London Teaching Hospital Research Articles

PTH-155 Evidence for a ‘Weekend Effect’ in the Management of Acute GI Bleeding in a Central London Teaching Hospital

Introduction NICE guidance recommends that endoscopy should be performed within 24 hours of admission with a non-severe upper gastrointestinal bleed (UGIB). This audit reviewed cases over a six month period in a central London teaching hospital to establish compliance. We also evaluated whether there was a greater delay at weekends compared to weekdays. Methods 41 patients were identified with a non-variceal UGIB. Patient notes were reviewed to collect data on arrival time, endoscopy time and findings, and clinical details to calculate a Rockall score. Arrival and endoscopy time were used to calculate time to endoscopy; these figures were used to compare weekend versus weekday performance. Results Rockall scores were normally distributed with mean of 3.8, median 4 and mode 4. The range was 0–10. Mean time from admission to endoscopy was 21 hours. 61% of patients had an endoscopy within the first 24 hours of admission, and therefore met NICE guidance. The mean Rockall score of patients receiving endoscopy within 24 hours was 4.32. Those whose endoscopy occurred later than 24 hours had a mean score of 3.3. Mean time to endoscopy in those admitted on weekdays was 17 hours, with 66.6% undergoing endoscopy within 24 hours. The range of waiting times was 1–48 hours. In comparison, mean time to endoscopy at weekends was 30 hours with 60% undergoing endoscopy within 24 hours. The range was 10–75 hours. 2 patients (5.1%) had a second UGIB during admission. Both of those were inpatients for other reasons at the time of their first bleed. Conclusion Only 61% of patients underwent endoscopy within 24 hours of admission. However those who got earlier endoscopies had higher mean Rockall scores which suggest they were prioritised appropriately. Patients admitted at the weekend waited longer on average for their endoscopy and even the quickest weekend endoscopy was 10 hours after arrival. There is undoubtedly some “weekend effect” seen. However, the percentage meeting the NICE guidance is similar (60% versus 66%). The longest weekend wait was 75 hours compared to 48 on weekdays,presumably as low-risk patients have a longer wait out of hours. The reason for the delay is likely multifactorial, but significantly the endoscopy department is closed over the weekend. To scope patients the on call endoscopist competes with emergency theatre lists. In a busy London hospital with a Major Trauma Centre and General, Orthopaedic and Vascular surgery, a sub-acute GI bleed will not be prioritised. The fundamental question for the hospital is whether the endoscopy department should open at the weekend. Costing has put this at almost £100 000 per annum (including a seven day out of hours on call nurse) to offer just an emergency service. Disclosure of Interest None Declared

P164 Management of primary and secondary syphilis in a large London teaching hospital

Background/introduction Acute syphilis is on the increase and prompt treatment is vitally important to prevent onward transmission. Aim(s)/objectives To ensure compliance with BASHH audit outcomes for the management of acute syphilis. Methods We collected all patients who had been coded as primary or secondary syphilis (A1 or A2) for 12 months from May 2014. Demographics, symptoms at presentation and subsequent management were collected. Results 132 records were returned with 89% (117/131) identifying as men who have sex with men (MSM). 55% (72/132) were HIV positive, with 3 new HIV diagnoses. 70% (89/128) had symptoms of acute syphilis; with an ulcer, 87% (41/47) had herpes simplex virus (HSV) PCR which was positive in 7% of cases. Dark ground microscopy was performed in 38% (20/52) with one third being positive. 42% (56/131) were treated for syphilis on their initial visit (14% if seen by a technician, 31% if seen by a nurse and 51% if seen by a medic, p = 0.006). 90% had been treated by 2 weeks. Discussion/conclusion MSM comprised the majority of acute syphilis with high rates of new HIV diagnoses, reinforcing the importance of routine HIV testing. There was a high co-infection prevalence of HSV. Dark ground microscopy was positive in a third of samples, perhaps due to technical difficulties in the clinic. Only 4 in 10 patients were treated at the first visit indicating a lack of awareness of symptoms of acute syphilis. More education on recognising and treating acute syphilis, especially in high risk groups, is needed.

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 …

The barriers to accessing primary care resulting in hospital presentation for exacerbation of asthma or chronic obstructive pulmonary disease in a large teaching hospital in London

Asthma and chronic obstructive pulmonary disease (COPD) account direct costs of £1 billion each per year in the United Kingdom (UK). A national review of asthma deaths found that a significant proportion of patients die without seeking medical assistance or before emergency medical care could be provided. This study aims to establish the pathway that patients undertake to access care in the lead up to an accident and emergency (A&E) attendance and/or inpatient admission. Patients attending A&E and/or following an inpatient admission due to an exacerbation of asthma or COPD were reviewed by a specialist respiratory pharmacist during weekday working hours. Over a one-year period, 920 (224 asthma and 696 COPD) presentations for exacerbation of asthma and COPD were reviewed. Although the majority of the patients were registered with a general practitioner (GP), less than 50% received medical attention from their GP and/or had an active intervention prior to presenting to hospital. These findings correlate with those found in the national review of asthma deaths. At a time of increasing demands on healthcare resources, these results pose the question of how we can better triage patients to appropriate care settings to minimise unscheduled care and improve patient outcomes.

The characteristics and outcome of bacteraemia in renal transplant recipients and non-transplant renal patients.

There is lack of outcome data for bacteraemic patients on specialist renal units. We described demographic, clinical, microbiological data and outcomes for bacteraemic adult renal transplant and non-transplant patients at a London Teaching Hospital. We also assessed the appropriateness of empirical antibiotic policy. From December 2012 to November 2013, demographic, clinical and microbiological data were collected on consecutive patients with bacteraemia on a specialist UK renal unit. Empirical anti-microbial policy, based upon sites of infection, was piperacillin/tazobactam and amikacin, or meropenem for graft pyelonephritis, and vancomycin and gentamicin for suspected central venous catheter (CVC) associated infection. 113 bacteraemic episodes occurred in 83 patients. One patient had two bacteraemic episodes, one on haemodialysis and another after transplantation so appear in both groups. In the non-transplant group, 30-day mortality was 4/59 (6.8%), more than the renal transplant group, 0/25 (0%). While graft pyelonephritis was the predominant cause of bacteraemic episodes in renal transplant patients, 25/36 (69.4%), there were a variety of other causes in the non-transplant group including uncomplicated line associated bacteraemia, 36/77 (46.8%), complicated line associated bacteraemia, 11/77 (14.3%) and bacteraemia unrelated to vascular access sites 19/77 (24.7%). Overall, commonest isolates were Methicillin-sensitive Staphylococcus aureus 20/77 (26.3%), and Escherichia coli 28/113 (24.8%). There were no Methicillin-resistant Staphylococcus aureus isolates and, among Enterobacteriaceae, 15/57 (26.3%) were extended spectrum beta-lactamase producers. Death only occurred in the non-transplant renal group. Empirical antibiotic treatment with either piperacillin/tazobactam and amikacin, or meropenem was appropriate for renal transplant recipients as most bacteraemic episodes were secondary to graft pyelonephritis. Vancomycin and gentamicin was appropriate empirical antibiotic treatment for non-transplant patients with CVC associated infections, but not optimal for other sites of infection.

Using heel protectors for the prevention of hospital-acquired pressure ulcers.

Pressure ulcers are a frequent, but often preventable, occurrence among patients in acute care facilities, and the heel is one of the anatomical locations most commonly affected. Multiple clinical guidelines recommend the use of robust assessments to identify at-risk patients and the application of heel protection devices to reduce the likelihood of developing heel pressure ulcers. A quality improvement initiative involving robust skin-assessment practices, staff education, and the use of heel protection devices was analysed retrospectively to evaluate the efficacy of current practice interventions. These analyses revealed that the incidence of heel pressure ulcers was inversely correlated with the number of heel protectors used at two large acute NHS teaching hospitals in inner London, and that the consistent and early use of heel protectors improved patient outcomes and reduced costs of care.

Maternal ethnicity and its impact on the haemodynamic and blood pressure response to labetalol for the treatment of antenatal hypertension

ObjectiveBlood pressure (BP) control outside pregnancy is associated with a reduction in adverse cardiovascular events, and in pregnancy with improved outcomes. Outside pregnancy, there is evidence β-blockers are less effective...

A Simple Method to Forecast Future Bed Requirements: A Pragmatic Alternative to Queuing Theory

Aims: To review the current state of hospital bed planning, and to develop a simple tool to estimate short-term future bed requirements using historical bed occupancy data. Study Design: Analysis of daily bed occupancy between January 2008 and October 2015. Synthesis of trends into a method for forecasting bed numbers for each day of the year. Place and Duration of Study: Daily occupied bed statistics for King’s College University Hospital, a large London Teaching Hospital having 1,600 beds. Methodology: An eight-year time-series of daily midnight bed occupancy covering elective, emergency and transfer admissions has been used to estimate the number of beds required to deliver a delay-free hospital. Results: In this large 1,600 bed hospital it is estimated that 100 extra beds (a 6.3% increase) are required to deliver delay free admissions, i.e. no delays to admission from the emergency department or delays due to cancelled elective operations. Conclusion: The analysis reveals that far higher flexibility is required in staffing levels than is currently available. Potential strategies are discussed to address this issue.

A Five Year Experience of Acute Intrahepatic Cholestasis in Patients with Sickle Cell Disease at a Large Teaching Hospital in London

Background:Acute intrahepatic cholestasis (AIC) is a rare but severe form of sickle hepatopathy, caused by sickling within hepatic sinusoids, leading to vascular stasis, hypoxic damage and can lead to acute hepatic failure. It is characterised by a combination of clinical, laboratory and radiological features. There is tender hepatomegaly, hyperbilirubinaemia without evidence of extrahepatic biliary obstruction, coagulopathy and thrombocytopenia. Transaminitis, if present is mild or moderate.AIC has a high fatality rate if not treated promptly. Although there is a dearth of evidence on how to treat AIC, the most frequently recommended intervention is by exchange blood transfusion. We report our experience of managing patients with this rare yet serious complication of sickle cell disease at a large tertiary centre over the course of 5 years.Methods:A retrospective review of adult patients who attended the sickle cell service from 1st January 2010 to 30th June 2015 was undertaken. All patients who had had a bilirubin level greater than 300umol/L were identified. Patients with evidence of 'secondary' causes of hyperbilirubinaemia such as biliary sepsis, acute biliary or extrahepatic duct dilatation were excluded.For the remaining patients, clinical notes were reviewed for history of tender right upper quadrant, peak bilirubin levels, coagulation studies, ferritin, ultrasonography or other liver imaging, pre-existing co-morbidities and immediate and long-term clinical outcome were recorded.Results:We identified 16 cases of AIC in 15 patients, out of an excess of 582 patients who attended the Sickle Cell Department over the course of 5 years. In three of these cases, there was also an associated generalised vaso-occlusive crisis. There were 10 male and five female, all of whom had sickle cell anaemia (HbSS), with a median age of 30years (20-48 years).In terms of pre-existing liver disease, one patient had autoimmune hepatitis; another two had chronically deranged liver functions with radiological features suggestive of cirrhosis. Table 1AgeSexPeak bilirubin; conjugated%INRAPTRThrombocytopeniaConcurrent crisis (VOC)Outcome25F398; 65%1.281.17NoNoAlive25F386; 61%1.221.97NoNoAlive36M299; 69%1.281.33NoYesAlive20M299; 63%1.491.22NoNoAlive37M693; 74%1.371.54NoNoAlive38F671; 100%1.211.41YesNoAlive25F686; 83%1.071.53YesNoAlive25M585; 78%1.251.14NoNoAlive34M450; 88%1.121.58YesNoAlive30M694; 96%2.593.77YesNoDeceased48M719; 66%3.002.33YesNoDeceased22M975; 98%4.0>5NoNoDeceased25F310; N/A1.472.06YesYesAlive25M1043; 99%3.43>5YesNoDeceased44F478; 100%1.331.40NoNoAlive46M644; 91%2.081.2YesNoDeceasedThe findings on ultrasonography included increased liver reflectivity, hepatomegaly and in two cases, cirrhosis. Choledolithiasis was present in 6 cases, with no evidence of gall bladder infection, inflammation or duct obstruction. Cholecystectomy had been performed in 3 cases; two of these patients had chronically dilated intrahepatic ducts.All patients received transfusions to lower the Haemoglobin S% to less than 30%. Eleven patients received exchange blood transfusions within 72hours of presentation. The remainder, who had received transfusion recently (majority at local hospital) received further transfusions within a week of admission to keep HbS% <20%.Seven of the 11 patients who recovered now have normal transaminases with mildly elevated bilirubin levels. Three patients have markedly elevated transaminases and bilirubinaemia, two of whom had previous cholecystectomy and chronically dilated intrahepatic ducts. The third has a heterogenous liver with features of sickle hepatopathy and probable early features of liver fibrosis, while the fourth went on to have a successful liver transplant.There were 5 deaths; all in male patients aged between 22 and 48 years. Two had established cirrhosis; one also had autoimmune hepatitis and CMV viraemia. A third patient had liver biopsy evidence of fibrosis, while a fourth had a CT description of liver with a nodular contour. The fifth patient,was previously fit and well and adenoviraemia was diagnosed.Discussion:Our experience supports the view that AIC can successfully be reversed by timely exchange blood transfusion, and suggests that underlying liver disease and viraemia confer a poor outcome, irrespective of age. DisclosuresNo relevant conflicts of interest to declare.

Do the Safety and Efficacy Outcomes Reported in the Clinical Trials of Direct Oral Anticoagulants (DOAC) Translate to the Real-World?

Do the safety and efficacy outcomes reported in the clinical trials of direct oral anticoagulants (DOAC) translate to the 'real-world'?Background: A number of DOACs are now available for clinicians to prescribe in clinical practice. Whilst the results from large clinical trials demonstrate that these agents are as effective as vitamin K antagonists, there is some concern that the patients studied in the trials were not representative of patients, clinicians encounter in everyday practice. The aim of our study was to compare the real-world clinic population commenced on a DOAC to that from the clinical trials for these agents, in order to assess potential differences in safety and efficacy.Patients and methods: A retrospective observational cohort study was undertaken. Patients who were initiated on a DOAC (apixaban, dabigatran and rivaroxaban) at a large teaching hospital in South East London between 1st August 2012 and 31st July 2014 were identified through pharmacy issue data with those followed-up for a minimum of 6 months included. Baseline demographic data, rates of stroke/VTE and rates of major/non-major clinically relevant (NMCR) (ISTH definition) bleeding were assessed and compared to pooled data reported from the corresponding Phase III trials. Differences between groups were compared using t-tests or chi-squared tests.Results: During the review period, 748 patients were initiated on a DOAC, 365 for atrial fibrillation (AF) and 383 for venous thromboembolism (VTE). In terms of demographic differences, the real-world AF population comprised more females, were significantly older, had poorer renal function and a lower body weight. In contrast, the real-world VTE population typically had a higher body weight and poorer renal function, compared to the trial population, (table 1). Efficacy of DOACs was found to be similar across both the VTE and AF populations. With respect to safety, the real-world AF population experienced similar rates of major bleeding and a significantly lower rate of NMCR bleeding compared to the trial populations. In contrast, the real-world VTE population experienced a significantly higher rate of major bleeding, particularly gastrointestinal bleeding. Although the rate of NMCR bleeding was similar, there was a significantly higher rate of urogenital bleeding in the real-world VTE population, specifically heavy menstrual bleeding in women.Conclusions: The efficacy outcomes of DOAC use in a real-world AF and VTE population are consistent with the Phase III trials, despite some significant differences in baseline characteristics. However, a significantly increased rate of major bleeding was observed in the real-world VTE population, which requires further investigation.Table 1Baseline demographic characteristics, efficacy and safety outcomes in the real-world population versus the trial populationAtrial FibrillationVenous ThromboembolismTrial population+N=28,342Real-world populationTrial population++Real-world populationN=365N=8,716N=383Baseline Demographics, mean (SD) unless otherwise specifiedAge, years72(9.6)76.8 *(12.1)56.9(14.2)55.6(18.7)Female (%)10451(36.9)215 *(58.9)3753(43.1)184(48.0)Weight, kg82.7(19.5)77.3 *(22.6)84.9(19.6)88.2 *(23.0)Creatinine clearance, mL/min69(26.7)58.1 *(26.9)105.8(40.7)91.1 *(37.6)Concomitant aspirin therapy10341(36.5)49 *(13.4)-0(0)Previous VKA use (%)15711(55.4)193(52.9)-85(22.2)Efficacy (%)All-cause mortality1695(6.0)37 *(9.1)160(1.8)10(2.5)Stroke676(2.4)8(2.0)-1(0.3)VTE39(0.1)1(0.2)192(2.2)7(1.8)Safety (%)Major Bleeding1419(5.0)17(4.2)79(0.9)15 *(3.8)Intracranial170(0.6)1(0.2)6(0.1)2 *(0.5)Gastrointestinal644(2.3)8(2.0)8(0.1)8 *(2.0)Non-major Clinically relevant (NMCR) bleeding4824(17.0)30 *(7.4)540(6.2)26(6.6)Gastrointestinal-9(2.2)53(4.2)10(2.5)Urogenital296(4.2)16(3.9)100(2.5)38 *(9.6)+Pooled data from ARISTOTLE, RE-LY and ROCKET-AF trials++Pooled data from AMPLIFY, RE-COVER and EINSTEIN-PE/DVT trials*p<0.05 DisclosuresPatel:Bayer plc: Research Funding. Auyeung:Bayer PLC: Research Funding. Arya:Bayer plc: Research Funding.

An audit of fracture clinic services in a London district general hospital: Are patients being referred according to national guidance?

s / International Journal of Surgery 23 (2015) S15eS134 S80 Aim: Informed consent is essential so patients are aware of the benefits and potential risks of surgery. The objective of this audit was to assess whether patients were consented appropriately for total knee replacement (TKR) and total hip replacement (THR). We used “Orthoconsent” which is endorsed by the British Orthopaedic Association as the set standard. Methods: This was a retrospective audit undertaken within a London Teaching Hospital. Data was collected for 10 patients undergoing TKR and 10 patients undergoing THR. Participants were identified from ward lists and all had capacity to give consent. Results: THR consent forms had 71% documented completion of the benefits and occurring risks required to make informed consent. TKR consent forms were completed with 42% accuracy. In many instances, important risks that are specific to these operations were not stated. Conclusion: Inadequate consent can lead to false expectations and may lead to litigation. The use of template consent forms (TCF) may improve consent for TKR and THR by providing the information required to responsibly consent for the operation. Patients can raise concerns before signing the consent form, allowing for “Informed Consent”. We have developed TCFs for use in our hospital and strongly recommend there use nationally. 0115: AN AUDIT OF FRACTURE CLINIC SERVICES IN A LONDON DISTRICT GENERAL HOSPITAL: ARE PATIENTS BEING REFERRED ACCORDING TO NATIONAL GUIDANCE? J. Balogun-Lynch, C. Jennings, P. Haggis, R. Dimock, Z. Little. Northwick

Patient attendance at a UK dental hospital emergency clinic.

A questionnaire survey was performed within a dental emergency clinic at a London teaching hospital to determine patients' reasons for attendance and satisfaction with their care. Questionnaires were distributed to all patients registering for the dental emergency clinic over a four week period. A total of 1,058 questionnaires were returned, with an average satisfaction score of 9.3/10. The majority of patients (58%) reported symptomatic dental attendance. Common reasons for irregular attendance were lack of perceived 'need' for care and concerns about cost of care. Patients with irregular attendance were significantly more likely to report their past dental care had been affected by cost than regular attenders. Fifty-one percent of all respondents had tried to make an appointment with a dentist prior to attending the emergency clinic, and 21% of patients with a GDP reporting difficulty accessing urgent care at their practice. Forty-nine percent of patients attending the emergency clinic were referred to oral surgery clinics. Overall, this survey revealed high levels of satisfaction with care in this dental emergency clinic. Patients' reasons for attendance at the clinic can be considered in terms of 'push' and 'pull' factors, deterring them from primary dental care and drawing them into secondary/tertiary care environments.

Audit of pharyngeal pouch surgery in derby from 2007–2014, are we following nice guidance?

Audit of pharyngeal pouch surgery in derby from 2007–2014, are we following nice guidance?

The first successful elective laparotomy.

From time to time I ask a group of nurses or medical students or even surgeons if they can tell me when the first successful elective laparotomy was performed, where it took place and who was the surgeon. After much thought, someone will guess "end of the 19th century", suggest some great teaching hospital in London or Edinburgh or Vienna and hazard the name of Joseph Lister. To date, no one has given me the correct answer--the date was 1809, the place Danville, in Kentucky USA and the surgeon was Ephraim McDowell.

Objective analysis of patient diaries used in an intensive care unit (ICU) in a London teaching hospital

Patient diaries are used in the ICU setting to alleviate psychological distress in patients and their relatives.[1] Much work has been done to evaluate the effects of diaries, but little work has been done to examine protagonist involvement and the content of the narrative within the diaries.

The clinical and operational consequences of prolonged occupancy strain and the use of non-intensive care beds to deliver critical care in a central london teaching hospital

Since 2000, there has been a marked reduction in non-clinical critical care transfers in England. ICNARC have reported that this has been associated with a reduction in case-mix adjusted mortality (1). One consequence has been the need to open critical care beds in non-specified locations in hospitals such as post anaesthesia recovery and high dependency areas. Here we report the consequences of an unprecedented strain on ICU capacity sustained at a central London teaching hospital over a 12 month period in 2013 (graph 1). During this period, ICU capacity reached >150% requiring a number of different emergent solutions including the use of main theatre recovery and high dependency areas. We also describe some of the clinical and operational lessons we learnt.

Baseline observation of performance and inter-professional utilisation of institutional hospital electronic technologies to access and communicate key clinical information in a central london teaching hospital critical care unit

Optimisation of communication in critical care is known to improve quality including patient outcomes [1]. Electronic systems have been shown to facilitate improved access to information and its transfer in this setting, but effectiveness is dependent on design [2, 3].

Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations and case recognition.

Background: previous studies have indicated a prevalence of dementia in older admissions of ∼42% in a single London teaching hospital, and 21% in four Queensland hospitals. However, there is a lack of published data from any European country on the prevalence of dementia across hospitals and between patient groups.Objective: to determine the prevalence and associations of dementia in older patients admitted to acute hospitals in Ireland.Methods: six hundred and six patients aged ≥70 years were recruited on admission to six hospitals in Cork County. Screening consisted of Standardised Mini-Mental State Examination (SMMSE); patients with scores <27/30 had further assessment with the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Final expert diagnosis was based on SMMSE, IQCODE and relevant medical and demographic history. Patients were screened for delirium and depression, and assessed for co-morbidity, functional ability and nutritional status.Results: of 598 older patients admitted to acute hospitals, 25% overall had dementia; with 29% in public hospitals. Prevalence varied between hospitals (P < 0.001); most common in rural hospitals and acute medical admissions. Only 35.6% of patients with dementia had a previous diagnosis. Patients with dementia were older and frailer, with higher co-morbidity, malnutrition and lower functional status (P < 0.001). Delirium was commonly superimposed on dementia (57%) on admission.Conclusion: dementia is common in older people admitted to acute hospitals, particularly in acute medical admissions, and rural hospitals, where services may be less available. Most dementia is not previously diagnosed, emphasising the necessity for cognitive assessment in older people on presentation to hospital.

Impact of mupirocin resistance on the transmission and control of healthcare-associated MRSA.

ObjectivesThe objectives of this study were to estimate the relative transmissibility of mupirocin-resistant (MupR) and mupirocin-susceptible (MupS) MRSA strains and evaluate the long-term impact of MupR on MRSA control policies.MethodsParameters describing MupR and MupS strains were estimated using Markov chain Monte Carlo methods applied to data from two London teaching hospitals. These estimates parameterized a model used to evaluate the long-term impact of MupR on three mupirocin usage policies: ‘clinical cases’, ‘screen and treat’ and ‘universal’. Strategies were assessed in terms of colonized and infected patient days and scenario and sensitivity analyses were performed.ResultsThe transmission probability of a MupS strain was 2.16 (95% CI 1.38–2.94) times that of a MupR strain in the absence of mupirocin usage. The total prevalence of MupR in colonized and infected MRSA patients after 5 years of simulation was 9.1% (95% CI 8.7%–9.6%) with the ‘screen and treat’ mupirocin policy, increasing to 21.3% (95% CI 20.9%–21.7%) with ‘universal’ mupirocin use. The prevalence of MupR increased in 50%–75% of simulations with ‘universal’ usage and >10% of simulations with ‘screen and treat’ usage in scenarios where MupS had a higher transmission probability than MupR.ConclusionsOur results provide evidence from a clinical setting of a fitness cost associated with MupR in MRSA strains. This provides a plausible explanation for the low levels of mupirocin resistance seen following ‘screen and treat’ mupirocin usage. From our simulations, even under conservative estimates of relative transmissibility, we see long-term increases in the prevalence of MupR given ‘universal’ use.

Fantasies of medical reality: An observational study of simulation-based medical education

Medicine is increasingly taught in immersive simulated environments, to supplement the apprenticeship model of work-based learning. Clinical research on this educational practice focuses on its realism, defined as a property of simulation technology. We treat realism as a function of subjective but collectively organised perception and imbued with fantasy, which we define by drawing on Lacanian studies of virtual reality and workplace organisation. Data from an observational study of four simulation centres in London teaching hospitals is drawn on to present an account of what was taught and learned about medicine, including medical failure, when medical practice was simulated.