic consumption are often obtained through prospective and retrospective point prevalence audits of antibiotic usage, but such studies are very resource intensive and only provide a snapshot of consumption. The objective of the study reported here was to examine longitudinal total antibacterial usage at a national level and cross-sectional usage at an individual hospital trust level using a commercial database that captures antimicrobial prescribing from at least 99% of English hospital Trusts.

Enhanced Mean–Variance Portfolios: A Controlled Integration of Quantitative Predictors

<h3>Introduction</h3> The 4 h emergency standard for English acute trusts was introduced in 2003 and became full established by 2008 at 98% for all Emergency Department (ED) patients to be seen and discharged. This study examined the impact of the target for older patients attending departments. <h3>Methods</h3> Routine patient level data was received from 15 English EDs representing 774 095 individual patient attendances during May and June for 2003 to 2006. The data were used to determine the distribution of the total time spent in the EDs. Attendances were compared for older patients (65 years and above) with younger age groups. <h3>Results</h3> A total of 145 596 attendances were for patients aged 65+ years (18.9%). Across each year analysed, these older patients have a significantly longer median total time in the ED than those younger than 65 years (162 min vs 103 min, p&lt;0.001). In addition, older patients are significantly more likely to leave the emergency department in the last 20 min prior to 4 h (12.4% vs 5.2% in those &lt;65 years, p&lt;0.001). This proportion is growing year on year in both the admitted and discharged categories of patients. Finally, older patients are significantly more likely to breach the 4-h than their younger counterparts (16.6% vs 6.3%, p&lt;0.001). <h3>Conclusions</h3> There are some unintended consequences of introducing the 4 h target in UK emergency departments. While the target has reduced overall time in departments, the older patient appears to be disadvantaged relative to younger patients. Older patients are more likely to be ‘rushed through’ to other unmonitored areas of the hospital just prior to the target or to breach the target altogether. This finding calls in to question the benefits that the target is conveying for individual patients, and especially the most vulnerable in society.

The effect of organisational resources and eligibility issues on transition from child and adolescent to adult mental health services

To investigate the organisational factors that impede or facilitate transition of young people from child and adolescent (CAMHS) to adult mental health services (AMHS). Thirty-four semi-structured interviews were conducted with health and social care professionals working in child and adult services in four English NHS Mental Health Trusts and voluntary organisations. Data were analysed thematically using a structured framework. Findings revealed a lack of clarity on service availability and the operation of different eligibility criteria between child and adult mental health services, with variable service provision for young people with attention deficit hyperactivity disorder, autism spectrum disorders and learning disabilities. High workloads and staff shortages were perceived to influence service thresholds and eligibility criteria. A mutual lack of understanding of services and structures together with restrictive eligibility criteria exacerbated by perceived lack of resources can impact negatively on the transition between CAMHS and AMHS, disrupting continuity of care for young people.

Testing accelerated experience-based co-design: a qualitative study of using a national archive of patient experience narrative interviews to promote rapid patient-centred service improvement

BackgroundMeasuring, understanding and improving patients’ experiences is of central importance to health care systems, but there is debate about the best methods for gathering and understanding patient experiences and how to then use them to improve care. Experience-based co-design (EBCD) has been evaluated as a successful approach to quality improvement in health care, drawing on video narrative interviews with local patients and involving them as equal partners in co-designing quality improvements. However, the time and cost involved have been reported as a barrier to adoption. The Health Experiences Research Group at the University of Oxford collects and analyses video and audio-recorded interviews with people about their experiences of illness. It now has a national archive of around 3000 interviews, covering around 75 different conditions or topics. Selected extracts from these interviews are disseminated for a lay audience onwww.healthtalkonline.org. In this study, we set out to investigate whether or not this archive of interviews could replace the need for discovery interviews with local patients.ObjectivesTo use a national video and audio archive of patient experience narratives to develop, test and evaluate a rapid patient-centred service improvement approach (‘accelerated experience-based co-design’ or AEBCD). By using national rather than local patient interviews, we aimed to halve the overall cycle from 12 to 6 months, allowing for EBCD to be conducted in two clinical pathways rather than one. We observed how this affected the process and outcomes of the intervention.DesignThe intervention was an adapted form of EBCD, a participatory action research approach in which patients and staff work together to identify and implement quality improvements. The intervention retained all six components of EBCD, but used national trigger films, shortened the time frame and employed local service improvement facilitators. An ethnographic process evaluation was conducted, including observations, interviews, questionnaires, cost and documentary analysis including previous EBCD evaluation reports.SettingIntensive care and lung cancer services in two English NHS hospital trusts (Royal Berkshire and Royal Brompton and Harefield).ParticipantsNinety-six clinical staff (primarily nursing and medical) and 63 patients and family members.InterventionFor this accelerated intervention, the trigger film was derived from pre-existing national patient experience interviews. Local facilitators conducted staff discovery interviews. Thereafter, the process followed the usual EBCD pattern: the film was shown to local patients in a workshop meeting, and staff had a separate meeting to discuss the results of their feedback. Staff and patients then came together in a further workshop to view the film, agree priorities for improvement and set up co-design working groups to take these priorities forward.ResultsThe accelerated approach proved readily acceptable to staff and patients; using films of national rather than local narratives did not adversely affect local NHS staff engagement, and may in some cases have made the process less threatening or challenging. Local patients felt that the national films generally reflected important themes, although a minority felt that they were more negative than their own personal experience. However, they served their purpose as a ‘trigger’ to discussion, and the resulting 48 co-design activities across the four pathways were similar in nature to those in EBCD but achieved at reduced cost. AEBCD was nearly half the cost of EBCD. However, where a trigger film already exists, pathways can be implemented for as little as 40% of the cost of traditional EBCD. It was not necessary to do additional work locally to supplement the national interviews. The intervention carried a ‘cost’ in terms of heavy workload and intensive activity for the local facilitators, but also brought benefits in terms of staff development/capacity-building. Furthermore, as in previous EBCDs, the approach was subsequently adopted in other clinical pathways in the trusts.ConclusionsAccelerated experience-based co-design delivered an accelerated version of EBCD, generating a comparable set of improvement activities. The national film acted as an effective trigger to the co-design process. Based on the results of the evaluation, AEBCD offers a rigorous and effective patient-centred quality improvement approach. We aim to develop further trigger films from the archived material as resources permit, and to investigate different ways of conducting the analysis (e.g. involving patients in doing the analysis).FundingThe National Institute for Health Research Health Services and Delivery Research programme.

The Use and Functionality of Electronic Prescribing Systems in English Acute NHS Trusts: A Cross-Sectional Survey

ObjectivesTo describe current use of electronic prescribing (EP) in English acute NHS hospital trusts, and the use of multiple EP systems within the same hospital.DesignDescriptive cross-sectional postal survey.SettingAcute NHS hospital trusts in England.ParticipantsThe survey was sent to chief pharmacists in all acute English NHS hospital trusts in 2011. Where trusts comprised multiple hospitals, respondents were asked to complete the questionnaire for their main acute hospital.Main Outcome MeasuresPrevalence of EP use in acute NHS hospitals; number of different EP systems in each hospital; stages of the patient pathway in which EP used; extent of deployment across the hospital; comprehensiveness regarding the drugs prescribed; decision support functionalities used.ResultsWe received responses from 101 trusts (61%). Seventy (69%) respondent hospitals had at least one form of EP in use. More than half (39;56%) of hospitals with EP had more than one system in use, representing 60 different systems. The most common were systems used only for discharge prescribing, used in 48 (48% of respondent hospitals). Specialist chemotherapy EP systems were second most common (34; 34%). Sixteen specialist inpatient systems were used across 15 hospitals, most commonly in adult critical care. Only 13 (13%) respondents used inpatient electronic prescribing across all adult medical and surgical wards. Overall, 24 (40%) systems were developed ‘in-house’. Decision support functionality varied widely.ConclusionsIt is UK government policy to encourage the adoption of EP in hospitals. Our work shows that EP is prevalent in English hospitals, although often in limited clinical areas and for limited types of prescribing. The diversity of systems in use, often within the same hospital, may create challenges for staff training and patient safety.

P1 An analysis of 8,503 cases of mesothelioma from the National Lung Cancer Audit

BackgroundThe National Lung Cancer Audit records outcomes in lung cancer and mesothelioma on a population scale, in order to explain the wide variations seen within the UK and between the...

Epidemiology of Alzheimer's disease in Wales

BackgroundThere is a rapidly progressive increase in the ageing population around the world, especially in developed countries such as the UK, Japan, and Germany. Dementia is the third leading cause of death in the USA, on a par with cerebrovascular diseases. Alzheimer's disease is the most common cause of dementia, accounting for more than 60% of cases. There have been several studies on the incidence of dementia; however, many have been based at single sites or only within a suburb of cities. Studies on the incidence of Alzheimer's disease are even more limited. I aimed to study the epidemiology of Alzheimer's disease in individuals aged 60 years and older in Wales and the relation between Alzheimer's disease and age. MethodsI used the Patient Episode Database for Wales to identify patients who were diagnosed with Alzheimer's disease between 1999 and 2010. This database contains all inpatient and day case activity undertaken in NHS Wales in addition to data for Welsh residents treated in English Trusts. The data are gathered and coded at each hospital. The records are then electronically transferred to the NHS Wales Informatics Service, where they are validated and merged into the main database. There are about 100 000 episodes of care processed per month. The cases of Alzheimer's disease were extracted from the database using the International Classification of Diseases (version 10) diagnosis codes G300, G301, G308, G309. The incidence of Alzheimer's disease was calculated using the mid-year population estimates of Wales for each year of the study. The rates are expressed per 1000 person-years. A Poisson regression model was fitted to assess temporal trends. Rate ratios and 95% CIs were calculated and compared over the study period. The data were analysed using SPSS version 18.0 and the level of statistical significance at which the null hypothesis was rejected was 0·05. FindingsDuring the 12 years, 14 534 people were diagnosed with Alzheimer's disease in Wales (appendix). The overall prevalence of Alzheimer's disease in individuals 60 years or older was 1·8% and the overall incidence was estimated as 1·5 per 1000 person-years. However, this figure is likely to be a substantial underestimate because only patients who present to doctors are included in the database. The prevalence of Alzheimer's disease in individuals between 60 and 74 years was 0·5%, rising to 4·5% in those aged 75 years and older. The incidence of Alzheimer's disease increased during the study period from 1·4 per 1000 person-years in 1999 to 1·9 per 1000 person-years in 2010 (appendix). InterpretationThe incidence of Alzheimer's disease is progressively increasing in Wales. Prevalence and incidence rates rise with age. Public awareness needs to be enhanced to identify symptoms of Alzheimer's disease earlier, which will enable adequate support to be provided as soon as possible to extend patients' independence and slow the progression of symptoms. FundingNone.

Views of the chairs of Scottish health boards on engagement with quality management and comparisons with English trusts

To describe the views of the chairs of Scottish health boards on the engagement of their boards with healthcare quality and to compare them with the views of the chairs of boards of English acute trusts. The focus of the Scottish Health Boards is on providing and commissioning care, while in England the acute trusts only provide care. We mailed a questionnaire, based on one used in England, to the 14 health board chairs in NHS Scotland in January 2011. The results were compared with the results of a similar questionnaire given to English acute trust chairs in 2009. Most chairs in Scotland (67%) prioritised oversight of quality. Quality is considered at most Board meetings (92%), taking over 20% of time for 69% of chairs. Most boards have local quality targets and feedback quality data to staff. Compared with England, boards in Scotland meet less frequently and focus less on quality (shorter discussions, less frequent data review, fewer local targets) but they are more optimistic about their board's performance. Although most chairs of Scottish boards view quality as a priority, they pay less attention to it than chairs in England, possibly due to their additional role in commissioning care.

The National One Week Prevalence Audit of Universal Meticillin-Resistant Staphylococcus aureus (MRSA) Admission Screening 2012

IntroductionThe English Department of Health introduced universal MRSA screening of admissions to English hospitals in 2010. It commissioned a national audit to review implementation, impact on patient management, admission prevalence and extra yield of MRSA identified compared to “high-risk” specialty or “checklist-activated” screening (CLAS) of patients with MRSA risk factors.MethodsNational audit May 2011. Questionnaires to infection control teams in all English NHS acute trusts, requesting number patients admitted and screened, new or previously known MRSA; MRSA point prevalence; screening and isolation policies; individual risk factors and patient management for all new MRSA patients and random sample of negatives.Results144/167 (86.2%) trusts responded. Individual patient data for 760 new MRSA patients and 951 negatives. 61% of emergency admissions (median 67.3%), 81% (median 59.4%) electives and 47% (median 41.4%) day-cases were screened. MRSA admission prevalence: 1% (median 0.9%) emergencies, 0.6% (median 0.4%) electives, 0.4% (median 0%) day-cases. Approximately 50% all MRSA identified was new. Inpatient MRSA point prevalence: 3.3% (median 2.9%). 104 (77%) trusts pre-emptively isolated patients with previous MRSA, 63 (35%) pre-emptively isolated admissions to “high-risk” specialties; 7 (5%) used PCR routinely. Mean time to MRSA positive result: 2.87 days (±1.33); 37% (219/596) newly identified MRSA patients discharged before result available; 55% remainder (205/376) isolated post-result. In an average trust, CLAS would reduce screening by 50%, identifying 81% of all MRSA. “High risk” specialty screening would reduce screening by 89%, identifying 9% of MRSA.ConclusionsImplementation of universal screening was poor. Admission prevalence (new cases) was low. CLAS reduced screening effort for minor decreases in identification, but implementation may prove difficult. Cost effectiveness of this and other policies, awaits evaluation by transmission dynamic economic modelling, using data from this audit. Until then trusts should seek to improve implementation of current policy and use of isolation facilities.

The role of professional communities in governing patient safety

Using the example of medication safety, this paper aims to explore the impact of three managerial interventions (adverse incident reporting, ward-level support by pharmacists, and a medication safety subcommittee) on different professional communities situated in the English National Health Service (NHS). Semi-structured interviews were conducted with clinical and managerial staff from two English NHS acute trusts, supplemented with meeting observations and documentary analysis. Attitudes toward managerial intervention differ by professional community (between doctors, nurses and pharmacists) according to their existing norms of safety and perceptions of formal governance processes. The heterogeneity of social norms across different professional communities and medical specialties has implications for the design of organisational learning mechanisms in the field of patient safety. The paper shows that theorisation of professional "resistance" to managerialism privileges the study of doctors' reactions to management with the consequent neglect of the perceptions of other professional communities.