Scottish Teaching Hospital Research Articles

381-P: Real-Time Ward-Level Monitoring of Nurse Performance Level Is able to Demonstrate Improved Management of Inpatient Hypoglycemia following an Education Intervention

Aims: The aims of this study were (a) to demonstrate that analyses of glucometer data/metadata can reveal real-time ward-level patient-centred outcomes relevant to hypoglycemia (b) to test whether a 6-month education and mentoring intervention improved relevant performance levels. Methods: Ward glucometer data were analysed for periods of 9 months before and after the intervention in 9 wards (256 beds) in a large Scottish teaching hospital. Results were compared with 9 control wards, matched for size, specialty and acuity. Hypoglycemia was defined as <4mmol/l (72mg/dl). Process control charts were constructed for each clinical unit. At each hypoglycemic event, +1 (success) or -1 (fail) was generated for TTR (time to repeat CBG) and TTHR (time to hypo resolution). The gradient of the plot represents performance level, allowing comparison pre- and post-intervention for both ward groups. Results: Total hypo events = 5187. Significant improvements in performance level were demonstrated in the intervention wards but not the control wards in TTR at 10, 15, 20 and 30 mins and TTHR at 10, 15 and 20 mins (Table). Conclusions: This study demonstrates the utility of the process control charts in CBG-related patient outcomes, and quantifies the significant improvement in hypoglycemic management derived from an education intervention. Disclosure C. Sainsbury: Consultant; Self; MyWay Digital Health. Research Support; Self; Sanofi. Speaker’s Bureau; Self; AstraZeneca. C. Skivington: None. M. Robertson: None. G.C. Jones: None. S.J. Cleland: None. Funding Sanofi

Care home residents who die in hospital: exploring factors, processes and experiences.

Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital. This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives. During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this. Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24hours-a-day support to manage difficult symptoms and acute changes.

The differences between patient and optometrist experiences of contact lens hygiene education from the perspective of a Scottish university teaching hospital

BackgroundContact lens related keratitis is a frequent presentation to acute ophthalmology services. Patients often do not recall being counselled regarding the safe use of contact lenses therefore fail to comply with guidance.This study aimed to identify the content and format of advice given to patients with contact lens keratitis concerning appropriate hygiene practices, determine their compliance with this and finally characterise optometrist practices regarding contact lens advice provided to patients. MethodsAll adult patients presenting with contact lens related keratitis to the acute ophthalmology clinic were asked to complete a survey. Information was collected on lens type, format of advice received and compliance.Community optometrists were asked to complete an electronic survey on their contact lens review practices and routine patient education. ResultsAll patients surveyed recalled counselling on initiation of contact lenses; however 12% (6/50) were given no advice on return visits. This advice was in written format for 20% (10/50) of patients on initiation increasing to 32% (16/50) on renewal.Many patients slept (22%), showered (44%) or swam (36%) in lenses. 92% cleaned their contact lenses appropriately, but cases were washed infrequently (19% of cases cleaned < monthly) or with tap water (27%).All optometrists surveyed claimed to provide advice to patients in either written or verbal format for new and returning contact lens users. 49% (16/33) of optometrists gave written advice to patients on initial contact lens fitting, but only 1/33 continued with written advice for repeat customers. ConclusionThis study identified that although most patients were informed of appropriate hygiene requirements, compliance was poor. Optometrists regularly provide verbal advice but do not routinely offer written support and there is a mismatch between patient recollection and self-reported optometrist practice. It is suggested that patient education needs greater emphasis and both verbal and written information should be regularly provided on initial review and follow up assessments.

Preoperative prediction of Difficult Laryngeal Exposure (DLE) during Microlaryngoscopy (ML): Use of LARYNGOSCORE in a scottish teaching hospital

Preoperative prediction of Difficult Laryngeal Exposure (DLE) during Microlaryngoscopy (ML): Use of LARYNGOSCORE in a scottish teaching hospital

A qualitative study of determinants of patient behaviour leading to an infection related hospital admission.

Objectives To describe and understand the determinants of patients' behaviours surrounding admission to hospital for an acute infective episode Method Patients admitted to the infection or acute medicine admission units of a major Scottish teaching hospital and commenced on antibiotic therapy after admission were included. Semi-structured face-to-face interviews were conducted using a pre-piloted interview schedule guide that focused on gathering information about patient behaviours and experiences prior to admission to hospital with an acute infection. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework Approach. Emerging themes were matched to the Theoretical Domains Framework of behavioural determinants. Results Twenty-one patients consented to participate and 18 transcripts were suitable for analysis. The most common infections were those of the skin, soft tissue and respiratory tract. From the patients' perspectives, behavioural determinants that appeared to impact their admission to hospital were principally their knowledge, beliefs of consequences, the environmental context and resources (mainly out-of-hours services), social influences and their own emotions. Determinants such as knowledge of the signs and symptoms, beliefs of consequences and environmental context were facilitators of health seeking behaviours. The main barriers were a lack of awareness of consequences of infection potentially leading to delayed admission impacting infection severity, stay in secondary care and resource utilisation. Conclusions This study has shown that any initial patient-centred intervention that is proposed to change patient behaviour needs to be based on behavioural determinants emerging in this research. The intervention may include aspects such as patient education on resources available out-of-hours and ways to access the healthcare system, education on recognising signs of infection leading to prompter treatment and positive reinforcement for patients who present with recurrences of infection.

New institutionalisation following acute hospital admission: a retrospective cohort study

Backgroundinstitutionalisation following acute hospital admission is common and yet poorly described, with policy documents advising against this transition.Objectiveto characterise the individuals admitted to a care home on discharge from an acute hospital admission and to describe their assessment.Design and settinga retrospective cohort study of people admitted to a single large Scottish teaching hospital.Subjects100 individuals admitted to the acute hospital from home and discharged to a care home.Methodsa single researcher extracted data from ward-based case notes.Resultspeople discharged to care homes were predominantly female (62%), widowed (52%) older adults (mean 83.6 years) who lived alone (67%). About 95% had a diagnosed cognitive disorder or evidence of cognitive impairment. One-third of cases of delirium were unrecognised. Hospital stays were long (median 78.5 days; range 14–231 days) and transfers between settings were common. Family request, dementia, mobility, falls risk and behavioural concerns were the commonest reasons for the decision to admit to a care home. About 55% were in the acute hospital when the decision for a care home was made and 44% of that group were discharged directly from the acute hospital.Conclusionscare home admission from hospital is common and yet there are no established standards to support best practice. Decisions should involve the whole multidisciplinary team in partnership with patients and families. Documentation of assessment in the case notes is variable. We advocate the development of interdisciplinary standards to support the assessment of this vulnerable and complex group of patients.

Dipeptidyl peptidase 4 inhibitors in routine clinical practice: experiences from a Scottish teaching hospital

Aims: This study aimed to assess the effect of dipeptidyl peptidase 4 inhibitors (DPP4i) on glycaemia and weight control and review adherence to renal dosing guidance in routine clinical practice. Methods: A retrospective review of type 2 diabetes patients prescribed a DPP4i was undertaken in a general hospital. Date, type and dose of DPP4i, HbA1c, weight and renal function were recorded at initiation of DPP4i therapy and at the first follow-up appointment at least 3 months later. Results: Between March 2008 and June 2012, 335 patients were initiated on DPP4i therapy of whom 263 were eligible for study inclusion (baseline median HbA1c 73 mmol/mol (IQR 65-83), median weight 90.8kg (IQR 79.7-104), approximately 74.8% with eGFR >50ml/min/1.73m2). Sitagliptin 100mg daily was the most commonly prescribed DPP4i (90.5%). Median time between DPP4i initiation and follow-up was 189 days (IQR 140-239). At follow-up there was a reduction in HbA1c (median -8.5 mmol/mol; 95%CI -10, -6.5; p<0.005) and body weight (median -0.45kg; 95% CI -1.15, -0.25, p0.033). At initiation the dose of DPP4i was appropriate for 87.7% of patients. Conclusions: DPP4i are effective in reducing HbA1c and body weight in routine specialist secondary care. Inappropriate prescribing in 70% of patients with eGFR <50ml/min/1.73m2 prompted a review of prescribing practice.

Imminence of death among hospital inpatients: Prevalent cohort study

Background: There is a dearth of evidence on the proportion of the hospital population at any one time, that is in the last year of life, and therefore on how hospital policies and services can be oriented to their needs. Aim: To establish the likelihood of death within 12 months of a cohort of hospital inpatients on a given census date. Design: Prevalent cohort study. Participants: In total, 10,743 inpatients in 25 Scottish teaching and general hospitals on 31 March 2010. Results: In all, 3098 (28.8%) patients died during follow-up: 2.9% by 7 days, 8.9% by 30 days, 16.0% by 3 months, 21.2% by 6 months, 25.5% by 9 months and 28.8% by 12 months. Deaths during the index admission accounted for 32.3% of all deaths during the follow-up year. Mortality rose steeply with age and was three times higher at 1 year for patients aged 85 years and over compared to those who were under 60 years (45.6% vs 13.1%; p < 0.001). In multivariate analyses, men were more likely to die than women (odds ratio: 1.18, 95% confidence interval: 0.95–1.47) as were older patients (odds ratio: 4.99, 95% confidence interval: 3.94–6.33 for those who were 85 years and over compared to those who were under 60 years), deprived patients (odds ratio: 1.17, 95% confidence interval: 1.01–1.35 for most deprived compared to least deprived quintile) and those admitted to a medical specialty (odds ratio: 3.13, 95% confidence interval: 2.48–4.00 compared to surgical patients). Conclusion: Large numbers of hospital inpatients have entered the last year of their lives. Such data could assist in advocacy for these patients and should influence end-of-life care strategies in hospital.

Increasing skills and confidence in caring conversations: a course

This paper describes a service development in healthcare support workers (HCSWs) across departments in a large Scottish teaching hospital. In any healthcare setting, communication can be complex and challenging. Many healthcare support workers and ward clerks are often the first face seen by patient or family entering the ward. As junior members of the team, this task can appear daunting, particularly as there is limited access to formal training or support. There are also few chances to reflect on practice and develop skills, such as communication. The course was designed to fill this gap and give 15 support workers an opportunity to practise and reflect in a supported manner using patient, staff and family stories as a vehicle for deeper learning. Evaluation of this course, which was highly valued, showed that this was a successful method of encouraging reflection and self-awareness, as a way of improving their communication skills.

An interesting case of new-onset ketosis-prone diabetes in a Scottish teaching hospital

Background: Clinical teaching for many years has been to assume that diabetic ketoacidosis is pathognomic of type 1 diabetes. However, this dogma is now increasingly questioned as increasing numbers of people are admitted with diabetic ketoacidosis without the typical features of autoimmune type 1 diabetes. Such individuals are increasingly diagnosed with ketosis-prone diabetes, a heterogenous syndrome where individuals present with diabetic ketoacidosis or unprovoked ketosis but are usually autoantibody negative and have no residual β-cell function. Classification of ketosis-prone diabetes using the Aβ system can aid in diagnosis and treatment decisions. Case report: An Afro-Caribbean male presented with hyperglycaemic ketosis. Initially diagnosed with type 1 diabetes and treated with a basal-bolus regimen, he was able to stop insulin completely within one month of presentation following rapid improvements in glycaemic control and repeated hypoglycaemia. Clinical investigation revealed he was negative for β-cell autoantibodies and had a stimulated C-peptide of &gt;0.5 pmol/ml, suggesting preserved β-cell function. A diagnosis of ketosis-prone diabetes (A-β+) was made. Discussion: A high index of suspicion for ketosis-prone diabetes should arise when someone presents with diabetic ketoacidosis, who is obese, middle-aged, male and with a strong family history of type 2 diabetes and from a Black or Hispanic population. There is currently limited evidence on the pathophysiology of this transient β-cell defect, with suggestions that it may be related to glucotoxicity.

Cancer of Oesophagus or Gastricus – New Assessment of Technology of Endosonography (COGNATE): report of pragmatic randomised trial

Endoscopic ultrasonography is recommended for staging gastro-oesophageal cancers, but has never been evaluated. COGNATE (Cancer of Oesophagus or Gastricus - New Assessment of Technology of Endosonography) therefore aimed to evaluate whether adding 'endoscopic ultrasound' (EUS) to the usual staging algorithm changes treatment, improves (quality-adjusted) survival, and uses resources cost-effectively. Pragmatic parallel-group trial. Patients with gastro-oesophageal cancer received standard staging algorithms. Multidisciplinary teams chose provisional management plans from endoscopic mucosal resection, immediate surgery, surgery after chemotherapy, or chemotherapy and radiotherapy. We used dynamic randomisation to allocate consenting patients remotely by telephone in equal proportions between EUS and not. Thereafter we recorded changes in management plan, use of health-care resources, and three aspects of participant-reported quality of life: generic [measured by European Quality of Life - 5 Dimensions (EQ-5D)], cancer related [Functional Assessment of Cancer Therapy - General scale (FACT-G)] and condition-specific [FACT - Additional Concerns scale (FACT-AC)]. We followed participants regularly until death or the end of the trial - for between 1 and 4.5 years. We devised a quality assurance programme to maintain standards of endosonographic reporting. Eight British hospitals, of which two - one Scottish teaching hospital and one English district general hospital - contributed 80% of participants; we combined the other six for analysis. Patients were eligible if they had a diagnosis of gastro-oesophageal cancer, had not started treatment, were free of metastatic disease, were fit for surgery (even if not planned) and had American Society of Anesthesiologists and World Health Organization grades of less than 3. Intervention group: standard staging algorithm plus EUS; control group: standard staging algorithm. Primary: quality-adjusted survival. Secondary: survival; health-related quality of life (EQ-5D, FACT-G and FACT-AC scales); changes in management plan; and complete resection rate. Although blinding participants was neither possible nor desirable, those responsible for analysis remained blind until the Trial Steering Committee had reviewed the definitive analysis. We randomised 223 patients, of whom 213 yielded enough data for primary analysis. EUS improved survival adjusted for generic quality of life with a hazard ratio of 0.705 [95% confidence interval (CI) 0.499 to 0.995], and crude survival with a hazard ratio of 0.706 (95% CI 0.501 to 0.996). The benefits of EUS were significantly greater for those with poor initial quality of life, but did not differ between centres. EUS reduced net use of health-care resources by £2860 (95% 'bootstrapped' CI from -£2200 to £8000). Combining benefits and savings shows that EUS is likely to be cost-effective, with 96% probability of achieving the National Institute for Health and Care Excellence criterion of costing of < £20,000 to gain a QALY. There were no serious adverse reactions attributable to EUS. EUS enhanced the management plan for many participants, increased the proportion of tumours completely resected from 80% (44 out of 55) to 91% (48 out of 53), and improved the survival of those who changed plan; although underpinning the significant differences in outcome, none of these process differences was itself significant. Endoscopic ultrasound significantly improves (quality-adjusted) survival, has the potential to reduce health-care resource use (not statistically significant) and is probably cost-effective (with 96% probability). We recommend research into the best time to evaluate new technologies. ISRCTN1444215. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 39. See the HTA programme website for further project information.

PTH-166 Patient Preference for the Management of Chronic Gastrointestinal Disorders

IntroductionGastroenterology has a large and expanding outpatient workload, much of which deals with chronic relapsing disorders. In our Scottish Teaching Hospital it is the second busiest speciality by referral rate...

Factors affecting decision making about fertility preservation after cancer diagnosis: a qualitative study

To increase our understanding of factors underlying the decision to store gametes after the diagnosis of cancer. Qualitative interview study. Andrology, Haematology, and Oncology Departments of a Scottish teaching hospital, and patients' own homes. Sixteen men and 18 women aged 17-49 years recently diagnosed with cancer; 15 health professionals concerned in cancer care. Audio-recorded semi-structured interviews were transcribed verbatim and analysed thematically. Topics included perceptions of diagnosis; prognosis; future reproductive choices; priorities; quality of information received; communication and decisions made about future reproductive choices; and the role of partners, family, friends and healthcare professionals. Professional interviews examined their role in decision making and that of protocols and guidelines, together with information emerging from patient interview analysis. Themes identified following analysis of interview transcripts. The primary barriers to pursuing fertility preservation were the way in which information was provided and the 'urgent need for treatment' conveyed by staff. Survival was always viewed as paramount, with future fertility secondary. Sperm banking was viewed as 'part and parcel' of oncology care, and the majority of men quickly stored sperm as 'insurance' against future infertility. Few women were afforded the opportunity to discuss their options, reflecting clinicians' reservations about the experimental nature of egg and ovarian tissue cryopreservation, and the need for partner involvement in embryo storage. Significant gaps in the information provided to young women diagnosed with cancer suggest the need for an early appointment with a fertility expert.

Introduction of a low pressure suction system for day case large volume paracentesis: results from a scottish teaching hospital

IntroductionIn most centres including our own, large volume paracentesis (LVP) has traditionally been performed under free drainage. The authors sought to evaluate the safety and efficacy of a low pressure...

Incidence of community-acquired meticillin resistant Staphylococcus aureus hand infections in Tayside, Scotland: a guide to appropriate antimicrobial prescribing

The prevalence of community-acquired meticillin resistant Staphylococcus aureus (ca-MRSA) as an important cause of hand infections has gained much recognition. The clinical impact of this is less well documented in the United Kingdom. This study looks at the incidence of hand infections in an urban Scottish teaching hospital over a 12 month period.

Training and competency in rapid sequence intubation: the perspective from a Scottish teaching hospital emergency department

BackgroundRapid sequence intubation (RSI) is an established core competency for emergency medicine trainees. The training and experience required to achieve competency is unclear.AimsTo illustrate the RSI training and experience attained...

Thinking Ahead of the Surgeon: Developing a Behavioural Rating System for Scrub Practitioners' Non-Technical Skills (SPLINTS)

Efforts to reduce adverse event rates in healthcare have revealed the importance of identifying the essential non-technical (cognitive and social) skills for safe and effective performance and developing tools for rating and training those skills. The focus of studies to date has been surgeons, anaesthetists, or the whole team, with less attention paid to other professionals. The aim of the study was to develop a behavioural rating system for non-technical skills of the scrub practitioner (nurse/technician). This paper reports an interview study, as part of a task analysis, to identify the critical non-technical skills for this role, and the development of a prototype behavioural rating system. Experienced scrub practitioners (n = 25) and consultant surgeons (n = 9), from four Scottish teaching hospitals, were interviewed using a semi-structured design. Data that described generic non-technical skills were extracted from the interview transcripts and thereafter, psychologists and panels of perioperative practitioners (n = 4) used an iterative process to develop a skills taxonomy. Three categories of non-technical skills were identified as critical for safe and effective scrub practitioner performance. These were; situation awareness, communication and teamwork, task management. Three underlying skill elements for each of the three categories were labeled by the expert panels and they provided examples of good and poor behaviours for each of these skill elements, drawing on their domain knowledge. The reliability and psychometric properties of the prototype skills taxonomy and behaviour rating system are currently being tested using standardized, simulated scenarios.

Economic evaluation of diagnosing and excluding ectopic pregnancy.

The diagnosis of ectopic pregnancy in women presenting in early pregnancy is often protracted, relying on costly investigations that are psychologically burdensome to the patient. The aim of this study was to evaluate the financial costs to the health services in Scotland of the current methods used to diagnose and exclude ectopic pregnancy, and compare these with that of a theoretical single diagnostic serum biomarker. We conducted a retrospective cost-description analysis (with and without costs of diagnostic laparoscopy) of the health-care costs incurred by all patients presenting to a large Scottish teaching hospital between June and September 2006 with pain and bleeding in early pregnancy, where ectopic pregnancy was not excluded. Additionally, a cost minimization analysis was performed for the costs of current ectopic pregnancy investigations versus those of a theoretical single diagnostic serum biomarker. This included sensitivity analyses where the biomarker was priced at increasing values and assumed to have less than 100% diagnostic sensitivity and specificity. About 175 patients were eligible to be included in the analysis. Forty-seven per cent of patients required more than three visits to diagnose or exclude ectopic pregnancy. The total yearly cost for diagnosing and excluding ectopic pregnancy was 197K pound sterling for the hospital stated, and was estimated to be 1364K pound sterling for Scotland overall. Using a theoretical diagnostic serum biomarker we calculated that we could save health services up to 976K pound sterling (lowest saving 251K pound sterling after subanalysis) every year in Scotland. Ectopic pregnancy is expensive to diagnose and exclude, and the investigation process is often long and might involve significant psychological morbidity. The development of a single diagnostic serum biomarker would minimize this morbidity and lead to significant savings of up to 1 million pounds per year in Scotland.

Blow-out fractures: Patterns of ocular motility and effect of surgical repair

The decision to repair an orbital blow-out fracture depends on several factors, but evidence for the optimum timing of surgery is not clear. We retrospectively studied all patients with orbital injuries who were referred to the eye department at a Scottish teaching hospital over a 10-year period from 1997 to 2006. We aimed to document the incidence and pattern of disturbances of ocular motility after blow-out fractures, and identify the rates of early and late resolution of these deficits, both spontaneously and after surgical repair. We found that most patients with blow-out fractures had a motility defect for an acute phase; approximately one third of which resolved spontaneously within 2 weeks. Recovery of motility after orbital surgery occurred in less than half the patients, and was not immediate. Continuing recovery also occurred in those who did not undergo surgery. Entrapment of muscle or tissue is not the only cause of motility disturbance after blow-out fractures, and orbital surgery is only one aspect of management in those patients with persistent motility defects.

Predictors of the need for rapid sequence intubation in the poisoned patient with reduced Glasgow coma score

Aim:In patients presenting to the emergency department (ED) with significant poisoning and reduced Glasgow coma score (GCS), the decision to proceed with rapid sequence intubation can be a difficult one....