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

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.

Outcomes of day case shoulder replacement surgery in a stand-alone day care unit in the United Kingdom

Background: This review aims to compare the outcomes for day case shoulder replacement with in-patient shoulder replacement surgery in a district general hospital. Methods: Seventy-three patients had 82 shoulder arthroplasty procedures. Forty-six procedures were undertaken in a dedicated stand-alone day-case unit and 36 were undertaken as in-patient cases. Patient were followed up at 6 weeks, 6 months and annually. Results: There was no significant difference between the outcomes of shoulder arthroplasty procedures performed in the day case or in-patient settings making this a safe option for surgical care in a unit with an appropriate care pathway. Six complications in total were observed, three in each group. Operation time was statistically shorter for day cases by 25.1 min (95% CI - 36.5 to −13.7; d = −0.95, 95% CI −1.42 to 0.48). Estimated marginal means (EMM) revealed lower post-surgery oxford pain scores in day cases (EMM = 3.25, 95% CI 2.35, 4.16) compared with inpatients (EMM = 4.65, 95% CI 3.64 to 5.67). Constant shoulder scores were higher in day cases versus inpatients. Conclusion: Day case shoulder replacement is safe with comparable outcomes to routine inpatient care for patients up to ASA 3 classification with high satisfaction and excellent functional outcomes.

A Covid -19 Virtual Ward Model: A Preliminary Retrospective Clinical Evaluation From a UK District General Hospital

Objective: This study aims to evaluate the safety, utilization, ability to reduce length of hospitalization and overall outcomes of a COVID-19 virtual ward providing ongoing treatment at home. Method: A retrospective single-center study of patients discharged to the COVID-19 virtual “step down” ward between January 27th 2021 and March 2nd 2021. The referral process, length of hospitalization, length of stay on the virtual ward, readmissions, and ongoing treatment requirements including supplemental oxygen, antibiotics, and/or steroids were all noted. Results: A total of 50 patients were referred to the virtual ward. 43 referrals were accepted, 39 of which were from the respiratory ward. Four patients were readmitted, all due to hypoxia. All readmissions occurred within 5 days of discharge. 72% (n = 31) were discharged home with an ongoing oxygen requirement. 14.3% of patients were discharged with antibiotics only, 9.5% with steroids only and 23.8% with both antibiotics and steroids. The mean length of hospital stay for patients discharged to the virtual ward was 10.3 ± 9.7 days and 11.9 ± 11.6 days for all covid positive patients during this time. On average, patients spent 13.7 ± 7.3 days on the virtual ward. The average number of days spent on oxygen on the virtual ward was 11.6 ± 6.0 days. Conclusion: The virtual ward model exemplifies the potential benefits of collaborative working between primary and secondary care services, relieving pressure on hospitals whilst providing ongoing treatments at home such as supplemental oxygen. It also facilitates an early supported discharge of clinically stable patients with an improving clinical trajectory by managing them in the community.

Video-consultation in the Emergency Department: An Assessment of the Potential Benefit for a UK District General Hospital (Preprint)

BACKGROUND DGH Emergency department referrals to a tertiary centre depend on information available from a ‘generalist’ clinician in discussion with a specialist team. If there is uncertainty, the lowest risk strategy is often to transfer the patient. Video consultation allowing the specialist team to see and talk to the patient whilst still in the Emergency department could improve decision making about patient transfer. OBJECTIVE This study assessed the potential benefit of real time video consultation between remote specialist and Emergency department patient across all specialities. METHODS Detailed patient data was collected prospectively for 6 months on all patients presenting to a DGH Emergency department who required input from a specialist team in the nearest tertiary centre. These patients were discussed retrospectively with the specialist teams to determine whether video conferencing could have benefited the patient’s management. The logistics for use of videoconferencing were explored. RESULTS 18,799 patients were seen in the Emergency department during the study period. 413 referrals were made to the tertiary centre specialist teams. Review of patients transferred indicated 193 might have benefited from video consultation. If the specialist team could be accessed via video conferencing only whilst a senior member was available in hospital (0800-2200hr) then a maximum of only 5 patients per week across all specialities would use the equipment. If 24hr specialist access was available this would increase to 7 patients per week. CONCLUSIONS Video consultation between emergency department patient and specialist has limited potential to improve patient management.

TROPONIN IS INDEPENDENTLY ASSOCIATED WITH DEATH IN PATIENTS WITH COVID: A RETROSPECTIVE STUDY

Objective: We performed a single-centre retrospective observational study investigating the association between troponin positivity in patients hospitalised with COVID-19 and increased mortality in the short term. Methods: All adults admitted with swab-proven RT-PCR COVID-19 to Homerton University Hospital (HUH) from 04.02.20 to 30.04.20 were eligible for inclusion. We retrospectively analysed demographic and biochemical data collected from the physical and electronic patient records according to the primary outcome of death at 28 days during hospital admission. Troponin positivity was defined above the upper limit of normal according to our local laboratory assay (>15.5ng/l for females, >34 ng/l for males). Univariate and multivariate logistical regression analyses were performed to evaluate the link between troponin positivity and death. Results: Mean length of stay for all 402 hospitalised COVID-19 patients at HUH was 9.1 days (SD 12.0). Mean age was 65.3 years for men compared to 63.8 years for women. A chi-squared test showed that survival of COVID-19 patients was significantly higher in those with a negative troponin (p = 3.23 x10-10) compared to those with a positive troponin. In the multivariate logistical regression, lung disease, age, troponin positivity and CPAP were all significantly associated with death, with an AUC of 0.8872, sensitivity of 0.9004 and specificity of 0.6292 for the model. Within this model, troponin positivity was independently associated with short term mortality (OR 3.23, 95% CI 1.53-7.16, p=0.00278). Conclusions: We demonstrated an independent association between troponin positivity and increased short-term mortality in COVID-19 in a London district general hospital.

PREVALENCE OF FAT-SOLUBLE VITAMIN DEFICIENCIES ASSOCIATED WITH SEVERE ACUTE MALNUTRITION: A PROSPECTIVE OBSERVATIONAL STUDY

Background: Severe acute malnutrition (SAM), among children below five years of age is global health problem contributing to childhood morbidity, mortality and remains a major embarrassment to optimal human capital development in India. Objectives: Study aim was to accesses fat soluble vitamins deficiencies among children with SAM and outcomes after treatments with F-75/F-100 plus vitamins mix. Methods: The study was prospective observational conducted in the nutritional rehabilitation center (NRC) at district general hospital for 6 months. Anthropometric measurements were taken to determine their nutritional status. Results: 100 patients of NRC were enrolled in the study. Sixty nine percent (69) patients had weight/height (WT/HT) Z score<−3 standard deviation (3 SD), 16 % with Z score<−2 and 15% of them had Z score<−4 malnutrition. Out of 100 children, 46% children were males, and 56% children were females. Vitamin E deficiencies (54%) were highly prevalent in hospitalized SAM groups, followed by 28% vitamin D and 18% were vitamin A deficient. Conclusion: Micronutrient deficiencies were highly prevalent with fat soluble vitamins and recovered on application of WHO protocols during hospitalization induced satisfactory fat-soluble vitamin status recovery significant (p<0.05).