IMPACT OF A CLINICAL PATHWAY ON THE MANAGEMENT OF FIRST SEIZURES AT A DISTRICT GENERAL HOSPITAL

2015 ◽  
Vol 86 (11) ◽  
pp. e4.149-e4
Author(s):  
Zoya Georgieva ◽  
Harith Altemimi
Keyword(s):  
Cultural Change ◽  
Clinical Pathway ◽  
District General Hospital ◽  
Blood Glucose Measurement ◽  
Glucose Measurement ◽  
Junior Doctors ◽  
Neurology Clinic ◽  
Drug History ◽  
The Impact

Diagnostic confidence and management of first seizures can be challenging, particularly for junior doctors. This audit evaluates the impact of a clinical pathway based on recommendations by the College of Emergency Medicine, which intended to improve the management of such patients at a UK DGH.A systematic search identified cases spanning 3 months either side of the date of introduction of the pathway. 23 pre- and 25 post-pathway cases presenting to A&E or as inpatients were randomly selected, excluding cases with a known seizure-related diagnosis.The pathway was only utilised in 16% of cases. Referral to neurology clinic increased from 30% to 52%, but attending within the recommended 2 weeks of ictus remained infrequent (8%). Clinical assessment worsened in several categories, including documenting a drug history, obtaining an ECG, and blood glucose measurement. Documenting discussions about driving decreased from 43% to 36%.Findings confirm suboptimal investigation and follow-up of first seizures, with a surprising deterioration after introduction of a local clinical guideline. This audit demonstrates the importance of cultural change in addition to the availability of a structured guideline. We propose this can be achieved by dedicated junior doctor training sessions and development of a patient information leaflet.

The Introduction of An Intravenous Fluid Bundle to Improve the Prescribing of Intravenous Fluids Within a District General Hospital (Preprint)

2022 ◽  
Author(s):  
Abdul-Rahman Gomaa ◽  
Sharan Sambhwani ◽  
Jonathan Wilkinson
Keyword(s):  
Point Of Care ◽  
Kidney Injury ◽  
District General Hospital ◽  
Good Clinical Practice ◽  
Point Prevalence ◽  
Grand Round ◽  
Junior Doctors ◽  
Improvement Project ◽  
Increased Risk ◽  
The Impact

BACKGROUND Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines (NICE CG174). This is believed to be due to lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It also incurs avoidable costs to hospitals. OBJECTIVE This quality improvement project (QIP) aims to ensure that IV fluid prescriptions are: safe, appropriate and adhere to evidence-based NICE guidance. The project’s aims will be achieved through implementing multiple interventions that are categorised under: educational, changing prescribing habits and raising awareness. METHODS Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches.  Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription. RESULTS These interventions were assessed on trial wards via a weekly point prevalence audit of the new IV fluid prescription chart (bundle; IFB) for the duration of the trial. Parameters monitored were: incidence of deranged U&E’s, incidence of acute kidney injury (AKI) and the number of days between the latest U&E’s and the patient’s IV fluid prescription. Of all of the patients on the IV fluid bundle, 100% had a documented weight, review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased from 24% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 0.6 day. CONCLUSIONS Prescribing IV fluids is a complex task that requires significant improvement both locally and nationally. With 85% uptake of the IFB, we were able to significantly improve all measured outcomes. Through carefully structured interventions geared towards tackling the confounding issues identified from previous audits and process mapping we have shown that prescribing IV fluids can be made safer.

scholarly journals Discrepancies Between Blood Glucose and Interstitial Glucose—Technological Artifacts or Physiology: Implications for Selection of the Appropriate Therapeutic Target

2017 ◽  
Vol 11 (4) ◽  
pp. 766-772 ◽  
Author(s):  
Thorsten Siegmund ◽  
Lutz Heinemann ◽  
Ralf Kolassa ◽  
Andreas Thomas
Keyword(s):  
Blood Glucose ◽  
Therapeutic Target ◽  
Diabetes Management ◽  
Glucose Monitoring ◽  
Blood Glucose Measurement ◽  
Glucose Measurement ◽  
Glucose Levels ◽  
Therapeutic Decisions ◽  
The Impact ◽  
Selection Of

Background: For decades, the major source of information used to make therapeutic decisions by patients with diabetes has been glucose measurements using capillary blood samples. Knowledge gained from clinical studies, for example, on the impact of metabolic control on diabetes-related complications, is based on such measurements. Different to traditional blood glucose measurement systems, systems for continuous glucose monitoring (CGM) measure glucose in interstitial fluid (ISF). The assumption is that glucose levels in blood and ISF are practically the same and that the information provided can be used interchangeably. Thus, therapeutic decisions, that is, the selection of insulin doses, are based on CGM system results interpreted as though they were blood glucose values. Methods: We performed a more detailed analysis and interpretation of glucose profiles obtained with CGM in situations with high glucose dynamics to evaluate this potentially misleading assumption. Results: Considering physical activity, hypoglycemic episodes, and meal-related differences between glucose levels in blood and ISF uncover clinically relevant differences that can make it risky from a therapeutic point of view to use blood glucose for therapeutic decisions. Conclusions: Further systematic and structured evaluation as to whether the use of ISF glucose is more safe and efficient when it comes to acute therapeutic decisions is necessary. These data might also have a higher prognostic relevance when it comes to long-term metabolic consequences of diabetes. In the long run, it may be reasonable to abandon blood glucose measurements as the basis for diabetes management and switch to using ISF glucose as the appropriate therapeutic target.

THE IMPACT OF AN EPILEPSY-CARE BUNDLE ON THE MANAGEMENT OF ACUTE SEIZURES IN A LARGE LONDON-BASED DISTRICT GENERAL HOSPITAL

2015 ◽  
Vol 86 (11) ◽  
pp. e4.107-e4
Author(s):  
Aravindhan Baheerathan ◽  
Kohilan Gananandan ◽  
Orlando Swayne
Keyword(s):  
District General Hospital ◽  
Business Case ◽  
Medical Emergency ◽  
Initial Assessment ◽  
Care Bundle ◽  
Staff Turnover ◽  
Acute Seizures ◽  
Neuro Imaging ◽  
The Impact

IntroductionSeizures account for 2–3% of presentations to the Accident & Emergency department. The National Audit of Seizure management in Hospitals (NASH) has demonstrated significant variances with regards to initial assessment and subsequent management. Standardised management protocols are crucial in optimising the care of this commonly encountered medical emergency.MethodsThe care of 30 patients admitted with seizures over a 1–month period was retrospectively reviewed. Following this a trust-wide seizure bundle was implemented and another 30 patients were reviewed. Data collection specifically assessed: ▸ Demographics of patients admitted, ▸ Immediate assessment & initial investigations, ▸ Consequent neuro-imaging & specialist investigations, ▸ Referral pathway.ResultsThe results showed poor uptake of the bundle and consequently management was broadly unchanged. The most significant results were:▸ 24% of cases did not have a senior review▸ 70% of cases were not discussed with neurology▸ 36% of cases did not have any follow up arrangedConclusionThe implementation of a seizure bundle can be challenging in the context of a unit that has a rapid staff turnover and is heavily staffed by locum physicians. Repeated staff education is required. This evidence is being used in a business case to employ an epilepsy nurse at Northwick Park. (Aravindhan Baheerathan and Kohilan Gananandan will both be presenting authors and contributed equally to this abstract).

KNOWLEDGE OF PRESCRIBING IN PARKINSONISM AMONG JUNIOR DOCTORS

2015 ◽  
Vol 86 (11) ◽  
pp. e4.97-e4
Author(s):  
Jonathan Bedford ◽  
David Whiteside ◽  
Pooja Dassan
Keyword(s):  
General Hospital ◽  
Annual Meeting ◽  
District General Hospital ◽  
Junior Doctors ◽  
Appropriate Prescribing ◽  
The Impact ◽  
Assessment Questions

Junior doctors are primarily responsible for prescribing medications for patients with parkinsonism attending a district general hospital. We assessed levels of confidence and knowledge of appropriate prescribing in a variety of circumstances among 30 junior doctors at Ealing Hospital, using a 5 part questionnaire. Only 10% felt confident in prescribing a regimen for patients with parkinsonism who are unable to take their usual medications orally. 60% could not select a suitable anti-emetic, and just 2 respondents answered all assessment questions correctly. Confidence in prescribing improved with seniority but overall scores in the assessment section did not.We have designed a protocol to assist doctors when managing patients with parkinsonism on the ward, and are conducting teaching sessions to improve understanding. The impact of these interventions will be assessed and presented at the Annual Meeting.

A Psychiatric Consultation/Liaison Clinic: Follow-up of Fifty-Four Patients Referred from Neurology

1988 ◽  
Vol 17 (3) ◽  
pp. 213-221 ◽  
Author(s):  
Joseph Schwartz ◽  
Nancy Speed ◽  
Michael Kuskowski
Keyword(s):  
Psychiatric Disorders ◽  
Psychiatric Consultation ◽  
Liaison Psychiatry ◽  
Psychiatry Clinic ◽  
Outpatient Consultation ◽  
Neurology Clinic ◽  
Consultation Liaison Psychiatry ◽  
The Impact

To assess the impact of psychiatric consultation, the authors reviewed the charts of patients referred from a neurology clinic to an outpatient consultation/liaison psychiatry clinic. The patients were found to have both significant neurologic and psychiatric disorders. Only 46 percent returned to see their neurologists within six months of the referral. This finding highlights a major problem in outpatient consultation.

scholarly journals EP.FRI.271 The impact of Surgical Assessment Unit on emergency and ambulatory surgical care in a district general hospital

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Aloka Suwanna Danwaththa Liyanage ◽  
Philip Apter ◽  
Gemma Causer ◽  
Krishnan Gokul ◽  
Paul Ainsworth
Keyword(s):  
Care Delivery ◽  
Surgical Care ◽  
District General Hospital ◽  
Direct Access ◽  
Post Discharge ◽  
Similar Time ◽  
Assessment Unit ◽  
Audit Period ◽  
The Impact

Abstract Aims There has been a paradigm shift in the delivery of emergency and ambulatory surgical care necessitated by paucity of beds, improved expedited diagnostics and delayed transit in Emergency departments. The objective of a surgical assessment unit (SAU) is to reduce the number of semi-urgent admissions, provide direct access to urgent surgical admissions bypassing the ED, expeditious assessment by senior clinicians and to reduce the number of OPD follow up. In our setting, the SAU came into existence on all 5 working days at 12-hour daily schedule and its impact was evaluated retrospectively.  Methods Prospectively maintained data base over a 2-month period was examined. Pre and post SAU figures were compared to judge any quantitative improvement in surgical services.  Results During the audit period of 2 months there were 156 emergency patients and 190 ward attenders for follow up care. Majority of these patients were assessed within 4 hours and discharged or ambulated. Numbers being admitted overnight purely to facilitate investigations showed a decrease of 44.6% post SAU establishment. There was a reduction in post discharge outpatients appointments when compared to a similar time period pre SAU (14% difference).   Conclusion The SAU, although initially conceived and designed purely to cope with increased admissions and to minimise breaching of emergency department targets, has shown quantitative and qualitative improvement in emergency and ambulatory surgical care delivery. 

scholarly journals Seizure Impact on the School Attendance in Children with Epilepsy: Prospective Study in the Pediatrics Neurology Clinic at Tikur Anbessa Specialized Hospital,Addis Ababa, Ethiopia

2019 ◽  
Author(s):  
Oumer Hassen ◽  
Ayalew moges Beyene
Keyword(s):  
Prospective Study ◽  
Children And Adolescents ◽  
Behavioral Problems ◽  
School Attendance ◽  
Addis Ababa ◽  
School Absenteeism ◽  
School Aged Children ◽  
Neurology Clinic ◽  
The Impact

Abstract Abstract Background: Epilepsy is the most common chronic neurological disease seen in Pediatrics Neurology Units in developing countries and like other chronic disorders it has been found to negatively affect school attendance and academic performance influencing school life of children. An educational underachievement can also be due to comorbid learning and behavioral problems in these children. The impact of epilepsy on school attendance may also contribute to the academic difficulties of children with epilepsy. The purpose of this study is to assess school absenteeism and determine which factors influence school absenteeism in school aged children and adolescents with epilepsy. Methods: A hospital based prospective study was conducted among school aged children and adolescents with epilepsy between the ages of 7-18 years attending at the Paediatric Neurology Clinic and their primary caretakers. A sample of 183 children and adolescents were included in the study. The participants (children and their parents/caregivers) gave information concerning the socio-demographic data, primary caregiver’s information like educational status, information concerning child’s seizure and epilepsy status disclosures to teachers and peer. And medical cards were thoroughly reviewed. Descriptive statistics and bi-variate logistic regression analysis was done to assess determinants of school absenteeism. Results: The prevalence of school absenteeism among children aged 7-18years at PNC follow up was 69.4%.Among other factors female sex with AOR 2.19(95% CI 1.03-4.84), having symptomatic seizure AOR 2.51(95% CI 1.09-5.86), having seizure at school and having longer duration of seizure were statistically significant association with school absenteeism. Conclusion: This study demonstrated the school absenteeism is very common among children aged 7-18 years at PNC follow up (69.4%) and that seizure has a significant impact on children’s school attendance. Keywords: Epilepsy; School; Childhood; Absenteeism; Ethiopia Trial registration: N/A

scholarly journals Junior doctor-led quality improvement project to improve safety and visibility of an interspecialty referral system

2021 ◽  
Vol 10 (3) ◽  
pp. e001323
Author(s):  
Dowan Kwon ◽  
Won Young Moon ◽  
Michelle Akhunbay-Fudge ◽  
Brandon Pieters ◽  
Jeni Pillai ◽  
...  
Keyword(s):  
Cultural Change ◽  
District General Hospital ◽  
Electronic Record ◽  
Referral System ◽  
Junior Doctors ◽  
Electronic Patient Records ◽  
Improvement Project ◽  
Team Members ◽  
Stakeholder Satisfaction ◽  
Qualitative Feedback

Interspecialty referrals for increasingly complex hospital inpatients are common and miscommunication often leads to delays in patient care. In a district general hospital, a web-based system generated an email referral, which lacked visibility and tracking/audit of the process, with no record generated automatically in paper inpatient notes or electronic patient records (EPR). We aimed to improve the visibility and safety of the interspecialty referral system.We canvassed stakeholders, informally and via an online satisfaction survey, collecting qualitative and quantitative data about attitudes to the existing system, generating ideas for change. We process mapped the system, identifying points of weakness. We adapted our EPR system, using a work-around solution, to develop a form that could be emailed from the EPR. This generated a permanent record within the EPR and an electronic record of the referral having been sent. We measured the visibility of referrals and responses within the EPR. We generated an online training ‘how-to’ video and reaudited stakeholder satisfaction.There was a significant increase in the proportion of junior doctors satisfied or very satisfied with the interspecialty referral system (27/31 postintervention; 87.1% vs 26/55 preintervention; 47%; p<0.0001) and more believed that the visibility was adequate or very adequate (24/31 postintervention; 77.4% vs 9/55 preintervention; 16.4%; p<0.0001). Visibility of referrals by project team members on the EPR increased from a baseline of 3.5% to 83.6% and the visibility of responses to these referrals on the EPR increased from 4.6% to 40.7%. Qualitative feedback was excellent, hospital executive approval was gained and our work-around system spread to non-team members.We developed a more visible and reliable interspecialty referral system, adapting existing EPR capabilities, which was popular with users and led to cultural change in interspecialty referral responders. A formal EPR redesign, informed by our project, is in development.

scholarly journals 51 Working Collaboratively: Geriatrician Input in Older Patients Undergoing Emergency Laparotomy Reduces Overall Length of Stay - A Complete Audit Loop

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i14-i17
Author(s):  
K A Khan ◽  
M Richters ◽  
A Mubarak ◽  
C Thorn ◽  
S Chalstrey ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Elderly Patients ◽  
Postgraduate Medical Education ◽  
District General Hospital ◽  
Emergency Laparotomy ◽  
Junior Doctors ◽  
Allied Health Professionals ◽  
Catchment Population ◽  
Surgical Ward ◽  
The Impact

Abstract Background Great Western Hospital is a busy district general hospital with a catchment population of 340,000. Target population of this study was elderly patients aged &gt;70 undergoing Emergency Laparotomy (EL). Introduction Approximately 8% of the population is aged over 75 years and operations in this patient group account for 23% of all surgical procedures. The 2010 National Confidential Enquiry into Patient Outcome and Death report “An Age Old Problem”, suggested routine daily input from Geriatrics should be available to elderly patients undergoing surgery. This study focuses at the impact of Geriatrician input for EL patients with primary outcome of reduction in Length of Stay (LoS). Methods The service was designed with allocation of 4 hours per week of Consultant Geriatrician and 2.5 days per week of a Clinical Innovation Fellow (CIF) time. The existing team of surgical junior doctors, nursing and allied health professionals carried out plans suggested by the geriatrician. Retrospective data (Prior to service initiation) for the emergency laparotomy patients &gt;70 years, was collected from December 2015-May 2016. Prospective data collected from February 2018 – July 2018 for EL patients aged &gt; 70, patients with inpatient stay &gt; 7 days, patients with delirium/ inpatient falls. Length of stay and Inpatient mortality were compared between the two cohorts. Intervention Prior to the establishment of this service the medical support was provided on ad-hoc basis. Funding was obtained from local postgraduate medical education for CIF and twice weekly consultant led ward rounds were carried out. Patients were recruited from hospital database and from a referrals book kept at surgical ward. Results 45 patients were included in prospective study and Mean LoS was 17.8 days, which was reduced from 22.5 days prior to Geriatrician involvement (N=56). Average 4.7 days per patient were saved. IP mortality was 8.8% (2/4 deaths were palliative resections) after geriatrician input compared to 8.9% previously. 6.6% of patients had a new medical diagnosis, 24.4% patients were followed up in prospective cohort. Conclusions This study suggests the regular geriatrician input reduces the inpatient LoS. A day stay at surgical ward costs roughly £250, for 45 patients in last six months it saved approximately £52,875.

scholarly journals Integrating Motivational Interviewing into Clinical Care to Increase Physical Activity Levels in Women with Gestational Diabetes

2020 ◽  
Author(s):  
Ralph Smith ◽  
Ashley Ridout ◽  
Angus Livingstone ◽  
N. Wango ◽  
Yvonne Kenworthy ◽  
...  
Keyword(s):  
Physical Activity ◽  
Glycaemic Control ◽  
Gestational Diabetes ◽  
Motivational Interviewing ◽  
Clinical Pathway ◽  
Moderate Intensity ◽  
Activity Levels ◽  
Physical Activity Levels ◽  
The Impact

Abstract Background: Regular physical activity (PA) improves glycaemic control in women diagnosed with Gestational Diabetes (GDM). However, PA advice competes with other components of care, with many women forgoing the benefits of regular PA. Motivational interviewing (MI) is an effective technique for increasing individual PA levels. A clinical pathway was developed integrating MI on PA into the routine care. This report evaluates the impact of MIs on self-reported PA levels.Methods: Women attending a single centre NHS GDM clinic were invited to engage in an individual PA-focused MI session, delivered by a trained midwife. This included goal setting and activity planning. All women had a confirmed diagnosis of GDM based on a 75g oral glucose tolerance test using the International association of diabetes and pregnancy study group diagnostic thresholds. A modified version of the exercise vital sign was used to evaluate self-reported aerobic PA levels at baseline and two-week telephone follow-up. PA levels were coded into three categories: i) red (<30mins moderate intensity PA (MIPA)/week), ii) amber (30-150mins MIPA/week) and iii) green (150mins MIPA/week). Women with contraindications to PA were excluded. The main outcome was the difference PA levels from baseline to two weeks. The Pearson’s Chi-squared test was used to evaluate statistical difference in self-reported PA levels from baseline to follow-up.Results: Complete follow-up data was obtained from 62 women. Mean gestation was 27+5/40 weeks (9-36+4/40), mean age 31.7y (21-43y) and mean BMI 29.9kg/m2 (18.3-48.2 kg/m2). At baseline, 19 (30.6%) were coded red (<30mins MIPA/week); 26 (41.9%) amber (30-150mins MIPA/week); and 17 (27.4%) green (150mins MIPA/week). Self-reported physical activity levels of these women at two-week follow-up revealed only 3 (4.8%) women coded red, 24 (38.7%) amber and 35 (56.5%) green. This demonstrates a significant association for increased PA levels after MI at two-week follow-up (p=0.0001).Conclusion: This new clinical pathway provides encouraging results, showing that self-reported PA increased significantly at two-week follow-up. Further work is now required to examine the impact on glycaemic control, maternal and fetal outcomes, and maintenance of PA levels. This model of care should be integrated into other high-risk patient groups.

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