Sheffield Teaching Hospitals NHS Foundation Research Articles

Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources

hospitals are under pressure to reduce waiting times and costs. One strategy that may be effective focuses on optimising the flow of emergency patients. we undertook a patient flow analysis of older emergency patients to identify and address delays in ensuring timely care, without additional resources. prospective systems redesign study over 2 years. the Geriatric Medicine Directorate in an acute hospital (Sheffield Teaching Hospitals NHS Foundation Trust) with 1920 beds. older patients admitted as emergencies. diagnostic patient flow analysis followed by a series of Plan Do Study Act cycles to test and implement changes by a multidisciplinary team using time series run charts. 60% of patients aged 75+ years arrived in the Emergency Department during office hours, but two-thirds of the admissions to GM wards were outside office hours highlighting a major delay. Three changes were undertaken to address this, Discharge to Assess, Seven Day Working and the establishment of a Frailty Unit. Average bed occupancy fell by 20.4 beds (95% confidence interval (CI) -39.6 to -1.2, P = 0.037) for similar demand. The risk of hospital mortality also fell by 2.25% (before 11.4% (95% CI 10.4-12.4%), after 9.15% (95% CI 7.6-10.7%) which equates to a number needed to treat of 45 and a 19.7% reduction in relative risk of mortality. The risk of re-admission remained unchanged. redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.

Managing and monitoring tuberculosis using web-based tools in combination with traditional approaches

Tuberculosis (TB) remains a global health emergency. Ongoing challenges include the coordination of national and international control programs, high levels of drug resistance in many parts of the world, and availability of accurate and rapid diagnostic tests. The increasing availability and reliability of Internet access throughout both affluent and resource-limited countries brings new opportunities to improve TB management and control through the integration of web-based technologies with traditional approaches. In this review, we explore current and potential future use of web-based tools in the areas of TB diagnosis, treatment, epidemiology, service monitoring, and teaching and training.

HIV transmission, the Law and the work of the clinical team, January 2013

Mary Poulton (chair), Kings College Hospital NHS Foundation Trust Jane Anderson, Homerton University Hospital NHS Foundation Trust Yusef Azad, National AIDS Trust James Chalmers, School of Law, University of Glasgow Anna Maria Geretti, Institute of Infection and Global Health, University of Liverpool Mark Nelson, Chelsea and Westminster Hospital Chloe Orkin, Barts and the London NHS Trust Matthew Phillips, Manchester Royal Infirmary; NHS North Western Deanery Lisa Power, Terrence Higgins Trust, London Anton Pozniak, Chelsea and Westminster Hospital Karen Rogstad, Sheffield Teaching Hospitals NHS Foundation Trust

Editorial introductions

Editorial introductions

Orthopaedic Surgery – Development of Gas Gangrene not negligent: Housam v Sheffield Teaching Hospitals NHS Foundation Trust (High Court, 25th October 2012 – Judge Baker QC)

Orthopaedic Surgery – Development of Gas Gangrene not negligent: <i>Housam v Sheffield Teaching Hospitals NHS Foundation Trust</i> (High Court, 25th October 2012 – Judge Baker QC)

An overview of a UK paediatric visual impaired population and low vision aid provision

A retrospective study was carried out to evaluate the paediatric visual impaired population attending the Low Vision Clinic at Sheffield Teaching Hospitals NHS Foundation Trust, over a period of 14 years. Data were collected and analysed for children less than 17 years for prevalence, demographics, registration status, aetiologies, and types of low vision aids issued. The total number of children identified was 204. Of these, 19 percent of the children were registered blind, 45 percent were registered partially sighted, and 36 percent were not registered. The four diagnostic groups were genetic (29%), prenatal (36%), perinatal (23%), and childhood (12%). Describing local characteristics of paediatric visual impairment is a useful measure of current low vision service provision. This information can further inform educational, social, and health needs for the visually impaired children to ensure adequate service provision.

P133 A Single Centre Retrospective Survival Analysis of Patients with Interstitial Lung Disease

IntroductionIdiopathic pulmonary fibrosis is a chronic, progressive condition. BTS guidelines indicate that the ‘triple therapy’ - Prednisolone, Azathioprine, N-acetylcysteine (NAC) – can be considered in the management of UIP (usual...

Philosophical and theoretical perspectives for advanced nursing practice – fifth edition William Cody Practice development co-ordinator, evidence-based practice, Sheffield Teaching Hospitals NHS Foundation Trust Jones &amp; Bartlett Learning 400 $80.95/£37.99 978 0 7637 6570 5 9780763765705

Philosophical and theoretical perspectives for advanced nursing practice – fifth edition William Cody Practice development co-ordinator, evidence-based practice, Sheffield Teaching Hospitals NHS Foundation Trust Jones &amp; Bartlett Learning 400 $80.95/£37.99 978 0 7637 6570 5 9780763765705

Trust not liable for damage to sperm: Allinson and Phelan v Sheffield Teaching Hospitals NHS Foundation Trust (Barnstaple County Court, 19/5/11 – Judge Tyzak)

Trust not liable for damage to sperm: <i>Allinson and Phelan v Sheffield Teaching Hospitals NHS Foundation Trust</i> (Barnstaple County Court, 19/5/11 – Judge Tyzak)

Visual rehabilitation following cerebellar stroke

Aim: To present a small case series of patients with visual complications following primary acute cerebellar stroke, document the types of visual deficit that occur, examine recovery patterns and identify rehabilitation strategies available. Methods: A small, consecutive case series of patients referred to the Orthoptic Stroke Service at Sheffield Teaching Hospitals NHS Foundation Trust with primary acute cerebellar stroke in 2007–2008 is presented. The types of visual deficit that occurred and the orthoptist’s contribution to patient rehabilitation are outlined. Results: Seven patients were included in this series. All had manifest nystagmus with or without oscillopsia. The main complaint was of ‘blurred vision’. Nystagmus varied in different positions of gaze, down gaze being the most troublesome for rehabilitation. Other deficits identified were skew deviation, internuclear ophthalmoplegia, and fixation abnormalities including saccadic intrusions and square wave jerks. Recovery was often incomplete, although in most cases some functional improvement did occur and most often in primary position. Conclusions: Patients who have suffered cerebellar stroke, especially those with vague visual symptoms and those failing to respond to rehabilitation, should be referred for orthoptic assessment. This provides invaluable information that can explain difficulties with rehabilitation and give patients insight into their symptoms. Advice and therapy can help overcome problems in many cases.

MGluR Control of Interneuron Output Regulates Feedforward Tonic GABAA Inhibition in the Visual Thalamus

Metabotropic glutamate receptors (mGluRs) play a crucial role in regulation of phasic inhibition within the visual thalamus. Here we demonstrate that mGluR-dependent modulation of interneuron GABA release results in dynamic changes in extrasynaptic GABA(A) receptor (eGABA(A)R)-dependent tonic inhibition in thalamocortical (TC) neurons of the rat dorsal lateral geniculate nucleus (dLGN). Application of the group I selective mGluR agonist dihydroxyphenylglycine produces a concentration-dependent enhancement of both IPSC frequency and tonic GABA(A) current (I(GABA)tonic) that is due to activation of both mGluR1a and mGluR5 subtypes. In contrast, group II/III mGluR activation decreases both IPSC frequency and I(GABA)tonic amplitude. Using knock-out mice, we show that the mGluR-dependent modulation of I(GABA)tonic is dependent upon expression of δ-subunit containing eGABA(A)Rs. Furthermore, unlike the dLGN, no mGluR-dependent modulation of I(GABA)tonic is present in TC neurons of the somatosensory ventrobasal thalamus, which lacks GABAergic interneurons. In the dLGN, enhancement of IPSC frequency and I(GABA)tonic by group I mGluRs is not action potential dependent, being insensitive to TTX, but is abolished by the L-type Ca(2+) channel blocker nimodipine. These results indicate selective mGluR-dependent modulation of dendrodendritic GABA release from F2-type terminals on interneuron dendrites and demonstrate for the first time the presence of eGABA(A)Rs on TC neuron dendritic elements that participate in "triadic" circuitry within the dLGN. These findings present a plausible novel mechanism for visual contrast gain at the thalamic level and shed new light upon the potential role of glial ensheathment of synaptic triads within the dLGN.

Implementing an interprofessional patient record

This paper describes the implementation of an interprofessional patient record (IPPR) at Sheffield Teaching Hospitals NHS Foundation Trust (STHFT). The IPPR was a two-year project, commencing in May 2008, aimed at creating a single IPPR to which all staff contribute. Prior to the IPPR, records were profession specific with nursing, medical and therapy staff keeping separate ones. This paper describes the process for the project including the stakeholder engagement plan, the development of IPPR standards, the education and training programme and the key measures used to assess implementation. The staff survey and clinical audit data suggest that the IPPR was successfully implemented with many of the perceived benefits realised. The keys to success of this major change project were: time spent engaging clinical staff, board level support, the appointment of a dedicated project team and the involvement and support of many staff involved in patient records throughout STHFT.

Impact of Different Sectioning of Excision Biopsies of the Cervical Transformation Zone for Detection of Invasive Cervical Cancer in 2 European Centers Related to National Cervical Screening Programs

The impact of the number of sections used in cervical excision biopsies of transformation zone on sensitivity of histological detection of cervical cancer is poorly documented. To assess whether different techniques of sectioning cervical excision biopsies in 2 European laboratories influence the finding of cervical cancer by histopathological examination. The routine assessment at the Department of Histopathology and Cytology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK (Sheffield), encompassed sectioning a cone in 3-mm tissue blocks and cutting 3 levels per block. At the Institute of Pathology, Faculty of Medicine, University of Ljubljana, Slovenia (Ljubljana), cones were cut in a 3- to 4-mm-thick tissue block, and 10 levels were cut per block, spaced every 100 microm. The number of blocks and levels per block were assessed for each cone. Histopathological detection of cervical carcinoma between the laboratories was compared. Among 820 cones in the Sheffield laboratory, we detected 35 invasive carcinomas, whereas 6 invasive carcinomas were detected among 94 cones in the Ljubljana laboratory. Although the Slovenian laboratory examined a significantly larger number of levels per cone biopsy (64 vs 24 in Sheffield), this was not associated with a larger proportion of invasive cervical carcinoma, especially foci of stage IA1 or high-grade cervical intraepithelial neoplasia diagnosed on excision biopsies: 6.4% of invasive cervical carcinomas (5 [83.3%] of stage IA1) in Ljubljana and 4.3% (30 [85.7%] of stage IA1) in Sheffield laboratory (P > 0.05); 71.2% of high-grade cervical intraepithelial neoplasia in Ljubljana and 75.5% in Sheffield (P > 0.05). Our assessment showed that a method with a large number of levels per cervical cone or large loop excision of the transformation zone biopsy did not increase sensitivity for the detection of cervical cancer. However, extensive sectioning substantially affects the pathologist's workload, and this may need to be reconsidered.

Supporting clinical innovation: An organization‐wide approach to practice‐based development

AbstractEngaging clinicians in practice development initiatives can be a daunting task, especially if those staff groups are spread over a five‐site NHS Trust. Within Sheffield Teaching Hospitals NHS Foundation Trust (STHFT), the geography across the city adds a unique dimension to bringing about changes in practice and using the best possible evidence. Specific strategies need to be put in place in order to enable clinicians to access specialist help within the Trust, using the available networks to their best advantage and thereby reducing repetition. The role of a practice development team situated within such a large organization can influence changes in practice and encourage newer innovative ways of working. Copyright © 2009 John Wiley &amp; Sons, Ltd.

Outcomes of Patients with Haematological Malignancies Admitted to Either High Dependency Unit (HDU) or Intensive Care Unit (ICU) with or without Haemopoeitic Stem Cell Transplantation (HSCT): Analysis of Prognostic Factors for Survival

Background: Patients with haematological malignancies (HM) receive intensive chemotherapy regimens including HSCT rendering them immunocompromised and susceptible to complications such as, cardio-pulmonary toxicity, hepatic and renal failure, GVHD, sepsis and haemorrhage. Patients (pts) with HM may require critical care (CC) admission. Many studies have looked at the ICU setting for these pts but few have evaluated the use of non invasive cardio-pulmonary support on HDU prior to intensive care escalation or invasive intervention. The Haemato-Oncology Unit at Sheffield Teaching Hospitals NHS Foundation Trust is a tertiary referral centre, serving a population of 1.5 million. Critical care facilities are divided into HDU and ICU. Levels of care provided on HDU include non-invasive respiratory (non-invasive ventilation or continuous positive airway pressure) and cardiovascular (vasopressor/inotropic) support, but not mechanical ventilation (MV) or renal replacement therapy (RRT), both of which are provided on ICU. We evaluated all admissions to HDU and ICU for pts with HM in order to better understand the prognostic markers for this cohort of pts.Subjects and Methods: We retrospectively analysed consecutive HM (including HSCT) admissions to HDU or ICU over a 66 month period, between September 2002 and March 2008. We analysed predictors of mortality including age, white cell count (WBC), Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score, PaO2:FiO2 ratio as well as requirement for respiratory or cardiovascular support or RRT. Unit survival, hospital survival and overall survival at the time of study (OS) were evaluated.Results: One hundred and sixty two pts (n=107 HDU, n=55 ICU) were admitted to CC during the study period comprising n=191 admissions (n=128 HDU, n=22 HDU transferred to ICU, n=63 ICU). Of the HDU admissions n=38 pts received HSCT, and of the ICU admissions n=28 pts received HSCT. The median age for the entire cohort was 59 yrs (range 16–83 yrs). The median age for the HSCT and non HSCT pts was 50 yrs (range 17–68 yrs) and 63 yrs (range 16–83 yrs) respectively. Of the n=162 pts, n=99 (61%) were male, n=63 (39%) female. Types of HM varied, AML n=48 (25%), Myeloma n=40 (21%), NHL n=36 (19%), MDS n=16 (8%), ALL n=16 (6%), CLL n=12 (6%), CML n=9 (5%), others n=13 (7%). Overall median WBC was 3.6×109/l (range 0.0–746×109/l), median WBC for HSCT and non HSCT admissions was 3.1×109/l (range 0.1–31.6×109/l) and 4.1×109/l(range 0.0–746×109/l) respectively. The overall mean APACHE II score for all HDU admissions was 16.2 (SD ± 5.9) and 23.7(SD±7.2) for all ICU admissions. The overall median PaO2:FiO2 ratio for all HDU admissions was 15 kPa and 12 kPa for all ICU admissions. In total n=61 (32%) admissions required respiratory support (n=35(18%) MV, n=26 (14%) non invasive respiratory support), n=91 (48%) received cardiovascular support while n=25 (13%) required RRT. For all HDU admissions, unit survival, hospital survival and OS was 81%, 55% and 27% respectively compared to 52%, 44% and 13% for all ICU admissions. For HDU admissions escalated to ICU, unit survival, hospital survival and OS was 32%, 32% and 9% respectively. For non HSCT pts admitted to HDU, unit survival, hospital survival and OS was 79%, 54% and 26% respectively, compared to 84%, 55% and 29% for HSCT pts. For non HSCT pts admitted to ICU, unit survival, hospital survival and OS was 53%, 44% and 14% respectively, compared to 54%, 43% and 14% for HSCT pts. An APACHE II score of >30 was associated with a unit survival of 44%. No pts with an APACHE II score >36 survived. Unit survival for admissions requiring no organ support was 87%, one organ support 79%, two organ support 22% and three organ support 58%. Unit survival for pts requiring MV was 23%.Conclusions: Our study demonstrates that MV, requirement for two organ support, admission APACHE II score >30 are all poor prognostic factors for pts with HM admitted to CC. Interestingly of the n=12 pts requiring MV, cardiovascular support and RRT n=7 (58%) survived to ICU discharge, demonstrating that selected pts requiring multi-organ support may have a better prognosis. Requirement for single organ support was associated with better outcome. Our study demonstrates that the majority of HM pts requiring CC can be appropriately managed in the HDU setting. We aim to develop a predictive scoring system for HM pts requiring CC using the evaluated prognostic factors.

Step to it: a toolkit for evidence‐based practice

AbstractThe ease with which evidence‐based practice can be applied will have a significant impact on whether it is effectively utilised by health care professionals. This article describes how members of the Evidence‐Based Council within Sheffield Teaching Hospitals NHS Foundation Trust resolved this issue by developing a user‐friendly toolkit and workbook which systematically introduces the key elements that need to be considered and applied in order to enhance evidence‐based practice at ward level. Copyright © 2007 John Wiley &amp; Sons, Ltd.

44 Experiences of developing a business case for a new NHS radiopharmacy

Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffiel, UK British Nuclear Medicine Society Oral and Poster Abstracts 2007

P32 The prediction of renal output efficiency for interrupted Technetium-99m-labelled-mercaptoacetyltriglycine (99mTc-MAG3) renograms

Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK British Nuclear Medicine Society Oral and Poster Abstracts 2007

Developing a foundation apprenticeship in care

This article explores the development of a foundation apprenticeship in care at Sheffield Teaching Hospitals NHS Foundation Trust. The benefits for recruitment and development of the workforce are discussed.

Female urology: editorial comment

Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK Correspondence to Christopher R. Chapple, Consultant Urological Surgeon, Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Professor of Urology, Sheffield Hallam University, Sheffield, UK E-mail: [email protected]