Follow-up Arrangements Research Articles

Improving patient discharge process using electronic medication input tool and on-line guide to arranging follow-ups.

Complete, accurate and timely discharge summaries (TTOs) enable effective communication between hospital teams and GPs. It can prevent adverse events and reduce hospital readmission rates (1). If the discharge summary does not contain important information (e.g. follow-up arrangements, accurate discharge medication list), or if follow-up arrangements are not made, then patient care and outcome can be adversely affected (2,3).An electronic Medication Input Wizard was developed to improve the quality and reduce the error rates of TTOs. The Wizard makes entering drug information faster; prompts for reasons medication changes; provides examples for Controlled Drug (CD) prescribing; and prompts to refer patients taking warfarin to anticoagulation clinic. An on-line guide was developed which explains how to arrange investigations and appointments. Retrospective studies of TTOs were carried out before and after these interventions, analysing documentation of medication and completion of intended follow-up arrangements.A baseline audit found 65% of medication changes on TTOs were not clearly documented, and only 8% with changes documented reasons. 40% of prescriptions for CDs were incorrect delaying discharge by 4.9 hours per patient. 80% of intended follow-ups actually happened.After intervention, TTOs written using the Wizard had 100% of medication changes documented, and 75% were documented with reasons. CD errors decreased to 28% (76% of errors were done without using the Wizard). Follow-up arrangements that occurred increased to 86%. A survey showed 78% of Doctors reported the Wizard was faster than typing the details in separate textboxes, and 94% believed it was beneficial.Systems should be optimised to encourage better documentation of medication details and reduce prescribing errors. Guides that explain how to make follow-up arrangements should be accessible to Doctors, to make sure follow-ups are organised correctly.

Primary care follow-up and measured mental health outcomes among women referred for ultrasound assessment of pain and/or bleeding in early pregnancy: a quantitative questionnaire study

ObjectivesTo examine the extent of primary care follow-up and mental health outcomes among women referred for ultrasound assessment of pain and/or bleeding in early pregnancy, including those whose pregnancy is...

Endoscopy Reporting Standards

The Canadian Association of Gastroenterology (CAG) recently published consensus recommendations for safety and quality indicators in digestive endoscopy. The present article focuses specifically on the identification of key elements that should be found in all electronic endoscopy reports detailing recommendations adopted by the CAG consensus group. A committee of nine individuals steered the CAG Safety and Quality Indicators in Endoscopy Consensus Group, which had a total membership of 35 voting individuals with knowledge on the subject relating to endoscopic services. A comprehensive literature search was performed with regard to the key elements that should be found in an electronic endoscopy report. A task force reviewed all published, full-text, adult and human studies in French or English. Components to be entered into the standardized report include identification of procedure, timing, procedural personnel, patient demographics and history, indication(s) for procedure, comorbidities, type of bowel preparation, consent for the procedure, pre-endoscopic administration of medications, type and dose of sedation used, extent and completeness of examination, quality of bowel preparation, relevant findings and pertinent negatives, adverse events and resulting interventions, patient comfort, diagnoses, endoscopic interventions performed, details of pathology specimens, details of follow-up arrangements, appended pathology report(s) and, when available, management recommendations. Summary information should be provided to the patient or family. Continuous quality improvement should be the responsibility of every endoscopist and endoscopy facility to ensure improved patient care. Appropriate documentation of endoscopic procedures is a critical component of such activities.

Reducing short-stay hospital admissions by ruling out non-ST elevation myocardial infarction and estimating coronary artery disease likelihood on an emergency department observation ward.

Chest pain is an important presentation in adult patients attending emergency departments (ED). The process of ruling out an acute coronary syndrome (ACS) conventionally requires a short in-patient stay. This places a significant burden on healthcare systems. Recent developments have encouraged us to explore the role of an ED observation ward in the management of these patients.We designed and implemented two proformas (‘flowformas’). The first provides integrated guidance and documentation for the management of chest pain in the ED. In patients determined to be at low risk of short-term adverse outcomes the ACS rule-out process is now completed on the ED observation ward rather than on the cardio-respiratory admission ward. The second proforma is used before discharge to determine the likelihood of underlying coronary artery disease (CAD), thereby allowing risk-based follow-up arrangements to be made. We collected data on all patients admitted to EDU on the NSTEMI rule-out pathway over a 12-month period.Between Feb 2012 and Feb 2013, 816 patients fulfilling the criteria were admitted on the pathway. 67 patients (8%) required admission due to ACS. 15 patients were admitted on two, and one on three occasions.In conclusion, it is possible to deliver ACS rule-out on an emergency observation ward. This reduces healthcare costs and shortens hospital stay.

Outcomes in Canadian Emergency Department Syncope Patients – Are We Doing a Good Job?

BackgroundLittle is known about the outcomes of adults with syncope seen in Canadian Emergency Departments (EDs). ObjectivesWe sought to determine the frequency, timing, and type of serious adverse outcomes occurring in these patients, and the proportion that occur outside the hospital. MethodsWe conducted a health records review of syncope patients presenting to a tertiary care ED over an 18-month period. We included all patients older than 16 years of age who fulfilled the syncope definition (sudden transient loss of consciousness with spontaneous complete recovery), and excluded those with altered mental status, alcohol or illicit drug use, seizure, or trauma. We assessed for outcomes in the ED and after ED disposition. We also evaluated follow-up arrangements for patients discharged from the ED. ResultsOf the total 87,508 patient visits, 505 (0.6%) were due to syncope. The mean age was 58.5 years (range 16–101 years), 70.1% arrived by ambulance, and 12.3% were admitted to the hospital. Five patients died: 2 in the ED, 1 as an inpatient, and 2 after discharge. Overall, there were 49 (9.7%) serious outcomes, with dysrhythmias being the most common (4.6%); 22 (4.4%) occurred in the ED, 15 (3.0%) in the hospital, and 12 (2.4%) outside the hospital. Eight serious outcomes occurred in patients discharged from the ED without any planned follow-up. ConclusionAlthough syncope represented < 1% of all patient visits, morbidity was substantial, particularly in patients discharged from the ED. Future research should help clinicians identify syncope patients at high risk for serious outcomes.

Hrozba CBRN látek se zaměřením na třídu biologických agens (Modelový příklad pro letiště)

This article describes the question of CBRN and their possible abuses in civil aviation. The problem includes security analysis identified by the Civil Aviation as the most significant class of this group-biological agents. The authors pay them special attention. The second part of paper contains model situation in case of emergency: virus variola (smallpox) attack in a terminal of medium-size international airport. Depending on the detailed properties of virus, transport hub and afflicted area, there are two versions of attack- for summer and winter timetable, according to expected progress of virus extension, and follow-up arrangements.

Impact of Dietary Protein Exchange 0n Patient’s Compliance, Applicability and Efficiency in Chronic Kidney Disease

The application of Low Protein Diet (LPD) in the treatment of CKD has been more accepted by all medical stuffs nowadays. However, the diversity and complexity of therapeutic diet as well as being difficult to obtain more detailed consultation have caused poor long-term maintenance and compliance in most patients.To investigate patient’s compliance to dietary therapy as well as the impact of Dietary Protein Exchange (DPE) on patient’s compliance in CKD patients.To investigate patient’s self understanding and prehension to educational resources on DPE in CKD patients.CKD patients are diagnosed in clinics from 6 hospitals according to the random digits table. 200 enrolled patients are randomly divided into test groups and control groups after signing the concent forms.Test groups:Face to face education of the utilization of new DPE as well as attentions in follow-up is conducted by dietitians.Control groups:Regular face to face counseling as well as attentions in follow-up is conducted by dietitians.Time arrangement for follow-up,3 times within 24 weeks (week 4, 12 and 24 respectively).180 cases completed the trail. Compared with control group, the test group patients’s compliance with DPI was better, 58.5±6.8 gvs45.6±8.9 g p

751 OPTIMAL FOLLOW-UP ARRANGEMENTS FOR INVASIVE SQUAMOUS CARCINOMA OF THE PENIS

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease II1 Apr 2012751 OPTIMAL FOLLOW-UP ARRANGEMENTS FOR INVASIVE SQUAMOUS CARCINOMA OF THE PENIS Hussain M. Alnajjar, Matthew J.A. Perry, Rowland W. Rees, Catherine M. Corbishley, and Nick A. Watkin Hussain M. AlnajjarHussain M. Alnajjar London, United Kingdom More articles by this author , Matthew J.A. PerryMatthew J.A. Perry London, United Kingdom More articles by this author , Rowland W. ReesRowland W. Rees London, United Kingdom More articles by this author , Catherine M. CorbishleyCatherine M. Corbishley London, United Kingdom More articles by this author , and Nick A. WatkinNick A. Watkin London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.837AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Follow up arrangements for squamous cell carcinoma of the penis (SCCp) are generally based on small retrospective studies. EAU guidelines recommend close follow up for 5 years in all patients. We aimed to provide more stratified follow-up arrangements based on risk of recurrence derived from a large contemporary series of patients treated at a single supra-network centre. METHODS Prospective review of all newly diagnosed primary SCCp treated surgically from 2000-2011. Tumour recurrence was defined as local (penile), regional (inguinal), distant recurrence (pelvic nodes/metastatic) at least 3 months after definitive primary surgery. Inclusion criteria: all patients regardless of tumour grade who had penile surgery leaving no residual glanular epithelium, with clear local margins, fully staged regional nodes and pathological N stage pN0/pN1. RESULTS 228 of 420 (54%) newly diagnosed SCCp patients met the inclusion criteria. All were fully staged with sentinel node biopsy or prophylactic node dissection and confirmed to have N0/N1 nodal status. In the first 12 months surveillance there were 5 local, 2 regional and 2 distant recurrences (3.9%). 2/228 developed late local recurrence (17 and 29 months). Both had G1T1 lesions locally excised. No patient had nodal or metastatic disease after 12 months. The remainder of the patients remained disease free at a mean of 44 months follow up. CONCLUSIONS For patients who have penile surgery which removes all glanular epithelium and have been staged N0 or N1, there are few recurrences overall, and the majority occur within 12 months of primary treatment. We therefore recommend a maximum follow up of one disease-free year for this sub-group who represent a significant proportion (54%) of all patients with invasive cancer. This will reduce the burden of unproductive surveillance. All other patients should continue to be followed up five years. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e307 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hussain M. Alnajjar London, United Kingdom More articles by this author Matthew J.A. Perry London, United Kingdom More articles by this author Rowland W. Rees London, United Kingdom More articles by this author Catherine M. Corbishley London, United Kingdom More articles by this author Nick A. Watkin London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Improving patient follow-up after inpatient stay.

Follow-up is a vital part of ongoing patient safety. It allows for subsequent investigations to be checked and acted upon, encourages specialist review of patients and ensures that patients with chronic conditions receive the appropriate secondary care input. This study aims to highlight and quantify current problems with how follow-up arrangements are made within our hospital and provide a suitable solution to ensure that these problems are minimised. 20 sets of clinical notes were analysed for plans of follow-up and then compared with the discharge summaries produced. Hospital computer systems were used to find out which interventions happened, and when, to get the baseline data. A simple follow-up prompt sheet was introduced and a further 20 sets of notes were audited to complete the study. Patient follow-up improved after the introduction of a simple follow-up prompt sheet but highlighted the need for a complete change in the way follow up is arranged at our hospital. There is a need for an online system for requesting follow-up appointments in our hospital. This is vital given the 24 hour environment that we work in with many patients being discharged out of normal working hours. This is currently being discussed with management and we hope that the introduction will be imminent to improve the future safety of all patients.

The association between childhood cognitive ability and adult long-term sickness absence in three British birth cohorts: a cohort study

ObjectivesThe authors aimed to test the relationship between childhood cognitive function and long-term sick leave in adult life and whether any relationship was mediated by educational attainment, adult social class...

Emergency and out of hours care of patients with inherited bleeding disorders

Recently, the United Kingdom Haemophilia Centre Doctors Organisation published recommendations for the standard of care for assessment and treatment of patients with bleeding disorders in the emergency department (A&E). An audit was undertaken to compare the level of care to the acceptable standards in a tertiary hospital A&E, attached to a haemophilia comprehensive care centre. A&E attendances were found by cross referencing all patients with known bleeding disorders against the EDMS attendance system. Visits from the past 3 years were identified to produce sufficient data and electronic notes from these visits were then accessed, and marked against the proforma. Data were available from 45 of a total of 54 patients, who had a total of 75 emergency visits documented. In all aspects of care, the standards were not adequately met including the average length of time between booking and clinical assessment, early initiation of specific haemostatic treatment, seeking haematology advice and arrangement of follow-up. Also no specialist clotting investigations were done with only 9/11 patients admitted having their haematological diagnosis recorded. In addition, only very few patients had the severity of bleeding disorder noted and less than half their first line treatment documented. There were significant differences in the standard of care for haemophilia patients provided by the A&E department when compared with acceptable standards. Measures have been put in place and policies have been drafted to improve this situation and provide the best possible care to persons with haemophilia.

Tympanic Membrane Rupture in the Survivors of the July 7, 2005, London Bombings

The goal of this study was to analyze the prevalence of tympanic membrane rupture in the survivors of the London bombings of July 2005 and to assess whether tympanic membrane rupture provides a useful biomarker for underlying primary blast injuries. Cross-sectional study. Survivors of the 4 blasts of London bombings on July 7, 2005. Data were gathered from medical records and the London's Metropolitan Police evidence documenting the injuries sustained by 143 survivors of the blasts. All patients with tympanic membrane rupture or primary blast injury were identified. Analysis was made of distance against prevalence of tympanic membrane rupture. Correlation between tympanic membrane rupture and other forms of primary blast injury was then assessed. Results from the 143 survivors showed a 48% prevalence of tympanic membrane rupture across all 4 sites. Fifty-one patients had isolated tympanic membrane rupture with no other primary blast injuries. Eleven patients had tympanic membrane rupture and other primary blast injuries, but only one of these was an initially concealed injury (blast lung). Tympanic membrane rupture in survivors of the London bombings on July 7, 2005, had a high prevalence affecting half of patients across a range of distances from the blasts. Tympanic membrane did not act as an effective biomarker of underlying blast lung. In a mass casualty event, patients with isolated tympanic membrane rupture with normal observations and chest radiography can be monitored for a short period and safely discharged with arrangement for ear, nose, and throat follow-up.

Index of Suspicion in the Nursery

A 2.94-kg male infant is born at 39 weeks to a 19-year-old G1P0 woman. The pregnancy was complicated by gestational diabetes. The woman had no significant past medical history, including sexually transmitted diseases, and no significant family history. Prenatal screening for group B Streptococcus, Chlamydia, gonorrhea, syphilis, and human immunodeficiency virus were negative. Delivery is complicated by prolonged rupture of membranes for 18 hours, maternal fever (temperature of 38.9°C), and failure to progress. The baby is delivered in good condition by cesarean section. Apgar scores are 8 at 1 minute and 9 at 5 minutes. Vital signs are within normal limits, and physical examination at birth shows no abnormal findings of note. The infant is admitted to the newborn nursery for observation. Blood culture is drawn and empiric antibiotics are started. Hematologic parameters are within normal limits and C-reactive protein measures 0.5 mg/dL. Antibiotics are continued for suspected chorioamnionitis. He is otherwise feeding well, euthermic, and looking well, and his blood culture remains negative. On postnatal day 7, the nurse notices two vesicular skin lesions: one on the right side of the forehead (Fig. 1) and the other on the vertex of the scalp (Fig. 2). Both comprise groups of clustered tiny vesicles that have minimal erythema at their bases. Vital signs and physical examination findings are within normal limits. The result of a simple test supports the diagnosis, and further laboratory investigations confirm the cause. Figure 1. Vesicular lesions on the right side of the forehead. Figure 2. Vesicular lesions on the vertex of the scalp. # Case: Blister in a Baby: Benign or Bothersome? {#article-title-2} ### Differential Diagnosis Vesiculobullous lesions in neonates should never be ignored because the cause could range from benign, self-limited conditions to serious fatal diseases. Early diagnosis and management are crucial …

Non-surgical management of ectopic pregnancy: appropriate risk management must be in place

Advances in technology have facilitated early diagnosis of ectopic pregnancy, which in turn has increased the scope for non-surgical treatment. Unfortunately risks associated with such management, including maternal death, are coming to the fore. This paper highlights the risks and how they could be avoided. The risks include rupture of ectopic pregnancy during treatment with methotrexate or during expectant management, inadvertent administration of methotrexate to viable early intrauterine pregnancy, methotrexate embryopathy, allergic reaction to methotrexate, development of methotrexate pneumonitis and fatal administration of methotrexate to a woman with a concurrent medical problem. There is an urgent need for appropriate risk management procedures to be applied in units where non-surgical (i.e. expectant or medical) management of ectopic pregnancy is offered. Risk management should address organisational issues such as safe handling of the chemotherapeutic agent, prescription and supply, consent (informed choice), documentation and adequacy of follow-up arrangements. Women undergoing non-surgical management should have ready access (for example by telephone) to professional advice and to surgical intervention in the event of an emergency.

The incidence of pulmonary neoplasms discovered by serial computed tomography scanning after endovascular abdominal aortic aneurysm repair

Serial computed tomography (CT) scanning is routinely used to follow up endovascular exclusion of abdominal aortic aneurysms (AAAs). Nonvascular diseases can be identified, and these exams include images of the lung bases, which can provide information that leads to the diagnosis of pulmonary neoplasms. This study was conducted to determine the rate and type of pulmonary-based oncologic diseases identified by serial CT scanning of patients with endovascular repair of AAAs. A retrospective review of 138 consecutive patients receiving endovascular AAA exclusion during an 8-year period was performed. Length of follow-up and number of CT scans performed was recorded. CT characteristics of the lesion (size, character, and suspicion of malignancy), type of biopsy procedure performed, and final pathologic diagnosis were collected. Oncologic treatments and survival length were also evaluated. Pulmonary lesions were found in 25 patients (18%), of whom 5 (4%) died during follow-up, and 13 (9%) had stable, subcentimeter lesions and continue to have surveillance from vascular specialists only. Seven patients (5%) with pulmonary lesions were referred for evaluation by thoracic surgeons. Six patients (4%) underwent biopsy of the lesion and were diagnosed with cancer. One patient refused a biopsy and is being monitored with serial CT scans. Four lung cancers (1 small cell and 3 non-small cell), one primary pulmonary carcinoid tumor, and one B-cell lymphoma were discovered. No changes were noted in the lesions in the patient receiving CT surveillance. More than half of the cancers were diagnosed in stage I, with a mean lesion diameter of 11 mm at biopsy. Of 25 patients with pulmonary nodules, 24 were men. The patients diagnosed with cancer are all still alive, with a mean survival length of 2.5 years (range, 0.5-6 years) after oncologic treatment. Serial CT scans may reveal a high rate of pulmonary malignancies in a population with AAAs. Attention to the incidental finding of pulmonary nodules on CT scans and arrangement of appropriate follow-up by the vascular surgeon is important for patients undergoing surveillance after endovascular AAA repair. These results indicate that aggressive management of these lesions (early thoracic surgery consultation and biopsy) is appropriate in this high-risk population and may offer early diagnosis and improved long-term survival.

P234 BLF and BTS “Ready for home” survey of the experiences of patients admitted to hospital with COPD. Pt2: the discharge process

Introduction and ObjectivesA secure discharge from hospital following an admission for COPD is an important reflection of the quality of hospital care. Information about the discharge process will help inform...

A baseline study of anticoagulant management in UK hospitals

ObjectivesTo undertake a baseline study of the management of anticoagulants in order to allow later comparison of the impact of the National Patient Safety Agency (NPSA) patient safety alert (including...

Effect of Hospital Follow-up Appointment on Clinical Event Outcomes and Mortality

Decreasing hospital readmission and patient mortality after hospital dismissal is important when providing quality health care. Interventions recently proposed by the Centers for Medicare and Medicaid Services to reduce avoidable hospital readmissions include providing patients with clear discharge instructions and appointments for timely follow-up visits. Although research has demonstrated a correlation between follow-up arrangements and reduced hospital readmission in specific patient populations, the effect of hospital follow-up in general medicine patients has not been assessed. For this study, we reviewed hospital dismissal instructions for general medicine patients dismissed in 2006 from Mayo Clinic hospitals in Rochester, Minnesota (n = 4989), and determined whether specific appointment details for follow-up were documented. Survival analysis and propensity score-adjusted proportional hazards regression models were developed to investigate the association of follow-up appointment arrangements with hospital readmission, emergency department visits, and mortality at 30 and 180 days after discharge. Of the 4989 dismissal summaries, 3037 (60.9%) contained instructions for a follow-up appointment. No difference was found between those with a documented follow-up appointment vs those without regarding hospital readmission, emergency department visits, or mortality 30 days after dismissal. However, those with a documented follow-up appointment were slightly more likely to have an adverse event (hospital readmission, emergency department visit, or death) within 180 days after dismissal. Improved discharge processes, including arrangement of hospital follow-up appointments, do not appear to improve readmission rates or survival in general medicine patients. Therefore, national efforts to ensure follow-up for all patients after hospital dismissal may not be beneficial or cost-effective.

Spatial Pattern of Glaucomatous Visual Field Loss Obtained with Regionally Condensed Stimulus Arrangements

To assess the spatial distribution of glaucomatous visual field defects (VFDs) obtained with regionally condensed stimulus arrangements. Sixty-three eyes of 63 glaucoma subjects were examined with threshold-estimating automated static perimetry (full threshold 4-2-1 dB strategy with at least three reversals) on an automatic campimeter or a full-field perimeter. Stimuli were added by the examiner to regionally enhance spatial resolution in regions that were suspicious for a glaucomatous VFD. These regions were characterized by contiguous local VFDs, attributable to the retinal nerve fiber bundle course according to the impression of the examiner. The added stimulus locations were subsets of a predefined, dense perimetric grid. All VFD locations with P < 0.05 (total deviation plots) were assessed by superimposing the visual field records of all participants. Glaucomatous VFD loss occurred more frequently in the upper than in the lower hemifield, with a typical retinal nerve fiber-related pattern and a preference of the nasal step region. More than 50% of the eyes with predominantly mild to moderate glaucomatous field loss showed defective locations in the immediate superior paracentral region within an eccentricity of 3°. Conventional thresholding white-on-white perimetry with regionally enhanced spatial resolution reveals that glaucomatous visual field loss affects the immediate paracentral area, especially the upper hemifield, in many eyes with only mild to moderate glaucomatous visual field loss. Detailed knowledge about the spatial pattern and the local frequency distribution of glaucomatous VFDs is an essential prerequisite for creating regionally condensed stimulus arrangements for adequate detection and follow-up of functional glaucomatous damage.

Monoclonal gammopathy of undetermined significance: to screen or not to screen for multiple myeloma? – response

Monoclonal gammopathy of undetermined significance: to screen or not to screen for multiple myeloma? – response