Hospital In Northern Ireland Research Articles

Using the Liverpool Care Pathway for a dying patient

This article describes the experience of staff in one acute hospital in Northern Ireland who adapted the Liverpool Care Pathway (LCP) for the dying patient to suit their organisation. It focuses on one patient's journey, from diagnosis to terminal care. The patient remained on the care pathway for 12 days. This reflection demonstrates that, as long as patients continue to meet the criteria for the LCP, some may be on the care pathway for more than the recognised average of two days.

High Quality Acute Care for the Severely Injured is not Consistently Available in England, Wales and Northern Ireland: Report of a Survey by the Trauma Committee, The Royal College of Surgeons of England

A survey was undertaken to determine the extent to which acute hospitals in England, Wales and Northern Ireland were meeting the acute trauma management standards published in 2000 by The Royal College of Surgeons of England and the British Orthopaedic Association. A questionnaire comprising 72 questions in 16 categories of management was distributed in July 2003 to all eligible hospitals via the link network of the British Orthopaedic Association. Data were collected over a 3-month period. Of 213 eligible hospitals, 161 (76%) responded. In every category of acute care, failure to meet the standards was reported. Only 34 (21%) hospitals met all the 13 indicative standards that were considered pivotal to good trauma care, but all hospitals met at least 7 of these standards. Failures were usually in the organisation of services rather than a lack of resources, with the exception of the inadequate capacity for admission to specialist neurosurgery units. A minority of hospitals reported an inability to provide emergency airway control or insertion of chest tube. The data have not been verified and deficiencies in reporting cannot be excluded. The findings of this survey suggest that high quality care for the severely injured is not available consistently across England, Wales and Northern Ireland, and appear to justify concerns about the ability of the NHS to deal effectively with the current trauma workload and the consequences of a major incident.

Photocarcinogenic risk of narrowband ultraviolet B (TL-01) phototherapy: early follow-up data

Conflicts of interest: none declared. Sir, We read with interest the article by Man et al.1 following on from their original notification.2 We too have recently compared all patients treated with narrowband ultraviolet UVB (TL‐01) in the dermatology department of Craigavon Area Hospital (a large regional hospital in Northern Ireland) against the Northern Ireland Cancer Registry. Since 1993, 484 patients have received at least one course of TL‐01 UVB (a course being ≈ 18 treatments) for a variety of skin disorders including psoriasis, eczema and polymorphic light eruption, the majority being for psoriasis. Levels of cancer in these patients were verified by the Northern Ireland Cancer Registry, a ‘population‐based registry (1·7 million) which receives data electronically from multiple sources including all pathologically diagnosed skin cancers’. Levels of cancer in the cohort of patients were as expected for rates in the general population. Four patients were found who cross‐referenced with the register; of these none had developed skin cancer although one patient was identified who had received TL‐01 UVB as treatment for pre‐existing mycosis fungoides. The three remaining cases were unrelated: two cases of carcinoma in situ of the cervix and one hydatidiform mole of pregnancy. Both conditions were present before TL‐01 UVB therapy. The rates of skin cancer in Northern Ireland (figures obtained from the Northern Ireland Cancer Registry) are shown in Table 1.

Surveillance for Barrett??s oesophagus: results from a programme in Northern Ireland

The reported incidence of adenocarcinoma in patients with Barrett's oesophagus in surveillance programmes varies widely. Great Britain has one of the highest incidence rates of this cancer in the world, but there are no data from Ireland reporting its incidence in patients with Barrett's oesophagus undergoing surveillance. We carried out a study of all such patients at a large District General Hospital in Northern Ireland. A retrospective review of all patients with Barrett's oesophagus from January 1986 to March 2004 at Altnagelvin Area Hospital, Derry, Northern Ireland was performed. Barrett's oesophagus was defined as specialized intestinal metaplasia present in the tubular oesophagus. A total of 277 patients had Barrett's oesophagus. Twenty-one patients had adenocarcinoma and two patients had high-grade dysplasia at initial endoscopy and were excluded. Of the remaining 254 patients, 178 were entered into the surveillance programme (127 men, 51 women). The average follow-up period was 3.4 years, resulting in 613 patient-years of follow-up. Three patients developed adenocarcinoma, an incidence of 1/204 patient-years of follow-up. Two of the three patients had early-stage (T1 or T2) cancers detected and are alive and well. A total of 429 surveillance endoscopies were performed, and a marked year-on-year increase in the workload generated as a result of the surveillance programme was observed. The incidence of adenocarcinoma in patients in Northern Ireland was similar to the incidence reported by other large institutions. Clinical benefit is suggested but is not certain from these data, because of biases that affect surveillance programmes. Large multicentre studies are required to determine whether surveillance is beneficial.

Psychosexual health 5 years after hysterectomy: population-based comparison with endometrial ablation for dysfunctional uterine bleeding.

We report a population-based comparison of psychosexual health 5 years after contrasting amounts of surgical treatments for heavy periods [dysfunctional uterine bleeding (DUB)]. Women's fears about sexual function after hysterectomy might not be unfounded. The psychosexual problems may return and/or develop with time. The removal of ovaries at the time of hysterectomy is associated with greater deterioration of self-reported sexual function. Surgical menopause significantly impairs sexual wellbeing. We failed to observe uniform beneficial effects of hormone replacement therapy (HRT) on reported psychosexual health. To compare self-reported bothersome sexual function; loss of interest in sex, difficulty in becoming sexually excited and vaginal dryness 5 years after surgical management of DUB [transcervical endometrial resection/ablation (TCRE) or subtotal and total hysterectomy, with and without prophylactic bilateral oophorectomy (BO)]. Prospective cohort study up to 5 years post-surgery for DUB, TCRE or hysterectomy, with or without BO. Over 400 NHS and private hospitals in England, Northern Ireland and Wales. Of 11,325 women who responded to the 5-year questionnaire, over 9500 (84%) were valid cases, and over 8900 (94%) did complete the questions relating to psychosexual function. Most were between the ages of 39 and 45 years, married or cohabiting. Self-reported experience of bother, recorded as 'some', 'severe' and 'extreme', to questions on (1) libido loss, (2) difficulty with sexual arousal, and (3) vaginal dryness during the past 4 weeks, 5 years after surgery. Five years after surgery for DUB, the crude and adjusted prevalence of psychosexual problems was higher after hysterectomy than after TCRE. Amongst the women with concurrent BO, the age- and HRT-adjusted odds ratios for extreme psychosexual problems were increased by 80% (libido loss), 82% (difficult sex arousal) and 69% (vaginal dryness) compared with TCRE. Five years after hysterectomy more women reported having bothersome psychosexual function than did the women who had a less invasive operation. Hormone therapy, although related to surgical method, did not reduce this long-term detrimental effect. The odds were particularly high amongst women with concurrent BO. Women should be advised that they might be at higher risk of psychosexual problems following hysterectomy, compared with a less invasive procedure.

Institutionalization after stroke

There are widespread regional variations in the institutionalization rate after stroke. This study sought to identify the factors that predict institutionalization after a primary diagnosis of stroke and determine whether institutionalization rate could be used to assess the quality of hospital care. A retrospective case note audit of 2778 consecutive admissions with stroke, between 1 September and 31 October 2000 from a randomly selected sample of 79 hospitals in England, Wales and Northern Ireland. Data were collected on demographics, case-mix, clinical outcome, organization of discharge, and place of residence at discharge and at three and six months. The figures from this audit were validated using data from the 1998 National Sentinel Audit of Stroke. Overall 14% of patients previously living at home were discharged to nursing or residential homes. Using logistic regression, Barthel Index score at discharge accounted for 40% of variation. Two-thirds of patients with a discharge Barthel score of < 5 were institutionalized. Age alone explained 14% and when taken together with discharge Barthel and length of stay it accounted for 54% of variation. On admission 22% of the variation in institutionalization rate could be accounted for by total Glasgow Coma Score (15, < 15), age and ability to walk unaided. Regional variations in institutionalization rates are evident and may in part be explained by differences in ease of access to the institutions. Discharge disability and older age were the dominant factors determining admission to nursing and residential homes. It is not possible to predict sufficiently reliably for an individual patient the likelihood of institutionalization at admission or at 72 h after admission, to justify early resource allocation decisions.

Investigation of the decontamination arrangements for endoscopes in Northern Ireland

At the beginning of June 2004, a hospital in Northern Ireland announced that the arrangements for cleaning and disinfecting one of their endoscopes were not fully in accordance with necessary standards

A qualitative evaluation of information leaflets for gastroscopy procedure

Written information sent to patients prior to diagnostic gastroscopy is an important part of the process of informing and preparing them for the procedure. Yet there is ample evidence in the literature that information leaflets do not measure up to the required standard. In this study, information leaflets from a random sample of seven hospitals in Northern Ireland that carried out gastroscopy as a day procedure were evaluated using a checklist of items recommended by the British Society of Gastroenterology (BSG) for inclusion in leaflets for patients undergoing diagnostic gastroscopy. The results showed that the number of written materials sent to patients prior to the procedure varied between units. There were inconsistencies in the information given by the same unit, and overall, there was a lack of vital information in most of the leaflets. Some of the information was confusing and ambiguous. The potential risk of the procedure was explained in only one of the leaflets. Patients' right to choose to have a mild sedative was not made clear in most of the leaflets. More should be done to address these gaps and inconsistencies in the written information provided to patients prior to gastroscopy.

Costing the hospital-based process of resettling people with learning disability in the community.

Much has been written about the costs and cost-effectiveness of community care for people with learning disabilities resettled from long stay hospital care. However, comparatively little has been published about the cost of hospital services relating to the preparatory process before eventual resettlement and the disengagement of formal, sustained input from hospital staff. This study describes and costs the input provided by a hospital based multi-disciplinary team into the resettlement of adults with learning disabilities from long stay wards in Muckamore Abbey Hospital in Northern Ireland between 1996 and 1999 (n = 71). The study employs a retrospective survey design. Information about the nature and frequency of the input of each member of hospital multi-disciplinary team was collected for each former client. According to the level of professional resources expended during the resettlement process, each former client was then categorised into one of three categories. One case was then selected at random to represent each category. A summary of clinical information, a description of the resettlement process and an estimate of the cost of the process was provided for each case. Approximately 55% of people resettled in the community during the study period did so with a modest degree of input from hospital staff. For 18% resettlement proved to be a demanding and prolonged process, requiring intensive input from hospital staff. Financial costs of the resettlement process ranged from approximately stg£1,500 to stg£8,000, with an average of stg£3,400 for each person. This study provides evidence of the input by hospital staff into the process of community resettlement of long stay hospital clients and the associated costs. These costs must be included in service budgets if quality care and appropriate service provision is to be maintained in resettlement practice.

Nurses' knowledge of prevention and management of constipation.

Constipation is often a preventable problem in health care; therefore health professionals must have the appropriate knowledge to help patients prevent this common complaint occurring. The purpose of this study was to assess nurses' knowledge of constipation in a teaching hospital in Northern Ireland. A knowledge questionnaire on constipation was obtained and adapted for use in this study using a non-experimental survey design to assess a convenience sample of nurses (n = 131) within various hospital specialities. The results demonstrated gaps in nurses' knowledge of constipation and also indicated that knowledge varied between specialties and between nursing grades. Educational initiatives must not allow bowel care, often labelled 'basic nursing care', to be neglected in postregistration education and training.

Patient anxiety while on a waiting list for coronary artery bypass surgery: A qualitative and quantitative analysis

Objective: The purpose of this study was to describe the nature and intensity of anxiety felt by patients awaiting coronary artery bypass surgery. Design: A prospective, cross-sectional study design was used, with a qualitative interview and State Trait Anxiety Inventory. Setting: Study took place in 2 large tertiary referral hospitals in Northern Ireland. Participants: Seventy patients were randomly selected within 4 weeks of their referral for cardiac surgery. Results: Participants in this study cited 5 main sources of anxiety: chest pain, uncertainty, fear of the operation, physical incapacity, and dissatisfaction with the care offered to them. The State Trait Anxiety Inventory scores of this sample were high at all stages of data collection. There was a statistically significant relationship (P≤.01) between increasing angina and state and trait anxiety. Conclusion: This study identifies the major sources of anxiety described by this sample. In doing so it may facilitate greater understanding of the needs of these patients and assist in the development of specific interventions to help alleviate this problem. (Heart Lung® 2003;32:23-31.)

The lived experience of violence in accident and emergency

Aim: To investigate the lived experience of violence of nurses in one A&E department. Rationale: Following an extensive literature review, it was elicited that there was very little evidence of the psychological impact of violence in A&E. Background/Introduction: Violence in the health service has increased over the last decade associated with a corresponding increase in the published literature on this topic. While violence in A&E departments would appear common, little evidence exists on the psychosocial impact of these incidents on A&E nurses. Research methods: A qualitative domain using a phenomenological philosophy was utilised. Sampling was of a volunteer nature and data were collected using interview. Nurses were sampled from one major acute hospital in Northern Ireland. Results: Participants expressed feelings of frustration, anger, and fear. Support from colleagues was greatly valued and lack of feedback from management was cited as being common. Discussion: Frustration and anger were synthesised into the “why me” principle with nurses not knowing why they were the focus for attack. Violent incidents were associated with a sense of isolation but colleague support developed a sense of belonging. Conclusions: Whilst a useful insight was provided, more research is essential into this emotive topic.

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Physical restraint in the care of older people raises complex issues of clinical care, law and ethics. This observational study included in its sample all patients from rehabilitation wards for older people situated in two acute care hospitals in Northern Ireland. Over a thousand observations were made using a modified version of Magee et al's (1993) Research Observation Sheet. Most patients were subjected to some form of restraint on at least one occasion over the three-day observation period.

Responsibility for controlled drugs in operating departments.

The difficulties experienced with the recruitment and retention of registered nurses has made it necessary for NHS trusts to review the traditional role of nurses and to transfer some of their duties to other groups of staff in order to maintain services. For example, in the operating department, operating department assistants and operating department practitioners (ODAs/ODPs) are undertaking some of the duties that were previously the responsibility of nurses. This article presents the findings of a survey to determine the extent to which ODAs/ODPs have access to controlled drugs in operating theatres. The survey was initially undertaken by the author in Welsh hospitals during 1998. The mixed responses generated discussion in the Duthie Review Committee (Committee Chairman, personal communication, Royal Pharmaceutical Society of Great Britain (RPSGB), 1999) and led to a collaborative exercise based on a random selection of NHS trust hospitals in England, Scotland and Northern Ireland to obtain a broader data across the UK. Despite a clear legal position concerning possession, the survey showed that practice varied widely and that some trusts may be contravening the Misuse of Drugs Regulations 1985 in order to keep the service running when registered nurses are not available.

Deliberate self-poisoning presenting at a rural hospital in Northern Ireland 1976–1996: relationship to prescribing

Purpose – This study reports on a project to monitor deliberate self-poisoning in a rural area of Northern Ireland over a 20-year period. Comparison is made with reports from large urban centres. In addition, a local prescribing database allows assessment of any association between psychotropic drug prescription and use for deliberate self-poisoning. Materials and methods – Frequency of self-poisoning, demographic details and drugs used were recorded for all episodes of deliberate self-poisoning occurring at Craigavon Area Hospital for the years 1976, 1986, 1991 and 1996. It was possible to compare prescriptions of psychotropic drugs with their use for deliberate self-poisoning between the years 1991 and 1996 in the region served by the hospital, using the Defined Daily Dose (DDD) system. Results – In this rural area the pattern of deliberate self-poisoning has changed, as in urban centres, with a rise in frequency and the male/female ratio approaching unity. The pattern of drug use has altered, with paracetamol overtaking benzodiazepines as the most commonly used agent. More recently, antidepressants have become the second most frequently used drug class for this purpose. Psychotropic medications used for self-poisoning altered in proportion to their prescription between the years 1991 and 1996. Conclusions – In the face of a continuing rise in deliberate self-poisoning, which is effecting both urban and rural areas, care should be taken to prescribe the least toxic agent available as this is associated with likely frequency of self-poisoning for most classes of psychotropic drug.

Attitudes to cancer of medical and surgical nurses in a district general hospital

The personal beliefs and attitudes of nurses can have serious implications for their practice. Yet there are a lack of studies on nurses' attitudes to cancer in the UK in general, and in Northern Ireland specifically. The need for such studies is further emphasized by the importance of nurses' role in the Cancer Units of district general hospitals, as proposed by the Calman–Hine Report (Department of Health 1995). The aim of this study was to assess the attitudes to cancer of medical and surgical nurses who care for cancer patients in one district general hospital in Northern Ireland. A questionnaire comprising the Cancer Attitude Scale (Corner 1993) was administered to 106 qualified nurses. The response rate was 68.9% (n=73). Responses to items on the Cancer Attitude Scale show that while generally these nurses held positive attitudes, a high proportion also held negative views about cancer. Of particular concern were their attitudes to the value of active treatments. The implications of these findings are discussed.

Staff threatened by patients claiming paramilitary links

Hospital in Northern Ireland is the scene of 'brutal attacks' against nurses

Prospective study of clinical and functional status in patients awaiting coronary artery bypass surgery

The objectives of this study were two-fold. Stage 1 was to describe the clinical and sociodemographic characteristics of patients on the waiting list for coronary artery bypass surgery. Stage 2 was to assess changes in functional status using the SF36 at three intervals over patients’ first year on the waiting list. A cross-sectional study using a postal questionnaire was designed for Stage 1, while Stage 2 was a prospective study using SF36. The setting for the study was two large teaching hospitals in Northern Ireland which receive referrals for coronary angiography. All patients referred for coronary artery bypass over a consecutive six month period formed the study sample. The study consisted of Stage 1: 175 patients at referral for surgery, and Stage 2: 70 randomly selected patients. Results of this study found at Stage 1 that 65% of patients had grade 3–4 angina, 63% of those eligible to work were unemployed due to heart disease and 50% reported a recent decrease in income. Stage 2 found that at referral for surgery patients’ mean functional status was considerably less than 60% of optimum capacity on every dimension of the SF36. Functional status improved between referral and six months, but deteriorated between six months and one year – physical role limitations (10.4–1.8) and social function (52.7–38.1) (p = < 0.05). There was a significant association between functional status and angina grade (p = < 0.05). Waiting for coronary artery bypass surgery was associated with angina, unemployment and reduction in income in this sample. Levels of functional status were low and deteriorated further after waiting longer than six months for surgery.

Finding time for patients: an exploration of nurses' time allocation in an acute psychiatric setting.

This article explores the proportion of work time psychiatric nurses spend in potentially psychotherapeutic one-to-one communication with patients. Twenty staff nurses from three acute admission wards in a psychiatric hospital in Northern Ireland were observed. The time spent in a selection of routine activities was recorded using a specially developed observation system Nurses' Daily Activity Recording System (NURDARS). The main findings were: (i) less than half of the working day (42.7%) was spent in patient contact, and (ii) the proportion of work time which was devoted to potentially psychotherapeutic interaction with patients was very small (6.75%). The implications and limitations of the study are discussed and suggestions are made for the management and practice of psychiatric nursing, for the education of psychiatric nurses, and for further research.

Medical and surgical nurses' perceptions of their level of competence and educational needs in caring for patients with cancer.

Recent proposals recommend that cancer patients are cared for, as much as possible, in specialist cancer units and centres. However, a large number of these patients will still be admitted to medical and surgical wards of general hospitals at one time or other. Yet little is known about the knowledge and skills of nurses dealing with this group of patients. A survey design was used to assess the self-reported level of competence, in a number of activities relating to their work with cancer patients, among medical and surgical nurses (n = 106) in a district general hospital in Northern Ireland. It also aimed to identify their self-reported educational needs in caring for this group of patients. Results showed that these nurses cared for people with a range of cancers. While they reported an above-moderate level of competence, they also rated their level of competence higher in physical than in psychosocial care. Among their self-perceived educational needs were more knowledge, and skills in psychosocial care, communication, dealing with side-effects of treatment and pain management.