Clinical audit on possible causes of hospital initiated clinic cancellations and recommendation to improve the service

AimsThe aim of this audit is to explore the possible causes of clinic cancellation in an inner city CMHT and the recommendation to reduce the burden.BackgroundCancellations of planned appointments have been a major and long-standing problem for healthcare organisations across the world. It represents a significant loss of revenue and waste of resources, have significant psychological, social and financial implications for patients and their families and represent a significant loss of training opportunities for trainees. Re-scheduling appointment is one of the major issues of inconvenience to the patients. It also increases workload for the patient appointment team.MethodData have been collected retrospectively from patient appointment booking team regarding clinic cancellation with causes of cancellation recorded in the system (01/07/2019–30/09/2019). The investigators have investigated if the cancellation has been made when it was absolutely necessary to cancel the clinic (Unavailability of doctors due to leave/on calls) and if patients have been informed at least 8 weeks prior to the appointed clinic as per trust protocol.ResultTotal number of 193 clinics were booked at the CMHT from July 2019 – September 2019. About 54% clinics were cancelled during the time period. The Clinic Cancellation rate was higher in September (68%) and was lowest in August (30.30%). As the month of July is the changeover period for trainees, the number of clinics booked during August was relatively less than normal. 72% clinics were cancelled by junior doctors and 28% clinics were cancelled by consultants at the CMHT. The major cause of clinic cancellation was unavailability of the junior doctors due to on call (31.58%) which was not communicated to the patient appointment booking team. Due to annual leave, 25% clinics were cancelled and 21% clinics were cancelled due to study leave. In both cases it is evident that, lack of communication between clinicians and patient appointment team are primarily responsible for hospital-initiated clinic cancellations. As per Patient Appointment booking team, around 50% cases, patients were informed 8 weeks in advance before cancelling the clinics.ConclusionThis is evident from this audit that the number of hospital-initiated clinic cancellations can be reduced by improving communication between Patient Appointment booking service, Medical staffing department and clinicians. The findings of the audit have been shared locally with CMHT managers, clinicians and with the patient appointment booking team.

Counting ECGs in acute psychiatry – The patients' price for junior doctors' rotations

AimsOn 05/08/20, when a new cohort of doctors rotated onto an acute ward, (John Dickson Ward, Maudsley Hospital, London) a new handover tool on MS Teams was introduced, which replaced previously used MS Word document. The new handover tool can be accessed and edited by any of the users in the team. We hypothesised that the introduction of an interactive, live-updated tool would help improve physical health monitoring for patients, especially compliance with ECG taking. The aim of this project was to test this hypothesis.MethodAuthors have reviewed electronic documentation of patients admitted to and discharged from John Dickson Ward between 01/04/2020 and 24/12/2020. Evidence of whether an ECG was performed, was offered but declined by the patient, or was not offered were noted in the final audit. Patients were divided into 3 groups: (1) Patients admitted and discharged from 01/04/20 – 05/08/2020; (2) Patients admitted and discharged from 05/08/2020 – 24/12/20, and (3) Patients admitted before the intervention date, but discharged after the date (i.e., the period when new junior doctors had rotated onto the ward). Fifty patient records were identified in Group 1, fifty in Group 2, and 18 in Group 3.ResultSurprisingly, the percentage of patients who had a documented ECG did not improve after the intervention, with 37/50 (74%) of patients having an ECG in Group 1, and 37/50 (74%) of patients having an ECG in Group 2. However, an incidental finding was made that significantly fewer patients received ECGs during the changeover period (Group 3), with only 6/18 (33%) of patients receiving ECGs. The percentage of patients who were not offered ECGs also increased during the changeover period, with 2/50 (4%) in Group 1, and 3/18 (17%) in Group 3 not being offered.ConclusionThis incidental finding highlights the challenges associated with the junior doctor changeover period. Much time is needed for doctors to adjust to their new surroundings and methods of working, and this may result in basic elements of patient care being overlooked. We surmise that other elements, such as ensuring all patients having regular blood tests and physical examinations, may also be of a lower standard during this period. There is scope for future audits to address this, and for future quality improvement projects to implement changes ensuring medical care remains at a high standard during junior doctor changeover periods.

Impact of Spirituality in Management

In today's times, we live in the changeover period between the ancient meaning of work as subsistence and the new meaning of work as a livelihood. Novel management methods and new organizational systems are necessary to keep up with this emergent context. Spirituality in the workplace states that personnel seek nourishment for both the extents, i.e. their vertical and horizontal, extents of their spirituality at work. It is about people and organizations perceiving work as a spiritual pathway, as a chance to cultivate and to do something for humanity. It is all about care, empathy, and sustenance of others, about truthfulness and persons being truthful to themselves and others, endeavoring to live their values more effusively while performing their work. The present chapter stresses the impact of spirituality in management. The study concludes that for any organization to run efficiently, spirituality is the core to attain happiness, contentment, and success at the same time.

Impact of Rhythmic Oral Activity on the Timing of Muscle Activation in the Swallow of the Decerebrate Pig

The pharyngeal swallow can be elicited as an isolated event but, in normal animals, it occurs within the context of rhythmic tongue and jaw movement (RTJM). The response includes activation of the multifunctional geniohyoid muscle, which can either protract the hyoid or assist jaw opening; in conscious nonprimate mammals, two bursts of geniohyoid EMG activity (GHemg) occur in swallow cycles at times consistent with these two actions. However, during experimentally elicited pharyngeal swallows, GHemg classically occurs at the same time as hyoglossus and mylohyoid activity (short latency response) but, when the swallow is elicited in the decerebrate in the absence of RTJM, GHemg occurs later in the swallow (long latency response). We tested the hypothesis that it was not influences from higher centers but a brain stem mechanism, associated with RTJM, which caused GHemg to occur earlier in the swallow. In 38 decerebrate piglets, RTJM occurred sporadically in seven animals. Before RTJM, GHemg had a long latency, but, during RTJM, swallow related GHemg occurred synchronously with activity in hyoglossus and mylohyoid, early in the swallow. Both early and late responses were present during the changeover period. During this changeover period, duplicate electrodes in the geniohyoid could individually detect either the early or the late burst in the same swallow. This suggested that two sets of geniohyoid task units existed that were potentially active in the swallow and that they were differentially facilitated or inhibited depending on the presence or absence of rhythmic activity originating in the brain stem.

Use of fishmeal to reduce lamb weight loss on dietary change

Year round production of lamb Is constrained by the seasonal breeding of the ewe with a shortage of lambs onto the UK market In the first two quarters of the year leading to enhanced prices in this period. Lambs sold onto this market in the past have received little variable premium due to strong market prices. Transfer of support from variable premiums to headage payments in 1992 should encourage farmers to spread the marketing period of lamb into the period of shortage. New systems of storing lamb have been developed involving a housed store period from September to November on a straw based diet followed by turnout to swedes for finishing. Large liveweight loss on adjustment to the straw based diet has been a constraint In previous trials (Dingwall et al, 1989). Previous work on slimming diets for sheep (Vipond et al, 1989) suggests fishmeal supplementation during the changeover period could reduce weight loss and improve performance.

A COMPARISON OF UREA AND ALFALFA CUBES AS A SOURCE OF PROTEIN ENSILED WITH CORN SILAGE

Sixteen Holstein cows in mid-lactation were randomly assigned for a 35-day period to either corn silage supplemented with urea (4.95 kg/tonne) or corn silage supplemented with alfalfa cubes (90 kg/tonne) at ensiling time. These treatments were then reversed during a 7-day changeover period and the trial continued for a further 35 days. The silages were fed ad libitum and grain was fed in the parlor at the rate of 1.0 kg/4.0 kg milk yield. The protein and acid detergent fiber contents of the urea–corn silage were 11.6 and 25.3%, while those of alfalfa–corn silage were 11.1 and 28.6%. Cows offered the urea–corn silage consumed less forage dry matter expressed as percent of body weight, 2.04 vs. 2.11 and produced less milk, 26.08 vs. 26.86 kg/day (P < 0.05). During the feeding of the alfalfa cube–corn silage, cows gained an average of 4.09 kg/35 days, but lost 3.68 kg/35 days when urea–corn silage was fed (P < 0.05). There was no effect of form of nitrogen supplementation on milk composition or rumen volatile fatty acids, but blood urea nitrogen and plasma glucose were significantly higher (P < 0.05) and plasma calcium lower for cows fed urea–corn silage than for those fed alfalfa cube–corn silage. Apparent dry matter and protein digestibilities were higher for the urea–corn silage than for cows fed alfalfa cube–corn silage but digestibility of acid detergent fiber fraction was greater for cows fed alfalfa cube–corn silage.