Does a limited nurse triage service reduce junior doctor psychiatric on-call workload?

Aims and Method

To investigate whether nurse triage might reduce junior doctors' on-call workloads in a general adult psychiatry in-patient unit, we measured changes in workload after the introduction of a limited (overnight and weekend mornings) nurse triage service on the unit, comparing pre-triage work levels with levels 1 year later. This time frame allowed the new service to settle in, and controlled for seasonal variations in workload.

Results

The number of ‘work episodes' went up, especially during the night shifts, but the average length of each episode went down (both statistically significant, P < 0.001). The net result was a slight increase in workload in terms of total time spent dealing with episodes, most notably at night.

Clinical Implications

A limited overnight nurse triage service was ineffective on its own as a means of reducing the out-of-hours workload of junior doctors, and even slightly increased it. A more comprehensive triage service, with a greater range of alternatives to admission, might have had a different result.

Loop ileostomy following anterior resection: is it really temporary?

INTRODUCTION

A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal.

METHOD

Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital.

RESULTS

A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal.

CONCLUSIONS

One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.

Use of Hartmann's procedure in England

INTRODUCTION

Hartmann's procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate.

METHOD

Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann's procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann's.

RESULTS

Approximately 3950 Hartmann's procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann's were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann's were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann's procedure and reversal was 284.5 days (interquartile range 181-468.25).

CONCLUSION

This study represents the single largest cohort in whom outcome after Hartmann's procedure has been studied. A majority of Hartmann's are performed as an emergency for benign diseases and most of them are not reversed.

Management of acute gallbladder disease in England

BACKGROUND

Recent literature suggests that early laparoscopic cholecystectomy for acute gallbladder disease is safe and efficacious, but few data are available on the management of acute gallbladder disease in England.

METHODS

Hospital Episode Statistics data for the years 2003-2005 were obtained from the Department of Health. All patients admitted as an emergency with acute gallbladder disease during the period from April 2003 to March 2004 were included as a cohort. Repeat emergency admissions for acute gallbladder disease, and cholecystectomies performed during the first admission, an emergency readmission or an elective admission were followed up until March 2005.

RESULTS

Some 25,743 patients were admitted as an emergency with acute gallbladder disease, of whom 3791 had an emergency cholecystectomy during the first admission (open cholecystectomy (OC) 29.8 per cent, laparoscopic conversion rate (LCR) 10.7 per cent) and 9806 patients had an elective cholecystectomy (OC 11.3 per cent, LCR 8.3 per cent) during the study period.

CONCLUSION

Early cholecystectomy for acute gallbladder disease is not widely practised by surgeons in England. Open cholecystectomy is more commonly used in the emergency than in the elective setting. Early laparoscopic cholecystectomy following an emergency admission carries a higher conversion rate than elective cholecystectomy.

Oesophagectomy practice and outcomes in England

Background

The 2001 UK National Health Service guidance on improving outcomes recommended centralization of oesophageal resection. The aim of this study was to analyse national trends in oesophageal resection in England to determine whether centralization has occurred and its impact on outcomes.

Methods

The study used data from Hospital Episode Statistics for 1997–1998 to 2003–2004 and included patients who had resection for oesophageal cancer. The annual hospital volume was grouped into five categories based on the recommendation for annual volume for a designated centre.

Results

A total of 11 838 oesophageal resections were performed. The total number of hospitals performing resections decreased, mainly owing to a fall in the number of very low-volume hospitals (117 in 1997 to 45 in 2003). The proportion of resections performed in very high-volume hospitals increased from 17·8 per cent during 1997–1999 to 21·9 per cent during 2002–2003 (P &lt; 0·001). The overall in-hospital mortality rate was 10·1 per cent, with a significant reduction over time (from 11·7 to 7·6 per cent; P &lt; 0·001). The decline in mortality rate may be due to increased numbers of patients undergoing surgery in higher-volume hospitals. There was an increase in the annual number of new patients from 5672 to 6230 during the study, although a fall in the proportion of resections from 31·5 to 26·0 per cent (P &lt; 0·001).

Conclusion

Centralization and multidisciplinary team expertise partly explain the improvement in mortality rate, but changes in preoperative selection also play a part.

CARREL: an internet platform for the distribution of human organs for transplantation

BACKGROUND

Human organs for transplant from a deceased donor are presently distributed in Spain by means of manual handling and telephone or fax transmission of data. This procedure is conducted organ by organ with the information transmitted sequentially. This process has several inherent drawbacks, the main one being the long length of time to allocate organs on many occasions. A difficulty of this type could be solved by means of an electronic system of data management and transmission through the Internet. CARREL is a platform that could provide an alternative organ distribution procedure. The main objective of CARREL was to increase the efficiency, safety, rapidity, and quality of organ distribution for transplantation, thereby helping the allocation process.

MATERIALS AND METHODS

CARREL is a database system, accessible through the Internet, to which any medical center authorized to perform organ transplants in Spain may subscribe. CARREL allows information share between centers, including administrative, anthropometric, immunological, analytical, and clinical data, as well as parameters concerning donor maintenance.

CONCLUSIONS

CARREL is an online system that can reduce organ distribution time, directly store complete information concerning the donor, and also share data between centers. It facilitates communication between transplant coordinators at different centers, thereby improving and hastening candidate selection.

EVALUATION OF A CLINICAL SCREENING INSTRUMENT TO IDENTIFY STATES OF THIAMINE DEFICIENCY IN INPATIENTS WITH SEVERE ALCOHOL DEPENDENCE SYNDROME

AIMS

To develop a Thiamine Deficiency Questionnaire (TDQ), and to assess its reliability in the identification of Thiamine deficiency, in patients with severe alcohol dependence.

METHODS

58 severely alcohol dependent patients underwent socio-demographic, medical, psychiatric, and alcohol use assessment, including administration of the Thiamine Deficiency Questionnaire (TDQ). The Red Blood Cell Thiamine Pyrophosphate concentration provided the 'gold standard' to test the validity of the instrument. Univariate 2 x 2 diagnostic test tables and multivariate analysis were performed.

RESULTS

A set of eight questionnaire items had an overall predictive power of 73.7%. Two of these were highly specific: 'missed meals due to lack of funds', and the clinical co-occurrence of medical conditions potentially related to poor nutrition. The Michigan Alcohol Screening Test and serum gamma glutamyl transferase were moderately predictive.

CONCLUSIONS

Screening that combines socio-demographic, clinical and biological factors, and/or standardized questionnaires, could improve early recognition of thiamine deficiency.

The North Staffordshire Suicide Study: a case-control study of suicide in one health district

BACKGROUND

The aim of the study was to identify sociodemographic and clinical risk factors for death from suicide and undetermined injury in residents of one health district.

METHOD

Data were collected on all cases of suicide (ICD-9 E950-959) and undetermined injury (ICD-9 E980-989) for residents in North Staffordshire Health District between 1991 and 1995. Controls identified from the Coroner's inquest register, who died from other causes, were matched for age and sex.

RESULTS

Two hundred and twelve pairs of cases and matched controls were identified. Multivariate analysis (conditional logistic regression) showed that the risk of death due to suicide and undetermined death was associated with: recent separation, relationship difficulties, experience of financial difficulties, history of past criminal charges or contact with the police, a past history of deliberate self-harm, being on psychotropic medication at the time of death and a diagnosis of bipolar affective disorder. For sociodemographic variables, a univariate analysis found associations between the cases and being separated, living alone, having a past history of criminal charges and unemployment. Cases were more likely to have a psychiatric disorder, past history of deliberate self-harm and a past history of psychiatric contact for themselves or a family member. Controls were more likely to have a current medical disorder. Cases were more likely than controls to be on any form of medication at the time of death and to have received a prescription for psychotropic or non-psychotropic medication in the week and month before death. Cases were more likely than controls to have had contact with medical services in the week and month before death, with the general practitioner in the week before death and with psychiatric services at any time in the year before death. Strong associations were found between suicide and undetermined injury and life events such as recent separation and bereavement, and financial and relationship difficulties.

CONCLUSIONS

The study provides an analytical investigation utilizing a dead control group, data gathered from several sources and adequate numbers of cases. It confirms many of the risk factors identified in other studies and highlights the high proportion of suicides who have been in recent contact with the criminal justice system or have been prescribed medication shortly before death.