Hospital IT Systems Research Articles

Dementia case-finding in acute hospitals: a qualitative study of perspectives of hospital clinicians and general practitioners

BackgroundConcerns about hospital care of older people with dementia have led to UK Department of Health targets for acute hospitals to identify patients who could have dementia. Although dementia does not fit screening programme criteria, this requirement for dementia case-finding (DCF) reflects policy drives encouraging earlier diagnosis. Hospitals have set up their own processes to conduct assessments on all people aged 75 years and older with unplanned hospital admissions longer than 72 h and inform general practitioners (GPs). The potentially far-reaching effects are unknown. The Cascade study is exploring how hospitals across the East of England are implementing DCF, how results are communicated to GPs, and the impacts on patients and their subsequent care. We aimed to describe current DCF practice and to understand perspectives of both primary and secondary care clinicians on objectives, challenges, barriers, and perceived benefits of DCF. MethodsWe conducted topic-guided telephone interviews and focus groups with relevant health-care professionals contacted through multiple strategies. Direct e-mail invitations to hospital staff including Trust dementia leads and nurse specialists and invitations to GPs circulated through clinical and research networks, primary care services, and local GP forum meetings aimed for a purposive sample representing hospitals across the East of England. Anonymised transcripts were analysed with a framework approach. FindingsWe undertook interviews and focus groups with 23 hospital staff and 36 primary care staff (including 30 GPs). Hospitals differed in their approaches to DCF in terms of how, when, and by whom cognition was assessed and ways in which DCF outcomes were recorded and communicated to GPs. Although hospital IT systems were set up to ensure DCF completion, non-compliance could be a problem, especially within specialties where DCF was not a priority. Overall, staff in secondary care were more positive than were those in primary care about the benefits of DCF, including its awareness-raising, although there were concerns about impacts on resources and workload. GPs raised concerns about duplication of effort, the lack of an evidence-base for DCF, lack of access to information, limited post-diagnostic support services, and the appropriateness of DCF in the hospital setting. InterpretationPreliminary findings re-affirm that policies affecting public health need implementation that allows evaluation to inform the evidence-base. FundingNational Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East of England

Transforming the purchasing strategy of high-tech medical equipment in healthcare systems

ABSTRACTIn healthcare settings, implementing centralized strategic sourcing in healthcare systems can result in stronger supply chains, improved logistics, and improve the treatment of patients who utilize the newly purchased technologies. This study examines health technology acquisition and purchasing literature and develops a cross-functional acquisition strategy that leverages the acquisition of high-tech medical equipment for healthcare systems. The strategy is derived by combining best practices developed using decentralized purchasing strategies by healthcare facilities and successful buyer-supplier relationships from multiple industries. The strategy allows hospital systems to evaluate the efficacy of the equipment, the ability of the equipment to benefit the patient population, and the ability of the equipment to integrate with existing hospital IT systems. If the equipment proves to be a beneficial acquisition, the system can then form a buyer-supplier relationship to allow for the most efficien...

Assessment of survival in retrospective studies: The Social Security Death Index is not adequate for estimation

Assessment of survival in retrospective studies: The Social Security Death Index is not adequate for estimation

PTH-059 The Absence of Clear Pathways Leads to Poor Utilisation of Faecal Calprotectin in Primary Care and Failure to Comply with Nice Guidance

Introduction Irritable bowel syndrome (IBS) has a prevalence of around 15% in the UK and up to 20% are referred to secondary care. Current practice shows that GPs are excellent at identifying and referring cases of inflammatory bowel disease (IBD) but due to the high prevalence of IBS, 60% of outpatient colonoscopies performed are normal. Faecal Calprotectin (FCP) is recommended by NICE to assist differentiating IBD from IBS in patients where cancer isn’t suspected. This was expected to speed the time to diagnosis, reduce referrals and unnecessary endoscopies. Implementation across the UK is patchy. Locally the test was instituted for primary care without the development of an agreed care pathway as recommended by NICE. Methods A retrospective audit of 193 consecutive patients with primary care initiated FCP tests from 01/02/15-02/02/15 were reviewed. Referral information, demographics, blood results, endoscopy and histology reports as well as patient outcomes were extracted from hospital and primary care IT systems using a standardised proforma. 10 paediatric cases were excluded. We aimed to assess the outcomes of testing in the absence of agreed clinical guidelines. Results Complete data was available for 183 adult patients. 29.5% did not meet NICE criteria for FCP testing. 20% met criteria for suspected colorectal cancer referral. 91.2% of patients with negative results (FCP 100) were referred for further investigation. 28.6% of patients with indeterminate results (50–100) had a repeat test, of which 70% were persistently abnormal but only 20% were subsequently referred. No patients were assessed for factors which may cause false positive results. 82% of endoscopies were performed in patients with a positive FCP. 14% of the patients scoped were diagnosed with IBD, all had a positive FCP but only 37% had abnormal blood tests. Conclusion Use of FCP testing in the absence of a clear pathway leads to poor compliance with NICE guidance and is inappropriate in nearly 1/3rd of patients. There is clear reliance on the negative predictive value to avoid referral but this approach does not account for the highly variable pre-test probability and consequent detrimental effect on reliability. FCP is used too often in patients with unclear indications: upper GI symptoms; short symptom duration or suspected cancer criteria. False positive confounders do not appear to be considered, resulting in inconsistent retesting of indeterminate results. The results suggest that without a clear pathway FCP is commonly misused and misinterpreted, with the potential to delay or even fail to diagnose major GI pathology. This supports the use of a clear pathway for testing which we have now developed. Disclosure of Interest None Declared

ONE YEAR MORTALITY ASSOCIATED WITH THE SIMPLIFIED MISSED SCORE

Objectives & BackgroundEarly recognition and treatment of sepsis in the emergency department (ED) has been shown to reduce mortality. At present, we are able to identify patients who satisfy the...

PTH-070 Nurse Led One Stop Upper Gi Clinics Are Safe And Allow Rapid Assessment Of Patients With Suspected Gastro-oesophageal Malignancy

IntroductionMeeting 2 week referral targets presents a challenge to many hospitals. Commonly patients are seen in clinic prior to investigation with resultant additional delays in time to investigation. Nurse led...

AB0308 Spontaneous Ankle and Knee Fractures in Rheumatoid Arthritis: A CASE Report Study

BackgroundThe occurrence of spontaneous extremity fractures in rheumatoid arthritis (RA) has been only occasionally reported in the medical literature [1]. New onset ankle or knee pains can be misinterpreted as...

152 The impact of IMRT on the treatment of patients with N3M0 lung cancer at The Christie

Methods: Patients with non-small cell lung cancer treated with 36Gy in 12 fractions over the last 2 and half years were identified via the Varian patient manager treatment system. Demographic, histopathological, clinical and toxicity data were collected from patient records and hospital IT systems. Data were anonymised and analysed by the authors. Results: The total number (N) of patients available for analysis was 56. The results are summarised in the table. The median age of patients at the start of treatment was 70 years (range 37 85 years). Post-radiotherapy haemoptysis was reported in 3 patients (5.1%). No patient developed myelopathy. The commonest described toxicity was dysphagia, but only 3 (6.9%) developed grade 3 dysphagia. Most patients were treated with radiotherapy via an AP-PA parallel opposed pair, median field size was 120.96 cm2 (range 75.5 209.33 cm2), consistent with the comparator where field size did not normally exceed 200 cm2. Conclusions: High dose palliative radiotherapy in Oxford University’s NHS Trust is safe and tolerable with no radiation induced myelopathy. The main toxicity of dysphagia is generally non-severe. The median survival of patients is comparable to the 9 month survival seen in the 13 fraction arm of the MRC Trial, indicating a genuine application to everyday radiotherapy practice.

Clinical outcomes in the first year of life of premature infants

The aim of this retrospective cohort study was to investigate clinical outcomes of the first year of life of premature infants discharged from the Neonatal Intensive Care Unit (NICU) based on mortality and readmission data, and the motor development of the children. The sample consisted of 170 children with gestational age under 37 weeks and who survived hospitalization in neonatal intensive care unit (NICU). Data were collected from medical records, the hospital IT system and telephone interview with the caregiver. The authors found 100% survival during the study period and that 39.4% of the infants were often readmitted (26.5%) due to respiratory conditions. Their development was considered as expected, when using the corrected age. In conclusion, the premature infants from this study showed good clinical evolution of the proposed observation.

PWE-049 Five Year Retrospective Morbidity and Mortality Figures for Colonoscopy in a District General Hospital

IntroductionBetween 1 July 2007 and 31 August 2012, 15284 colonoscopies were performed by Gastroenterologists, Colorectal Surgeons, Gastroenterology and Surgical trainees and Nurse Endoscopists. Over the 5 year period our unit...

Spotlight on managers at fitness to practise hearings

By Sally Gillen and Christian Duffin A NURSING and Midwifery Council (NMC) hearing involving two former emergency nurses at Stafford Hospital has exposed a catalogue of allegations about poor workplace culture. At their hearing last month, nurses Sharon Turner and Tracy White denied bullying colleagues, transferring patients in soiled sheets to wards and falsifying waiting time records. Instead, they described how their concerns about understaffing were ignored. The two nurses worked as emergency department (ED) sisters at Mid Staffordshire NHS Foundation Trust between 2005 and 2009, the period of care failings highlighted in the high profile inquiry by Robert Francis QC. Ms Turner is accused of five charges, which concern alleged mistreatment of patients, verbal abuse of patients and staff, racist comments about junior doctors, and repeated falsification of waiting time data. Ms White is accused of five charges, which concern the alleged transfer of patients before they had been assessed, verbal abuse of patients and staff, and falsification of waiting time data. Responding to the allegations against them, the nurses said they had alerted managers to staffing shortages and were required regularly to explain breaches of the four-hour waiting time target. Ms Turner told the NMC fitness to practise panel that staff were under great pressure to meet targets. She said nurse managers could use hospital IT systems to monitor what was happening in the ED even when they were at home and, on one occasion, a manager who worked between 9am and 5pm had phoned her at 4am.

The rise and fall of England's National Programme for IT

The rise and fall of England's National Programme for IT

Three-Year Outcomes of a Visible Haematuria Clinic—No Initial Role for Urine Cytology?

Objective: To review patients presenting in a specialist macroscopic (visible) haematuria clinic during 2005, incorporating 3 years of follow-up, and to assess the role of urine cytology. Patients and methods: All patients attending the 2005 macroscopic haematuria clinic were identified. All subsequent admissions, pathology and imaging for each patient were captured from the hospital IT system during 3 years of follow-up and reviewed retrospectively. Results: Five hundred and three patients were assessed. No significant abnormalities were diagnosed in 52%, benign disease in 27% and malignant disease in 21% (including 14% urothelial cancer, 3% renal cancer and 4% prostate cancer). All bladder tumours were diagnosed with flexible cystoscopy and the 3 upper-tract urothelial tumours by ultrasound. Overall, cytology had a sensitivity of 66% and specificity 90% but did not diagnose tumours that were not identified with other investigations. Patients with abnormal cytology without apparent cause underwent various investigations including IVU, cystoscopy and biopsy and no tumours were identified. After 3 years no occult diseases became apparent. Conclusions: Half of all those attending with visible haematuria had significant urological diagnoses (21% urological cancer). Urine cytology did not appear to add significant information in the initial assessment of visible haematuria.

PTH-070 The impact oral bowel cleansing agents on patients undergoing colonoscopy and the potential service implications of the draft BSG guidelines for NPSA alert (RRR012)

<h3>Introduction</h3> Bowel preparation is essential for successful lower GI endoscopy but can be unpleasant for patients. Responding to the NPSA alert (NPSA/2009/RRR012) the BSG issued draft guidelines, stipulating assessment and eGFR for all patients and product depending on patient risk (risks; CCF, low eGFR, cirrhosis, diuretics/ACEi/ARB/NSAIDs). Compliance will have service implications for most units. We aimed to determine the effect of oral bowel cleaning agents on patient experience and quantify the service implications of the draft guidelines. <h3>Methods</h3> All colonoscopies performed in Oct 2009 were included. Data were obtained from patient interview, hospital IT systems and Unisoft. A structured patient telephone interview evaluating side-effects, assessment process and their experience was determined using a satisfaction scale (1=much worse than expected 2=slightly worse 3=as expected 4=slightly better 5=much better) or a severity scale (between 1=none and 5=worst imaginable). <h3>Results</h3> General: 265 colonoscopies (M/F 1:1) were performed, 186 patients were contacted with 115 responding (sample rate 43% uptake rate 61.8%). Mean age was 62.2 years (SD 14.5, 58% male). 96.5% took all the bowel preparation, with unpleasant side effects (incontinence, pain, nausea/vomiting, faint, dizzy, collapse) in 23.5%. Median responses for; experience of the bowel prep and overall experience, were 3 (as expected). For; pain caused by prep, prep affecting decision to have a repeat test and severity of side effects, the medians were 1 (none). However prep had a moderate (score 3) impact on their lives. <h3>BSG Guidelines</h3> 97.4% were reviewed before colonoscopy and 98.3% received written instructions. 20% had no traceable eGFR. Interestingly 22% of patients with no comorbidities and no medications had GFR&lt;60. 38.2% were “at risk” (neprotoxic drugs, low eGFR, significant comorbidities). Overall 6.9% has adverse side effects (collapse, dizzy, fainting). Incidence of adverse side effects was higher in those with eGFR &lt;60 (17.9%) than those with eGFR &gt;60 (4.7%). Significant comorbidity identified 50% of patients with adverse side-effects, comorbidity and medication identified 62.5%, while eGFR &lt;60 and comorbidity combined (± medication) increased the sensitivity to 87.5%. <h3>Conclusion</h3> The majority manage the full bowel preparation but almost a quarter experienced side-effects. Service provision for eGFR would be required in 20%. The “at-risk” classification identifies some patients with adverse side effects but a combination of eGFR &lt;60 and significant comorbidities (cirrhosis, CCF) was more sensitive. A service stratification using PEG based preparations for patients with eGFR&lt;60, Cirrhosis or CCF or changing to just using PEG preparations is being reviewed locally as a solution to the guidance.

PTU-018 Emergency readmission following elective endoscopy: audit of 29 868 day-case procedures performed at four teaching hospitals in northwest England

<h3>Introduction</h3> Despite emergency readmission being a NHS quality indicator and unplanned admission after elective endoscopy a GRS auditable outcome; there is a lack of audit standards and difficulties in attaining these data due to limitations in hospital IT systems. Commercial analytical reporting tools that use NHS administrative data can generate local reports from HES and may serve as a starting point for clinical audit. <h3>Aim</h3> To determine the prevalence, demographics, aetiology and outcomes of emergency readmissions following elective endoscopy. <h3>Methods</h3> From 1.4.08 to 31.3.09 emergency admissions within 6 days of a day-case upper or lower GI endoscopy (ERCP excluded) were identified from analyses of NHS administrative data at RLUH, AUH, SRH, and SMUH. Using a standard proforma, each readmission was audited using case notes, endoscopy database, and the hospital informatics systems. Two senior doctors determined the validity of the admission subdividing them into; unrelated, possible and definite with the latter two categories defining an endoscopy readmission. <h3>Results</h3> Of the 29 868 daycases, 235 admissions were identified, of which 147 were endoscopy readmissions. The following data all relates to endoscopy readmissions. <b>Demographics</b> Male:Female ratio=1:1; Mean age (SD): 65.1 years (17). <b>Readmission rate</b> overall was 0.49% (0.56% for upper and 0.42% for lower GI procedures) with highest rates for therapeutic uppers (1.75%) &gt; therapeutic lowers (0.56%) &gt; diagnostic upper (0.47%) &gt; diagnostic lower (0.38%). <b>Aetiology</b> The most common reasons for admission were vascular events (26.5%) &gt; Symptoms such as pain (17%), GI haemorrhage (17%), suspected/confirmed perforation (17% (confirmed 6.1%))&gt; respiratory (10.2%) causes &gt;bowel obstruction (4.8%): <b>Investigations</b> 71% required simple blood tests and/or x-rays and 26%, cross-sectional imaging. <b>Treatment</b> 84.4% required only observation, 4.8%; surgery, 2.7%; repeat endoscopy, and 7.5% IV antibiotics. <b>Outcomes</b> 24.5% were short-stays discharges from either AED, or medical/Surgical assessment units. Mean LOS was 8.2 (13) days and 30-day mortality was 6.8%. <h3>Conclusion</h3> Commercial analytical reporting tools combined with local interpretation and multicentre collaboration was essential for determining useful information regarding endoscopy readmissions. Readmission rates predictably varied with the procedure type (0.38–1.75%) with therapeutic procedures having the highest. While most patients required simple observation/supportive care, LOS was considerable and mortality rate among readmitted cases was significant.

A fresh start for hospital IT systems?

The Health Informatics Report published by the Department of Health in July this year admits that delivering electronic care record systems in hospitals ‘has not progressed as quickly as people would wish’. It recognizes that ‘there is a need for interim initiatives so patient information can be made available across different IT systems, different care providers and different care settings ahead of strategic systems’ (Department of Health, 2008). With local development no longer held back in anticipation of the ‘strategic systems’, where should IT developers and clinicians focus their collective efforts?

Personal Digital Assistants for Clinical Teams: Lessons Learned from Two Pilot Studies in a Scottish Teaching Hospital

AbstractPersonal Digital Assistants (PDAs) or hand-held computers are increasingly popular clinical support tools, including in the UK where different professional groups use them for a range of education, clinical, informational, organizational, research and other purposes. However, projects developing PDA use remain small scale and patchy. Integrated hospital IT systems remains elusive and relatively few projects have, so far, described beside or ‘point of care’ use for a comprehensive range of educational, clinical, and informational functions. A Scottish teaching hospital is amongst the first UK hospitals to attempt this. This paper describes two short pilot studies of contrasting (cradle-based and wireless) hardware and a range of software functions (applications) for ‘point of care’ use. Local clinicians, technicians, educationalists and researchers collaborated to ready and test PDAs incorporating innovative Education, Patient, and Information applications, for introduction to clinical teams (doctors, nurses, and pharmacists) in medical wards at the hospital. This paper describes the two projects and outlines the strengths, weaknesses and lessons learned from this innovative work.

The Effect of IT Capital on Hospital Efficiency

The academic literature on hospital information technology is relatively sparse despite its important implications for hospital management, with only limited empirical evidence linking implementation of hospital IT systems with improvements in health care quality, financial and operational performance. This study aims to corroborate the observational evidence by using a cost function estimation approach to examine the impact of IT capital investments on hospital cost efficiency.

Setting safety standards by designing a low-budget and compatible patient identification system based on passive RFID technology

This paper outlines a large-scale audit for the enhancement of quality of care and staff and patient safety using passive RFID (Radio Frequency ID) wrist bands, which link to a patient's database, in order to reduce errors in patient care. It has been developed with a collaboration between the University Hospital, Birmingham, UK and Napier University, UK. The key feature of the work is the usage of passive RFID tags as an integral part of a low budget out-of-the box strategic patient information system which should be compatible with most hospital IT systems.

Data mining for improved cardiac care

Cardiovascular Disease (CVD) is the single largest killer in the world. Although, several CVD treatment guidelines have been developed to improve quality of care and reduce healthcare costs, for a number of reasons, adherence to these guidelines remains poor. Further, due to the extremely poor quality of data in medical patient records, most of today's healthcare IT systems cannot provide significant support to improve the quality of CVD care (particularly in chronic CVD situations which contribute to the majority of costs).We present REMIND, a Probabilistic framework for Reliable Extraction and Meaningful Inference from Nonstructured Data. REMIND integrates the structured and unstructured clinical data in patient records to automatically create high-quality structured clinical data. There are two principal factors that enable REMIND to overcome the barriers associated with inference from medical records. First, patient data is highly redundant -- exploiting this redundancy allows us to deal with the inherent errors in the data. Second, REMIND performs inference based on external medical domain knowledge to combine data from multiple sources and to enforce consistency between different medical conclusions drawn from the data -- via a probabilistic reasoning framework that overcomes the incomplete, inconsistent, and incorrect nature of data in medical patient records.This high-quality structuring allows existing patient records to be mined to support guideline compliance and to improve patient care. However, once REMIND is configured for an institution's data repository, many other important clinical applications are also enabled, including: quality assurance; therapy selection for individual patients; automated patient identification for clinical trials; data extraction for research studies; and to relate financial and clinical factors. REMIND provides value across the continuum of healthcare, ranging from small physician practice databases to the most complex hospital IT systems, from acute cardiac care to chronic CVD management, and to experimental research studies. REMIND is currently deployed across multiple disease areas over a total of 5,000,000 patients across the US.