Large National Health Service Hospital Research Articles

Adoption by clinicians of electronic order communications in NHS secondary care: a descriptive account

BackgroundDue to the rapid advancement in information technology, changes to communication modalities are increasingly implemented in healthcare. One such modality is Computerised Provider Order Entry (CPOE) systems which replace paper,...

Qualitative Insights Into Patients' and Family Members’ Experiences of In-Hospital Medication Management After a Critical Care Episode

BackgroundPatient recovery after a critical illness can be protracted, requiring a care continuum that extends along a patient pathway from the critical care unit, hospital ward and into the community care setting. High-quality care on patient transfer from critical care, including medication safety, is facilitated by education for patients and families, family engagement, support systems and healthcare professional-patient communication. Currently, there is uncertainty on how healthcare professionals can and should engage with critical care patients and family members about their medication. Research QuestionWe aimed to explore the views and experiences of critical care patients and family members about their involvement, communication, understanding, and decision making related to their medication following transfer from critical care to the hospital ward. Study Design and MethodsQualitative study, using semi-structured interviews, conducted with critical care patients and family members after transfer from critical care to a hospital ward in a large National Health Service hospital Trust. Anonymized transcripts of interviews were thematically analysed using a coding framework developed from understandings of patient and family engagement in their medication. ResultsTwenty-seven participants (15 patients and 12 family members of patients) completed the interviews. We identified five themes and 15 sub-themes, providing an overview of patients and family members’ views on their medication management during their acute illness and ongoing recovery. Themes identified were: Impact of acute illness and treatment burden on pre-existing illness; Pre-existing knowledge and capability; Beliefs about persons roles and expectations; Care continuity and individualised information exchange; and Engagement in practice. InterpretationCritical care patients and family members want to engage with healthcare professionals about their medication. Health care professionals must take an individualized approach to communication and timing, acknowledging the dynamic interplay between patients and family members, using multimodal forms of communication.

A qualitative evaluation of weekly reflective practice sessions for the intensive care unit pharmacy team during the COVID-19 pandemic

Despite well-being initially being high on the agenda for UK health organisations, the COVID-19 pandemic has highlighted significant gaps around provision for well-being of pharmacists in the UK. The COVID-19...

COVID-19: how prepared are front-line healthcare workers in England?

SummaryNational efforts are underway to prepare the UK National Health Service (NHS) for the COVID-19 pandemic; however, the efficacy of these interventions is unknown. In view of this, a cross-sectional survey of front-line healthcare workers (HCWs) at two large acute NHS hospital trusts in England was undertaken to assess their confidence and perceived level of preparedness for the virus. The survey found that there has been moderate success in readying HCWs to manage COVID-19, but that more still needs to be done, particularly in relation to educating HCWs about laboratory diagnostics.

An investigation into prescribing errors made by independent pharmacist prescribers and medical prescribers at a large acute NHS hospital trust: a cross-sectional study

IntroductionPharmacists in the UK can register as independent pharmacist prescribers (IPPs) on completion of appropriate higher education training. IPPs have had the same prescribing privileges as medical doctors since 2009....

Clinicians' perceptions of the quality of outsourced radiology and actions taken around perceived imaging errors in practice.

Outsourcing of radiological reporting services has fundamentally altered communication between radiologists and clinicians in clinical decision making, which relies heavily on diagnostic imaging. The aim of this study was to understand clinicians' perspectives and experiences of interpretation of outsourced reports in clinical practice, if the author of imaging reports matters to clinicians, and actions taken to deal with perceived errors. A printed survey was distributed to a purposive sample of 50 of the 250 senior medical and surgical staff of a large National Health Service hospital in the UK who regularly engaged with the Radiology Department between May and October 2017, representing 20% of this hospital workforce. The survey consisted of ten questions examining clinicians' opinions on radiology reporting, with comment options to encourage respondents to give further detail. Participants were requested to return the survey to the study investigators. The survey elicited a 100% response rate (n = 50). A constant comparative framework was used to guide analysis, revealing themes relevant to the ongoing inter-professional relationship between clinicians and radiologists. The disparity between in-house and externally sourced radiology reports and underlying issues of trust surrounding outsourced reports were the most significant themes identified. This study found outsourcing of radiology reporting needs multi-disciplinary team availability regarding the interpretation and discussions around capacity for effective communication. It raises important issues around often under-acknowledged additional workloads imposed on in-house radiologists. There are financial and pragmatic clinical aspects in pathways of radiology practice which require further research and examination. • Utilisation of outsourcing is increasing in practice in response to imaging demands. • Outsourcing increases departmental primary reporting capacity but may increase the workload of the local radiologist. • The development of strategies for outsourcing examinations may lessen demands on the in-house workforce.

Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study

AimFrail individuals may be at higher risk of death from a given acute illness severity (AIS), but this relationship has not been studied in an English National Health Service (NHS) acute hospital setting. MethodsThis was a retrospective observational study in a large university NHS hospital in England. We analyzed all first non-elective inpatient episodes of people aged ≥75years (all specialties) between October 2014 and October 2015. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS) of the Canadian Study on Health & Aging, and AIS in the Emergency Department was measured with a Modified Early Warning Score (ED-MEWS<4 was considered as low acuity, and ED-MEWS≥4 as high acuity). A survival analysis compared times to 30-day inpatient death between CFS categories (1–4: very fit to vulnerable, 5: mildly frail, 6: moderately frail, and 7–8: severely or very severely frail). ResultsThere were 12,282 non-elective patient episodes (8202 first episodes, of which complete data was available for 5505). In a Cox proportional hazards model controlling for age, gender, Charlson Comorbidity Index, history of dementia, current cognitive concern, and discharging specialty (medical versus surgical), ED-MEWS≥4 (HR=2.87, 95% CI: 2.27–3.62, p<0.001), and CFS 7–8 (compared to CFS 1–4, HR=2.10, 95% CI: 1.52–2.92, p<0.001) were independent predictors of survival time. ConclusionsWe found frailty and AIS independently associated with inpatient mortality after adjustment for confounders. Hospitals may find it informative to undertake large scale assessment of frailty (vulnerability), as well as AIS (stressor), in older patients admitted to hospital as emergencies.

Collecting the data but missing the point: validity of hand hygiene audit data

Monitoring of hand hygiene compliance (HHC) by observation has been used in healthcare for more than a decade to provide assurance of infection control practice. The validity of this information is rarely tested. To examine the process and validity of collecting and reporting HHC data based on direct observation of compliance. Five years of HHC data routinely collected in one large National Health Service hospital trust were examined. The data collection process was reviewed by survey and interview of the auditors. HHC data collected for other research purposes undertaken during this period were compared with the organizational data set. After an initial increase, the reported HHC remained unchanged close to its intended target throughout this period. Examination of the data collection process revealed changes, including local interpretations of the data collection system, which invalidated the results. A minority of auditors had received formal training in observation and feedback of results. Whereas observation of HHC is the current gold standard, unless data collection definitions and methods are unambiguous, published, carefully supervised, and regularly monitored, variations may occur which affect the validity of the data. If the purpose of HHC monitoring is to improve practice and minimize transmission of infection, then a focus on progressively improving performance rather than on achieving a target may offer greater opportunities to achieve this.

A qualitative investigation of patients' and caregivers' experiences of severe sepsis*.

To explore and describe the subjective experiences and long-term impact of severe sepsis on survivors of severe sepsis and their informal caregivers (e.g., spouse or family member) through qualitative research methods. A qualitative exploratory study using semi-structured interviews with survivors of severe sepsis and their informal caregivers in the United Kingdom and United States. Participants also completed a demographic background form and sites provided medical history details. Transcripts were analyzed using a thematic analysis approach. Patients were recruited from a large National Health Service hospital in the United Kingdom and a level 1 trauma center hospital in the United States. Caregivers were recruited through eligible patients. Interviews were conducted either face to face in participant's homes or another convenient location or over the telephone. Patients who were 18 years old or older and had experienced an episode of severe sepsis in the previous 12 months were recruited by clinical staff in each hospital. Caregivers were family members or friends who had provided informal care for the patient after their episode of severe sepsis. None. Thirty-nine interviews were conducted with 22 patients and 17 informal caregivers (of these 28 were conducted face-to-face and 11 by telephone). Five main themes were identified in the qualitative analysis: awareness and knowledge of severe sepsis; experience of hospitalization, ongoing impact of severe sepsis; impact on caregivers; and support after severe sepsis. Experiences varied depending on the patients' health prior to the severe sepsis, with the worst affected reporting lasting impacts on multiple aspects of their life. The study extends what was understood about severe sepsis from the patients' and caregivers' perspectives from the previous limited literature. Caregivers as well as patients reported enduring impact. The study also identified problems of lack of awareness of diagnosis and understanding of severe sepsis by patients and caregivers and difficulties accessing appropriate healthcare providers and ancillary services after discharge from hospital.

A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital.

Acute kidney injury (AKI) is a common and serious problem in hospitalized patients. Early detection is critical for optimal management but in practice is currently inadequate. To improve outcomes in AKI, development of early detection tools is essential. We developed an automated real-time electronic alert system employing algorithms which combined internationally recognized criteria for AKI [Risk, Injury, Failure, Loss, End-stage kidney disease (RIFLE) and Acute Kidney Injury Network (AKIN)]. All adult patients admitted to Nottingham University Hospitals were included. Where a patient's serum creatinine increased sufficiently to define AKI, an electronic alert was issued, with referral to an intranet-based AKI guideline. Incidence of AKI Stages 1-3, in-hospital mortality, length of stay and distribution between specialties is reported. Between May 2011 and April 2013, 59,921 alerts resulted from 22,754 admission episodes, associated with 15,550 different patients. Overall incidence of AKI for inpatients was 10.7%. Highest AKI stage reached was: Stage 1 in 7.2%, Stage 2 in 2.2% and Stage 3 in 1.3%. In-hospital mortality for all AKI stages was 18.5% and increased with AKI stage (12.5, 28.4, 35.7% for Stages 1, 2 and 3 AKI, respectively). Median length of stay was 9 days for all AKI. This is the first fully automated real time AKI e-alert system, using AKIN and RIFLE criteria, to be introduced to a large National Health Service hospital. It has provided one of the biggest single-centre AKI datasets in the UK revealing mortality rates which increase with AKI stage. It is likely to have improved detection and management of AKI. The methodology is transferable to other acute hospitals.

Improving quality, service delivery and patient experience in a musculoskeletal service

The purpose of this quality improvement initiative was to enhance service delivery and patient experience in a musculoskeletal out-patient setting. A cross-sectional survey, with 6 annual stages, evaluated the musculoskeletal outpatient physiotherapy service in a large National Health Service hospital in Southern England. The population comprised 1095 patients, referred by medical staff to the service from rheumatology, orthopaedics, pain clinic and occupational health departments. The individual clinician-initiated strategies for quality improvement included: cue cards; reminders; reflections and training. The systems-changes comprised revised documentation and booking systems. The primary outcome was patient experience, measured with the Chartered Society of Physiotherapy's standardised ‘Patients feedback’ questionnaire. Attendance data was a secondary outcome. This initiative showed that strategies to motivate individual clinicians to change their behaviour were unsuccessful, whereas system-changes resulted in 32/37 improvements (8 statistically significant) in patient experience. Furthermore, the revised systems resulted in a 6% decrease in wasted appointments. It is essential that clinical services are evaluated through the eyes of their users. This initiative demonstrates the value of service evaluations (alongside research) and the importance of patient feedback to show how it can drive change and positively impact upon health-care experiences. Furthermore, this work has shown that active implementation strategies with systems-level changes produced greater improvements in service quality and patient experience, than simply encouraging and supporting clinicians to change their behaviour.

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital

Objectives:To estimate the extent, nature and consequences of adverse events in a large National Health Service (NHS) hospital, and to evaluate the reliability of a two-stage casenote review method in...