Units In England Research Articles

A Census of Current Sedation Monitoring Practices in Adult General Intensive Care Units in England

Under- and over-sedation in intensive care units (ICUs) have potentially deleterious consequences. The Intensive Care Society (ICS) produced guidelines in 2007 to unify sedation management. The aim of the current census was to investigate how sedation practice was subsequently implemented in England. A telephone-based questionnaire to the ‘nurse-in-charge’ was iteratively developed at the host institution until respondent concordance was greater than 80%. Two hundred and four adult general ICUs across England were then contacted. One hundred and sixty units (79%) completed the survey; 82% of responding ICUs had a written sedation policy; all responding ICUs used a sedation scoring system, mainly the Richmond Scale (64%). All responding ICUs assessed and documented sedation levels, with 73% formally assessing this at least two-hourly; 91% of responding ICUs had a formal sedation holding policy; 73% of responding nurses felt there was adequate medical guidance provided on sedation depth; 27% of responding ICUs had bispectral index (BIS) monitors, with 74% of these units using them for monitoring sedated patients receiving neuromuscular blocking agents. Sedation management has improved nationally over the last five years. Written sedation policies, sedation scoring and sedation holding are standard practice. However, some nurses feel they need more guidance on choosing sedation depth, and some units assess sedation depth less frequently than two-hourly. In order to optimise clinical practice, we propose that sedation depth be a goal-directed therapy that is addressed at each patient review.

Choice and Competition Between Adult Congenital Heart Disease Centers

Although concentrating adult congenital heart disease services at high-volume centers has been widely advocated, the potential beneficial effects of competition and patient choice have received relatively little attention. We aimed to assess the degree of patient choice and competition between adult congenital heart disease units and to investigate whether competition indices correlate with clinical quality or research output. Competition between the 10 major adult congenital heart disease units in England was evaluated based on the Herfindahl-Hirschman Index, representing the sum of squared market shares of individual units. In addition, to account for geography and feasible access, we calculated spatial indices of competition based on travel time by road. These indices were correlated with 30-day mortality postpulmonary valve replacement in adult patients (as obtained from the National Central Cardiac Audit Database) and the aggregate research impact factors of individual centers. On a national level, a high level of competition without obvious dominant players was found (Herfindahl-Hirschman Index between 0.107 and 0.013). When accounting for geography, however, important disparities in patient choice and competition faced by individual centers emerged. The degree of local competition was correlated significantly with clinical outcomes and research output. In contrast, no association between center volume and outcome could be established. Beyond the usual focus on concentrating services at high-volume centers, the potentially beneficial effects of competition should not be ignored. Therefore, policymakers should consider fostering a competitive environment for adult congenital heart disease centers or at least avoiding creating government-granted monopolies in the field.

Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation

Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI. The study is registered with PROSPERO as CRD42012001840. The National Institute for Health Research Health Technology Assessment programme.

EPA-0442 – All things being equal? predictive validity of the hcr-20 among heterogenous groups of secure psychiatric inpatients

Introduction The HCR-20 is the most widely used structured violence risk assessment tool in medium secure units in England and has good predictive validity for inpatient violence. However little is known about whether its predictive validity varies between different clinical and demographic groups. Objectives 1) collect HCR-20 risk assessment and three month follow-up data for all eligible inpatients 2) examine the ability of the HCR-20 to predict various indices of inpatient aggression using receiver operating characteristics (ROC), and 3) compare AUC values derived from different groups (i.e. men vs. women) Aim determine if the HCR-20 performs equally across different clinical and demographic groups. Methods This study was conducted amongst inpatients at St Andrew's (N=505). Demographic (age, ethnicity, gender), clinical (diagnosis) and routinely collected risk assessment data (HCR-20) were collated. Incidents of aggression were coded using the OAS for the three months following assessment. Results ROC analysis revealed that the HCR-20 total, Clinical scale and Risk Management scale were predictive of all types of aggression; the Historical scale was a significant predictor of verbal aggression and physical aggression towards objects but not physical aggression towards people. The predictive efficacy of the HCR-20 differed according to gender and diagnosis, with superior performance obtained with women and those with a diagnosis of personality disorder. Conclusions This study reveals differences in the HCR-20's efficacy between groups. Further development and optimisation of the HCR-20 may be required. Alternatively, interventions to prevent aggression may be more effective among some groups. Future research should address these issues.

The Cardiac Output Monitoring EvaluaTion –UK (COMET-UK) study

The aim of the Cardiac Output Monitoring EvaluaTion-UK (COMET-UK) study was to update reports of cardiac output (CO) monitoring use and to examine whether there is any association between the frequency of CO monitoring use in adult, general intensive care units and patient outcomes. Questionnaires were sent to all intensive care units in England, Wales and Northern Ireland (n=221) asking whether the unit had used CO monitoring in the last two years and, if so, to give details of average frequency of use and which CO monitors were available. The majority of units (n=100, 45.2%) used CO monitoring most days or a few times a week and 33 (14.9%) monitored CO every day (response rate 100%). The most commonly available methods were oesophageal Doppler (n=127, 57.5%), LiDCO (n=96, 43.4%) and PiCCO (n=92, 41.6%). There was no significant difference in risk-adjusted acute hospital mortality (p=0.25) or length of stay (p=0.48) across categories of frequency of use. However for ventilated vs non-ventilated patients and different quartiles of illness severity, there was an association between higher frequency of use and worse outcome among non-ventilated and lowest risk admissions quartiles. The COMET-UK study found that CO monitoring is in common use; however, there was no evidence that more frequent use of CO monitoring was associated with improved outcomes.

Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study

IntroductionResearch has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England.MethodsWe conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital.ResultsThe analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation.ConclusionsWe found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.

Review of radiation therapy services for neurofibromatosis (NF2) patients in England

Objective. It is widely accepted that stereotactic radiosurgery (SRS) is less effective in controlling NF2-related vestibular schwannomas (VS-NF2), than sporadic VS. Concerns persist regarding the risks of malignant transformation and the development of secondary tumours. In recent years there has been an increase in the number of centres offering SRS and fractionated stereotactic radiotherapy (SRT) services for VS. The NF2 National Commissioning Group service framework has recommended limiting radiation therapies for VS-NF2 to SRS (Gamma Knife) provided in Sheffield.The aims of this review were to:1) Establish the current provision of SRT and SRS services in England.2) Determine the radiation therapies employed for NF2 patients since 2000.3) Determine the feasibility of identifying a national cohort of NF2 patients in England who have received radiation therapy since 2000.Methods. The lead clinicians managing VS patients in the major regional neurosurgical units in England, and those providing SRS services to NF2 patients were contacted and when possible, databases were examined. Results. A total of 18 NHS centres and 2 private centres were included. This included the four NF2 ‘hub centres’ (Cambridge, London, Oxford and Manchester). Their NF2 databases identified 4, 8, 23 and 42 VS-NF2 treatments with SRS or SRT, respectively since 2000. Eleven centres reported that they had referred VS-NF2 patients exclusively to Sheffield. Each estimated that they had referred no more than one patient per year.The survey identified four Gamma Knife Centres and six Linac SRS/SRT centres with the capacity to treat VS and VS-NF2 patients. Of these, four centres confirmed that they had treated VS-NF2 patients. Conclusion. Since 2000 fewer than 100 SRS and SRT treatments have been undertaken for VS-NF2 patients. Approximately 60% of these have been performed in Sheffield. There is considerable uncertainty regarding the role of radiation therapy in the management of VS-NF2 and consequently a range of views and practice.

Reducing ventilator associated pneumonia in adult patients through high standards of oral care: A historical control study

Implement and evaluate the impact of oral hygiene measures (teeth brushing, 1% oral chlorhexidine and oropharyngeal suction) on the incidence of ventilator-associated pneumonia (VAP) and the costs of prevention and treatment. A historical control study of all 1087 patients, mechanically ventilated for at least 48hours in a general adult critical care unit, between July 2009 and December 2011. The incidence of VAP in 528 patients before a practice change was compared with the incidence in 559 patients after a practice change. The clinical audit cycle was used to review compliance with existing standards and implement a regime of enhanced oral hygiene. The costs of changing the oral care regime and the treatment of VAP with antibiotics was calculated. 22 bed combined intensive care and high dependency unit in England. (1) Compliance with standards for oral care. (2) The incidence of VAP before and after the change. 91% (95% CI 90-93%) compliance with the standards for oral care was achieved throughout the 30 months of the study with very little difference before (90%, 95% CI 88-93%) and after (92%, 95% CI 90-95%) the changes in oral care standards were introduced. Of 528 patients mechanically ventilated for at least 48 hours before the change, 47 developed VAP. The mean incidence of VAP was 0.09 (8.9%) (95% CI 0.07-0.12). The mean VAP per 1000 ventilator days was 13.6 (95% CI 13.1-14.0). After the change 24 of 559 patients developed VAP. The mean incidence of VAP after the change was 0.04 (4.1%) (95% CI 0.03-0.06). The mean VAP per 1000 ventilator days was 6.9 (95% CI 6.5-7.1). There was a £6319 ($10,112, €7518) cost saving on preventing and treating VAP following the practice change. A statistically significant difference (p<0.01) was seen between the incidence of VAP expected and that observed after the change in oral care. This represents a relative risk reduction of 0.53 (95% CI 0.25-0.71) and number needed to treat (NNT) of 21. An enhanced oral care bundle, incorporating 1% Chlorhexidine Gluconate, was associated with a significant reduction in VAP and the costs of treating VAP. Limitations of the study relate to analysis of other variables, in particular severity of illness, between the two groups and the lack of agreement in the literature on VAP criteria, which limits generalisation of these findings.

‘Finding a Balance’ in Involving Patients in Goal Setting Early After Stroke: A Physiotherapy Perspective

Collaborative goal setting (between patient and professional) confers benefits within stroke and neurological rehabilitation, and is recommended in clinical guidelines. However, evidence suggests that patient participation in rehabilitation goal setting is not maximized, particularly within the hospital setting. The purpose of this study was to investigate physiotherapists' perceptions about their experiences of collaborative goal setting with patients in the sub-acute stages after stroke, in the hospital setting. This qualitative study employed constructivist grounded theory methodology. Nine physiotherapists, of varying experience, were selected using purposive then theoretical sampling from three National Health Service hospital stroke units in England. Semi-structured interviews were conducted, audio-recorded and transcribed. Transcripts were coded and analysed using the constant comparative method of grounded theory to find common themes. Three themes emerged from the data: 1) 'coming to terms with stroke' - the individual patient journey; 2) the evolution of goal setting skill - the individual physiotherapist journey; and 3) 'finding a balance' - managing expectations and negotiating interactions. A provisional grounded theory was constructed, which highlighted that, from the physiotherapists' perspective, collaboration with patients within goal setting early after stroke involved finding a balance between numerous different drivers, which have the potential to compete. Patient-directed and therapist-directed goal setting approaches could be viewed as opposite ends of a continuum, along which patient-centred goal setting is possible. Physiotherapists perceived that collaborating with patients in goal setting was important but challenging. Goal setting interactions with other professionals, patients and families were perceived as complex, difficult and requiring significant effort. The importance of individuality and temporality were recognized suggesting that the goal setting approach needs to be adapted to the context and the individuals involved.

Survey of policy for MRSA screening in English cataract surgical units and changes to practice after updated National guidelines

BackgroundNational guidelines on MRSA (methicillin-resistant Staphylococcus aureus) screening policy in England have changed on a number of occasions, but there is limited data on its influence at a local level. The aim of this study was to determine if changes in National policy influenced preoperative screening of cataract patients for MRSA.MethodsA structured telephone survey was conducted on all 133 ophthalmology units in England in 2004 and again in 2007 for the initial responders, after a change in national policy.ResultsA total of 74 units (56%) responded in 2004 and 71 units (96% of initial respondents) in 2007. In 2004, 57% of units screened for MRSA. They screened groups at high risk of carriage, including patients with previous MRSA (93%) and patients from Nursing homes (21%). Swab sites included the nose (100%), eyes (31%) and perineum (62%). In 2007, there was no significant change in the number of units that screened for MRSA (57% vs 66%; p = 0.118; McNemar test). However, more units screened for MRSA in patients from nursing/residential homes (21% vs 51%; p = 0.004, McNemar test), and in patients who had recent admission to hospital (12% vs 36%; p = 0.003). In the second survey, 3 units (6%) now screened patients who were close relatives of MRSA carriers.ConclusionThis survey has highlighted inconsistences in MRSA screening practice of day-case cataract surgery patients across England after 2 major national policy changes. A change in DoH policy only led to more units screening patients for MRSA from high risk groups.

Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study.

BackgroundIn England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration.MethodsThis was a secondary analysis of data collected in a national prospective cohort study including 27,842 ‘low risk’ women with singleton, term, ‘booked’ pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer.ResultsThe median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8–10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers.ConclusionsTransfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women.

English Consensus Protocol Evaluating Candidacy for Auditory Brainstem and Cochlear Implantation in Neurofibromatosis Type 2

Hearing loss resulting from bilateral vestibular schwannomas (VSs) has a significant effect on the quality of life of patients with neurofibromatosis Type 2 (NF2). A national consensus protocol was produced in England as a guide for cochlear implantation (CI) and auditory brainstem implantation (ABI) in these patients. Consensus statement. English NF2 Service. Clinicians from all 4 lead NF2 units in England. A protocol for the assessment, insertion and rehabilitation of CI and ABI in NF2 patients. Patients should undergo more detailed hearing assessment once their maximum aided speech discrimination score falls below 50% in the better hearing ear. Bamford-Kowal-Bench sentence testing scores below 50% should trigger assessment for auditory implantation, as recommended by the National Institute for Clinical Excellence guidelines on CI. Where this occurs in patients with bilateral stable VS or a unilateral stable VS where the contralateral cochlear nerve was lost at previous surgery, CI should be considered. Where VS surgery is planned, CI should be considered where cochlear nerve preservation is thought possible, otherwise an ABI should be considered. Intraoperative testing using electrically evoked auditory brainstem responses or cochlear nerve action potentials may be used to determine whether a CI or ABI is inserted. The NF2 centers in England agreed on this protocol. Multisite, prospective assessments of standardized protocols for auditory implantation in NF2 provide an essential model for evaluating candidacy and outcomes in this challenging patient population.

Achieving a positive balance

British Journal of MidwiferyVol. 21, No. 11 BirthwriteAchieving a positive balanceCathy WarwickCathy WarwickSearch for more papers by this authorCathy WarwickPublished Online:18 Nov 2013https://doi.org/10.12968/bjom.2013.21.11.766AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References National Perinatal Epidemiology Unit (2012) The Birthplace cohort study: Key findings. www.npeu.ox.ac.uk/birthplace/results (accessed 22 October 2013) Google ScholarNational Federation of Women's Institutes and NCT (2013) Support Overdue: Women's experiences of maternity services. NCT, London Google ScholarRoyal College of Midwives (2013) Evidence to the NHS Pay Review Body for 2014. RCM, London Google ScholarRoyal College of Midwives, Birthchoice UK (2013) Trends in Freestanding Midwife-led Units in England and Wales 2001-2013. RCM, London Google ScholarSandall J, Soltani H, Gates S, Shennan A, Devane D (2013) Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Library 3: CD004667 Google ScholarTracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckmann M, Bisits A, Homer C, Foureur M, Welsh A, Kildea S (2013) Caseload midwifery care versus standard maternity care for women of any risk: [email protected], a randomised controlled trial. The Lancet 382: DOI: 10.1016/s0140-6736(13)61406-3 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byPriority issues from 0–199 March 2015 | British Journal of Midwifery, Vol. 23, No. 3Joint call for addressing issues in the 0–19 health-care service16 March 2015 | British Journal of School Nursing, Vol. 10, No. 2Priority issues from 0–1920 March 2015 | Journal of Health Visiting, Vol. 3, No. 3 1 November 2013Volume 21Issue 11ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 18 November 2013 Published in print 1 November 2013 Information© MA Healthcare LimitedPDF download

Risk factors of lameness in sows in England

Lameness in pigs is a major welfare concern and one of the most commonly reported reasons for premature culling of breeding sows. In this study, the prevalence of lameness in sows was estimated using data from 76 pig breeding units in England and risk factors associated with the occurrence of lameness were examined. The prevalence of lameness in sows was 4.5% (farm median 5.0%, range 0–40%), with at least one lame sow being observed at 54% of the 76 farms. Relative risk (RR) of lameness was determined by multivariable Poisson regression analysis. Farms with high producing sows had a lower rate of lame sows than farms with a medium level of production (P=0.01). However, medium levels of production on a farm were associated with higher levels of lameness than farms having the lowest level of production (P=0.02). Farms where the stockman had responsibility for more sows resulted in an increased risk of lameness (P=0.0062). When indoor units were considered, the area of the pen and younger sows (two parities or less) had higher risk of lameness (P=0.001 and P=0.026 respectively). An increased awareness of the risk factors behind lameness is essential in farm management and can be useful when designing housing areas as well as developing future prevention plans for lameness.

‘Being in a womb’ or ‘playing musical chairs’: the impact of place and space on infant feeding in NICUs

BackgroundBecoming a parent of a preterm baby requiring neonatal care constitutes an extraordinary life situation in which parenting begins and evolves in a medical and unfamiliar setting. Although there is increasing emphasis within maternity and neonatal care on the influence of place and space upon the experiences of staff and service users, there is a lack of research on how space and place influence relationships and care in the neonatal environment. The aim of this study was to explore, in-depth, the impact of place and space on parents’ experiences and practices related to feeding their preterm babies in Neonatal Intensive Care Units (NICUs) in Sweden and England.MethodsAn ethnographic approach was utilised in two NICUs in Sweden and two comparable units in England, UK. Over an eleven month period, a total of 52 mothers, 19 fathers and 102 staff were observed and interviewed. A grounded theory approach was utilised throughout data collection and analysis.ResultsThe core category of ‘the room as a conveyance for an attuned feeding’ was underpinned by four categories: the level of ‘ownership’ of space and place; the feeling of ‘at-homeness’; the experience of ‘the door or a shield’ against people entering, for privacy, for enabling a focus within, and for regulating socialising and the; ‘window of opportunity’. Findings showed that the construction and design of space and place was strongly influential on the developing parent-infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding.ConclusionsIf our proposed model is valid, it is vital that these findings are considered when developing or reconfiguring NICUs so that account is taken of the influences of spatiality upon parent’s experiences. Even without redesign there are measures that may be taken to make a positive difference for parents and their preterm babies.

Service attachment: The relative contributions of ward climate perceptions and attachment anxiety and avoidance in male inpatients with psychosis

It has been suggested that mental health services can help meet the attachment needs of inpatients and improve patient outcomes through the provision of a 'secure base'; however, what defines the latter is unclear. Perception of ward climate might be a useful indicator. The aim of this study was to examine whether inpatient perceptions of the ward climate, which is partly under the control of the service, or inpatients' own personal levels of attachment anxiety and avoidance are more associated with their attachment to their service. Seventy-six men diagnosed with a psychotic illness, who were residents in one of four regional medium-security units in England, completed questionnaire measures of service attachment, personal attachment style and ward climate. Ward climate was more strongly associated with service attachment than personal levels of attachment anxiety and avoidance. The most important aspect of ward climate for service attachment was the depth and influence of staff support for the inpatients. Although patient characteristics are important influences on development of service attachment, ward climate is also important. The latter may be easily and reliably monitored with a brief questionnaire. Strategies to enhance and maintain its positive components are likely to be important for progress with forensic hospital inpatients who have a psychotic illness.

Ten years of asthma admissions to adult critical care units in England and Wales

ObjectivesTo describe the patient demographics, outcomes and trends of admissions with acute severe asthma admitted to adult critical care units in England and Wales.Design10-year, retrospective analysis of a national audit...

High dependency care: Education of midwives and preparation for practice

This paper explores issues around the education and competencies of midwives who are involved in the delivery of high dependency care. It argues that all midwives who provide this specialist care should possess the appropriate clinical skills and knowledge relevant to the management of this cohort of women. It also discusses the rational for the development of high dependency care in midwifery and the role of the midwife, as well as the location for care delivery and preparation for practice. The evidence base for this paper comes from research currently being undertaken into the organisation, provision and education of high dependency care within the midwifery setting. The study is being conducted in maternity units in England with a delivery rate in excess of 3000 per year, and is using a series of individual semi-structured interviews with midwives, consultant obstetricians, consultant obstetric anaesthetists and midwifery educationalists. The study will contribute to the debate on the delivery of high dependency care in the maternity setting and highlights the importance of specialist education relating to this area of practice.

£500 million A&amp;E winter funding will not solve problems, says RCN

Plans for struggling A&E units in England to share an extra £500 million over the next two years to relieve winter pressures will not solve the deep-rooted problems facing urgent and emergency care, the RCN has warned.

Characteristics and outcome of children admitted to adult intensive care units in England, Wales and Northern Ireland (1996–2011)

Despite centralisation of paediatric intensive care units (PICU) in the UK, children continue to be admitted to adult intensive care units (AICU). We aimed to analyse trends in the admission of children to AICUs over a 16-year period from 1996, and describe their case mix, outcome and resource use in a recent cohort (2009-2011). We extracted data from consecutive admissions of children (1996-2011) to AICUs from the Intensive Care National Audit and Research Centre Case Mix Programme Database. We studied case mix, outcome and resource use as well as regional, seasonal and temporal variations in admissions of children to AICU. A total of 13,430 children were admitted to AICUs between 1996 and 2011 (representing 1.3% of all admissions). This proportion decreased from 2.8% in 1996 to 0.6% in 2011. Crude mortality fell from 6.7 to 2.8%, and the proportion transferred out to a PICU rose from 18.9 to 51.4%. In recent years (2009-2011), half of the 2,320 admissions of children occurred in just three English Strategic Health Authorities. The median length of unit stay was 7.7 h (IQR 3.8-19.7) for survivors and 11.5 h (IQR 5.0-36.2) for non-survivors. The number of children admitted to AICUs in England, Wales and Northern Ireland has been steadily declining since 1996. In recent years, half of all children admitted to AICUs are transferred to PICU, usually following a short stay. The reasons for regional variation in paediatric admissions to AICUs, and the cause of death in the small number of children who die in AICUs, are unclear.