Do not attempt cardiopulmonary resuscitation (DNACPR) decisions for older medical inpatients: a cohort study

ObjectivesA decision not to attempt cardiopulmonary resuscitation in the event of cardiorespiratory arrest requires a discussion between the doctor and the patient and/or their relatives. We aimed to determine how many older patients admitted to acute medical wards had a pre-existing 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision, how many had one recorded on the ward and how many of those who died had a DNACPR decision in place.MethodsA prospective cohort study, using data from medical records, of 481 consecutive patients aged ≥65 years admitted to the six acute medical wards of the John Radcliffe Hospital, Oxford.Results105/481 (22%) had a DNACPR decision at ward admission, 30 of which had been made in the emergency unit. A further 45 decisions were recorded on the ward, mostly after discussion with relatives. Of the 37 patients who died, 36 had a DNACPR decision. For the 20 deceased patients whose DNACPR decision was recorded during their admission, the median time from documentation to death was 4 days with 7/20 (35%) recorded the day before death.ConclusionsOlder patients with multimorbidity need the opportunity to discuss the role of CPR earlier in their care and preferably before acute hospital admission.

Clinical signs, interventions, and treatment course of three different treatment protocols in patients with Crouzon syndrome with acanthosis nigricans

OBJECTIVE Crouzon syndrome with acanthosis nigricans (CAN) is a rare and clinically complex subtype of Crouzon syndrome. At three craniofacial centers, this multicenter study was undertaken to assess clinical signs in relation to the required interventions and treatment course in patients with CAN. METHODS A retrospective cohort study of CAN was performed to obtain information about the clinical treatment course of these patients. Three centers participated: Erasmus Medical Centre, Rotterdam, the Netherlands; John Radcliffe Hospital, Oxford, United Kingdom; and Hôpital Necker-Enfants Malades, Paris, France. RESULTS Nineteen patients (5 males, 14 females) were included in the study. All children were operated on, with a mean of 2.2 surgeries per patient (range 1–6). Overall, the following procedures were performed: 23 vault expansions, 10 monobloc corrections, 6 midface surgeries, 11 foramen magnum decompressions, 29 CSF-diverting surgeries, 23 shunt-related interventions, and 6 endoscopic third ventriculostomies, 3 of which subsequently required a shunt. CONCLUSIONS This study demonstrates that patients with the mutation c.1172C>A (p.Ala391Glu) in the FGFR3 gene have a severe disease trajectory, requiring multiple surgical procedures. The timing and order of interventions have changed among patients and centers. It was not possible to differentiate the effect of a more severe clinical presentation from the effect of treatment order on outcome.

Pre-existing asthma as a comorbidity does not modify cytokine responses and severity of COVID-19

Background A significant portion of COVID-19 sufferers have asthma. The impacts of asthma on COVID-19 progression are still unclear but a modifying effect is plausible as respiratory viruses are acknowledged to be an important trigger for asthma exacerbations and a different, potentially type-2 biased, immune response might occur. In this study, we compared the blood circulating cytokine response to COVID-19 infection in patients with and without asthma. Methods Plasma samples and clinical information were collected from 80 patients with mild (25), severe (36) or critical (19) COVID-19 and 29 healthy subjects at the John Radcliffe Hospital, Oxford, UK. The concentrations of 51 circulating proteins in the plasma samples were measured with Luminex and compared between groups. Results Total 16 pre-existing asthma patients were found (3 in mild, 10 in severe, and 3 in critical COVID-19). The prevalence of asthma in COVID-19 severity groups did not suggest a clear correlation between asthma and COVID-19 severity. Within the same COVID-19 severity group, no differences were observed between patients with or without asthma on oxygen saturation, CRP, neutrophil counts, and length of hospital stay. The mortality in the COVID-19 patients with asthma (12.5%) was not higher than that in patients without asthma (17.2%). No significant difference was found between asthmatic and non-asthmatic in circulating cytokine response in different COVID-19 severity groups, including the cytokines strongly implicated in COVID-19 such as CXCL10, IL-6, CCL2, and IL-8. Conclusions Pre-existing asthma was not associated with an enhanced cytokine response after COVID-19 infection, disease severity or mortality.

A quality improvement project: documentation of liaison psychiatry patient reviews in the John Radcliffe Hospital, Oxford

AimsAssess how current practice reflects recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Treat as One: bridging the gap between mental and physical healthcare report (January 2017).Develop template for electronic documentation of liaison psychiatry reviews and implement for trial period.Re-audit after trial period to assess for change in quality of documentation.BackgroundThe John Radcliffe Hospital (JR) is a tertiary centre and has a large liaison psychiatry department with 14 consultants. Patient reviews by the liaison team are documented using a blank note type, on an electronic system used by all specialties within the hospital trust. The NCEPOD Treat as One report makes recommendations for the content of documentation of liaison psychiatry reviews which aim to improve communication between specialties.Method86 patients referred to liaison psychiatry at the JR in September 2018 were randomly selected. Four liaison psychiatry consultants appraised the quality of documentation of anonymized reviews by consultant colleagues. The audit tool was a questionnaire containing 12 questions developed by the four consultants based on the NCEPOD Treat as One report. Data were collated from these questionnaires. The template for electronic documentation was developed to reflect the report recommendations and after discussion with the liaison psychiatry team. The template has been implemented and is used for all initial patient reviews.ResultThe 12 questions of the audit tool can be divided into two groups: assessment and management. As part of the assessment, the majority of reviews included a primary diagnosis (77.9%) and reason for referral (66.3%). Other aspects of the assessment were documented in the minority of reviews: mental capacity (19.8%), need for DOLS (2.3%), risks (27.9%) and risk management (7%). Regarding the management, the majority of reviews included: clear plan with numbered/bullet points (61.6%), medication changes (51.4%), useful plan (73%) and answered the reason for referral (69.8%). Other aspects of the management were documented in the minority of reviews: each action point assigned (47.7%) and non-medical MDT advice (18.6%).ConclusionThe main area for improvement in documentation of assessment agreed by the liaison team is risk. The main areas agreed for improvement in documentation of management are medication changes, assigning action points to individuals, and including advice for non-medical MDT members. The next step is re-audit, planned for March 2020.

The Antenatal and Postnatal Consequences of Antenatal Exposure to Prolonged Low Dose Indomethacin

Despite its many clinical applications, indomethacin is seldom used in pregnancy, principally because of concerns regarding the potential for constriction of the arterial duct. The aim of this study was to document adverse antenatal effects and postnatal outcomes after in utero exposure to low-dose indomethacin. We studied a retrospective cohort of pregnancies between 2005 and 2016 at the John Radcliffe Hospital, Oxford, UK, in which mothers at extremely high risk of preterm birth were treated as prophylaxis with indomethacin 25 mg, 12 hourly, before 29 weeks. Antenatal effects on the arterial duct and postnatal outcomes were analysed. Overall, 198 fetuses had in utero follow-up, and 13 (6.6%) had ductal constriction, all within 9 days of starting treatment. No ductal constriction was seen in pregnancies when therapy was started before 20 weeks, and all effects were reversed after cessation of therapy. An analysis of postnatal complications was possible in 181 neonates. There were eight (4.4%) neonatal deaths, all but one associated with extreme preterm birth. Seven (5%) patent ductus arteriosus cases occurred in the 140 neonates delivered after 28 weeks who were alive at discharge. Postnatal complications were not more common in neonates in whom antenatal ductal constriction had been demonstrated. In conclusion, fetuses exposed to prolonged low dose indomethacin have a low incidence of in utero complications; these complications can be diagnosed with ultrasound and are reversible. Adverse postnatal events are related to gestation at birth and do not appear more common.

Maintenance therapy with infliximab or vedolizumab in inflammatory bowel disease is not associated with increased SARS-CoV-2 seroprevalence: UK experience in the 2020 pandemic

Background There has been great concern amongst clinicians and patients that immunomodulatory treatments for IBD may increase risk of SARS-CoV-2 susceptibility or progression to severe disease. Methods Sera from 640 patients attending for maintenance infliximab or vedolizumab infusions between April and June 2020 at the John Radcliffe Hospital (Oxford, UK) and Royal London Hospital (London, UK) were tested using the Abbott SARS-CoV-2 IgG assay. Demographic and clinical data were collated from electronic patient records and research databases. Results Seropositivity rates of 3.0% (12/404), 7.2% (13/180), and 12.5% (7/56) were found in the Oxford and London adult IBD cohorts and London paediatric IBD cohorts respectively. Seroprevalence rates in the Oxford adult IBD cohort were lower than that seen in non-patient facing health-care workers within the same hospital (7.2%). Seroprevalence rates of the London paediatric IBD cohort were comparable to a contemporary healthy cohort collected at the same hospital (54/396, 13.6%). Conclusions SARS-CoV-2 seropositivity rates are not elevated in patients with IBD receiving maintenance infliximab or vedolizumab infusions. There is no rationale based on these data for elective interruption of maintenance therapy, and we recommend continuation of maintenance therapy. These data do not address the efficacy of vaccination in these patients.

48 Specialist Physiotherapist Leading in the Frailty Revolution in Ambulatory Emergency Care at the John Radcliffe Hospital, Oxford

Background The Ambulatory Assessment Unit (AAU) at the John Radcliffe Hospital aims to provide excellent care for complex patients with varying range of medical presentations. It sees over 50% of the acute take in operational hours, with over 40% of AAU patients over the age of 70. Staff feedback consistently identified a suboptimal service provided to the frail group within this patient cohort. A dedicated physiotherapist specialising in older people living with frailty joined the team in October 2018 to address this. Aims Early identification of patients with frailty attending the unit Improve staff understanding of frailty to enhance patient care Assess patients to either enable a patient to return home safely or support ambulatory pathway Refer to community services that can support the patient and enable them to live well after hospital attendance Review the impact of the specialist physiotherapist’s role Methods Introduction of frailty identification as per frailty team guidance Frailty questionnaire to ascertain baseline understanding and learning needs to develop staff training Assess patients using a Comprehensive Geriatric Assessment Raise staff and patient awareness of community support services available within the community Data collection to review interventions taken, bed days saved and re-attendance rates Results 129 new patients were seen in a 4-month period. 85% returned home the same day; 64% had their ambulatory pathway supported with therapy intervention and 21% had an acute admission avoided directly due to therapy. 15% were admitted to an acute bed for safety 60% of patients were referred to community services and 50% were signposted to a range of community and support services The re-admission rates for therapy related reasons within 7 days and 30 days were 0% and 4% respectively. 38 bed days were saved with a calculated cost saving of £15,162 Future service delivery and conclusions There is ongoing work to obtain patient experience data for those who had their admission avoided directly due to therapy intervention. A training programme on frailty for all members of the MDT is to be developed. A dedicated therapy service in an ambulatory setting has a role in ensuring that patients’ needs are met in the most appropriate place and enhances their quality of life after hospital attendance.

Implementing a community model of early pregnancy care

· Introduction · In the UK Early Pregnancy Assessment Units (EPAUs) are usually situated alongside hospital maternity and gynaecology services. In June 2018, the Oxford EPAU relocated from the John Radcliffe Hospital to a community clinic. This is to our knowledge, the UK’s first community-based EPAU. This change was inspired by our patient feedback describing the co-location of the EPAU with maternity services as distressing. · Methods · Following the introduction of the community EPAU we developed a database to capture information on the patients seen in the clinic. This is a retrospective observational study of a single cohort of patients attending the clinic over an 8 month period. Data was collected from 1 st July 2018 to 28 th February 2019. This data included clinical, safety and patient experience outcomes. · Results · 2920 patient episodes were recorded, 1932 were new patients. 72.2% were diagnosed as viable pregnancies, 389 miscarriages were diagnosed, of which 84.1% were incomplete/missed and 15.9% were complete. Once miscarriage was confirmed 48.6% chose conservative management, 19.9% chose medical management, and 31.5% chose surgical management. 25 ambulance transfers occurred due to ruptured ectopic, suspected ectopic, heavy bleeding, collapse, or ectopic with no personal transport. 32 unplanned admissions from patients seen in EPAU accounted for 2.7% of all patients seen in EPAU. 58 patients had ultrasonographically confirmed or suspected ectopic pregnancies- 3% of patients seen in clinic. Patient feedback questionnaires have been consistently positive. · Conclusion · The development of a community EPAU has improved services to allow care closer to home in an environment separate from maternity care. Our data shows that a community EPAU is safe, can deliver good patient care and is a service valued by patients. Further research is indicated to evaluate the cost-effectiveness of community EPAUs and the long term safety and effectiveness of care.

Implementing a community model of early pregnancy care

Introduction In the UK Early Pregnancy Assessment Units (EPAUs) are usually situated alongside hospital maternity and gynaecology services. In June 2018, the Oxford EPAU relocated from the John Radcliffe Hospital to a community clinic. This is to our knowledge, the UK’s first community-based EPAU. This change was inspired by our patient feedback describing the co-location of the EPAU with maternity services as distressing.Methods Following the introduction of the community EPAU we developed a database to capture information on the patients seen in the clinic. This is a retrospective observational study of a single cohort of patients attending the clinic over an 8 month period. Data was collected from 1st July 2018 to 28th February 2019. This data included clinical, safety and patient experience outcomes.Results 2920 patient episodes were recorded, 1932 were new patients. 72.2% were diagnosed as viable pregnancies, 389 miscarriages were diagnosed, of which 84.1% were incomplete/missed and 15.9% were complete. Once miscarriage was confirmed 48.6% chose conservative management, 19.9% chose medical management, and 31.5% chose surgical management. 25 ambulance transfers occurred due to ruptured ectopic, suspected ectopic, heavy bleeding, collapse, or ectopic with no personal transport. 32 unplanned admissions from patients seen in EPAU accounted for 2.7% of all patients seen in EPAU. 58 patients had ultrasonographically confirmed or suspected ectopic pregnancies- 3% of patients seen in clinic. Patient feedback questionnaires have been consistently positive. Conclusion The development of a community EPAU has improved services to allow care closer to home in an environment separate from maternity care. Our data shows that a community EPAU is safe, can deliver good patient care and is a service valued by patients. Further research is indicated to evaluate the cost-effectiveness of community EPAUs and the long term safety and effectiveness of care.