Large Acute NHS Trust Research Articles

Effect of implementing the NEWS2 escalation protocol in a large acute NHS trust: a retrospective cohort analysis of mortality, workload and ability of early warning score to predict death within 24 hours

ObjectivesTo describe the inpatient population, establish patterns in admission and mortality over a 4-year period in different cohorts and assess the prognostic ability and workload implications of introducing the National...

Electrocardiography Interpretation Proficiency Among Medical Doctors of Different Grades in the United Kingdom.

Electrocardiography interpretation is a core clinical skill for all doctors participating in emergency medical services. Given the majority ofECGsinitially performed in hospital on admission are reviewed by junior doctors, and the need for life-threatening pathology to be diagnosed or excluded, further understanding of the level of competency in interpretation and factors associated with this are needed. This was a cross-sectional, descriptive, analytical study. The data were collected using a structured questionnaire. This was comprised of two sections; the first section contained questions related to confidence, previous ECG learning and factors thought to be associated with ECG interpretation competence. The second section was an ECG quiz of 10 12-lead ECGs of varying complexity for interpretation assessment. Descriptive and inferential statistics were utilized for data analysis. Sixty-twodoctors from foundation year 1 to registrar level working in acute medicine across three hospitals participated. The mean overall percentage score for the ECG quiz was 45%. No association was found between junior doctor training grade and overall score on the ECG assessment. Undergraduate and postgraduate teaching strategies also did not impact competence. Only 9.7% reported themselves as "confident" interpreting ECGs. There was a trend towards higher levels of competency among those who felt they had undergone sufficient ECG teaching and those who sought regular feedback from other clinicians. This study demonstrated low overall levels of ECG interpretation competency among junior doctors in a large acute teaching NHS trust regardless of grade. Factors associated with competency remain unclear.

Do national policies for complaint handling in English hospitals support quality improvement? Lessons from a case study.

A range of public inquiries in the English National Health Service have indicated repeating failings in complaint handling, and patients are often left dissatisfied. The complex, bureaucratic nature of complaints systems is often cited as an obstacle to meaningful investigation and learning, but a detailed examination of how such bureaucratic rules, regulations, and infrastructure shape complaint handling, and where change is most needed, remains relatively unexplored. We sought to examine how national policies structure local practices of complaint handling, how they are understood by those responsible for enacting them, and if there are any discrepancies between policies-as-intended and their reality in local practice. Case study involving staff interviews and documentary analysis. A large acute and multi-site NHS Trust in England. Clinical, managerial, complaints, and patient advocacy staff involved in complaint handling at the participating NHS Trust (n=20). Not applicable. Findings illustrate four areas of practice where national policies and regulations can have adverse consequences within local practices, and partly function to undermine an improvement-focused approach to complaints. These include muddled routes for raising formal complaints, investigative procedures structured to scrutinize the 'validity' of complaints, futile data collection systems, and adverse incentives and workarounds resulting from bureaucratic performance targets. This study demonstrates how national policies and regulations for complaint handling can impede, rather than promote, quality improvement in local settings. Accordingly, we propose a number of necessary reforms, including patient involvement in complaints investigations, the establishment of independent investigation bodies, and more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints.

Standards of Care Received by People with Diabetes who Undergo Orthopaedic Surgical Procedures

Over the past ten years there have been guidelines that have been produced regarding the management of individuals with diabetes undergoing a surgical procedure. This clinical audit will be focusing on the area of orthopaedics and the standards of care received by individuals with diabetes. The audit examined retrospectively; the care received in a large acute NHS trust with a sample of 78 adult individuals with diabetes. Ten audit criteria were reviewed and evaluated and compared to the guidance that is currently available nationally. Both emergency and elective procedures were assessed to see if there were any variances in the management of individuals with diabetes. On review of the results, a number of recommendations will be put forward to the trust with regards to changes that should be implemented to enhance patient care.

Dynamic early warning scores for predicting clinical deterioration in patients with respiratory disease

BackgroundThe National Early Warning Score-2 (NEWS-2) is used to detect patient deterioration in UK hospitals but fails to take account of the detailed granularity or temporal trends in clinical observations. We used data-driven methods to develop dynamic early warning scores (DEWS) to address these deficiencies, and tested their accuracy in patients with respiratory disease for predicting (1) death or intensive care unit admission, occurring within 24 h (D/ICU), and (2) clinically significant deterioration requiring urgent intervention, occurring within 4 h (CSD).MethodsClinical observations data were extracted from electronic records for 31,590 respiratory in-patient episodes from April 2015 to December 2020 at a large acute NHS Trust. The timing of D/ICU was extracted for all episodes. 1100 in-patient episodes were annotated manually to record the timing of CSD, defined as a specific event requiring a change in treatment. Time series features were entered into logistic regression models to derive DEWS for each of the clinical outcomes. Area under the receiver operating characteristic curve (AUROC) was the primary measure of model accuracy.ResultsAUROC (95% confidence interval) for predicting D/ICU was 0.857 (0.852–0.862) for NEWS-2 and 0.906 (0.899–0.914) for DEWS in the validation data. AUROC for predicting CSD was 0.829 (0.817–0.842) for NEWS-2 and 0.877 (0.862–0.892) for DEWS. NEWS-2 ≥ 5 had sensitivity of 88.2% and specificity of 54.2% for predicting CSD, while DEWS ≥ 0.021 had higher sensitivity of 93.6% and approximately the same specificity of 54.3% for the same outcome. Using these cut-offs, 315 out of 347 (90.8%) CSD events were detected by both NEWS-2 and DEWS, at the time of the event or within the previous 4 h; 12 (3.5%) were detected by DEWS but not by NEWS-2, while 4 (1.2%) were detected by NEWS-2 but not by DEWS; 16 (4.6%) were not detected by either scoring system.ConclusionWe have developed DEWS that display greater accuracy than NEWS-2 for predicting clinical deterioration events in patients with respiratory disease. Prospective validation studies are required to assess whether DEWS can be used to reduce missed deteriorations and false alarms in real-life clinical settings.

Factors associated with sickness absence in a large NHS Trust.

Sickness absence rates vary widely across a large acute NHS Trust, with the highest rates in some of the largest directorates. This study was aimed to identify factors associated with sickness absence in teams and to inform interventions to improve staff health and well-being. Using 2018 data from the electronic staff record and NHS Staff Survey, we examined variables associated with cost centre sickness absence rates, perceived abuse and staff engagement scores using multivariable linear regression. Data were available for 9362/15 423 (61%) of staff. Cost centre sickness absence was significantly positively associated with predominance of nursing and midwifery staff (β = 0.28 [0.012-0.55]) and significantly inversely associated with predominance of medical and dental staff (β = -0.94 [-1.2 to -0.65]) and proportion white (β = -1.11 [-1.9 to -0.37]). Cost centre sickness absence was not significantly associated with staff engagement, reported abuse, age or higher headcount. Cost centre staff engagement was significantly positively associated with proportion white (β = 0.98 [0.42-1.6]). Reported abuse by managers (β = -13 [-22 to -4.2]) and by colleagues (β = -24 [-35 to -12]) was significantly inversely associated with proportion white. Reported abuse by colleagues was significantly associated with predominance of medical and dental (β = 7.6 [2.3-13]) and nursing and midwifery staff (β = 9.1 [4.4-14]). These observed associations of sickness absence, staff engagement and perceived abuse with job mix and ethnicity should be further explored. Individual or team-level data, rather than cost centre-level data, might more meaningfully elucidate why sickness absence rates vary between groups of staff.

Pilot study to evaluate safety culture perception in the operating theatres of an acute NHS Trust using the National Air Traffic Services (NATS) App

An area critical to safety in an organisation is the perceived and actual culture. National Air Traffic Services (NATS) work closely with large safety-critical industries including various aviation companies to enable them to identify strengths and vulnerabilities with the aim of improving safe practice. NATS have developed a simple free downloadable self-assessment App that individuals can use to assess their own culture perception in their organisation. The App has 16 questions arranged in four domains but to our knowledge it has not been used to date in healthcare. As part of the initiatives to improve staff culture, we evaluated operating theatre colleagues’ safety perception in our large acute NHS Trust in a pilot study using the NATS safety App. Staff downloaded the App to their smart device before completing it. Responses were sent anonymously through the App and collated by NATS. A total of 146 colleagues downloaded and completed the questionnaire. One hundred and seventeen staff (80%) felt encouraged to report safety concerns, but 86% (n=126) confirmed a lack of available support from healthcare managers. Only 43% of respondents (n=63) would find it easy to challenge colleagues if they observed unsafe behaviour. This pilot study has identified positive indicators of an evolving NHS safety culture, and some concerns about speaking up, support, and challenging colleagues without fear. These issues are known to occur across healthcare. Further work is needed in the NHS to provide a supportive environment to improve patient safety, and lower hierarchy in surgical teams.

Nosocomial COVID-19: experience from a large acute NHS Trust in South-West London

Transmission of coronavirus disease 2019 (COVID-19) in healthcare settings has significant implications for patients and healthcare workers, may amplify local outbreaks, and may place additional burden on already stretched resources. Risk of missed or late diagnosis of COVID-19 was high during the UK's initial ‘containment phase’, because of strict criteria for testing. The risk remains due to asymptomatic/pre-symptomatic transmission, complicated by challenges faced with laboratory testing. We present a case study of potential nosocomial transmission associated with the first case of COVID-19 at a large acute NHS Trust in South-West London, and we describe the prevailing burden of nosocomial infections.

An exploration of predictors of children's nurses' attitudes, knowledge, confidence and clinical behavioural intentions towards children and young people who self-harm.

To explore the potential predictors of children's nurses' attitudes, knowledge and confidence towards caring for children and young people admitted to hospital with self-harm. Admissions to paediatric inpatient settings for individuals who have self-harmed are growing. Limited previous research suggests that nurses have mixed attitudes towards people who have self-harmed and potentially lack the confidence to provide effective care. There is a specific paucity of research in this area for children's nurses. A cross-sectional descriptive survey was used to gather data for exploration of variables associated with attitudes, confidence, knowledge and clinical behavioural intentions of 98 registered children's nurses in a single tertiary children's hospital, colocated in a large acute NHS Trust in the UK. Data were collected over a 4weeks in 2015, using an online survey tool. The predictive effect of several demographic variables was tested on the outcomes of attitudes, knowledge, confidence and behavioural intentions, which were collected using relevant, previously used outcome measures. Increased experience was found to be associated with improved attitudes relating to negativity. Previous training in caring for children who had self-harmed was found to be associated with improved attitudes around perceived effectiveness of their care. Higher academic qualifications and having undertaken previous training on self-harm were each found to be associated with increased knowledge of self-harm, and increased age was associated with reduced knowledge of self-harm. This study provides an initial exploration of variables associated with attitudes, knowledge, confidence and behaviour intentions of registered children's nurses in relation to caring for CYP who have self-harmed. Targeted training on caring for CYP who have self-harmed should be considered as a component of continuing education for registered children's nurses in the UK to improve the experience and outcomes for this patient group.

Missed opportunities to identify occupational asthma in acute secondary care.

Occupational asthma (OA) accounts for one in six cases of new-onset adult asthma. Despite this it remains under-recognized in the UK. Delayed and missed diagnoses of OA lead to poor health outcomes for workers at significant cost to the UK economy. The burden of occupational aetiology on hospital admissions with asthma is not known. To measure how frequently medical professionals consider occupational aetiology in patients presenting to secondary care with acute asthma symptoms. We reviewed electronic records of working-age patients with asthma symptoms, presenting to three sites at a large West Midlands acute hospital NHS trust. We searched emergency department (ED) and acute medical unit (AMU) admission documents, looking specifically at documentation of employment status, job role and work effect on symptoms. We also examined the effect of using a prompt for enquiry about occupation contained within the clerking pro-forma. We searched 100 ED and 100 AMU admission documents. Employment status was established in only 20-31% of patients and none were asked about the effect of their work on current asthma symptoms. The use of a clerking pro-forma, including a prompt for occupation, increased documentation to 63% from 10 to 14% where an enhanced pro-forma was not used. Enquiry into employment status and work effect in working-age patients with asthma symptoms presenting to the ED and the AMU is poor. These may be missed opportunities to identify OA. We propose medical education about high-risk exposures and the use of pro-formas including prompts about occupational exposures.

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14

Background Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services. Objectives We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels. Methods We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods. Results We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends. Limitations Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative. Conclusions In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective. Future work Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Successful implementation of the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process in a large UK based NHS Trust

Purpose of study: To evaluate the implementation of the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process in a large acute NHS trust.

‘Our Care through Our Eyes’. Impact of a co-produced digital educational programme on nurses’ knowledge, confidence and attitudes in providing care for children and young people who have self-harmed: a mixed-methods study in the UK

Objectives(1) To determine the impact of a digital educational intervention on the knowledge, attitudes, confidence and behavioural intention of registered children’s nurses working with children and young people (CYP) admitted...

Short message service (SMS) texting as a method of communication during on call: prevalence and experience of medical staff in a large acute NHS Trust in the UK

With the widespread use of smartphones, text messaging has become an accepted form of communication for both social and professional use in medicine. To our knowledge no published studies have assessed the prevalence and use of short message service (SMS) texting by doctors on call. We have used an online questionnaire to seek information from doctors in a large NHS Trust in the UK about their use of texting while on call, what they use it for, and whether they send images relevant to patients’ care. We received 302 responses (43% response rate), of whom 166 (55%) used SMS while on call. There was a significant association between SMS and age group (p=0.005), with the 20-30-year-old group using it much more than the other age groups. Doctors in the surgical specialties used it significantly less than those in other speciality groups (p<0 .001). Texting while on call was deemed to be safe and reliable (p<0.001). Eighteen clinicians (11%) admitted to routinely sending images of patients by text, despite some being identifiable. Texting was mainly used to update colleagues on patients’ progress and give information about times of ward rounds and meetings. With the increasing use of texting in healthcare, much of which seems to be unregulated, further work and detailed guidance is required on what information may be given to ensure confidentiality and that SMS is a safe and acceptable method of communication to use when on call.

Homebirth in England: Factors that impact on job satisfaction for community midwives

This study explored the uptake of homebirth by healthy pregnant women from the perspective of community midwives (CMs). This paper presents factors that CMs expressed contributed to and/or detracted from their job satisfaction. Interviews were conducted with four practising CMs who were employed by a large acute NHS Trust in England providing a non-continuity model of care. Data were analysed thematically and are presented in two categories: (1) continuity of care and (2) working relationships and workloads. Findings suggest that if maternity service providers attended to factors that enhanced the job satisfaction of CMs inclined to support homebirth, this may contribute to increasing its uptake by pregnant women.

‘Unblocking flow constraints’ within a medical directorate at a large acute NHS trust

We aimed to create better flow within the acute medical bed base at a large acute NHS trust by increasing the volume of discharges, reducing occupancy levels, reducing length of stay and helping improve performance in the emergency department (ED). Following a challenging winter 2012/13, a core

Evaluation of an electrocardiograph-based PICC tip verification system

Performing a chest x-ray after insertion of a peripherally inserted central catheter (PICC) is recognised as the gold standard for checking that the tip of the catheter is correctly positioned in the lower third of the superior vena cava at the right atrial junction; however, numerous problems are associated with this practice. A recent technological advancement has been developed that utilises changes in a patient's electrocardiograph (ECG) recorded from the tip of the PICC as a more reliable method. This evaluation discusses how a vascular access team in a large acute NHS Trust safely and successfully incorporated the use of ECG guidance technology for verification of PICC tip placement into their practice.

Evaluation of an electrocardiograph-based PICC tip verification system

Performing a chest x-ray after insertion of a peripherally inserted central catheter (PICC) is recognised as the gold standard for checking that the tip of the catheter is correctly positioned in the lower third of the superior vena cava at the right atrial junction; however, numerous problems are associated with this practice. A recent technological advancement has been developed that utilises changes in a patient's electrocardiograph (ECG) recorded from the tip of the PICC as a more reliable method. This evaluation discusses how a vascular access team in a large acute NHS Trust safely and successfully incorporated the use of ECG guidance technology for verification of PICC tip placement into their practice.

Local implementation of the Essence of Care benchmarks

To understand clinical practice benchmarking from the perspective of nurses working in a large acute NHS trust and to determine whether the nurses perceived that their commitment to Essence of Care led to improvements in care, the factors that influenced their role in the process and the organisational factors that influenced benchmarking. An ethnographic case study approach was adopted. Six themes emerged from the data. Two organisational issues emerged: leadership and the values and/or culture of the organisation. The findings suggested that the leadership ability of the Essence of Care link nurses and the value placed on this work by the organisation were key to the success of benchmarking. A model for successful implementation of the Essence of Care is proposed based on the findings of this study, which lends itself to testing by other organisations.

An evaluation of patient satisfaction regarding the care and information provided by infection control nurses relating to MRSA

Meticillin resistant Staphylococcus aureus (MRSA) has attracted much sensationalist reporting from the media in recent years and has contributed to a high level of anxiety among the public in general. In response to this, and bearing in mind the Department of Health's encouragement to involve the patient in improving healthcare services, the Infection Prevention and Control Team (IPCT) at a large acute NHS trust undertook an evaluation of patient satisfaction with their MRSA related care. The aim was to improve the service currently offered by IPCT to inpatients who are either infected or colonised with MRSA. The survey demonstrated a general satisfaction with the current service. However, several recommendations are under review as a consequence of the study, including: ■ Content of information leaflets ■ Content of MRSA educational programmes ■ Ensuring attendance at mandatory infection control education sessions ■ The method of information provision for patients with MRSA ■ The amount of protected time for link practitioners. Other trusts may have similar issues, levels of patient satisfaction and patient concerns, and infection prevention and control teams may find it beneficial to review the issues identified through this survey.