Scottish Teaching Hospital Research Articles

Towards a Model of Care for Chronic Leg Ulcer: Lessons Learned from Studies in Scotland

Aim: To highlight the need for a different model of care delivery for chronic leg ulcer. Method: Analysis of data from the Scottish Leg Ulcer Trial and from surveys of leg ulcer care provision among General Practitioners, community nurses and health boards. Synthesis: General Practitioners and community nurses report serious deficiencies in education, training, protocols, equipment and support from the Acute sector. The Scottish Leg Ulcer Trial in a population of 2.65 million showed three-month healing rates of 30% with no improvement after dissemination of National (SIGN) Guidelines even when supplemented by a nationwide nurse training programme. Individual community nurses cared for an average of 1.5 ulcer patients per year. The more chronic the ulcer the poorer the healing rates. Only 17% of Scottish Teaching hospitals or District General hospitals provide a specialist led leg ulcer service. Conclusions: In the population at large, healing rates for leg ulcer are unacceptably low. Individual community nurses do not see enough leg ulcer patients to acquire or sustain the necessary clinical skills. Very few acute hospitals provide leg ulcer services. A new model of leg ulcer care is urgently required centred on multi-disciplinary teams, working in the interface between primary and secondary care, whose prime objectives should be prevention and early intervention. As an

Problem drinkers among acute care inpatients.

The objective of this study was to determine the prevalence of potential problem drinking among general hospital inpatients during a three-month period. The study was conducted in a large Scottish teaching hospital. The wards involved were the general medical, general surgical, orthopaedic and short-stay wards as they had been identified as clinical areas with problem drinking among inpatients. Patients were interviewed using a structured interview schedule as a screening instrument to detect potential problem drinkers. Of the patients interviewed, 25 per cent were shown to drink in excess of the BMA's guidelines for low-risk drinking: 8 per cent had had previous treatment for alcohol problems; 2 per cent were bout or seasonal drinkers; and 15 per cent were newly identified potential problem drinkers. Of the newly identified group, 75 per cent were men and 25 per cent women. Those who were unemployed formed the largest group of potential problem drinkers according to occupation, and patients from the short-stay ward were more likely to have an alcohol problem than those from other wards in the study. The patients in this study found to be at risk of experiencing alcohol-related problems might not be routinely identified with current screening methods. This method of screening, by asking patients about their recent drinking patterns, will help nurses to identify those who are potential problem drinkers and enable them to provide relevant advice and education to these patients.

Identifying opinion leaders in ward nurses: A pilot study

This pilot study assessed the validity of an instrument used to identify opinion leaders within a sample of nurses. Survey data were collected from all nurses within four surgical wards at a Scottish teaching hospital. The survey tool had three components: professional and personal characteristics; attitudes towards research; identification of opinion leaders. The main outcome measure was the identification of opinion leaders and the number of people who nominated each opinion leader. A total of 93 nurses were surveyed, of whom 61% (n=57) returned a questionnaire. However, only 40% (n=38) of the sample completed the opinion leader component of the survey tool. These response rates varied across the four wards. Four opinion leaders were nominated by more than five people: two in ward C; one in ward A; and one in ward D. Coverage across the wards was 58% (n=33) of those who had completed the questionnaire. This comprised just over one-third of the total sample (35%). All those identified as opinion leaders were of a significantly higher nursing grade than their non-opinion leader peers. The opinion leaders were also more likely to have academic qualifications and a greater awareness of research, and to participate actively in additional educational activities. The findings of this pilot study indicate that the survey instrument may be able to identify nurse opinion leaders in a ward. However, doubts exist over the use of the instrument to identify opinion leaders nominated by enough nurses in the sample.

Incidence of adenocarcinoma and mortality in patients with Barrett's oesophagus diagnosed between 1976 and 1986: implications for endoscopic surveillance.

The objective of this study was to investigate the incidence of oesophageal adenocarcinoma and its contribution to mortality in patients with Barrett's oesophagus, and to identify a subgroup of patients who may benefit from endoscopic surveillance. This was a retrospective study of a cohort of 70 patients diagnosed in the endoscopy unit of a Scottish teaching hospital as having Barrett's oesophagus between 1976 and 1986. Information was obtained from case notes, endoscopy records, histology reports and death certificates. Patients were included if they had: (a) columnar-lined oesophagus of at least 3 cm; (b) histological confirmation; and (c) absence of cancer when endoscopically diagnosed as having Barrett's oesophagus. The main outcome for the patients was development of adenocarcinoma or death. Information was available for 59 of 70 patients (84%). Forty-four patients were confirmed to have Barrett's oesophagus and were followed up for 418 patient-years. Only two patients developed oesophageal adenocarcinoma, resulting in an incidence of one case in 209 patient-years, a 55-fold risk compared with age- and sex-matched population in Scotland. Both these patients had intestinal metaplasia and Barrett's ulcer. The majority (90%) of patients died as a result of causes unrelated to adenocarcinoma of oesophagus. In patients under 70 years with intestinal metaplasia, 189 annual endoscopies would have been required to detect one cancer. Adenocarcinoma is an uncommon cause of mortality in patients with Barrett's oesophagus. Endoscopic surveillance is unlikely to alter overall mortality in patients with Barrett's oesophagus. However, by limiting endoscopic surveillance to patients under 70 years with intestinal metaplasia, the estimated cost per cancer detected can be reduced to ł23000.

Routine coagulation screening in the management of emergency admission for epistaxis--is it necessary?

The role of routine coagulation studies in the management of patients suffering from epistaxis is unclear. In an attempt to address this issue the case notes of all emergency admissions for epistaxis to a large Scottish teaching hospital were retrospectively reviewed over a one-year period. One hundred and forty patients (63 male, 77 female) were admitted between January and December 1998. The patients who had coagulation studies were identified and their results analysed. A total of 121 patients (86.4 per cent) had coagulation studies performed. Of these, 10 (8.3 per cent) had abnormal results and all were taking warfarin or a combination of warfarin and aspirin. No other coagulation abnormalities were identified. This study supports the view that there does not appear to be a role for routine coagulation studies in patients admitted with epistaxis. The investigation for potential haemostatic disorders should be performed when clinically indicated and, if necessary, in consultation with the haematology service.

The association between seniority of Accident and Emergency doctor and outcome following trauma

The actual survival of patients treated following trauma in four Scottish Teaching hospitals during five years was compared with predicted survival according to TRISS analysis. The data were analysed according to the seniority of the Accident and Emergency (A&E) doctor treating each patient. The group of patients treated by a consultant had a significantly better outcome ( p<0.05) than the group of patients treated by junior doctors. Analysis of outcome according to the grade of junior A&E doctor suggested a step-wise improvement in outcome with seniority, thus supporting the concept that an improved outcome is associated with experience and seniority. These results support calls for A&E consultants to be increasingly involved in the management of patients with major trauma. Such increased involvement would require an increase in the number of A&E consultants.

The Persistence and Clonal Spread of a Single Strain of Acinetobacter 13TU in a Large Scottish Teaching Hospital

This study describes the persistence and spread of a single strain of Acinetobacter 13TU in a large Scottish teaching hospital. Acinetobacter spp. are reported with increasing frequency as a cause of nosocomial infection. The species most implicated in these infections is Acinetobacter baumannii. Following an outbreak of infection with Acinetobacter 13TU within the intensive therapy unit (ITU) of Edinburgh Royal Infirmary (ERI) during 1994-1995, the current epidemiological Acinetobacter situation within the hospital was monitored to determine whether or not control of infection procedures instigated at that time had been successful in controlling the outbreak. Sixty-eight strains of Acinetobacter spp were isolated from clinical specimens received from various wards in the ERI and other associated hospitals over a 7-month period. Each isolate was typed phenotypically by the API20NE system and genotypically by pulsed field gel electrophoresis (PFGE) in order to compare them with the previous outbreak strain. Fifty-three percent of the isolates collected were originally identified as A. junii by API 20 NE, of which 83% (mainly from ITU) were shown to be genotypically related to the previous outbreak strain. Subsequent tDNA fingerprinting of one of the original outbreak strains showed it to be a member of the genospecies 13TU and not A. junii as originally thought.

Impact of resuscitation and thrombolysis on mortality rate from acute myocardial infarction

Our objective was to estimate the saving of life by thrombolysis and resuscitation in acute myocardial infarction (AMI) before and after hospital admission. We studied all 1516 patients admitted to a Scottish teaching hospital in 1990 and 1992 who had a final diagnosis of AMI, and 311 patients enrolled in the Grampian region early anistreplase trial (GREAT). Cardiac arrest occurred in 250 1516 (16%) hospital patients. Of these, 77 (31%) were discharged alive — a saving of 51 lives per thousand cases. 797 (53%) patients received thrombolysis, of whom 114 (14%) died. Assuming the same relative reduction in mortality as in the second international study of infarct survival (ISIS-2; 23%), 34 lives were saved by thrombolytic therapy, representing 22 lives per thousand cases. Of 311 patients in GREAT, 15 (5%) had prehospital cardiac arrest, with 7 patients surviving to discharge (48%) — a saving of 23 lives per thousand cases. Those patients given domiciliary thrombolysis had a one month mortality of 6.7% ( 11 163 ) compared with 12.2% ( 18 148 ) for those receiving hospital thrombolysis — a saving of 55 lives per thousand cases for prehospital thrombolysis. This is additional to 28 lives per thousand estimated for thrombolytic therapy in hospital, totalling 83 lives saved per thousand cases of AMI receiving thrombolytic therapy prehospital. In hospital, more lives were saved by resuscitation than by thrombolytic therapy, but this ratio was reversed in the period before hospital admission. These results emphasise the paramount importance of resuscitation in hospital, and the enhanced efficacy of thrombolysis when given at the earliest opportunity.

‘It's the little things that count’: the hidden complexity of everyday clinical nursing practice

This article reports on one aspect of a phenomenological study of everyday experience in nursing and how it contributes to the development of nursing expertise. The study was carried out with 10 'excellent, experienced' surgical ward sisters in two Scottish teaching hospitals. The ward sisters were found to help individual patients towards recovery by making the ward work for all. When moment-by-moment nursing practice, the context of nursing experience, is examined, it is found to be patient-centred and complex, geared towards multilayered goals. Three distinct yet inextricably intertwined processes--noticing, understanding and acting--characterize how nurses practise nursing. The quality of these processes contributes to the effectiveness of nurses' caring practices. The 'little things' of nursing practice make a difference to patients because they are imbued with nursing knowledge and skill.

Early supported discharge for elderly trauma patients: a report on a preliminary study

To cope with increasing numbers of elderly patients in acute orthopaedic units, various schemes have been introduced to expedite early rehabilitation and discharge. This paper reports a study undertaken in a large Scottish teaching hospital in order to assess the potential and requirements for a local scheme of early supported discharge for elderly trauma patients. Over a four-month period, data were collected from and about elderly patients (70+) admitted from home to the orthopaedic unit (overall sample of 282, detailed subsample of 100). Existing arrangements were shown to allow the apparently satisfactory direct discharge home of a substantial proportion (45%) of these patients in spite of their age (mean 80.2 years) and the fact that previous frailty was common and many (59%) lived alone. Findings of the study suggested that the number of discharges directly home could be increased with improved early rehabilitation, better pain control, systematic discharge planning, occupational therapy input and stronger links between the orthopaedic ward and the community services. Early clinical predictions of individual potential for direct discharge were unreliable. In a Scheme of Early Supported Discharge now in operation following the preliminary study, all patients admitted directly from home are considered.

Hyperkalaemia in patients in hospital.

Significant hyperkalaemia occurred in 406 out of 29 063 patients admitted to a major Scottish teaching hospital in one year (1.4%). Mortality was higher in these patients than in control patients and was strongly correlated with the severity of the hyperkalaemia. Overall seven deaths were directly due to hyperkalaemia (out of 58 deaths among patients with hyperkalaemia). Factors contributing to a poor prognosis were severity and speed of onset of hyperkalaemia and the presence of appreciable renal impairment. Patients with hyperkalaemia were older and more likely to be male; this trend was present in all diagnostic subcategories. Genitourinary disease, gastrointestinal disease, and cancer were significantly more common among the patients with hyperkalaemia than the controls. Hyperkalaemia due to drug treatment was invariably mild and non-fatal, whereas genitourinary disease was often associated with moderate to severe hyperkalaemia, which in two cases proved fatal. Use of electrocardiographic monitoring was rare, and although the treatment of hyperkalaemia was effective, it was often used when not required. Hyperkalaemia is a potential hazard in diabetic ketoacidosis, and use of potassium supplements should be carefully monitored during correction of the acidosis.

Reports by anaesthetists to procurators-fiscal: analysis of "anaesthetic deaths" over 10 years in four Scottish teaching hospitals.

Review of 489 "anaesthetic deaths" reported to procurators-fiscal over 10 years disclosed only 30 that were thought to justify such reporting. Most of the remainder occurred in patients so desperately ill at the time of operation that death was expected. Postmortem examinations ordered by the Crown authorities in nearly all cases were probably largely unrewarding and mostly unnecessary. The results suggest that the present regulation on reporting should be revised to focus more attention on the few deaths that occur in patients who have no apparent contraindication to anaesthesia or operation.

Trends in hospital necropsy rates: Scotland 1961-74.

Examination of mortality statistic for Scottish hospitals showed that from 1961 to 1974 necropsy rates fell by almost 0-6% a year; by 1974, the rate over the whole country was 23% of hospital deaths. The fall resulted from a reduction in the number of necropsies and a coincident rise in the number of number of deaths in hospital. The necropsy rate fell with increasing age, was rather lower for women than men, and was lower for some diseases than others. There were considerable inaccuracies in the figures from which these trands were drawn, and these were in turn due to inaccurate recording of clinical and necropsy data. Examination of necropsy returns from the Scottish teaching hospital departments showed that, while a similar fall in necropsy rates was seen in some, there was no consistent pattern.

Intravenous fluids in medical in‐patients.

1 Data from the Boston Collaborative Drug Surveillance Program were reviewed to determine the proportion of patients receiving intravenous fluids in the participating hospitals. 2 Wide differences between hospitals in the United States and four other countries were observed: i.v. fluids being given to 54% of patients in one American hospital and only 7% of patients in an Israeli one. A two-fold difference in the frequency of i.v. fluid use in two otherwise comparable Scottish teaching hospitals was observed. This difference was not due to observed patient characteristics, did not arise from selection bias or observational differences between the two hospitals and was unlikely to have arisen by chance. 3 It is concluded that the findings were due to different policies on the part of the attending physicians. Although the study could not be used to evaluate the beneficial effects of the administered fluids, adverse effects were common (15% of recipients) and in some instances potentially serious. Adverse effects were reported more frequently after infusion of 5% dextrose (13% of recipients) than after isotonic saline (7%) perhaps because of the low pH of the former solution.

SCOTTISH TEACHING HOSPITALS: Defects and Remedies

SCOTTISH TEACHING HOSPITALS: Defects and Remedies

Patients of pensionable ages in a Scottish teaching hospital: 1946 and 1955.

Patients of pensionable ages in a Scottish teaching hospital: 1946 and 1955.