Galloway Royal Infirmary Research Articles

Design and implementation of two medical escape rooms: An educational case study

Escape rooms (ERs) have become increasingly popular as an interactive educational experience, especially in medical education. We present an educational case study covering the design, implementation and evaluation of two medical ERs. We created ERs for senior medical students from Glasgow University on rotation at Dumfries and Galloway Royal Infirmary. Students assessed and managed a patient presenting with either stroke or sepsis. The information gained during students' assessment 'unlocked' padlocks or generated codes providing further information or equipment. The ERs were evaluated following analysis of video recordings, debriefings and student and faculty feedback. Evaluation was focused on students' perceptions of the teaching experience, with changes made to the scenario design following student feedback and faculty reflection. Feedback was positive; students enjoyed the 'fun' nature of the learning experience. They felt they gained knowledge covering the subject areas and that the ERs also highlighted the importance of non-technical skills. We discuss the aspects of ER design and implementation that we learnt during the evaluation process. We have shown that medical ERs provide an immersive and engaging learning experience for students. We recognise a need for a more objective review of knowledge gained. We hope that by sharing our design and assessment of two medical ERs, we may inform and inspire other educators to consider ERs as an innovative learning experience.

450 Retrospective Analysis of Surgical Clerk-Ins Within the Acute Receiving Unit: A Quality Improvement Project

Abstract Introduction Accurate patient documentation at the ARU is vital to patient safety and ensuring smooth handovers to secondary care services. Because the nature of surgical treatment requires frequent patient handovers, and this increases the risk of miscommunication, we aimed to assess the quality of surgical clerk-ins and identify areas for improvement. Method Emergency admissions at the Dumfries Galloway Royal Infirmary were audited, looking at documentation quality under various clerk-in sections. Data was analysed before presentation to clinical governance. Results When 46 patient clerk-ins were examined, venous thromboembolism (VTE) prophylaxis plans were performed in only 24% of admissions - less than 1 in 4 patients. Comparing out-of-hours and in-hours patient documentation, much higher omission rates were identified in the out-of-hours documentation: in systemic enquiry (42 vs 100%) and family history (31% vs 66%). Conclusions These results brought to attention the effect of hospital admission timing on patient documentation quality, and the lack of VTE prophylaxis planning. In surgery, these plans are key to minimising risk of avoidable thromboembolic complications. A departmental meeting was convened to stress the importance of accurate and comprehensive clerk-ins to ARU doctors. Future audits could explore the factors influencing documentation quality for out-of-hours admissions, and ways to address these issues.

Growth in sales of custom-compounded menopause hormones

In 2002, the Women’s Health Initiative (WHI), a randomised control trial that studied oestrogen plus progestin in healthy postmenopausal women in the USA, linked the use of combined hormone therapy to high rates of heart disease, dementia, stroke, and some forms of cancer. The results sent shockwaves through the medical profession and prompted some women to switch from hormone therapies prescribed by their doctors to natural alternatives. More than a decade after the original WHI fi ndings, a series of reports—including further WHI data—has cast doubt about the initial conclusions. Researchers now believe the WHI data was skewed towards women aged 63 years or older who had begun using hormone therapy on average 10 years after the onset of the menopause. By contrast, the Kronos Early Estrogen Prevention Study and Danish research led by Louise Schierbeck have highlighted the benefi ts of hormone therapy for many young women, such as relieving menopausal symp toms and helping to prevent osteoporosis. Many doctors now think there might be a window of opportunity for women to benefi t from hormone therapy if they are aged less than 60 years and are within 10 years of starting the menopause. But some women are still concerned and confused about traditional hormone therapies. The number of prescriptions in the USA for traditional hormone therapies approved by the US Food & Drug Administration (FDA) has plunged by 61% from 93 million in 2002 to 36 million in 2012, according to fi gures from Symphony Health Solutions. By contrast, a rising number of prescriptions are fi lled for custom-compounded bioidentical hormones, which are mixed for patients by pharmacists but not regulated by the FDA. JoAnn Pinkerton, Professor of Obstetrics and Gynecology at the University of Virginia, USA, and her colleagues presented their fi ndings of an analysed survey (investigated during October and November 2014) on March 6, 2015 at the Endocrine Society’s 97th annual meeting. They estimated that between 26 million and 36 million prescriptions are fi lled for custom-compounded bioidentical hormones. Of the 483 pharmacies that responded to the survey, 69% believed the number of customcompounded prescriptions they fi ll will rise by 2016, with most predicting an increase of between 5% and 25%. “We think that when the WHI came out showing an increased risk in heart disease, dementia, and breast cancer—even though the relative risks were small and the absolute risks were even smaller—people became very concerned and discontinued their hormones,” Pinkerton told The Lancet Diabetes & Endocrinology. “Some of them went to bioidenticals because there was a lot of hype and myth that they were safer than FDA-approved therapies.” Pinkerton highlighted concerns about the scarcity of clinical data on the safety of bioidenticals and fears about the quality and monitoring of custom-compounded products. She pointed to an outbreak of meningitis in 2012 in the USA that was traced to compounded intrathecal steroids after issues with contamination. Pinkerton also cited an investigation by More magazine in 2012, during which 10 of 12 samples of a medicine called TriEst from diff erent compounding pharmacies were found to contain the wrong amounts of oestrogen and progesterone. The American College of Obstetricians & Gynecologists and the American Society for Reproductive Medicine have echoed her concerns; after testing 29 internet-ordered samples of bioidentical customcompounded hormones, they noted that 34% failed one or more standard quality tests, including potency testing, compared with less than 2% in FDAapproved drug therapies. However, the North American Menopause Society has claimed that custom-compounded products can benefi t some consumers who have allergies, or who need dosages or mixtures that are not available commercially. Heather Currie, Associate Specialist Gynaecologist at the Dumfries & Galloway Royal Infi rmary in Dumfries, UK, and Chairman-elect of the British Menopause Society, said bioidentical hormones are only just starting to be used in the UK. “They haven’t taken off just yet but we are concerned that they will do”, she told The Lancet Diabetes & Endocrinology. “Even though there may not be many pharmacies selling them, women can still buy them over the internet.” The UK’s National Institute for Health and Care Excellence, will launch a consultation on its fi rst menopause guidelines in May 2015, with the guidance expected to be published in October 2015. Currie hopes the publication of the guidelines will be an opportunity to dispel some of the myths surrounding hormone replacement therapy.

A study of clinical and information management processes in the surgical pre-assessment clinic

BackgroundEstablishing day-case surgery as the preferred hospital admission route for all eligible patients requires adequate preoperative assessment of patients in order to quickly distinguish those who will require minimum assessment and are suitable for day-case admission from those who will require more extensive management and will need to be admitted as inpatients.MethodsAs part of a study to elucidate clinical and information management processes within the patient surgical pathway in NHS Scotland, we conducted a total of 10 in-depth semi-structured interviews during 4 visits to the Dumfries & Galloway Royal Infirmary surgical pre-assessment clinic. We modelled clinical processes using process-mapping techniques and analysed interview data using qualitative methods. We used Normalisation Process Theory as a conceptual framework to interpret the factors which were identified as facilitating or hindering information elucidation tasks and communication within the multi-disciplinary team.ResultsThe pre-assessment clinic of Dumfries & Galloway Royal Infirmary was opened in 2008 in response to clinical and workflow issues which had been identified with former patient management practices in the surgical pathway. The preoperative clinic now operates under well established processes and protocols. The use of a computerised system for managing preoperative documentation substantially transformed clinical practices and facilitates communication and information-sharing among the multi-disciplinary team.ConclusionSuccessful deployment and normalisation of innovative clinical and information management processes was possible because both local and national strategic priorities were synergistic and the system was developed collaboratively by the POA staff and the health-board IT team, resulting in a highly contextualised operationalisation of clinical and information management processes. Further concerted efforts from a range of stakeholders are required to fully integrate preoperative assessment within the health-board surgical care pathway. A substantial – yet unfulfilled – potential benefit in embedding information technology in routine use within the preoperative clinic would be to improve the reporting of surgical outcomes.

Emergency medical admissions, deaths at weekends and the public holiday effect. Cohort study

ObjectivesTo assess whether mortality of patients admitted on weekends and public holidays was higher in a district general hospital whose consultants are present more than 6 h per day on...

75 Paws for Thought - the Introduction of a Paediatric Advanced Warning Score in a District General Hospital

Background and aims: Dumfries and Galloway Royal Infirmary is a district general hospital in south west Scotland. The paediatric unit comprises 20 beds and is actively involved in the Scottish Patient Safety Programme.Many episodes of critical deterioration in children are caused by reversible respiratory (61%) and circulatory (29%) factors (Monaghan, 2005). Early recognition of these problems is enhanced by early warning score observation systems, promoting rapid intervention.Methods: PAWS is a validated early warning observation chart for the assessment of sick children (Egdell et al, 2008). The charts were designed to be similar to the hopspital's adult early warning score charts, promoting a smooth implementation process across the hopsital, particularly in the accident and emergency department. Observations are charted and scored according to a colour coded system. High scores identify children at risk of deterioration. These children are promptly reviewed by an appropriate member of the medical team.Results: PAWS is now used for all paediatric admissions and assessments. Ongoing audit gathers data on compliance of completion and accuracy of scores.Conclusion: The charts have been well accepted. We now have a common language to communicate patient information and PAWS has become an essential part of the handover process.PAWS: • facilitates rapid recognition of acutelly ill children • Allows staff to prioritise patients for review, treatment and ongoing assessment. • Empowers inexperienced staff who may be reluctant to ask for senior assistance (Day et al, 2005).

Sheenah Jean McKinnon Russell

The death of Dr Sheenah Jean McKinnon Russell took place just three weeks short of her 87th birthday in Dumfries and Galloway Royal Infirmary, where she had given outstanding and...

Glycine Encephalopathy and Anesthesia

To the Editor: Liu and Fan report delayed recovery from sevoflurane anesthesia in a child with glycine encephalopathy (1), a metabolic disease of defective glycine cleavage (2), and suggest that increased levels of glycine account for the inhibitory effects of the condition. We write to emphasize that inhibitory and excitatory signs may coexist. The excitatory phenomena result from NMDA receptor activation (3) and using ketamine as an antagonist is reported (4). We suggest that ketamine anesthesia is a reasonable choice for their patient: this agent has additional benefits of cardiorespiratory stimulation. Magnesium is also an NMDA receptor blocker (5). In theory, magnesium may be helpful but we are not aware of magnesium therapy for these patients. Dietary intake in chronically ill patients may be impaired leading to nutrient and electrolyte deficits. Magnesium deficiency may therefore be involved in this condition, but this is speculative. Other therapies may be useful in the perioperative period. Oral dextromorphan, formulated as cough medication has been used, which acts to non-competitively bind to the NMDA receptor (6). Sodium benzoate has also been used because its metabolism depletes available glycine and can decrease CSF glycine levels, improving seizure control and wakefulness (7). C. Barker, FRCA, Specialist Registrar P. Jefferson, FRCA, Consultant David R. Ball, MB, BS, Consultant Department of Anaesthesia Dumfries and Galloway Royal Infirmary Bankend Road Dumfries, UK. DG1 4AP [email protected] Drs. Liu and Fan have elected not to reply to this letter.

Group dynamics in telemedicine-delivered and standard multidisciplinary team meetings: results from the TELEMAM randomised trial

We compared breast cancer professional's perceptions of group dynamics during standard face-to-face and telemedicine-delivered multidisciplinary team meetings. Staff perceptions were measured by a Group Behaviour Inventory (GBl) consisting of 35 positive statements in 10 group behaviour sub scales: physical resources, knowledge resources, shared goals, climate, discussion norms, discussion behaviours, decision making, output, satisfaction and group status. The participants were based at a cancer centre (the Edinburgh Breast Unit) and two district general hospitals (Dumfries and Galloway Royal Infirmary and Queen Margaret Hospital, Dunfermline) in southern Scotland. Thirty-three (73%) of the core breast cancer multidisciplinary team members completed a pre-trial (face-to-face) GBl and 24 (72%) completed a post telemedicine GBl. Eleven professionals completed both. Both GBIs produced high and similar mean scores for the majority of the ten sub-scales. Participants who completed a GBI questionnaire had similar, although slightly lower, levels of positive attitudes to telemedicine-delivered compared to face-to-face breast cancer multidisciplinary meetings. These findings support the role of videoconferencing for facilitating multidisciplinary team working within a managed cancer clinical network.

Veggie protection

Everyone knows that fruit and vegetables are good for you, but a team of Scottish researchers has come up with an explanation for why vegetarians have a lower risk of heart disease and bowel cancer than their carnivorous neighbours. Pathologists led by John Peterson at the Dumfries and Galloway Royal Infirmary (Dumfries, Scotland) discovered that vegetarians had up to 12-times higher levels of salicylic acid circulating in their blood. Salicylate is the active anti-inflammatory ingredient in aspirin and has been shown to be effective against cardiovascular disease and cancer. The researchers compared blood samples from a population of vegetarian Buddhist monks in a monastery in southwest Scotland with samples from local non-vegetarians. The results, published in July in the Journal of Clinical Pathology, emphasize the need for a healthy diet including lots of fruit and veggies. JW

The Use of Aspirin and Opiates by Dumfries and Galloway General Practitioners in the Management of Acute Myocardial Infarction

In March 1994 a study in the British Medical Journal indicated a low rate of administration of aspirin and opiates by general practitioners in cases of suspected myocardial infarction. A retrospective analysis was made of 120 consecutive admissions to the medical intensive care unit of Dumfries and Galloway Royal Infirmary, by general practitioners, with a primary diagnosis of acute myocardial infarction. Of these 120 cases, 24% were given aspirin by their G.P. prior to admission and 64% were given opiate (IV or IM). Thirty-three percent were already on regular aspirin and of these 18% received further aspirin prior to admission. These figures were considerably better than those previously quoted and they showed that prior regular aspirin therapy did influence the GPs' decision on further administration of aspirin in the acute event. A questionnaire sent to all GPs in Dumfries and Galloway revealed that 100% carried aspirin in their medical bags, 62% claimed to give aspirin to patients with suspected MI, 95% used a British Heart Foundation approved dose of aspirin and 83.3% administered the aspirin using one of the approved methods.

Crichton Royal Hospital 1839–1989

On 4 June 1839 the first patient walked with friends the mile uphill to the new Crichton Institution from the lunatic wing of Dumfries and Galloway Royal Infirmary. Detailed clinical records support a diagnosis of melancholia; the patient was discharged well in 1844 and follow-up confirmed her recovery.

Burns' house and the Directors of Dumfries and Galloway Royal Infirmary.

Burns' house and the Directors of Dumfries and Galloway Royal Infirmary.