Rural District General Hospital Research Articles

Comparing Austin Moore and Bipolar Prostheses for Management of Femoral Neck Fractures in Low-Resource Hospitals in Rural India.

Femoral neck fractures in elderly individuals cause significant morbidity, and their management is particularly challengingin rural areas where healthcare access is limited. The recommended treatment for displaced femoral neck fractures in elderly patients with poor mobility, cognitive dysfunction and multiple comorbidities is a hemiarthroplasty, which can be performed with various implants, including monopolar implants like Austin Moore prosthesis (AMP) and bipolar prosthesis (BP). In developing countries like India, rural areas often have constraints with healthcare resources. Furthermore, the per-capita income is low, limiting access to affordable healthcare.As a result, treatment is often tailored to ensure affordability, and AMP continues to be used as it is a relatively inexpensive implant. The objective of our study is to assess and compare themortality, infection rate andfunctional outcomes (Harris hip score [HHS]) of AMP and BP in treating femoral neck fractures one year following surgery in a resource-constrained setting in a rural district general hospital in India. This retrospective observational study analysed all patients who underwent a hemiarthroplasty for acutely displaced femoral neck fractures between 1 January 2017 and 31 December 2017, with a minimum one-year follow-up following surgery. Pathological hip fractures, patients with pre-existing hip pathologies and those with an abbreviated mental test score of six or less were excluded. Medical records were reviewed, and demographic data, mortality, infection ratesand HHS one year following surgery were recorded and compared for patients who underwent hemiarthroplasty with an AMP and BP. A total of 118 patients underwent hemiarthroplasty, with two (1.69%) lost to follow-up. Therefore, 116 patients were included, comprising 81 (69.83%) women and 35 (30.17%) men, with similar demographics between both groups. No statistically significant difference was found in mortality rate (AMP 1, 1.79%, vs. BP 1, 1.67%, P= 0.96), infection rate (AMP 1, 1.82%, vs. BP 1, 1.69%, P= 0.96) and HHS (AMP 85.2 vs. BP 88.5; P= 0.08). No dislocations or periprosthetic fractures were noted at one-year follow-up in both groups. While AMP and BP have similar clinical and functional outcomes, AMP is more cost-effective and perhaps more suitable in low socioeconomic demographics and low-resource settings. Further research is suggested to evaluate long-term outcomes inunderserved populations with a low per-capita income.

WTP4.13 The Quality of Service of Index Admission Laparoscopic Cholecystectomy For Patients With Acute Biliary Symptoms: Re-audit From a Rural District General Hospital

Abstract Aims To continue evaluating our service of index admission laparoscopic cholecystectomy for acute biliary diseases. Methods A retrospective analysis was conducted. All patients who had an index admission laparoscopic cholecystectomy between 2016 & 2021 were identified from the hospital database. Data including demographics, time to diagnostic imaging, surgical technique, complications, re-operation, re-admission and mortality were collected from the hospital clinical information system “Myrddin” and patients’ notes. Results There were 335 patients (male: female 128:207) with median age of 62 years (range 16- 92years) presented as emergency with acute biliary symptoms and had index admission cholecystectomy. The reasons for acute admission were acute cholecystitis (n=205) acute pancreatitis (n=60), biliary colic (n=43) and calcular obstructive jaundice (n=27). The time to diagnostic imaging ranges from same day of admission to 3 days (mean= 0.81 days). Laparoscopic cholecystectomy was done in 333/335 with conversion rate of 1.5% (n=5). Five patients (1.5%) required re-operation because of bile leak. There was no major bile duct injury, no bleeding requiring any intervention. The re-admission rates within one week and within 30 days of surgery were (2.4%) and (0.9%) consecutively. Mean length of in-hospital stay (LOS) was calculated only for patients with acute cholecystitis and biliary colic (n=248) and it was 6.8 days. Mortality over 9 years period was 0.579% (3/518).These results are comparable to the available data from the national and international published data. Conclusions Index admission laparoscopic cholecystectomy is still safe and meets the recommended quality standards. Time to surgery has reduced compared to previous cycle and this led to decrease in LOS.

Using clinical surveillance software to support effective infection prevention and control for managing COVID-19

The speed, severity and scale of the COVID-19 pandemic challenged infection prevention and control (IPC) efforts at hospitals worldwide. Dorset County Hospital NHS Foundation Trust in Dorchester had an established pandemic plan, which had been developed in response to the swine flu (H1N1) pandemic in 2009. However, the COVID-19 pandemic developed to a level that modern health care had not seen before and it remains the largest challenge for health care to date. This article outlines the experience of a rural district general hospital using digital solutions for infection prevention and control before and during the pandemic. The author will explore the experience of a hospital that implemented specialised clinical surveillance software, how it was applied to management and control of COVID-19 cases, and how the availability of that system allowed for continued focus on controlling other pathogens in the hospital environment, even at the height of the pandemic.

Developing a junior-led near-peer simulated patient teaching programme in a minimal resource environment

High-fidelity simulation-based scenarios develop the knowledge and practical skills of medical students by recreating a more accurate reflection of managing difficult cases in high pressure environments. In circumstances with limited resources, ingenuity must be employed to recreate immersive environments. One creative method of achieving this is utilising ‘near peer tutors’ (NPTs), defined as ‘a trainee one or more years senior to another trainee’ [1]. NPTs can be employed as facilitators and simulated patients [2]. We aimed to design, implement and qualitatively evaluate a minimal resource simulation teaching programme for medical students that utilises NPTs, at a rural District General Hospital. A lesson plan was designed for the teaching sessions. This included a pre-session examination; a pre-session presentation; simulation cases followed by a ‘STOP5 Hot’ debriefing [3]; a post-session examination and participant feedback collection. 17 NPTs were recruited from Foundation Year (FY) 1 and 2 Doctors, with two or more allocated to facilitate each session. Roles divided amongst the NPTs included acting as a patient, acting as a nurse, leading the scenario. The ‘STOP5 Hot’ debrief was then facilitated by the lead NPT. Three lead clinicians were responsible for administration: a FY2 Doctor provided session resources; an Internal Medicine Trainee supervised each session; a FY1 Doctor communicated with NPTs and students. Qualitative feedback was collected from students at the end of each session in the form of a questionnaire. A total of 9 sessions were run from 7/1/22 – 31/3/22 attended by 22 medical students. The sessions were positively received by both students and teachers who described the sessions as ‘well organised’; an ‘open/accessible/safe learning environment’ and included ‘realistic scenarios’. Students described benefiting from ‘clear, useful feedback’; ‘observing the life-cycle of management within a scenario’ and the use of NPTs memory aids (including mnemonic devices). NPTs reported that the teaching ‘reinforced their skills in emergency assessments’, ‘time management of sessions was efficient’, and that the scenarios provided had ‘appropriate level of background information’. Suggested improvements included ‘greater variety/complexity of cases’, ‘scenario specific tick-lists to review management steps’, and ‘expanding the use of technology’. A junior-led near-peer simulated patient teaching programme was well received by both students and near-peer tutors. Further research could evaluate the improvement in knowledge of students following the sessions and the effectiveness of providing teaching opportunities to junior doctors. Future aspirations include expanding the portfolio of scenarios by collecting cases from junior doctors’ reflections. 1. Aba Alkhail B. Near-peer-assisted learning (NPAL) in undergraduate medical students and their perception of having medical interns as their near peer teacher. Medical Teacher. 2015;37(sup1):S33-S39. 2. Williams B, Song J. Are simulated patients effective in facilitating development of clinical competence for healthcare students? A scoping review. Advances in Simulation. 2016;1(1). 3. Walker C, McGregor L, Taylor C, Robinson S. STOP5: a hot debriefing model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine. 2020;7(4):259–266.

TU7.6 Comparing Cholecystectomy Day Case Rates during the pre-COVID and COVID Era at a Rural District General Hospital

Abstract Aims 67 000 cholecystectomies performed every year in the UK and 92% are laparoscopic. 75% of operations should be done as day cases. National rates vary between 6–50% with the most successful centres at 70%. Our aim was to audit the day case rate at our Trust pre-COVID and compare it to during COVID. Methods A retrospective audit of patients identified via clinical coding who had an elective cholecystectomy at one hospital in the Trust between 1 December 2018 to 31 November 2019. During COVID we did a prospective audit of patients identified via Theatreman who had an elective cholecystectomy at the Trust's designated “Green Hospital” between 21 September 2020 to 21 December 2020. Data for all patients was collected from electronic discharge summaries, clinic letters and patient notes. Results Pre-COVID our day case cholecystectomy rate was 73% compared to 54.7% during COVID. Pre-COVID conversion rate from planned day case to inpatient stay was 16.3% and during COVID the conversion rate increased to 44%. The waiting time for a cholecystectomy doubled during COVID to 26.3 weeks from 13.6 weeks pre-COVID. Average re-admission rate with symptomatic gallstones was 0.79 pre-COVID and 0.95 during COVID, with 64% of patients having at least one admission prior to surgery. The average length of stay pre-COVID was 0.75 days compared to 0.57 days during COVID. Summary COVID adversely affected our day case cholecystectomy rates with resultant increased waiting times for surgery and re-admissions with symptomatic gallstones however the average length of hospital stay was reduced.

Seizures and emergency department: characteristics and factors of repeat adult attendees.

To identify risk factors and characteristics for the repeated attendance at an emergency department (ED) following a seizure. A retrospective cohort study was conducted using non-identifiable data of individuals attending ED at least twice between 2015 and 2018, following a seizure. Data were drawn from the patient administration system of an English rural medium-sized teaching district general hospital emergency department (ED), serving a population of 566,000 people. It was analysed for bio-psycho-social features associated with repeat attendances. Of 3522 seizure-related attendances in the four years, 450 people were identified to be repeaters attending on two or more occasions (range 2-12). Just over a quarter (27%) were 18-29years old. Higher likelihood of re-attendance was associated with social deprivation and no fixed abode. Mental illness was a significant co-morbidity influencing repeat attendances. Nearly half (47%) had no recorded anti-seizure medication (ASM). Three fifth (60%) were on general medication and a quarter (25%) on psychotropics. Nearly a quarter (22%) had alcohol and recreational drug concerns. Just over a quarter (28%) had no previous epilepsy diagnosis. Nearly a fifth (n = 85, 19%) died during the study period. People who present repeatedly with seizures at ED are at significant risk of death over a four-year period and require pro-active clinical follow-up. People who are homeless or from socially deprived areas are over-represented in this group, as are those with alcohol problems, co-morbid mental health conditions and compliance issues. This suggests enhanced targeted intervention for this cohort is needed.

"Surgically Treated COVID-19-Positive Trauma Patients Had a Higher Fatality Rate" - A Rural District General Hospital's Perspective in the United Kingdom.

IntroductionOur study analyses the influence of the COVID-19 pandemic on perioperative death in elderly patients undergoing surgery for fractures who test positive for the virus during their admission in a rural hospital setting in the UK.MethodsOne hundred and fifty-six consecutive patients with age more than 75 years, who underwent surgery for fractures in Glangwili General Hospital during the second wave of the pandemic between 20th November 2020 and 20th January 2021, were included in this study. The 28-day mortality rate was estimated, and the results were compared to a matched cohort of patients from a similar duration before the pandemic (20th November 2019 to 20th January 2020).ResultsA total of 41 out of 156 patients were tested positive for COVID-19 in this study cohort. The overall 28-day mortality rate was 8.9% (n=15 patients) in comparison to 4% (n=8) in the comparative cohort of 196 patients from the pre-pandemic era. Of the 41 patients who tested positive for COVID-19, 11 patients died within 28 days of surgery, resulting in a mortality rate of 26.8% with a relative risk of 7.7(p=0.0461). Furthermore, 91% (n=10) of COVID-19-positive patients who died had an underlying cardiac disease and/or proximal femoral fractures. The 28-day mortality rate in those tested negative for COVID-19 was 3.5% (n=4).ConclusionThere is a significantly increased risk of death in the perioperative period on contracting COVID-19, in patients who are 75 years of age or older, especially those with associated cardiac comorbidities and who have sustained proximal femoral fractures.

Emergency hip disarticulations for severe necrotising fasciitis of the lower limb: a series of rare cases from a rural district general hospital.

Hip disarticulation is the removal of the entire lower limb through the hip joint by detaching the femur from the acetabulum. This major ablative procedure is rarely performed for infection but may be required in severe necrotising fasciitis. We present a single centre retrospective review of all cases of emergency hip disarticulations in patients with necrotising fasciitis between 2010 and 2020. All five patients included in the review presented with acute lower limb pain and sepsis. Three patients had comorbidities predisposing them to necrotising fasciitis. Three were deemed to be high risk and two were at intermediate risk of developing necrotising fasciitis. There were two deaths in the postoperative period. Of the three survivors, two required revision surgery for a completion hindquarter amputation and one for flap closure. All three survivors had good functional outcomes after discharge from hospital. Despite its associated morbidity, emergency amputation of the entire lower limb is a life-saving treatment in cases of rapidly progressing necrotising fasciitis and should be considered as a first-line option in managing this condition.

Comparing orthopaedic paediatric trauma in a rural district general hospital and an urban major trauma centre: A retrospective cohort study

BackgroundStudies from countries such as Australia and South Africa have demonstrated a difference in the types of injury managed in rural hospitals compared to larger, urban hospitals and so conclude staff require a different skill-set to work in these environments. There is some evidence this attitude may be prevalent amongst UK surgical trainees, resulting in difficulty recruiting to rural settings. In addition, studies have compared mortality in paediatric trauma patients in rural and urban hospitals, but none have described types of injury or orthopaedic operations required.We hypothesise the distribution of operative, orthopaedic paediatric trauma in a rural district general and an urban major trauma centre will not differ significantly in terms of patterns and mechanism of injury, orthopaedic intervention or time to theatre. Materials/methodsAll operative paediatric patients (0–15yrs) seen during an acute orthopaedic take at a rural district general and an urban major trauma centre were included. Non-operative admissions were excluded. Patients were identified using daily trauma work lists from each site. Outcomes were age, injury type, operation, time to theatre, seasonality and mechanism. Results183 patients from the urban hospital and 103 from the rural were identified. There were no significant differences found in age of patient, seasonality or time to theatre between cohorts (p > 0.05). There were also broadly similar patterns of injury and operations performed in both groups, although k-wiring was more often employed in the rural cohort than the urban (27% vs 17% of total operations). There were more bicycle and shinty related injuries in the rural cohort, and equine related in the urban. ConclusionsPaediatric trauma admissions do not vary significantly between rural and urban trauma centres, although the types of procedure performed may be less conservative in a rural hospital. This may be due to geography or differences in ED practice.

Patient and public involvement and engagement: Practice case study with reflections and learnings from a small rural district general hospital

The notion of patient and public involvement and engagement (PPIE) in research has been around for some time, and it is considered essential to ensure high-quality relevant research that is shared and that will make a difference. This case study of practice aims to share the PPIE practice from Dorset County Hospital NHS Foundation Trust, a small rural district general hospital. It describes the process of recruiting patients and members of the public as research volunteers, as well as the plethora of engagement and involvement activities with which they have been involved to date. This is followed by a reflection on the process and an overview of plans for the future, highlighting key challenges as well as learnings. A dedicated role to support/oversee PPIE activities is recommended to coordinate large groups of research volunteers, as well as to monitor the important impact of their input, which is considerable. Increasing diversity and access to under-served groups, and embedding the research volunteer role within the wider clinical research team, are also highlighted as fundamental challenges, as well as opportunities to make the most from this valuable resource. The case study of practice puts forward a recommendation to all research departments to embed PPIE in all of the work that they do.

The 31-month experience of transperineal template prostate biopsy at a rural district general hospital

Introduction: Transperineal template prostate biopsies (TPTPB) have been offered for prostate adenocarcinoma diagnosis since Mar 2017 at Hereford County Hospital, in conjunction with the Prostate Imaging Reporting and Data System (PI-RADS). This assesses the likelihood of clinically-significant cancer based on MRI prostate characteristics. Our study will evaluate this unit’s experience of TPTPB efficacy and safety.

Fluid balance chart audit in a rural district general hospital

Fluid balance charts are an important monitoring document for patient safety and clinical care. The National Confidential Enquiry into Patient Outcome and Death report shows that inaccurate fluid balance monitoring impacts patient deaths in the perioperative period.1 Our audit aimed to assess accuracy, completeness and attitudes towards fluid balance charts including evidence of appropriate escalation when required. This work is part of an ongoing audit conducted over an acute surgical and medical ward in a …

Metabolic Stone Screening – Can Education Improve Adherence to National Guidelines?

Nephrolithiasis is a common urological disease affecting approximately 13% of the global population. Identifying a preventable cause during follow-up for stone formation is a necessary factor in reducing recurrence. The majority of kidney stones are comprised of calcium, with oxalate and phosphate compounds account-ing for approximately 80% of stone formers. Serum analysis can be used to identify the levels of calcium in the blood, excluding metabolic causes for stones. Current NICE guidelines recommend performing a metabolic screen during an acute admission. Adherence to these guidelines from clinicians can be poor. We aim to see whether education can improve serum metabolic requests from clinicians in the UK. Method A case-control study was performed in a single rural district general hospital in the UK. Patients who pre-sented with renal colic were analyzed retrospectively for four months, looking at serum metabolic screen requests. Two months of education was then delivered to acute departments, with a further prospective study performed following this for six months. Outcomes were then compared between both groups to see if there was an improvement in serum requests following the delivery of local education. Results A total of 124 patients were included in our study. 50 patients were analyzed in cohort A over a 4-month period. Complete serum analysis was performed on 22% (n=11) of patients. Incomplete serum analysis was performed on 58% (n-29) of patients with uric acid being missed on all of them. 10 patients had no metabolic serum analysis performed at all, with 1 patient having a previous history of stones. A total of 74 patients were analyzed in cohort B over a 6-month period. This was following the 2 months of departmental education given by urologists. Complete serum analysis was performed on 24% (n=18) of patients. Incomplete serum analysis was performed on 55% (n=41) of patients with uric acid being missed from all of them. The remaining 21% of patients (n=15) had no metabolic serum screen performed at all. There was no significant difference seen between both cohorts after comparing metabolic serum requests before and after department education for 2 months (p=0.7287). Conclusion Improving adherence to clinical guidelines for metabolic screening has proved difficult with departmental teaching alone, with very little improvement achieved. Nevertheless, formal face-to-face education is ad-vocated to reinforce knowledge in junior doctors managing renal stones.

Follow-Up Colonoscopy Examination In Patients Aged 45 Years And Over Following Acute Appendicitis At A Rural District General Hospital

Follow-Up Colonoscopy Examination In Patients Aged 45 Years And Over Following Acute Appendicitis At A Rural District General Hospital

Improving the diagnostics of tuberculosis and drug resistance with Xpert MTB/RIF in a district general hospital in Sierra Leone: a quality improvement project

Sierra Leone has a high tuberculosis (TB) burden with a prevalence of 441 cases per 100 000 population. As a result of the Global Fund, some facilities in the country...

Use of Thermocoagulation Within a 'Screen and Treat' Cervical Cancer Screening Programme in Malawi: Outcomes at One Year, Professional Perspectives, and Client Experience

Background: Thermocoagulation (also known as thermoablation, previously as cold coagulation) is increasingly being adopted as an alternative treatment to cryotherapy within 'screen and treat' cervical screening services using visual inspection with acetic acid (VIA) in resource-constrained settings. This ablative treatment is suitable for low-grade squamous epithelial lesions. Given that much of the current systematic review evidence is drawn from high-income settings, it is critical that the evidence base for use within LMICs is strengthened. Aim: To evaluate the effectiveness of thermo-coagulation in the treatment of VIA-positive lesions within a 'screen and treat' program in Malawi, and its acceptability to clients and providers. Methods: Over the last four years, the Nkhoma Cervical Cancer Screening Program has implemented a 'screen and treat' approach using VIA and treatment using thermocoagulation in a rural district general hospital and associated health centers. Women with VIA-positive lesions are offered treatment with thermocoagulation; treated women are requested to return for review at three- six months, and at one year. Mechanisms to ensure monthly data collection and collation are in place. Semistructured qualitative face-to-face interviews were carried out in English with nineteen providers in nine health centers associated with Nkhoma Hospital: a range of issues were explored, including their experience with use of thermocoagulation. A patient experience questionnaire using validated facial pain scales was developed and translated into Chichewa: women complete this following treatment together with a patient attendant. Results: Between October 2013 and July 2017, over 1650 women have received treatment with thermocoagulation. Of a cohort of 446 treated women who had returned for a 1-year review visit by July 2017, 426 (95.5%) were VIA-negative, i.e., a treatment failure rate of < 5%, comparable with the international literature. Relationship between HIV status, initial VIA positivity, and treatment outcomes, will be presented. Staff reported professional satisfaction in being able to offer treatment consistently to VIA-positive clients, closer to their communities. For some, this was contrasted with previous experience of unavailable cryotherapy resulting in loss to treatment of patients. Over 120 women have completed pain scales questionnaires following treatment with the traditional machine, or with one of the two new hand-held models: their experiences (facial pain scales, and free-text comments) will be reported. Conclusion: In many low-resource settings, VIA-based screening with robust treatment protocols will remain central to cervical cancer control until the promise of HPV vaccination is fully realized. Thermocoagulation is an effective treatment modality, acceptable to clients and patients. Ongoing review of outcomes within and across treatment facilities is critical.

A case study exploring the effectiveness of an innovative "5Q Care Test" to determine whether patients with complex needs require health or social care.

A case study was conducted in 2016 to evaluate the effectiveness of an innovation to enable people with "complex" care requirements to be discharged from hospital to an appropriate service for their care, without using the NHS England Continuing Health Care (CHC) assessment. The setting was a rural district general hospital in England, where the quality outcomes and cost-effectiveness of the CHC assessment being conducted in hospital were giving cause for concern. The NHS CHC Framework advocates conducting these assessments in the community where a more accurate indication of long-term care can be determined. The "5Q Care Test" was collaboratively developed with health and social care partners, care providers, and CHC interest groups, including users of the services. It was implemented as a tool to support moving the CHC assessment into the community, as it enabled practitioners to swiftly determine patients' appropriate initial care pathway out of hospital. A full economic impact analysis was conducted 7months after the tool was introduced. The results showed significant improvement in the quality and cost-effectiveness of the "5Q Care Test," with a reduction in the hospital length of stay, which is known to be associated with improved outcomes for patients and financial savings.

Improving door-to-needle times for patients presenting with ST-elevation myocardial infarction at a rural district general hospital.

Acute coronary syndrome is a common condition with a major global impact on healthcare resources and expenditure. International guidelines are clear in specifying that patients with acute ST-elevation myocardial infarction (STEMI) should receive urgent coronary reperfusion with either primary percutaneous coronary intervention (PCI) or thrombolysis. Although PCI is the gold standard in the treatment of STEMI, this is not always achievable in a rural hospital with no cardiac catheterization service. Consequently, local recommendations on STEMI management exist to promote timely administration of thrombolysis within 30 minutes of patient arrival. However, translating updated clinical policy into practice is a challenging and complex task that requires a multi-faceted approach with sustained engagement from local stakeholders.Whilst working at a district general hospital in New Zealand, we noted a high incidence of patients presenting with STEMI receiving thrombolytic therapy outside the recommended 30 minutes door-to-needle time. Although final treatment was often only delayed by 5-10 minutes, we were concerned by the seemingly inconsistent management of these patients, often leading to unnecessary delays in the initiation of rapid reperfusion therapy.We therefore championed a newly updated clinical guideline and promoted an early STEMI recognition and treatment algorithm in our hospital to raise awareness amongst staff and improve door-to-needle times. We introduced a number of simple low-cost interventions that included educational sessions for junior doctors and cardiac nursing staff, as well as posters and training on the use of a remote electronic ECG interpretation system to streamline out-of-hours management.Overall, we found there to a be a steady improvement in door-to-needle times at our hospital, with 74% of patients receiving appropriate care within 30 minutes, compared to 43% prior to our interventions. This also translated to better patient outcomes.This project forms part of an ongoing process to instigate quality improvements in the management of STEMI within rural institutions. Whilst we have demonstrated improved utilisation of a local STEMI guideline and streamlining of out-of-hours services, the key challenge remains to ensure that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

A stress echocardiography service in a district general hospital: can we ensure quality without quantity?

We determined the accuracy, safety and clinical predictive value of stress echocardiography (SE) as a risk stratification tool for myocardial ischaemia when implemented in a rural district general hospital performing relatively low case volumes. We retrospectively reviewed 451 patients who were consecutively referred for SE between 2009 and 2012. 71 (16%) had a positive result and 367 (81%) …

A stress echocardiography service in a district general hospital: can we ensure quality without quantity?

We determined the accuracy, safety and clinical predictive value of stress echocardiography (SE) as a risk stratification tool for myocardial ischaemia when implemented in a rural district general hospital performing relatively low case volumes. We retrospectively reviewed 451 patients who were consecutively referred for SE between 2009 and 2012. 71 (16%) had a positive result and 367 (81%) …