London Teaching Hospital Research Articles

Experience using high-dose glucose-insulin-potassium (GIK) in critically ill patients

PurposeTo audit the use of GIK in terms of safety, haemodynamic effects, and impact on catecholamine dosage. Materials and methodsA retrospective, descriptive, evaluative audit of GIK use within the adult ICU of a London teaching hospital was conducted. Rescue therapy of GIK (up to 1.0Unitsinsulin/kg/h) was administered to improve cardiac function. Outcomes were ICU survival, change in cardiac index (CI) and blood lactate levels, events of hypoglycaemia, hyperglycaemia, hypokalaemia and hyperkalaemia, and discontinuation time of catecholamine inotropes. ResultsOf 85 patients treated with GIK, 13 (15.3%) survived their ICU stay and 9 (10.5%) were discharged home. In patients surviving until 72h, a trend of improved CI and lactate levels was seen, often with reductions in catecholamine dosing. Inotropes were discontinued in 35 (54%) patients. Severe hypoglycaemia (<2mmol/l), hyperglycaemia (>20mmol/l), hypokalaemia (<2.5mmol/l) and hyperkalaemia (>7mmol/l) during GIK affected 1, 6, 8 and 1 patients, respectively. These abnormalities were quickly identified. No measurable harm was noted. ConclusionsHigh-dose GIK can be safely used in critically ill patients, though blood glucose and potassium levels must be monitored frequently. GIK was associated with improved CI and blood lactate levels. Impact on survival requires prospective evaluation.

Does leadership style of modern matrons contribute to safer and more effective clinical services?

At the time of writing, the author was a modern matron in a surgical division of an NHS teaching hospital in London. This article considers the differences between leadership and management, and discusses the skills required by modern matrons to lead safe and successful clinical services. It also examines three leadership styles - transactional, transformational and situational - and their relevance to the role of modern matron.

Understanding antibiotic decision making in surgery—a qualitative analysis

ObjectiveTo investigate the characteristics and culture of antibiotic decision making in the surgical specialty. MethodsA qualitative study including ethnographic observation and face-to-face interviews with participants from six surgical teams at a teaching hospital in London was conducted. Over a 3-month period: (a) 30 ward rounds (WRs) (100 h) were observed, (b) face-to-face follow-up interviews took place with 13 key informants, (c) multidisciplinary meetings on the management of surgical patients and daily practice on wards were observed. Applying these methods provided rich data for characterizing the antibiotic decision making in surgery and enabled cross-validation and triangulation of the findings. Data from the interview transcripts and the observational notes were coded and analysed iteratively until saturation was reached. ResultsThe surgical team is in a state of constant flux with individuals having to adjust to the context in which they work. The demands placed on the team to be in the operating room, and to address the surgical needs of the patient mean that the responsibility for antibiotic decision making is uncoordinated and diffuse. Antibiotic decision making is considered by surgeons as a secondary task, commonly delegated to junior members of their team and occurs in the context of disjointed communication. ConclusionThere is lack of clarity around medical decision making for treating infections in surgical patients. The result is sub-optimal and uncoordinated antimicrobial management. Developing the role of a perioperative clinician may help to improve patient-level outcomes and optimize decision making.

Does Low Dose Steroids Confer Benefits in Sepsis and Septic Shock?

Over the last 40 years, the use of corticosteroids in sepsis and septic shock has evolved from the initial use of high-dose, short-duration steroid therapy in the 1980s, to the recent recommendation of using low-dose longerduration steroid therapy in refractory septic shock patients. A recent, prospective, open-label, randomized, controlled pilot trial of patients in four adult intensive care units in London-teaching hospitals showed that hydrocortisone decreased vasopressin requirements, reduced the duration and reduced the required dose, when used together in the treatment of septic shock, but it did not alter plasma vasopressin levels. The optimal dosing of hydrocortisone, about 300 mg/day, was agreed uniformly. As this dose also provides sufficient mineralocorticoid effects, the additional use of mineralocorticoid is not needed. Despite the fact that severely ill septic shock patients are given treatment, according to the current guidelines, the survival benefit is unproven. The benefits of steroids on less severely ill septic patients are still questionable. More research is highly recommended to successfully identify the benefits of steroids in septic shock.Birdem Med J 2017; 7(1): 48-59

Does the presence of a urinary catheter predict severe sepsis in a bacteraemic cohort?

Sepsis is a major cause of mortality with an estimated 37,000 deaths in the UK each year. This study aimed to determine host factors that can predict severe sepsis in a bacteraemic cohort. From December 2012 to November 2013, demographic, clinical and microbiological data were collected on consecutive patients with bacteraemia at a London teaching hospital. These data were used to categorize patients as having severe or non-severe sepsis. Multi-variate logistic regression was used to determine the association between host factors and severe sepsis. Five hundred and ninety-four bacteraemic episodes occurred in 500 patients. The majority of cases were in patients aged >50 years (382/594, 64.3%) and in males (346/594, 58.2%). The most common isolates were Escherichia coli (207/594, 34.8%) and meticillin-susceptible Staphylococcus aureus (57/594, 9.6%). In logistic regression multi-variable analysis, site of infection was significantly associated with severe sepsis. For catheter-associated urinary tract infections, the association was significant after adjustment for age, sex, Charlson comorbidity index and where infection was acquired (odds ratio 3.94, 95% confidence interval 1.70-9.11). Urinary catheters increase the risk of severe sepsis. They should only be used if clinically indicated. If inserted, a care bundle approach should be used and the anticipated removal date should be recorded unless a long-term catheter is required. In the context of sepsis, the presence of a urinary catheter should prompt immediate implementation of 'Sepsis Six' and consideration of transfer to a critical care unit.

Developing an Economic Case of Clinical Pharmacists' Interventions on Venous Thromboembolism Prophylaxis Through Service Evaluation.

Objective:Venous thromboembolism (VTE) has become a huge health problem as well as a financial burden for the National Health Service. The objective of this study was to characterize current practice of VTE prophylaxis (VTEP) and evaluate the economic impact of clinical pharmacists’ interventions (CPIs) on VTEP.Methods:A prospective service evaluation was conducted in a medical and surgical ward at a tertiary teaching hospital in London from 23 May to 08 June 2016. Appropriateness of risk assessment (RA) and VTEP and CPIs were categorized and assessed. Based on the results of the service evaluation, a pharmacoeconomic analysis was undertaken to estimate the cost savings by CPIs for inappropriate pharmacological VTEP.Findings:A total of 203 cases were analyzed. The rates of appropriateness for RA on admission, RA at 24 h and pharmacological VTEP were 58.6%, 39.7%, and 75.4%, respectively. In the medical ward, there was a significant difference of appropriate RAs between on admission and at 24 h (70.3% vs. 23.8%, respectively). Whereas, the rate of appropriate pharmacological VTEP accounted for 75.4% and the rate of appropriate prophylaxis was significantly higher in the medical ward than surgical ward (80.5% vs. 68.2%, P = 0.045). Of 50 cases of inappropriate pharmacological prophylaxis, 39 cases (78.0%) were corrected by clinical pharmacists. These CPIs resulted in £1,286.23 cost savings during the study and it was estimated to be £517,522/annum.Conclusion:CPIs had significant positive clinical and economic impacts on VTEP. There is more scope for the improvement of RA at 24 h through CPIs.

Economic value of pharmacy-led medicines reconciliation at admission to hospital: an observational, UK-based study

ObjectiveTo describe the cost–benefits of pharmacy-led medicines reconciliation (MR) on admission by applying a theoretical model (University of Sheffield School of Health and Related Research—SCHARR model) to real-world data.MethodsThis was...

Safety of vaginal delivery among dichorionic diamniotic twins over 10years in a UK teaching hospital.

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK. A retrospective study was conducted using data for women with dichorionic diamniotic twin pregnancies who attended a teaching hospital in London, UK, for delivery between January 4, 2000, and December 23, 2010. Among 892 women, 474 (53.1%) attempted vaginal delivery, 220 (46.4%) of whom achieved spontaneous vaginal delivery of both twins. Instrumental vaginal delivery was performed among 89 women (18.8%), and 165 (34.8%) women underwent emergency cesarean delivery. Delivery of the second twin by emergency cesarean (n=31) was predominantly for fetal distress (13 [41.9%]) or abnormal lie (10 [32.3%]). A 5-minute Apgar score of 9 or 10 was recorded for 384 (83.7%) of 459 first twins and 369 (82.9%) of 445second twins, irrespective of the mode of delivery. Vaginal delivery among dichorionic diamniotic twins had a good success rate and a low intrapartum emergency cesarean delivery rate. Training in cardiotocography and intrapartum procedures might further reduce the need for emergency cesarean delivery.

Multidrug-Resistant (MDR) and Extensively Drug-Resistant (XDR) Tuberculosis: Successes and Complications on Outpatient Parenteral Antimicrobial Therapy at a London Teaching Hospital Between 2009 and 2016

Multidrug-Resistant (MDR) and Extensively Drug-Resistant (XDR) Tuberculosis: Successes and Complications on Outpatient Parenteral Antimicrobial Therapy at a London Teaching Hospital Between 2009 and 2016

Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol.

BackgroundResilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation.MethodsThe settings are the Emergency Department and the Older Person’s Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known.DiscussionStudy outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people’s care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.

Clinical benefits, referral practice and cost implications of an in-hospital pain service: results of a service evaluation in a London teaching hospital.

In-hospital pain services (IPS) are commonplace, but evidence of efficacy is inadequate, and patients' pain management in any hospital ward remains problematic. This service evaluation aimed to measure the effect of a contemporary IPS, its appropriate use and cost-efficacy. Records of 249 adults reviewed by the IPS in an inner London Teaching Hospital over an 8-month period were analysed for demographic data, interventions, workload and change in pain intensity measured by numerical rating scale (NRS). Non-parametric tests were used to evaluate differences between initial and final NRS. Spearman's rank correlation analysis was used to create a correlation matrix to evaluate associations between all identified independent variables with the change in NRS. All strongly correlated variables (ρ > 0.5) were subsequently included in a binary logistic regression analysis to identify predictors of pain resolution greater than 50% NRS and improvement rather than deterioration or no change in NRS. Finally, referral practice and cost of inappropriate referrals were estimated. Referrals were thought to be inappropriate when pain was not optimised by the referring team; they were identified using a set algorithm. Initial median NRS and final median NRS were significantly different when a Wilcoxon signed-rank test was applied to the whole cohort; Z = -5.5 (p = 0.000). Subgroup analysis demonstrated no significant difference in the 'mild' pain group; z = -1.1 (p = 0.253). Regression analysis showed that for every unit increase in initial NRS, there was a 62% chance of general and a 33% chance of >50% improvement in final NRS. An estimated annual cost-saving potential of £1546 to £4558 was found in inappropriate referrals and patients experiencing no benefit from the service. Results suggest that patients with moderate to severe pain benefit most from IPS input. Also pain management resources are often distributed inefficiently. Future research is required to develop algorithms for easy identification of potential treatment responders.

ISQUA16-2509QUALITY AND SAFETY IN THE OLDER PERSON'S UNIT: A RESILIENCE ENGINEERING APPROACH

The Older Person's Unit presents a challenging clinical environment in which multi-disciplinary teams must work together in order to achieve a range of patient objectives. We argue that a Resilience Engineering approach offers valuable insight to understanding the complexities associated with routine work in this context. This study, set in the Older Person's Unit of a large London teaching hospital, utilises a Resilience Engineering approach in order to better understand the complexity surrounding this clinical setting. Over the course of an 18 month period, the research team were embedded within the hospital environment collecting a wide range …

Discussing sudden unexpected death in epilepsy: Are we empowering our patients? A questionnaire survey

ObjectiveTo examine patient knowledge about sudden unexpected death in epilepsy (SUDEP) compared to other risks in epilepsy. To explore patients’ experiences surrounding SUDEP disclosure and opinions on how information should be delivered.DesignA cross-sectional questionnaire.SettingRoyal Free Hospital, London outpatient epilepsy clinics.ParticipantsNew and follow-up patients attending epilepsy clinics at a London teaching hospital over six months. Patients identified as being at risk of suffering negative emotional or psychological consequences of SUDEP discussions were excluded.Main outcome measuresPatient knowledge about epilepsy risks; patient opinion regarding source, timing and delivery of SUDEP information; impact on health seeking behaviour.ResultsNinety-eight per cent of patients were aware of medication adherence, 84% of factors influencing seizure frequency, 78% of driving regulations, 50% of SUDEP and 38% of status epilepticus; 72% of patients felt that SUDEP information should be given to all patients. Preferences for timing of SUDEP discussions varied between those wanting information at diagnosis (40%) and those preferring to receive it after three clinic appointments (18%) to avoid information overload at the first consultation. Emotional responses (48% positive, 38% negative) predominated over measurable behavioural change following SUDEP discussions.ConclusionsLess than half the patients knew about SUDEP and status epilepticus. Although the majority of patients with epilepsy wish to be informed about SUDEP early on in their diagnosis, information must be delivered in a way that promotes patient knowledge and empowerment.

Quality improvement project to reduce paediatric prescribing errors in a teaching hospital

A quality improvement project to reduce paediatric prescribing errors was carried out in a London teaching hospital between June 2013 and March 2014. It involved paediatric medical and surgical wards...

Routine HIV testing in the Emergency Department: feasible and acceptable?

Routine HIV testing in non-specialist settings has the potential to significantly reduce late diagnosis and delay in treatment. The objective was to determine the feasibility and acceptability of HIV testing in an Emergency Department (ED) at a busy London teaching hospital. We conducted an observational cross sectional study between March-May 2012 where patients aged between 18-65 years attending St George's ED having serological tests were offered HIV testing by ED clinical staff. Patients were given an information leaflet on HIV, including how to obtain results. Data detailing whether the test was offered (feasibility) and whether the patient consented to the test (acceptability) were documented. Information regarding reasons for not offering HIV testing and reasons why the test was declined was also recorded. During the study period, 24,171 patients aged 18-65 were seen in the ED. Data were collected from 5657 patients. The mean age was 38 years, 57% were female and 27% identified themselves as white. 48% were offered HIV testing, of which 65% accepted. Incapacity to consent to testing was cited by clinicians as the commonest reason for not offering an HIV test (76%). 'Recent HIV test' was the commonest reason for declining a test (38%). One new HIV diagnosis was made. Our experience demonstrates that routine HIV testing in the ED is feasible and acceptable. However, to make HIV testing effective and part of routine clinical care, considerable clinical leadership, staff training and additional resources are required.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

ObjectivesReliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process...

The anatomy of clinical decision-making in multidisciplinary cancer meetings: A cross-sectional observational study of teams in a natural context.

In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was observed in relation to the meeting chairs’ input and their corresponding surgical input into case reviews.

The future hospital: integrated working and respiratory virtual clinics as a means of delivering high-value care for a population

To improve the respiratory health of an inner London population with high deprivation and smoking rates, and high premature mortality due to respiratory disease, through the development of an integrated respiratory team and a programme of virtual clinics in primary care. The population of Lambeth and Southwark consists of around 600,000 people, served by two clinical commissioning groups, two large London teaching hospitals and a mental health trust within an Academic Health Sciences Centre (King's Health Partners). They …

CC1 “Persistent genital arousal disorder – the experience of a London Teaching Hospital”

Background Persistent genital arousal disorder (PGAD) is a condition seen mainly in women characterised by spontaneous and often unrelenting sensation of genital arousal in the absence of sexual desire or stimulation. These sensations typically do not fully remit with orgasm and are by definition intrusive and distressing. The condition overlaps in some cases with pudendal neuralgia but needs to be differentiated from hypersexuality. Patients may present preferentially to GUM clinics in the knowledge that sexual symptoms will not be trivialised. Different opinions exist as to triggers, causes and treatment. Taking this into consideration we analysed a cohort of patients with PGAD assessing whether they were any common themes in terms of precipitating and relieving factors. Aim To describe our clinical experience and ascertain number of patients with diagnosis, common themes and treatment modalities. Methods 57 patients were diagnosed with PGAD since departmental code was introduced in 2006 and 39 patients notes were located and reviewed. Results Of these 69% were in a relationship and 64% had no history of past sexual abuse. Relieving factors were also varied among the cohort including masturbation and distraction. 95% were referred for mindfulness cognitive behavioural therapy and 51% were on medication such as amitriptyline, gabapentin, venlafaxine and nortriptyline. 72% were referred for pelvic floor physiotherapy. Discussion PGAD is rarely seen estimates say 1–6% are affected by this hence it is important as sexual health clinicians to be aware of it to reduce delays in diagnosis. Overall management of PGAD requires a holistic approach with multidisciplinary team involvement.

P086 An audit of the management of persistent and recurrent non-gonococcal urethritis (pNGU) in a large London teaching hospital

Background/introduction The British Association of Sexual Health and HIV (BASHH) released a new national guideline on the management of non-gonococcal urethritis (NGU) in 2015. This audit was completed to assess compliance and identify areas for service improvement. Aim(s)/objectives To compare the management of pNGU against national guidelines. Methods A retrospective case note review was performed for all patients having two or more NGU code (C4N) over a 12-month period from 1 st April 2014. We collected demographic details, presenting symptoms, signs, investigations, management and number of visits. Results 130 patients were identified from three different clinics within the same Trust. A total of 282 visits were recorded. 35.4% of visits were diagnosed as NGU and 66.2% as pNGU. We achieved 100% compliance with all four of BASHH auditable out comes (i.e. screening for C. trachomatis (CT) and gonorrhoea, documented offer of written information, delivery of first-line therapy and partner notification). Only one patient was diagnosed with CT. In recurrent visits, only 31.0% of further investigations were done and 12.6% of them were treated as pNGU according to the guideline. 55.2% of the patients had 4 or more visits. Discussion/conclusion We demonstrated high levels of compliance with national guidelines for managing NGU. However, management of patients with pNGU was sub-optimal with a lack of appropriate investigations and incorrect treatment regimes. Low levels of CT positivity in this cohort demonstrate the importance of further investigations. Correct pNGU treatment may also lead to fewer visits and reduced burden on the service.