Wrexham Maelor Hospital Research Articles

Optimising Care: Quality Improvement for Sustainable Practices in the Paediatric ADHD Clinic in Wrexham Maelor Hospital

Optimising Care: Quality Improvement for Sustainable Practices in the Paediatric ADHD Clinic in Wrexham Maelor Hospital

Effect of Peri-Operative Blood Transfusion on Short and Long-Term Mortality Rates in Elderly Patients With Neck of Femur Fractures: A Retrospective Study.

Introduction The current reported mortality rate for elderly neck of femur fractures (eNOFF) is relatively high in the UK. eNOFF patients commonly suffer from associated cardiovascular co-morbidities and tend to have fragile physiological states and poor physiological reserves. Although some studies have shown a potential link between blood transfusion and mortality in eNOFF patients, there is no general consensus on this matter. Therefore, our study aims to explore the possible association between blood transfusion and length of hospital stay (LOHS) as well as short- and long-term mortality rates in eNOFF patients by reviewing the practice of blood transfusion. Methods This retrospective study was conducted at Wrexham Maelor Hospital, which is part of the Betsi Cadwaladr University Health Board (BCUHB), Wales. The study included patients who were 65 years of age or older and presented with neck of femur fractures. Only patients who required surgical intervention were included, and those managed non-operatively were excluded from the study. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, New York, United States).Furthermore, unpaired t-tests and log-rank (Mantel-Cox) tests were performed to compare the groups that received blood transfusions. Results During the study period, a total of 501 eNOFF patients were included in the primary cohort of the study, with a mean age of 81 years (ranging from 65 to 102). The majority of the patients were female (n=340). Of the 501 patients, 79 (15.8%) received a blood transfusion during their treatment.Around 52.9% of the eNOFF patients were categorized as American Society of Anesthesiologists (ASA) III, but there was no statistically significant difference in the requirement of blood transfusion between patients in ASA III, II, and IV categories, as compared to ASA I. Additionally, the mean time to surgery was higher in patients who received a blood transfusion (35.8 hours), and this difference was statistically significant (p=0.035). Moreover, the average LOHS after surgery for eNOFF was longer in patients who needed peri-operative blood transfusion (22 days), and this difference in the means was statistically significant (p=0.022).At the one-year post-surgery mark, mortality was higher in the transfused group (33%), and long-term five-year mortality rates were also higher in this group (63.2%). Conclusion Peri-operative blood transfusion may confer certain benefits in the management of eNOFF ptients. However, it should not be regarded as a panacea for improving long-term outcomes. The decision to administer blood transfusion must be made on a case-by-case basis, with careful assessment of individual clinical indications, and the potential risks and benefits taken into consideration. To achieve optimal clinical outcomes, close monitoring and follow-up of eNOFF patients, both in the short-term and long-term, are essential.

Pharmacist review required in majority of acute kidney injury cases, finds pilot

A project set up to identify and provide more pharmacist support to patients with acute kidney injury (AKI) has identified that 74% of patients required pharmacist intervention to cut the risk of medicines-related harm. The pharmacy team at Wrexham Maelor Hospital in North Wales trialled the use of Information Reporting Intelligence System (IRIS) software, which […]

Are the staff in Heddfan Psychiatric Unit, Wrexham Maelor Hospital, are adhering to the personal protective equipment (PPE) guidance as per Public Health Education, England? a QIP

AimsThe aim of this audit is to assess whether healthcare staff are correctly donning and doffing PPE when entering and leaving the wards (changed to donning and doffing PPE when within 2 metres vicinity of a patient).MethodConsultants/ Junior doctors/ Ward managers/ Staff nurses/ student nurses/ Health care support workers/ Occupational therapist/ Psychologists/ Student nurses/ Housekeeping staff, were all included in this Audit. None of the staff was aware of this Audit and this was an entirely random observation. We used a standard proforma in order to audit. Followed by the Audit, we trained the staff in the unit and then re-audited.Result98% of them wore mask whilst in the ward and 94% of them washed their hands after doffing. 36% did not wear them appropriately and about 10-14% did not wear PPE at all. A mere 7 out of 50 alone used hand gel. Overall the donning and doffing of PPE was not being followed and adhered to according to the standards from PHE as per the first Audit. In particular, during donning only 1/3rd of them donned the PPE as per guidance. Likewise, the doffing technique was also poor, with only half of them removing the apron and mask correctly. Unfortunately, only 7 of the 50 people were observed to have used hand gel in between the doffing. This could be potentially increasing the risk of the spread of the coronavirus.We had trained almost 150 staff members in the Heddfan unit with regard to PPE/ donning and doffing.Handwashing prior to donning was achieved by all the staff. All the staff, that is 100 % of them adhered to the donning technique in line with the guidance in comparison to just 64% during the first Audit. Whilst hardly just 1/2 to 2/3rd of the staff followed the doffing technique adequately, the second audit showed that only 2 of the 50 staff did not follow the guidance. A meagre/ handful of them followed the utilisation of hand gel in between the tasks of doffing during the first Audit. Almost 90% of them followed the technique properly during the second Audit. Thus showing that the PPE training was successful.ConclusionFollowing the PPE training that was provided to them there was a good response from the staff and this went on to show how effectively we have managed the prevention/ contamination of virus in our unit.

900 An Audit of Effectiveness of Inhaled Methoxyflurane (Penthrox) Use for Reduction of Shoulder Dislocation

Abstract Introduction Shoulder dislocation is a painful injury best treated by early closed reduction. Patients often require intravenous sedation, with airway monitoring in a safe setting. We implemented methoxyflurane inhalational analgesia (Penthrox) to aid shoulder dislocation reduction without the need for sedation and evaluated the effectiveness and adverse events. Method Patients presenting to the minor injury’s unit at Wrexham Maelor Hospital between 01/04/2020 and 26/05/2020 with only shoulder dislocation were included. Patients had Penthrox and underwent closed reduction. Pre and post reduction shoulder radiographs were reviewed to determine reduction success and time between radiographs was evaluated. Adverse events were recorded. Reduction success and times between radiographs were compared to a consecutive retrospective cohort of patients who underwent closed shoulder dislocation reduction with sedation before implementing Penthrox. Results 22 patients were included. Mean patient age was 44.6 years. Majority were male (72%). Penthrox was used in 11 patients. All patients had their shoulder dislocation reduced successfully. Mean time between reduction radiographs for the Penthrox group was 40.8 min (95%CI 27.4 to 54.3). This was shorter than the intravenous sedation group mean 157.7 minutes (95%CI 92.3 to 223.2, p = 0.0026). No documented adverse events with Penthrox. Conclusions Simple shoulder dislocations can be reduced safely, quickly, and effectively using Penthrox.

Mervyn Theodore Rosenberg

Mervyn Theodore Rosenberg sadly died at the Wrexham Maelor Hospital on 9 May 2020 aged 86. Mervyn was born in Johannesburg, South Africa, and after completing his initial medical training at Witwatersrand University moved to London with his young …

Clinical reflective practice

Clinical reflective practice

Outcomes in the elderly patient following enhanced recovery pathways for elective lower-limb arthroplasty surgery.

Enhanced recovery pathways (ERPs) have been shown to reduce both morbidity and mortality, as well as length of stay, in very elderly patients undergoing joint replacement surgery. However, their impact on patient-reported outcome measures (PROMs) in this vulnerable cohort of patients has not previously been investigated. Oxford Hip and Knee Scores were collected pre- and postoperatively for patients undergoing joint replacement surgery at Wrexham Maelor Hospital, along with data on patient demographics. Of the 646 who had total hip replacements, 32 (4.95%) were aged 85 years or over, and of the 875 who had total knee replacements, 39 (4.46%) were aged 85 years or over. Similarly to younger patients, those over the age of 85 years saw a benefit in the outcome at 6 months and 24months following elective hip and knee arthroplasty on an ERP. This was reflected by a significant increase in the outcome scores at 6 months postoperatively in both age groups undergoing either a total hip replacement or total knee replacement. We found no detrimental effect of ERPs on PROMs data in older patients. In fact, these patients saw a similar benefit in outcome following elective hip and knee arthroplasty as the younger cohort.

Anticipating care needs of patients after discharge from hospital: Frail and elderly patients without physiological abnormality on day of admission are more likely to require social services input

IntroductionAcute admissions to hospital are rising. As a part of a service evaluation we examined pathways of patients following hospital discharge depending on data available on admission to hospital. MethodsWe merged data available on admission to the Wrexham Maelor hospital from an existing data-base in the Acute Medical Unit with follow up data from local social services as part of a data sharing agreement. Patients requiring support by social services post-discharge were matched with patients not requiring social services from the same post-code. ResultsStepwise logistic regression analysis identified candidate variables predicting likely support need. Decision tree analysis identified sub-groups of patients with higher likelihood to require support by social services after discharge from hospital. We found patients with normal physiology on admission as evidenced by a value of zero for the National Early Warning Score who were frail or older than 85years were most likely to require support after discharge. ConclusionsInformation available on admission to hospital might inform long term care needs. Prospective testing is needed. The algorithms are prone to be dependent on availability of local services but our methodology is expected to be transferable to other organizations.

Insulin‐treated diabetes: awareness and adherence to driving recommendations

Sir, We read with interest the recent article by Ken Shaw, entitled ‘Safe driving on insulin: improving implementation using new technology in glucose monitoring?’ (Pract Diabetes 2014;31[9]:361). Hypoglycaemia and hypoglycaemia unawareness are well-recognised and serious complications of insulin therapy. Hypoglycaemia has a significant negative impact on cognitive function, working memory, spatial awareness and emotional well-being.1-4 All of these parameters are essential for a safe driving performance. Studies have demonstrated that insulin-induced hypoglycaemia was associated with poor driving performance.5 At present in the UK, drivers with insulin-treated diabetes are issued with one- to three-year Group 1 licences or one-year Group 2 licences. The Driver and Vehicle Licensing Agency (DVLA) has published guidance on driving regulations and requirements, including recommendations for safe driving precaution measures, and sent it to these drivers at the time of their licences’ application and renewal.6 Nevertheless, previous studies have shown that patients’ awareness and adherence to DVLA's rules and regulations were poor.7, 8 We recently conducted a short survey to assess whether patients are aware of and follow the guidance. An anonymous questionnaire was given to all insulin-treated diabetes patients, over a three-month period. Patients were eligible if they: were >18 years old; had diabetes treated with insulin; held a current UK driving licence and had been driving. Temporary insulin users, e.g. women with gestational diabetes treated with insulin, were excluded. Patients were asked to fill in the questionnaire prior to the consultation with health care professionals in order to avoid recall bias. A total of 75 patients agreed to take part in the survey; however, only 61 patients completed the questionnaire. Over half of drivers in our cohort were aged 51 and above and nearly one-third were over 61 years of age. This age distribution reflects the proportion of elderly drivers in the National Transport Survey.9 The elderly driver group may need particular attention since increasing age is one of the risk factors for severe hypoglycaemia and hypoglycaemia unawareness. Seventy percent of the patients had type 1 diabetes, 25% type 2 diabetes and 5% other type of diabetes. Seventy-nine percent of patients said that driving is an essential part of their daily life or occupation; 93% of patients recognised symptoms of hypoglycaemia most of the time; 13% of patients had experienced a hypo (either mild or severe) while driving in the last 12 months. Just over 70% (43/61) always carry blood glucose testing kits while driving; 87% of patients always carry quick-acting carbohydrates in the car. Just under half of the patients (49%) always check their blood glucose level before driving. Just over half of the patients (52%) always take a break from a long journey to check blood glucose. Eleven percent of patients did not know the safe blood glucose level to drive and 7% said they would drive even when their blood glucose level is below 5mmol/L. Two would continue to drive even if they start to feel symptoms of hypoglycaemia or their blood glucose is less than 4mmol/L. Only 23% would wait the recommended 45 minutes before driving again after an episode of hypoglycaemia. Eighty-four percent of patients stated that they had received advice about driving and diabetes from health care professionals. Just over half of the patients thought that they have received comprehensive advice about driving and diabetes. Only 11% of patients would like to get more detailed information about DVLA rules and recommendations. Nearly 90% of patients thought that they already have enough information and did not want to seek more information. Ten out of 61 patients stated that they did not receive any form of education about driving and diabetes. Worryingly, nine of these patients did not want to get more information relating to driving and diabetes. The results of our study mirrored the findings of previous studies.7, 8, 10 In our sample of patients, most of them recalled that they have received some information about driving and diabetes. However, there is still considerable room for improvement in their knowledge and adherence to safety recommendations. Health care professionals should be more proactive: discussion about driving rules and recommendations should form part of the routine clinic encounter. A patient information leaflet is a good way of reinforcing what has been discussed during consultation. The results of this study raise questions about the knowledge of the health care professionals who complete DVLA fitness to drive forms concerning the recommendations for safe driving for people with insulin-treated diabetes. Further studies in this area are warranted. We thank all of the staff at the diabetes clinic in Wrexham Maelor Hospital for their assistance in distributing and collecting the questionnaire. There are no conflicts of interest declared. References are available at www.practicaldiabetes.com.

G537(P) Prospective re-audit of central line associated bloodstream infections on the neonatal unit following guideline implementation

Context This audit was carried out in Wrexham Maelor Hospital’s (WMH) neonatal unit (NNU) and conducted by the authors (two FY2 doctors and Staff Grade paediatrician). The guideline which has been implemented was approved by both medical and nursing teams. Problem A prospective audit performed in 2010–2011 showed that Wrexham Maelor Hospital’s (WMH) neonatal unit (NNU) had a high rate of central-line associated bloodstream infections (CLABSI) as compared to the rate reported by Centres for Disease Control and Prevention (USA). CLABSI have a high cost in terms of both morbidity and financial expenditure, and are preventable. Assessment of problem and analysis of its causes To quantify the problem the infection rate was expressed as number of central lines days per one CLABSI. CLABSI was defined as growth of the same organism in blood and central line tip cultures (obtained within 48 hrs of each other). The causes of CLABSI were assessed using CDC recommendations (Guideline for the prevention of intravascular catheter-related infections, 2011, CDC, USA). To impose the changes, CDC recommendations were adapted, local guideline developed and medical and nursing staff educated. Intervention A guideline was introduced in January 2013 that recommended use of 0.5% chlorhexidine in 70% alcohol (Hydrex® Pink), “check and do” list for clinicians, purchase of bundled supplies, continuous staff education, and nurse empowerment to stop non-urgent insertions if proper procedures were not followed. Study design This was a prospective re-audit. Strategy for change The “check-and-do” list was approved by the medical and nursing teams. The results of the initial audit were presented to the paediatric team along with the new guideline. It was agreed that the guideline would be followed and completed and list inserted into the notes of every patient who had a central line inserted from June 2013 onwards. The re-audit looked at the rate of CLABSI for all central lines (long lines, umbilical venous catheters [UVCs] and umbilical arterial catheters [UACs]) inserted between June 2013 and May 2014, and was prospective. Measurement of improvement The results of these pre- and post-guideline audits were compared. The CLABSI rate in the pre-guideline audit was 10 in 179 long line days. In the re-audit, the CLABSI rate was 0 in 201 long line days, and 3 in 530 all central line days (long lines, UVCs and UACs; Note the pre-guideline audit only looked at infections associated with long lines). The difference between the distributions of gestational age in the audits was non-significant (Mann-Whitney test). Effects of changes The re-audit data showed that the rate of CLABSI in the NNU have significantly decreased since the implementation of the guideline. CLABSI-associated morbidity and mortality have also decreased, which clearly benefited the patient group. Lessons learnt It is helpful when implementing change and new guidance to work as a multi-disciplinary team. We found that by doing so, the new guidance was well received and adhered to. Message for others We would recommend that all neonatal units establish an ongoing audit of CLABSI, and produce a guideline and check and do list if there is not already one in use. Our experience showed that significant reduction in CLABSI rate can be achieved in a relatively small NNU, over a relatively short time scale with similar effectiveness to that shown in larger NNUs and with close to zero additional costs.

Eras reduces unplanned overnight stay following orthopaedic day case surgery

Eras reduces unplanned overnight stay following orthopaedic day case surgery

Cook resonance metallic ureteric stent: Contemporary clinical series assessing feasibility, safety and efficacy

Cook resonance metallic ureteric stent: Contemporary clinical series assessing feasibility, safety and efficacy

The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients

IntroductionHospital badges have multiple important purposes, but their essential role remains the clear identification of the bearer, including their professional status. The modernisation of medical careers in the National Health...

Group psychotherapies for depression in persons with HIV: A systematic review

Studies investigating effectiveness of group psychotherapy intervention in depression in persons with HIV have showed varying results with differing effect sizes. A systematic review of randomized controlled trials of group psychotherapy in depression in persons with HIV has been conducted to present the best available evidence in relation to its effect on depressive symptomatology. Electronic databases were searched to identify randomized controlled trials. Selected studies were quality assessed and data extracted by two reviewers. If feasible, it was planned to conduct a meta-analysis to obtain a pooled effect size of group psychotherapeutic interventions on depressive symptoms. Odds ratio for drop out from group was calculated. The studies were assessed for their quality using the Quality Rating Scale and other parameters for quality assessment set out by COCHRANE. The quality of reporting of the trials was compared against the Consolidated Standards of Reporting Trials (CONSORT) checklist for non-pharmacological studies (CONSORT-NPT). Four studies met the full inclusion criteria for systematic review. The trials included in the review examined group interventions based on the Cognitive behavioral therapy model against other therapeutic interventions or waiting list controls. In all four studies, group psychotherapy was an effective intervention for reducing depressive symptoms in persons with HIV in comparison to waiting list controls. The reported benefits from the group psychotherapy in comparison to active controls were less impressive. There were no statistically significant differences in drop outs at post treatments across group psychotherapy, wait list control, and other active interventions. The methodological quality of the studies varied. The quality of reporting of the studies was sub-optimal. The results of this systematic review support that group psychological interventions for depression in persons with HIV have a significant effect on depressive symptomatology. This review also indicates that group cognitive behavioral therapies are an acceptable psychological intervention for persons with HIV and comorbid depression.

Vasectomy illustrated

BJU InternationalVolume 109, Issue 7 p. 1116-1127 Vasectomy illustrated Iqbal Shergill, Corresponding Author Iqbal Shergill Department of Urology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, WalesMr Iqbal S Shergill BSc (Hons) MRCS FRCS (Urol), Department of Urology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Croesnewydd Road, Wrexham LL13 7TD, Wales, UK. e-mail: [email protected]Search for more papers by this authorManit Arya, Manit Arya University College Hospital, London Barts Cancer Institute, London, UKSearch for more papers by this authorAsif Muneer, Asif Muneer University College Hospital, LondonSearch for more papers by this author Iqbal Shergill, Corresponding Author Iqbal Shergill Department of Urology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, WalesMr Iqbal S Shergill BSc (Hons) MRCS FRCS (Urol), Department of Urology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Croesnewydd Road, Wrexham LL13 7TD, Wales, UK. e-mail: [email protected]Search for more papers by this authorManit Arya, Manit Arya University College Hospital, London Barts Cancer Institute, London, UKSearch for more papers by this authorAsif Muneer, Asif Muneer University College Hospital, LondonSearch for more papers by this author First published: 13 March 2012 https://doi.org/10.1111/j.1464-410X.2012.11007.xCitations: 1 ILLUSTRATIONS by STEPHAN SPITZER, http://www.spitzer-illustration.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume109, Issue7April 2012Pages 1116-1127 RelatedInformation

Components separation with onlay mesh: A safe and effective repair for complex abdominal wall hernias. experience with 50 cases and the development of a triple mesh technique

s / International Journal of Surgery 10 (2012) S1–S52 S46 ABSTRACTS 0354: COMPONENTS SEPARATION WITH ONLAY MESH: A SAFE AND EFFECTIVE REPAIR FOR COMPLEX ABDOMINAL WALL HERNIAS. EXPERIENCE WITH 50 CASES AND THE DEVELOPMENT OF A TRIPLE MESH TECHNIQUE Steve Hornby, James Boorer, Neil Patel, Andrew Kingsnorth. Derriford Hospital, Plymout, UK Introduction: Closuring complex major abdominal hernias risks abdominal compartment syndrome. Components separation (CS) allows midline closure in most cases. This poster outlines our experience including postoperative quality of life (QoL) and the evolution of a triple mesh technique. Method: Retrospective case notes review and structured telephone interview of patients undergoing CS between October 2005 and May 2010 at Derriford Hospital. Results: 50 patients underwent CS; 41 underwent telephone follow-up (82%). Median follow-up was 29 months (range 3.2 57.6). 29 Patients were men;medianagewas60andBMI33.8 (range20-48.1).Woundcomplications affected16(38%); themajority settlingwithconservativemanagement. There was 1 recurrence of original hernia and 2 subsequent parastomal hernias. One patient developed a hernia related to the lateral release. Since developing the triple onlay technique there have been no recurrences. The series has one death related to small bowel ischaemia. 36(88%) of patients reported improved QoL; (95%) were happy to recommend the procedure to a friend. Conclusion: CS is associated with low mortality (2%); minimal long term morbidity and improved QoL. Triple mesh technique results in a low recurrence rate. We recommend CS with a triple onlay mesh for repairing complex major abdominal wall defects. 0357: THE ROLE OF PLAIN ABDOMINAL X-RAY IN ACUTE SURGICAL SETTING: A RETROSPECTIVE ANALYSIS Luke Stroman, Mohamed Ismat Abdulmajed, Cassandra McDonald, Palanichamy Chandran. Wrexham Maelor Hospital, Wrexham,

Impact of urgent suspected cancer (USC) versus non-USC referral pathways on survival of upper GI cancers

Introduction Department of Health published guidance on ‘Improving Outcomes in Upper Gastro-intestinal cancer’ in January 2001.1 One of the important recommendations was ‘Fast Track Endoscopy’ service within 2 weeks for patients with suspicion of cancer (‘the 2 weeks rule’). Our aim was to compare the detection of curative Upper GI cancers (Oesophagus and stomach) and survival in patients referred for Oesophago gastro duodenoscopy (OGD) via USC versus non-USC (routine) route in a District general hospital. Methods We performed a retrospective audit on all patients referred for OGD between October 2006 and April 2007 in Wrexham maelor hospital (Cross-border Upper GI Cancer center for North Wales and West Cheshire). Data on mode of referral (USC or non-USC), endoscopic and histological diagnosis, curative or palliative intervention (if cancer detected) was collected. Patients with upper GI cancers were followed to check for survival at 18 and 36 months. Results 404 patients had OGD in USC while 1538 patients via non-USC pathway. 25 Upper GI cancers were detected in USC and 18 in non-USC, out of which 28% (7) in USC and 27.7% (5) in non-USC cancers had curative intervention. Though USC pathway detected more cancers (6.2% of all OGDs performed) than non-USC (1.2%), there was no statistical significance in the detection of curative malignancies. At 18 months, 5 out of 7 patients who had curative treatment and 4 out of 18 with palliative approach survived in the USC group, while all 5 cured patients and 4 out of 13 palliated patients survived in the non-USC. At 3 years, five patients in the USC who had curative treatment (and survived at 18 months) along with two of the palliated patients were alive, while in the non-USC, four cured patients survived but all palliated patients died. Cox regression analysis did not find any statistically significant survival benefit between the two groups at 18- or 36-month follow-up (Kaplan-Meier survival curve attached). Conclusion ‘2-week rule’ for OGD in USC patients has no statistical advantage in detection of curative upper GI malignancies nor has survival benefit when compared with the non-USC referrals. Clarifying guidelines that would help detect ‘early’ cancers and resource diversion towards OGD surveillance in high-risk patients and creating public awareness are increasingly discussed as the only measures to improve survival in upper GI cancers.

The appropriate use of amiodarone

Cardiologists at Wrexham Maelor Hospital drew to our attention the fact that amiodarone may not be used appropriately in the treatment of atrial fibrillation (AF). Though the All Wales Medicine Strategy Group had developed shared care guidelines in 2007, there was anecdotal evidence that these were not well known, and that patients and their carers were ill informed about the need for monitoring for adverse effects. All 251 patients were reviewed by Wrexham primary care practices, with the assistance of the prescribing support team and in partnership with the consultants. The review of amiodarone prescribing revealed that the drug was no longer indicated in 50 % of patients who were taking it and a subsequent audit of 50 % of patients in primary care practices revealed that monitoring guidelines were not being followed. Consequently, working in partnership with secondary care services, we devised a template for good practice that included a patient information leaflet, a virtual clinic, educational talks and an educational campaign to raise awareness of the existence and content of the shared care guidelines.

How to use C reactive protein: postscript

We were grateful to a number of people who contacted us about our article on how to use C reactive protein (CRP).1 Abelian from Wrexham Maelor Hospital drew our attention...