Medium-sized District General Hospital Research Articles

Care First-Fund Later (CareFFuL): an end-of-life home care quality improvement project

Previous work found referrals for end-of-life care are made late in the dying process and assessment processes for care funding, through continuing healthcare fast-track funding often inhibit people being able...

The 'scan and treat' clinic; early evaluation of an advanced clinical practitioner (ACP) led combined echocardiography and outpatient cardiology clinic

Abstract Funding Acknowledgements Type of funding sources: None. Background There is increasing recognition that traditional models of hospital-based outpatient care in England are inefficient, unsustainable and do meet patient’s needs and preferences (RCP 2018). The National Health Service (NHS) ‘getting it right fist time’ (GIRFT) report for cardiology makes a number of recommendations including; increasing the utilisation non-medical roles such as Advanced Clinical Practitioners (ACPs), reducing face to face appointments, and triaging referrals with tests performed ahead of clinic appointments (NHS, 2021). We developed a novel clinic combining formal echocardiography with clinical assessment by a single British Society of Echocardiography (BSE) accredited ACP at medium sized district general hospital (DGH) in the west Midlands, England. No clinics of this type were identified in the literature, although there are studies demonstrating the efficacy of physiologist led valve clinics (Wasing et al., 2009) and cardiologist led ‘one stop’ clinics (Falces et al., 2008) Purpose To evaluate the case mix and early outcomes of the first 6 months of the scan and treat clinic. Methods Patient demographics, reason for referral and clinic actions were collected prospectively on an excel spreadsheet. A single un-blinded cardiologist reviewed the electronic patient records and echo images of 10 randomly selected patients from the first 3 months to assess the accuracy and appropriateness of documented diagnoses and treatment plans. Results 72 patients were seen over 11 clinics between July and December 2022. There was a low (6%) non-attendance rate, although a further 5 patients (7%) did not require an echo, due to booking errors. The most common reason for referral was suspected heart failure (33%) (table 1). Combined Heart Failure (HFrEF, HFmrEF, HFpEF) was also the most common primary diagnosis in the clinic (32%) (figure 1). There was a low rate of non-cardiac diagnoses (19%) and normal echocardiograms (33%) (figure 1). Clinic actions included prescribing (54%), cardiac monitors (24%), further imaging (15%) and blood tests (11%). The Cardiologist reviewer reported appropriate diagnosis and treatment of 10 radomly selected cases. Of 7 patients followed up in a cardiologist clinic before 10/01/2023, 5 had no significant changes in treatment or diagnosis, 1 patient had a pacemaker for asymptomatic 2nd degree AV block and another had Bisoprolol stopped due to side effects. Conclusion These preliminary results suggest the ‘scan and treat’ clinic is a viable alternative to traditional general cardiology clinic for patients who also require echocardiography. This review has a number of limitations including limited short term follow up, un-blinded cardiologist review and is not generalizable. This kind of initiative may help modernise and improve cardiology outpatient services. Further research is required to assess the efficacy of similar non-cardiologist led ‘one-stop’ clinic designs.Table 1Figure 1

Observational study of survival outcomes of people referred for ‘fast-track’ end-of-life care funding in a district general hospital: too little too late?

BackgroundEnd-of-life care requires support for people to die where they feel safe and well-cared for. End-of-life care may require funding to support dying outside of hospital. In England, funding is...

EGS P05 Surgical Same Day Emergency Care at a District General Hospital - Our Experience

Abstract Background Surgical Same day emergency care (SDEC) is a new service started at a medium sized district general hospital (DGH) since November 2021. The surgical SDEC service is divided into Theatre (ambulatory theatres) and non-theatre (Hot Clinic) pathways aiming at improving patient experience, and reducing length of stay (LOS), by introducing a pathway through which patients are assessed, diagnosed, and initiated treatment and discharge on the same day for common emergency surgical conditions of gallstone disease, appendectomy, painful hernia, and abscesses. The service delivery planned with the existing facilities leading to structured fewer admissions, increased diagnostics, coordinating the patient flow with preop assessments, day case theatre utilisation and post-operative criteria led discharge. The Surgical SDEC is now established, and we continue to audit to benchmark success, recommend improvement and for quality assurance. Methods It's a prospective data collection of patients admitted under general surgery with the above common surgical emergency presentations over 6 months period since the start of the service in November 2021. The inclusion criteria were stable patients of ASA grade 1 and 2, BMI less than 40 kg/m2, and with social support. The unstable patients, ASA 3 or more and without social support were excluded. The postoperative follow up was arranged with virtual ward, clinics and in the event a post-surgery hot clinic review. Results From 15th November 2021 to 27th May 2022, 192 surgical operations were carried out. 130 Laparoscopic cholecystectomies, 22 hernia repairs, 13 diagnostic laparoscopies, and 27 abscesses incision and drainage. There were 77 male patients and 115 female patients with age ranging from 20 to 88 years old. About 70% of the patients were successfully discharged on the same day with a readmission rate of 3.6%. The cholecystectomy patients had a mean waiting time of 3.2 days and almost all cases were done within a week of admission. All the other cases including appendectomy were performed either the same day or the following day. Conclusions Surgical Same Day Emergency Care service proved to be a step forward for improving patient care. It allows the same day diagnostics and treatment, and reduces the length of stay, prevents readmissions, improves the quality of care, and helps recovery following the impacts of the pandemic. Finally, it has a significant financial benefit by decreasing readmissions, and it also utilisation of hospital beds more desired cases.

1067 IMPROVING STOOL CHART DOCUMENTATION ON A CARE OF THE ELDERLY WARD

Abstract Introduction Constipation is a common and often overlooked problem with potentially serious consequences, including patient discomfort, urinary retention, delirium and bowel obstruction. These consequences can lead to prolonged hospital stay, increased healthcare costs and increased morbidity and mortality. Accurate stool chart documentation is an essential part of basic care that helps prevent this. The aim of the project was to increase daily stool chart documentation, including stool type, to 70% on a care of the elderly ward in a medium-sized district general hospital. Method We created a proforma to review each patients’ stool chart from the previous 24 hours. Daily data was collected by measuring the number of correctly completed stool charts on the ward. Initial baseline data showed an average daily completion rate of 24%. We tested 3 separate interventions over a 6 week period using Plan-Do-Study-Act (PDSA) methodology: Intervention 1- Increase staff awareness about stool charts via email, posters and at handovers Intervention 2- Complete stool charts every time routine observations are performed Intervention 3- Complete online stool charts. Results All interventions led to an improvement in the average daily stool chart completion rate. Intervention 1 caused the most significant improvement with the average daily stool chart completion rate increasing to 77%. Intervention 2 was the least successful change, with an average daily stool chart completion rate of 39%. Intervention 3 had an average daily stool chart completion rate of 64%. Conclusion Simple interventions like staff education and prompts to help culture and behaviour change led to a significant improvement in stool chart documentation rates. Paper documentation (intervention 1) fared better than online documentation (intervention 3) most likely due to the former requiring fewer processes to complete. Intense monitoring and documentation (intervention 2) was unsuccessful and was perceived to be burdensome.

Patients Lacking the Capacity to Consent to Hip Fracture Surgery May Be Undergoing Major Operations Without Their Next of Kin Being Involved in Best-Interests Decisions: A Quality Improvement Report.

BackgroundCognitively impaired patients with a hip fracture may be undergoing major operations without attempts being made to involve their next of kin (NoK) in best-interest decisions.MethodsWe used the Plan-Do-Study-Act (PDSA) methodology to guide our quality improvement (QI) project. Cognitively impaired hip fracture patients were identified retrospectively by searching the hip fracture database of a medium-sized district general hospital (DGH). Their medical notes were reviewed for documented attempts at contacting their NoK prior to surgery as well as on completion of the NoK section of the Consent Form Four.InterventionA simple feedback intervention was delivered in the form of a mixed verbal and visual presentation to the orthopaedic registrars responsible for obtaining consent from these patients.ResultsPost-intervention, there were documented attempts at contacting the NoK before surgery for all patients, a significant improvement from only 80%. There was also a significant increase in completion of the NoK section of the consent form, from 30% to 64.3%.ConclusionsSimple audit and feedback interventions can produce significant positive changes in communication between clinicians and the NoK of cognitively impaired patients with hip fractures. Further interventions have been implemented to sustain these improvements.

Prospective cohort study of induction of labor: Indications, outcome and postpartum hemorrhage.

INTRODUCTIONThis study was undertaken because of the increasing rate of induction of labor (IOL) in our hospital and its associated higher caesarean section (CS) rates. The objective was to ascertain the incidence, indications, methods, outcome, and complications of IOL, in particular postpartum hemorrhage.METHODSThis was a prospective observational cohort study of women who underwent IOL in a medium-sized district general hospital. Blood loss was measured by the gravimetric method and correlated to postpartum hemoglobin level within 48 hours of birth.RESULTSA total of 445 women needed IOL (incidence 33%). Common indications were: small for gestational age (SGA) or fetal growth restriction (FGR) (18%), spontaneous rupture of membrane (17%), reduced fetal movement (16%), prolonged pregnancy (15%), and diabetes (13%). In all, 67% women achieved spontaneous vaginal delivery and 18% underwent caesarean section. With regard to blood loss, 62 women (14%) had postpartum hemorrhage (PPH) of >1000 mL and 22 women (4.9%) had a blood loss >1500 mL. The caesarean section rate was higher than the overall emergency caesarean section rate in that year. Incidence of PPH in this cohort was higher than the normal incidence.CONCLUSIONSIncreasing trend of induction of labor (IOL) is due to the changing clinical policy on management of small for gestational age babies, spontaneous rupture of membrane, reduced fetal movement and other complications of pregnancy. There is conflicting evidence on the effect of IOL on caesarean section rates. IOL is a risk factor for PPH. Accurate measurement of blood loss is essential in detecting a fall in hemoglobin which in turn helps in the appropriate management of PPH.

Implementation of a cauda equina service in a medium-sized district general hospital in the UK.

This project explored how the implementation of national guidance for investigation and management of patients with suspected cauda equina syndrome impacted on service provision. Retrospective analysis of patients with suspected cauda equina syndrome during 12 months before the implementation of the national guidelines were compared with data from the 21 months following. Monthly mean numbers of referrals for suspected cauda equina syndrome increased from 10.1 to 18.9 (P<0.001). Statistically significant increases were also seen in the total number of magnetic resonance imaging scans for suspected cauda equina syndrome, and the number of magnetic resonance imaging scans performed out of hours. The mean time interval, from magnetic resonance imaging scan confirming cauda equina syndrome to starting emergency decompressive surgery, reduced from 14.87 hours to 9.57 hours. Compliance with the national guidance for suspected cauda equina syndrome is imperative for patients to receive optimal treatment. However, this project has demonstrated challenges related to increased pressure on resources.

Ten minutes with Dr Joseph Home, Medical Directors Leadership Fellow at Pennine Acute NHS Trust

### Biographies Dr Christopher Waugh is a Junior Doctor in Greater Manchester. With an interest in medical education and clinical research he is currently involved in several collaborative studies including...

Junior Doctors as senior clinical leaders – a reflection on my foundation year 2 (F2) experiences during the SARS-CoV-2 COVID-19 pandemic

ABSTRACT COVID-19 presented a huge unplanned pressure on health resources worldwide. Across the NHS, different approaches have been utilized to respond to the crisis. Leadership figures across services were faced with difficult decisions with potential scarcity of resources never before seen by NHS providers. In the medium-sized District General Hospital where I am based, one of the key changes implemented, was the placement of a Junior Doctor into Hospital management and Leadership teams. Under direct supervision from the Medical Director and Associate Director of Medical Education, I was released from a significant proportion of my clinical work to provide leadership and oversight into decisions affecting junior doctors. As a Foundation Doctor in my final rotation of Foundation Year 2, this provided a unique experience to not only observe senior policy and strategic decision making, but also to lead on several projects. Coming from a Trust with historically poor performance metrics in trainee experience, it was recognized that this was an opportunity to instigate both structural and cultural change across divisions. This article will discuss the lessons learned from this experience, highlighting areas for improvement, with the hope of empowering junior doctors to take senior leadership roles in the future.

The impact of an integrated heart failure service in a medium-sized district general hospital

ObjectivesAssessing the impact of a new integrated heart failure service (IHFS) in a medium-sized district general hospital (DGH) on heart failure (HF) mortality, readmission rates, and provision of HF care.MethodsA...

Protecting patients from infection: Improving topical prophylaxis compliance on surgical wards.

At a medium-sized district general hospital in the heart of England, it was identified that compliance to the administration of topical prophylaxis on three general surgery wards had reduced to 23%, following implementation of an electronic medication prescription record. Therefore, a quality improvement project was commenced to improve this compliance to protect patients from meticillin-resistant Staphylococcus aureus (MRSA) colonisation and associated bacteraemia. To improve compliance of topical prophylaxis administration on three surgical wards to protect patients from infection. Quality improvement plan - do - study - act (PDSA) cycles evaluated the effectiveness of four different strategies from baseline data which was 23% compliant in December 2016. These included teaching and communication strategies, prompts in medical notes, discontinuation of Mupirocin 2% nasal ointment as part of the topical prophylaxis regime and discontinuation of the topical wash lotion from requiring a prescription. The compliance of prophylaxis administration increased consistently throughout from 23% in December 2016 to 92% in March 2018. Consequently, the number of patients that developed a MRSA colonisation on the three wards reduced by 54%, from 13 in the 12 months before the study to six in the 12 months after the study. This study led to a change in the Trust MRSA Policy to better protect patients from infection, particularly surgical site infection and MRSA bacteraemia. It suggests that quality improvement methodology has a place in infection prevention practice.

Supporting ‘Baby Friendly’: a quality improvement initiative for the management of transitional neonatal hypoglycaemia

We describe a quality improvement initiative conducted in a medium-sized district general hospital with a neonatal intensive care unit, which involved working with the multidisciplinary team to create a ‘Baby...

Changes to the out-patient activity of a medium sized District General Hospital over 23 years

Changes to the out-patient activity of a medium sized District General Hospital over 23 years

Improving compliance with central venous catheter care bundles using electronic records.

Health care associated infections are a major contributor to avoidable harm experienced by patients in modern health care settings. Recent reports suggest that electronic checklists for the documentation of a central line bundle may significantly enhance documented process compliance and help to reduce catheter-related bloodstream infection rates. This paper describes the use of our electronic tool to monitor and feedback process compliance in conjunction of introducing bespoke central line insertion packs to tackle catheter-related bloodstream infections in our intensive care unit in a medium-sized district general hospital. Continuous quality improvement programme with 'Plan-Do-Study-Act' cycles was implemented. The central venous catheter insertion and maintenance bundle was rolled out in 2007. To monitor compliance with the bundle elements, an electronic tool was designed as part of our bedside Clinical Information System. From 2009, regular quarterly feedback was provided on the number of central venous catheter lines inserted, compliance with the insertion and maintenance bundle and catheter-related bloodstream infection rate using the data collected through the Clinical Information System. We have also introduced dedicated line insertion trolleys and factory-prepared insertion packs. We used segmented regression analysis to assess the changes in the catheter-related bloodstream infection rate before and after implementation of the central venous catheter bundle. Bundle compliance increased during the implementation period and reached over 95% within 6 months. We observed a significant reduction in the catheter-related bloodstream infection rate from 15.6/1000 days to 0.4/1000 days. Regression analysis showed that only the compliance had significant effect on the number and prevalence of catheter-related bloodstream infections. Implementation of evidence-based care bundles reinforced by real-time feedback on the performance of caregivers can significantly reduce the rate of catheter-related bloodstream infection in the intensive care unit. Ensuring that change processes are seamlessly integrated in the workflow with minimal administrative burden is crucial to the quality improvement process.

Evaluating a specialist nurse's role in a general paediatric surgical team.

A surgical care practitioner (SCP) is a registered nurse or allied health professional who, following specific education and competency training, carries out pre- and post-operative treatment and some surgical interventions under the supervision of a consultant surgeon, contributing to the maintenance of surgical services and the enhancement of patient care. With a cohesive approach, the SCP can do much to ensure continuity of care and mutual understanding and concordance between staff, child and family. Costs can be reduced and the surgical training of junior doctors supported. The results of this audit show that, with the inclusion of an SCP, higher quality general children's surgery can be provided at a medium-sized district general hospital, so that patients can be seen locally.

Planning ahead: Improving escalation plans before the weekend.

Handover is the system by which responsibility for patient care is transferred between healthcare professionals. A significant aspect of handover is the existence of an escalation plan for each patient in case of deterioration over the weekend. According to the Royal College of Physicians, all patients should have a clear escalation plan documented in the notes before a weekend, since parent medical teams (Consultant team in charge of care) are best placed to make these decisions. If left to on-call teams, at a time of deterioration over a weekend, they might not have all available information, the patient might be unable to be involved in the decisions, and the family might not be consulted.With this is mind, we decided to analyse the existing handover process in a medium sized district general hospital, with the aim of improving the process and the documentation of escalation plans. The results from our retrospective analysis of the system in place revealed a significant lack of documentation of escalation plans in the medical notes.Three sample wards were selected to analyse the current handover system and test proposed measures before hospital-wide implementation. After trialling of a physical handover meeting in addition to the existing intranet system and a proforma for the Friday ward round, the documentation of escalation plans in the patients' notes improved from 9.1% to 41.1%. Based on these results, as well as formal feedback from junior doctors and informal feedback from other staff, the physical handover meeting and Friday ward round proforma will be implemented throughout the Trust.Our interventions led to an improvement in the documentation of escalation plans in our hospital, thus saving precious time in the event of a patient's deterioration. This also ensures that families and patients are involved in the decision making process and kept informed, and reduces the burden for the weekend on-call teams.

REVIEW OF NEUROPHYSIOLOGY DATA IN PATIENTS REFERRED AS WINGED SCAPULA

We conducted retrospective analysis of patients referred to the neurophysiology department as winged scapula over a period of three and half years. Data is from a medium sized district general...

Audit of vaginal birth after one caesarean: the experience of a medium-sized district general hospital

Background and ObjectiveVaginal birth after Caesarean (VBAC) is recommended by the Royal College of Obstetricians and Gynaecologists after one Caesarean section (CS), assuming success rates of >70%. This figure is...

Faecal calprotectin—a useful screening test for detecting gastrointestinal inflammation in children

<h3>Aims</h3> Faecal calprotectin is a neutrophil cytosolic protein which is validated as a reliable non-invasive marker of gastrointestinal inflammation in adults as well as children. The authors carried out an audit to assess the utility of faecal calprotectin in evaluation of children with chronic gastrointestinal symptoms. <h3>Methods</h3> Stool samples from 104 children aged 1–16 years who presented to a medium sized district general hospital with gastrointestinal symptoms were analysed using a commercially available kit. The normal range of faecal calprotectin is &lt; 50 mcg/g. <h3>Results</h3> Faecal calprotectin was outside the normal range in 37 out of 104 patients (36%). There were a total of 20 children with inflammatory bowel disease (14—newly diagnosed, 6—relapse) and all of them except one had elevated faecal calprotectin of greater than 200.The likelihood of organic bowel pathology was high when faecal calprotectin was greater than 200. Faecal calprotectin as a stool marker for inflammatory bowel disease (IBD) had an overall sensitivity of 95% and specificity of 79%. The specificity of the test in predicting IBD increased to 98.8% when calprotectin measured greater than 200. The positive predictive value was 95% and negative predictive value was 98% when faecal calprotectin value was &gt; 200. High faecal calprotectin did not co-relate well with other inflammatory markers in children diagnosed with inflammatory bowel disease. <h3>Conclusion</h3> Raised faecal calprotectin of greater than 200 should prompt urgent further assessment in children as IBD can be a likely diagnosis however these levels can be found in non-IBD organic GI disease. Faecal calprotectin can be used as a screening test reliably in evaluation of a child with chronic gastrointestinal symptoms and faecal calprotectin value outside the normal range of 50 mcg/g should involve prompt review to decide whether further investigations are needed.