London Teaching Hospital Research Articles

Patient safety: culture eats strategy for breakfast

'One morning recently, a professor conducted a ward round on an elderly medicine ward in a London teaching hospital. The entourage stopped at an 82-year-old man's bed. The elderly patient was confused and so, unfortunately, was the junior doctor who presented the case.

Regeneration of cervix after excisional treatment for cervical intraepithelial neoplasia: a study of collagen distribution

To study the distribution of collagen in the regenerated cervical tissue after excisional treatment for cervical intraepithelial neoplasia (CIN). Cohort study. A large tertiary teaching hospital in London. Women who underwent repeat excisional treatment for treatment failure or persistent CIN. Eligible women who underwent a repeat excisional treatment for treatment failure, including hysterectomy, between January 2002 and December 2007 in our colposcopy unit were identified by the Infoflex(®) database and SNOMED encoded histopathology database. Collagen expression was assessed using picro-Sirius red stain and the intensity of staining was compared in paired specimens from the first and second treatments. Differences in collagen expression were examined in the paired excisional treatment specimens. A total of 17 women were included. Increased collagen expression in the regenerated cervical tissue of the second cone compared with the first cone was noted in six women, decreased expression was noted in five women, and the pattern of collagen distribution was equivocal in six women. There is no overall change in collagen distribution during regeneration following excisional treatment for CIN.

Implementing a good practice guide for CBRC: perspectives from the ESHRE Cross-Border Reproductive Care Taskforce

This article sets out views about cross-border reproductive care (CBRC) from the point of view of a professional clinicians’ group. After publishing the first international European dataset measuring the phenomenon of CBRC in six European countries in June 2010, the European Society for Human Reproduction and Embryology (ESHRE) Taskforce on CBRC set out to write a good practice guide, which aims at advising clinicians and professionals dealing with patients interested in seeking fertility treatment outside their country of residence. The background, outline and possible means of implementation of this guide are discussed here. The aims of the guide are to ensure quality of care and safety for all concerned, from patients to their future offspring, via gamete donors and surrogates if involved. Patient centredness is also an important aspect, as well as fair treatment of all parties, based on appropriate and intelligible information. This article sets out views about cross-border reproductive care (CBRC) from the point of view of a professional clinicians’ group. The author is a clinician and academic in a teaching hospital in London, and co-ordinates the European Society for Human Reproduction and Embryology (ESHRE) CBRC Taskforce. The taskforce published the first international European dataset measuring the phenomenon of CBRC in six European countries in June 2010, and then set out to write a good practice guide, which aims at advising clinicians and professionals dealing with patients interested in seeking fertility treatment outside their country of residence. This article discusses the guide’s background and genesis and explains the content. The aims of the guide are to ensure quality of care and safety for all concerned, from patients to their future offspring, via gamete donors and surrogates if involved. Patient centeredness is also an important aspect, as well as fair treatment of all parties, based on appropriate and intelligible information. Finally the guide also outlines how it is hoped the described principles may be disseminated and applied for all the stakeholders benefit.

Clinical characteristics of well women seeking labial reduction surgery: a prospective study

To assess clinical characteristics and expectations in well women requesting elective labial reduction surgery. Prospective study of women attending an outpatient gynaecology clinic. General gynaecology clinic at a Central London teaching hospital. Women requesting labial reduction surgery and referred by their general practitioner. The labia minora width and length were measured for all participants for comparison with published normal values. The presenting complaint was recorded, along with demographic details, expectations of surgery and sources of information regarding appearance of the labia. Labial measurements, reported symptoms and expectations of surgery. The labia of all participants were within normal published limits, with a mean (SD) of 26.9 (12.8) mm (right labia), and 24.8 (13.1) mm (left labia). The majority of complaints were regarding appearance or discomfort. Expectations were to alter the appearance with surgery. All women seeking surgery had normal-sized labia minora. Clear guidance is needed for clinicians on how best to care for the worried well woman seeking surgery.

Editorial introductions

Editorial introductions

Automating the monitoring of surgical site infections using variable life-adjusted display charts

We describe a software tool specifically developed to support the monitoring and reporting of the occurrence of surgical site infections (SSI) in hospitals. The tool uses data collected routinely by a London teaching hospital as part of its infection surveillance system, which includes post-discharge follow-up. Based on these data, the tool is used to generate graphs showing cumulative infections over time and variable life-adjusted display (VLAD) charts that account for the expected specialty average infection risk. The user can select, along with other options, the definition of infection used in the preparation of the graphs. Using an illustrative example of SSI monitoring in orthopaedic surgery, we demonstrate the tool and its intended use to trigger further scrutiny rather than draw firm conclusions. We show that the tool has the ability to generate departmental debate, which should ultimately lead to the increased safety of surgical patients. We recommend adopting the tool and VLAD charts wherever surgical site surveillance is continuous.

Vaccination against hepatitis B in an HIV outpatients' department: an audit against national vaccination guidelines

Practice related to hepatitis B vaccination of HIV outpatients in a London teaching hospital was audited against the British HIV Association (BHIVA) immunization guidelines 2004 and 2008, both before and after the implementation of a vaccination record sheet in the patients' notes. Adherence to the guidelines in the original audit was poor - only 67% of patients requiring vaccination for hepatitis B received a full course of vaccination. Following the introduction of the vaccination record sheet, this vaccination completion rate increased to 79% (BHIVA target 95%). Overall the percentage of patients managed according to BHIVA guidelines, including those who did not require vaccination, improved from 33% in the original audit to 61% in the re-audit. Introduction of a simple hepatitis B vaccination record sheet improved the quality of care for our HIV outpatients. Further modification of this system is warranted, perhaps by the introduction of a computerized reminder system.

Information about medicines to cardiac in-patients: Patient satisfaction alongside the role perceptions and practices of doctors, nurses and pharmacists

ObjectiveTo explore the satisfaction of cardiac in-patients regarding the information they received about their medicines, and the role perceptions and practices of practitioners whose responsibility it was to provide such information. MethodA questionnaire was constructed by selecting medicine information topics from a validated instrument, the Satisfaction with Information about Medicines Scale. Patients and practitioners were recruited from cardiac wards at a London teaching hospital providing tertiary care. ResultsQuestionnaires were returned by 140 patients and 52 doctors, 53 nurses and 4 pharmacists. Patients were satisfied with information about the action and usage of medicines but were significantly less satisfied with information about potential problems with their medicines. In parallel, practitioners provided more information about the action and usage of medicines than its potential problems. ConclusionsInformation gaps existed largely around potential problems with medicines which reflected the general lack of focus on these issues by the healthcare professionals studied. There was no consensus between doctors, nurses and pharmacists on perceptions of role responsibility of information provision. Practice implicationsPatients may become non-adherent to their medicines if insufficient information is provided. Role responsibilities should be co-ordinated when information about medicines is provided by a range of practitioners.

Patterns of HIV testing at a London teaching hospital between 2004 and 2007

To observe trends in testing for HIV between 2004 and 2007 in a London hospital and to observe the seroprevalence of HIV within subgroups. Tests were grouped according to source and reason for testing; 58,720 tests were considered (HIV-1 seroprevalence = 0.9%). The majority (75.4%) of tests were performed as part of routine and opt-out protocols including antenatal and genitourinary screening. Among people specifically seeking HIV testing, the HIV seroprevalence was 3.5%. Medical specialties performed fewer tests but a high HIV seroprevalence was observed, including infectious disease (seroprevalence 4.4%) and other medical specialties (seroprevalence 3.4%). A small number of specialties performed few HIV tests. HIV testing was cost-effective in virtually all settings. This study suggests that more HIV tests could be performed, for example, in acute medicine, and training might increase the number of tests offered in some settings. The most effective way of increasing testing appears to be opt-out testing.

Nurses' attitudes and beliefs about medication errors in a UK hospital

AbstractObjectiveTo investigate nurses' attitudes and beliefs about medication administration and medication system errors, and to determine the impact of these attitudes and beliefs at ward level.MethodSemi-structured interviews with a purposive sample of nurses who had been selected initially by ward specialty and then by grade.SettingA teaching hospital in London, United Kingdom.Key findingsSeventeen nurses were interviewed and their attitudes and beliefs about types of medication errors, causes of medication errors, reporting of medication errors and the responsibility for medication errors were explored. The types of errors mentioned by the nurses were consistent with those cited in the literature. Nurses believed both doctors and pharmacy staff to be sources of errors but by far the most common source of error was said to be the nurses themselves. Few of the nurses interviewed believed all errors were reported and almost all believed they were responsible for any errors which occurred when they were administering drugs. As well as blaming themselves, some also blamed the pharmacist and the doctor, if they had been involved. The nurses thought the fear of disciplinary action and having to admit to making a “silly” mistake stopped a nurse from reporting an error if it had no ill effects on the patient. They hoped anything that could harm the patient would be reported, as would any errors involving intravenous drugs, Controlled Drugs and drugs with serious side effects. They believed errors should be reported to the nurse in charge of the ward, the doctor and sometimes the ward manager, if necessary. Generally the nurses felt the patient should be informed if they might suffer any ill effects due to the error; if the error was not going to harm the patient, the nurses were divided as to whether the patient should even be told an error had occurred.ConclusionIt was felt that medication errors should be a learning experience which could allow the nurse to reflect on her own practice. The emphasis of errors should be shifted from the nurse to the situation in which it occurred as blaming the nurse was not considered to be very constructive.

Validation of a “desire for information” scale

Abstract Objective To validate a scale to measure patients' desires for information about their prescribed drugs. Methods Both quantitative and qualitative methods were used. Standardised bedside interviews were conducted with general medical patients in three hospitals over an eight-month period. The validity of the scale was explored by interfacing qualitative data from patients' perspectives and their scores to the scale. Setting General medical wards at three teaching hospitals in London. Key findings A total of 630 patients were recruited for interview; 50.2 per cent were male and 49.8 per cent female. The mean age for the population was 60 years. More than half (54 per cent) of the study population was retired, and the majority (82 per cent) described their cultural background as white. Through a factor analytic approach, the primary 12-item scale was refined to six items (designated F1), measuring “extent of information desired”. A second extracted factor (designated F2) measured “inhibited desire for information”, but was not considered reliable. The responses to semi-structured interviews gave valuable insights into the types of information sought: low-scorers declared no need for detailed information as this would sometimes even worry or frighten them, while high-scorers worried about not receiving enough information and requested specific details that would help them in their self care. Conclusion Interfacing qualitative responses to semi-structured and open questions and the quantitative scores contributed to the validation of a new six-item scale and gave insights into the types of information patients seek. By developing a tool to identify patients' desires for information, pharmacists will be able to identify and meet the drug information needs of patients in an appropriate and timely way.

An evaluation of the process-related medication risks for elective surgery patients from pre-operative assessment to discharge

Abstract Aim To investigate where the process-related medication risks occur in an elective surgery service with a pre-operative assessment clinic (PAC) and make recommendations for how pharmacy services should best be provided. Method The study involved identification of discrepancies in medication history taking, changes that occurred in patients' medication between PAC and admission, and changes that occurred between admission and discharge. Prescribing errors were identified and classified according to whether they occurred on admission, during the inpatient stay or on discharge, and whether they were identified and rectified by the existing pharmacy service. Setting Seventy-six patients recruited from the nurse-led PAC of a 580-bed London teaching hospital between May 2 and June 30, 2000. Key findings The PAC nurse omitted 27 per cent of medications from the medication history; the admitting doctor omitted 37 per cent from the medication history documented in the medical notes and 47 per cent from the inpatient medication chart; the majority of the omissions were complementary and over-the-counter preparations. Twenty-six per cent of patients had changes made to their medication between PAC and admission, and 85 per cent had changes made between admission and discharge. A total of 177 prescribing errors were identified (median of 1 error per patient; interquartile range 0–3), of which 38 per cent occurred on admission, 14 per cent during the inpatient stay and 48 per cent at discharge. Pharmacists made interventions to rectify 59 per cent of the errors. Conclusion Given the large number of changes to patients' medication that occurred between PAC and admission, we would not support the writing of inpatient medication charts or the supply of medication at this stage. For this group of patients in the study hospital, the greatest process-related medication risks occurred on admission and discharge, and pharmacy services should be provided accordingly.

Cost-effectiveness analysis of prostaglandin E2 gel for the induction of labour at term

To estimate the cost-effectiveness of prostaglandin E2 (dinoprostone) vaginal gel for the induction of labour at term from the perspective of the UK's National Health Service. Economic evaluation conducted as part of a randomised controlled trial. Maternity department at a major teaching hospital in London, UK. A cohort of 165 pregnant women presenting as cephalic between 36(+⁶) and 41(+⁶) weeks of gestation, for whom induction of labour was deemed necessary. Either 3-mg Prostin E2 vaginal tablets or 1- or 2-mg Prostin E2 vaginal gel were administered at 6-hourly intervals. Incremental cost per hour prevented between induction and delivery. The nonparametric bootstrap method was used to construct cost-effectiveness acceptability curves and estimate net benefits at alternative cost-effectiveness thresholds. Women receiving the gel accrued nonsignificantly higher costs (incremental cost £630; bootstrap 95% CI -£353, £2320; P = 0.43), and experienced a significantly reduced interval between induction and delivery (median of 1400 versus 1780 minutes; mean of 1711 versus 2765 minutes; P = 0.03). The incremental cost per hour prevented from induction of labour to delivery was estimated at £36. At a cost-effectiveness threshold of £100 per hour of care prevented, the probability that the gel is cost-effective was estimated at 0.83, and the mean net benefit to the health services was estimated at £1121 (bootstrap 95% CI -£1133, £3379). The results were sensitive to the inclusion of neonatal costs in the analysis and the value of the cost-effectiveness threshold. Notably, excluding neonatal costs increased the probability that the gel is cost-effective at a cost-effectiveness threshold of £100 per hour of care prevented to 0.99. This study suggests that prostaglandin E2 gel is probably more cost-effective than prostaglandin E2 tablets for the induction of labour at term. Given that the results are applicable to the general obstetric population requiring induction of labour at term, decision-makers should consider the likely economic impacts of their implementation.

Shellfish Allergy and Contrast Media

RATIONALE: A common misconception amongst physicians and radiographers is that shellfish allergy is a contraindication to use of iodinated-contrast media, due to the risk of anaphylactoid reactions. However, the major allergen in shellfish is the protein, tropomyosin, not iodine. We have investigated the prevalence of this popular myth, which can result in inappropriate patient management.METHOD: Doctors and radiographers within a London teaching hospital were asked to complete an anonymised questionnaire consisting of two questions: firstly, in patients with shellfish allergy can iodinated-contrast be given a) safely b) with caution or c) is contra-indicated. Secondly, an identical control question about gadolinium-contrast was also given. The correct answer was a) to both questions.RESULTS: Data was collected from 119 members of staff (104 doctors, 15 Radiographers). 37.8 % answered both questions correctly. Only 43.4% (n = 49 [45 Doctors, 4 Radiographers]) answered correctly that iodinated-contrast was safe, however, 86.7% (n = 98 [83 Doctors, 15 Radiographers]) correctly answered that gadolinium was safe. Within the 13 specialties questioned, Radiologists (n=8) got 100% correct, with radiographers answering 26.6% and only 12.5% of Cardiologists correctly answering both questions. 72.2 % of Consultants overall correctly answered that iodine was safe with a shellfish allergy whilst the most junior of doctors getting only 35.5%.CONCLUSION: There is poor understanding of the cause of shellfish allergy in non-radiologists, junior doctors and radiographers. This can lead to the withholding of iodinated-contrast media or unnecessary use of pre-medication. Better education is needed. RATIONALE: A common misconception amongst physicians and radiographers is that shellfish allergy is a contraindication to use of iodinated-contrast media, due to the risk of anaphylactoid reactions. However, the major allergen in shellfish is the protein, tropomyosin, not iodine. We have investigated the prevalence of this popular myth, which can result in inappropriate patient management. METHOD: Doctors and radiographers within a London teaching hospital were asked to complete an anonymised questionnaire consisting of two questions: firstly, in patients with shellfish allergy can iodinated-contrast be given a) safely b) with caution or c) is contra-indicated. Secondly, an identical control question about gadolinium-contrast was also given. The correct answer was a) to both questions. RESULTS: Data was collected from 119 members of staff (104 doctors, 15 Radiographers). 37.8 % answered both questions correctly. Only 43.4% (n = 49 [45 Doctors, 4 Radiographers]) answered correctly that iodinated-contrast was safe, however, 86.7% (n = 98 [83 Doctors, 15 Radiographers]) correctly answered that gadolinium was safe. Within the 13 specialties questioned, Radiologists (n=8) got 100% correct, with radiographers answering 26.6% and only 12.5% of Cardiologists correctly answering both questions. 72.2 % of Consultants overall correctly answered that iodine was safe with a shellfish allergy whilst the most junior of doctors getting only 35.5%. CONCLUSION: There is poor understanding of the cause of shellfish allergy in non-radiologists, junior doctors and radiographers. This can lead to the withholding of iodinated-contrast media or unnecessary use of pre-medication. Better education is needed.

Daily physiological goal-setting: medical prescription and nursing adherence in a London teaching hospital ICU

Individual, clearly defined physiological goal-setting can help to optimize patient care [1]. At our ICU, eight physiological goals can be prescribed on the daily ICU observation chart. These include Hb, MAP, ICP, CPP, pO2, pCO2, fluid balance and sedation scores. We performed a prospective audit assessing doctors' compliance with goal-setting, nursing adherence to these, and what goals nurses used when none were documented.

Impact of increased numbers of intensive care consultants on outcome in a central London teaching hospital

The standardised mortality ratio (SMR) is a key parameter by which ICUs quantify their performance. We report the effect of increased ICU consultant numbers on mortality and SMR in a central London teaching hospital.

Ectopic pregnancy: using the hCG ratio to select women for expectant or medical management

To identify variables that can be used to select women with an ectopic pregnancy for expectant or medical management with systemic methotrexate. Cohort study. Early Pregnancy Unit of a London teaching hospital. Women with a tubal ectopic pregnancy managed non-surgically. The diagnosis of tubal ectopic pregnancy was made using transvaginal sonography. Human chorionic gonadotrophin (hCG) levels had to be taken at 0 hour and 48 hours pre-treatment. Other recorded variables include presenting complaints, gestational age, progesterone levels, size of the ectopic mass and appearance of the ectopic on transvaginal sonography. Women were followed up until the outcome (success or failure) of management was known. Univariable analysis was performed to identify the variables associated with successful management using area under curves and relative risks. Thirty-nine women underwent expectant management (overall success rate 71.8%) and 42 had medical management (overall success rate 76.2%). The pre-treatment hCG ratio (hCG 48 hours/hCG 0 hour) was related to the failure of both expectant (area under curve 0.86, 95% CI 0.67-0.94) and medical (area under curve 0.79, 95% CI 0.58-0.90) management. History of ectopic pregnancy was related to failure of expectant management only (relative risk 0.46, 95% CI 0.16-0.92). The most important variable for predicting the likelihood of successful non-surgical management was the pre-treatment hCG ratio. New studies are required to validate the use of this variable and of history of ectopic pregnancy to predict the likelihood of successful non-surgical management in clinical practice.

Development of a core drug list towards improving prescribing education and reducing errors in the UK

To develop a core list of 100 commonly prescribed drugs to support prescribing education. A retrospective analysis of prescribing data from primary care in England (2006 and 2008) and from two London Teaching Hospitals (2007 and 2009) was performed. A survey of prescribing by foundation year 1 (FY1) doctors in 39 NHS Trusts across London was carried out. A core list of 100 commonly prescribed drugs comprising ≥0.1% prescriptions in primary and/or secondary care was developed in 2006/7. The core list remained stable over 2 years. FY1 doctors prescribed 65% drugs on the list at least monthly. Seventy-six% of FY1 doctors did not regularly prescribe any drugs not on the core list. There was a strong correlation between prescribing frequency (prescriptions for each drug class expressed as percentage of all prescriptions written) and error rate described in the EQUIP study (errors made when prescribing each drug class expressed as a percentage of all errors made), n= 39, r= 0.861, P= 0.000. Our core drug list identifies drugs that are commonly used and associated with error and is stable over at least 2 years. This list can now be used to develop learning resources and training programmes to improve prescribing of drugs in regular use. Complementary skills required for prescribing less familiar drugs must be developed in parallel. Ongoing research is required to monitor the effect of new training initiatives on prescribing error and patient safety.

Changing trends in the pattern and outcome of stab injuries at a North London hospital

Objective:To study the incidence, pattern and outcome of stab injuries attending a North London Teaching Hospital over a 3-year (2006-2008) period.Materials and Methods:A retrospective review of collected data from the Hospital database was conducted. The database contains comprehensive medical records for all patients attended by the trauma team for deliberate stab injuries. It is updated by the surgical team after each admission. All patients with deliberate penetrating injury who were attended by the service between 1 January 2006 and 31 December 2008 were identified. Patients who died in the prehospital phase, those managed exclusively by the emergency department and limb injuries without vascular compromise were excluded from the study.Results:Six hundred and nineteen patients with stab injuries (following knife crime) from North London attended the Hospital in the above period. One hundred and thirty-seven paients required surgical admission. Two were cases of self-inflicted knife injuries. Over the 3-year period the percentage of victims below 20 years of age is increasing. Ninety-three percent of knife crime occured between 6 pm and 6 am; recently moving toward week days from weekend period.Conclusions:The overall rate of penetrating injuries (stab injuries) is slowly declining. Timely cardiothoracic support facility is vital in saving lives with major cardiac stab injuries. Although alcohol drinking restriction has been lifted, most cases of stabbings are still occurring out-of-hours when surgical personnel are limited.

P84 The impact of a multidisciplinary educational programme on the prescribing of oxygen in an acute trust

Introduction and objectivesFollowing the publication of the BTS guideline1 and NPSA rapid response report2 on the use of oxygen, a multidisciplinary educational programme was developed to improve the prescription of...