Changing epidemiology of assault victims in an emergency department participating in information sharing with police: a time series analysis.

INTRODUCTION: Violent injury places a large burden on the NHS. We had implemented information sharing in our ED in 2007 and aimed to see which patient groups were most affected by information sharing, as this would provide clues as to how this complex intervention works. METHODS: Retrospective time series study of all the assault victims presenting for ED care between 2005 and 2014 at a single ED in England. RESULTS: 10 328 patients presented during the study period. There was a 37% decrease in the number of patients presenting after assault, consistent with national trends. The proportions of people arriving by ambulance, and the proportion of men did not change during the study period. There were no important changes in the age of our assault patients in this study. Greater, disproportionate, decreases in rates of violence were seen in patients who presented at the weekend up (incidence rate ratio (IRR)=0.57, 95% CI 0.50 to 0.64) versus weekdays (IRR=0.72; 95% CI 0.62 to 0.83) There were also disproportionately greater decreases over the study period in patients who were discharged with no hospital follow-up (IRR=0.51, 95% CI 0.45 to 0.56) versus those leading to either an inpatient admission (IRR=1.05, 95% CI 0.84 to 1.31) or outpatient follow-up (IRR=1.23, 95% CI 0.93 to 1.64). CONCLUSIONS: The epidemiology of violent injury at our institution has changed over the last 10 years and is most marked in a reduction of visits at the weekend, and in those who leave without follow up.

Bipolar disorder: The importance of clinical assessment in identifying prognostic factors - An Audit. Part 1: An analysis of potential prognostic factors.

BACKGROUND: Prognostic factors of bipolar disorder must be identified to assist in staging and treatment, and this may be done primarily during the initial psychiatric assessment. In fact, most of the prognostic factors, which determine disease outcome, could be detected from simple but often-unrecorded questions asked during the psychiatric clinic visit. METHODS: We collected data from the clinical notes of 70 bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors to determine whether various factors had relevance to prevalence, prognosis, or outcome. RESULTS: The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; a psychiatric comorbidity was noted in 26 patients (37.1%). 60.9% (42 patients) reported anxiety features and 12 patients (17.6%) were noted to have obsessive-compulsive characteristics. Percentages reported in our results are of the sample for which the data was available. Anhedonia is a depressive feature that was present in most of the population where this data was available (92.2%, 59 patients) and 81.8% (54 patients) reported suicidal thoughts during a depressive episode. 74.6% (47 patients) had a family history of bipolar disorder, depression, suicide or psychosis. 27 patients (39.7%) reported current alcohol use and 14 patients (22.6%) current illicit drug use. A comparison between 10 prognostic factors found that only the correlations between current illicit drug use/previous illicit drug use (χ(2)=11.471, P<0.001), current alcohol use/previous alcohol use (χ(2)=31.510, P<0.001) and current illicit drug use/anxiety (χ(2)=5.094, P=0.022) were statistically significant; the correlation between previous illicit drug use/previous alcohol use (χ(2)=5.071, P=0.023) and previous alcohol use/family history (χ(2)=4.309, P=0.037) were almost statistically significant. 17 patients (24.3%) of the 70 bipolar patients were assigned to a care coordinator; we have evaluated the possible differences between the patients with or without a care coordinator on the basis of the presence of 10 possible prognostic factors and found no statistically significant differences between these two groups of patients. CONCLUSIONS: We have identified several trends in our patients with bipolar disorder that agree with previous research. Our sample suggested that the assignation of a care coordinator is not done on a clinical basis. In our sample, some patients were found not to have information available so we suggest that a questionnaire to remind clinicians of potentially useful information would be helpful to aid in prognostication. In particular, specific features of the disease, like family history, age at onset, and features of depressive episodes may be highlighted as our sample suggests that these are often unrecorded when not known or negative.

Bipolar disorder: The importance of clinical assessment in identifying prognostic factors - An Audit. Part 2: Mixed state features and rapid cycling.

BACKGROUND: Rapid cycling in bipolar disorder complicates the clinical picture and worsens the long-term outcomes of bipolar disorder. Mixed states features do similarly and are known to present an increased risk to patients. Early recognition of these patterns can lead to better treatment strategies and improvement of the long-term course of the disease. METHOD: We collected data from the clinical notes of 70 bipolar outpatients seen at an ASPA (initial assessment) clinic about socio-demographic and clinical characteristics. RESULTS: The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; percentages reported in our results are of the sample for which the data was available. 71.7% (33 patients) of the sample reported mixed states features and 32 patients (72.7%) are recorded to have more than 4 changes in mood in a year. There were no statistically significant correlations between mixed state features or rapid cycling and anhedonia, suicidal ideation, borderline symptoms, OCD symptoms, anxiety, positive psychiatric family history, current alcohol use, previous alcohol use, current illicit drug use, or previous illicit drug use. An almost significant correlation was found between mixed state features and anxiety. Assignation of a care coordinator did not seem to be associated with these prognostic factors. CONCLUSIONS: The two subgroups of mixed state features and rapid cycling patients share very common clinical characteristics: high incidence of suicidal thoughts, high levels of anxiety, and high previous substance use - but low levels of current alcohol and drug use and high levels of features of atypical depression. These features of mixed state bipolar disorder and rapid cycling bipolar disorder should be identified during psychiatric assessment to identify useful information for prognosis.

Bipolar disorder: The importance of clinical assessment in identifying prognostic factors - An Audit. Part 3: A comparison between Italian and English mental health services and a survey of bipolar disorder.

BACKGROUND: Most of the prognostic factors of bipolar disorder, which determine disease course and outcome, could be detected from simple but often-unrecorded questions asked during the psychiatric clinic assessments. In previous parts of this research, we analysed various prognostic factors and focused on mixed states and rapid cycling subsets. We now compare our sample in England with a small sample from Italy to demonstrate the utility of focused prognostic questioning and of international comparison. METHODS: We collected data from the clinical notes of 70 English bipolar and 8 Italian bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors to determine whether various factors had relevance to prevalence, prognosis, or outcome. RESULTS: The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) English outpatients and 7 bipolar I (87.5%) and 1 bipolar II (12.5%) Italian outpatients. Differences between the groups are seen mainly in terms of age of onset, duration of both depressive and hypomanic episodes, presence of psychiatric family history, incidence of mixed state features and rapid cycling, presence of elated mood in response to past antidepressant treatment, and misuse of illicit drugs and alcohol. CONCLUSIONS: In order to promote improved mental health primary care, mental health systems in all countries should develop standardized epidemiological tools that are shared between countries. We recommend the use of a questionnaire that reminds clinicians of potentially prognostic information and suggest that this might identify important components of a potential standardized diagnostic and prognostic tool.

Developing key performance indicators for adult critical care transfer services: Scoping review and Delphi technique.

In 2021 NHS England commissioned regional Adult Critical Care Transfer Services. These services will replace a historically predominant ad hoc approach to adult critical care transfers nationally. It is anticipated that these new formal services will provide a system of robust regional & national governance previously acknowledged to be deficient. As part of this process, it is important that an agreed set of transfer service quality indicators are developed to drive equitable improvement in patient care. We used a Delphi technique to develop a set of key performance indicators through consensus for a recently established London critical care transfer service. We believe this may be the first-time key performance indicators have been developed for adult critical care transfer services using a consensus method. We hope services will consider tracking similar measures to enable benchmarking and drive improvements in patient care.

Demonstrating Improved Surgical Communication and HAndoveR Generates Earlier Discharges (DISCHARGED).

BACKGROUND: Weekend surgical handover at the Princess Alexandra Hospital NHS Trust in Harlow, Essex, did not fully comply with Royal College of Surgeons England guidelines. Out-of-hours care is under increased scrutiny, and we implemented a quality improvement intervention of a mandatory, standardized weekend handover form to streamline weekend care. This was shown to increase discharges and decrease lengths of stay for patients whose hospital stay included a weekend. METHODS: Data were collected for 15-week preimplementation and postimplementation. The number of patients handed over for senior weekend review was recorded, and for each, the presence or absence of a working diagnosis, relevant investigations, a management plan, and any outstanding tasks was recorded. A standardized weekend handover form was implemented, and these criteria as well numbers of discharges and lengths of stay were compared. RESULTS: An average of 32 patients was handed over each weekend before and after implementation. The average number of handovers with a listed working diagnosis (19.20 to 30.80, Δ11.60, P < 0.0001), management plan (16.40 to 31.73, Δ15.33, P < 0.0001), and tasks (16.60 to 29.13, Δ12.53, P < 0.0001) significantly increased. Average weekend discharges increased (39.07 to 48.93, Δ9.86, P = 0.0034). Average lengths of stay for emergency patients whose stays included a weekend shortened by 1.96 days (11.11 to 9.15 days, Δ-1.96, P = 0.0192) in keeping with the length of a weekend, with estimated annual cost-savings of between £740 000 and £3.82 million. CONCLUSIONS: Implementation of a standardized weekend handover form resulted in an increase in compliance to national guidelines as well as an increase in weekend discharges and decreased length of stay for emergency patients with significant cost-savings.

Near Peer Group training on 'How to be a Foundation doctor' Course.

This article was migrated. The article was marked as recommended. Introduction After graduating from medical school, all UK based doctors enter the Foundation Programme. There is on-going evidence, both anecdotally and published, that final year medical students continue to feel unprepared about starting work. We thus designed a one-day course aiming to improve these students' preparedness and anxiety levels. Methods Pre-course material was provided to the students with information on the skills that were going to be explored in the course. After an initial introduction, there was an interactive demonstration to refresh the students' knowledge on assessment of an unwell patient using the recognised ABCDE approach- Airway; Breathing; Circulation; Disability; Exposure . Thereafter, the students were split into 10 groups of 3 and 4 and rotated around 10 different stations. Each station was 40 minutes long and breaks were interspersed amongst the teaching to ensure that concentration was maintained. The emphasis was on near-peer teaching with guidance from a recently qualified doctor. Feedback was requested immediately post-course and three months afterwards. Results and Feedback The immediate feedback was very positive with the overall quality rated at 3.93/4. Regarding the 3 month feedback, there was an average reduction in anxiety levels by 18.3% (p<0.0001) and improvement in perceived preparedness levels by 24.7% (p<0.0001). All students agreed that the course will help them in preparing to become a foundation doctor and that similar courses should be offered to all final year students. Conclusions Practical courses focusing on preparedness can provide a unique opportunity for collaborative training by universities and foundation trusts. These courses are well evaluated and are perceived to improve anxiety and preparedness levels.