Parental poison prevention practices and their relationship with perceived toxicity: cross-sectional study.

OBJECTIVE: To describe poison prevention practices for a range of substances and explore the relationship between prevention practices and perceptions of toxicity. DESIGN: Cross-sectional study using a validated postal questionnaire. PARTICIPANTS: Parents with children aged 12-35 months on 23 health visitors' caseloads. SETTING: Areas of various levels of deprivation in Nottingham, UK. MAIN OUTCOME MEASURES: Possession and storage of substances, putting substances away immediately after use, and perceptions of toxicity. RESULTS: Dishwasher tablets (68%), toilet cleaner (71%), bleach (74%), oven cleaner (78%), oral contraceptives (80%), and essential oils (81%) were least likely to be stored safely. Children's painkillers (69%), cough medicine (72%), and essential oils (77%) were least likely to be put away immediately after use. More than 50% of parents perceived antibiotics and oral contraceptives as harmful in small quantities and cough medicines as harmful only in large quantities. Six substances perceived by parents to be more harmful were more likely to be put away immediately after use. Parents perceiving dishwasher tablets (OR 1.96, 95% CI 1.05 to 3.66), essential oils (OR 2.80, 95% CI 1.35 to 5.81), turpentine (OR 14.54, 95% CI 2.75 to 76.95), and rat/ant killer (OR 15.33, 95% CI 2.01 to 116.82) as more harmful were more likely to store these substances safely. CONCLUSIONS: Parents' perceptions of toxicity of substances were sometimes inaccurate. Perceived toxicity was associated with putting substances away immediately after use for six substances and with safe storage for four substances. The effect of addressing perceptions of toxicity on poison prevention practices requires evaluation.

Validating parents' self-reports of children's exposure to potentially toxic substances within the home.

OBJECTIVE: To validate self-reported possession and storage of a range of substances within the home. PARTICIPANTS: 30 families with children aged 12-35 months on health visitor caseloads in Nottingham, UK. METHODS: Self-reported possession and storage of potentially hazardous substances were validated by observations. Sensitivity, specificity, and predictive values were calculated for possession, storage, and exposure to substances. RESULTS: Self-reported low exposure to substances had high sensitivities (87-100%) and positive predictive values (75-100%) for all substances, except toilet cleaner (positive predictive value 62%) and high negative predictive values for commonly owned household products. Specificity and negative predictive value could not be estimated reliably for medicines and less commonly owned household products, as few families stored these unsafely. CONCLUSIONS: A measurement of exposure that combines self-reported possession and storage may be sufficiently accurate to identify families with safer poison prevention practices.

Problems found in the over-75s by the annual health check.

BACKGROUND: Research into the health of elderly people has found problems unknown to their general practitioners. It was anticipated that annual checks, as required by the 1990 general practitioner contract, would help to detect these problems, yet the value of these checks has been questioned. AIM: To investigate the problems found by general practice contractual annual checks of the over-75s and the consequent actions taken; to identify patient, demographic or practice characteristics associated with the discovery of problems. METHOD: In 40 practices, information was collected on patients over 75 years of age receiving a health check during a 3-month period. Practices used their normal methods of recruitment and assessment. Practice staff were interviewed to find how assessments were organized. RESULTS: Practices saw a mean of 12% of their over-75s during the study; 44% were found to have at least one problem. Action was taken to help resolve problems in 82% of patients with a problem. The most prevalent problems related to physical condition, and fewer functional problems than expected were found. There were large differences between practices in the proportions of elderly patients seen for a check and the proportion found to have problems; these were not attributable to practice size or demography. Multivariate analysis showed that practice or patient characteristics were poor predictors of finding problems. CONCLUSION: The argument in favour of conducting annual checks is supported by the finding that nearly half the patients assessed were found to have problems for which some action was taken. Some practices could increase their rate of uptake by modifying the organization of invitations for checks. More problems may be found by adopting a more functionally based assessment.

Residents of private nursing homes and their care.

A study was undertaken to examine the characteristics of residents in private nursing homes, to measure residents' dependency levels, to determine the adequacy of procedures for admitting new residents and to explore general practitioners' work with residents. Details were obtained of 61 nursing homes registered by Nottingham district health authority and of a selection of residents. Information about residents provided by the nurses in charge included aspects of self care, orientation and social integration, these items contributing to a dependency score for each resident. General practitioners completed postal questionnaires. Information was sought on the numbers of residents on the general practitioners' lists, visiting patterns, and opinions on their work with residents. It was found that almost half of the reports accompanying residents on admission were considered inadequate by the nurses in charge. The 357 residents varied widely in dependency level, need for nursing care and medication; 31% had low dependency scores. Most of the residents (57%), had been admitted from hospital, 26% from their own home and 15% from other nursing or residential homes. Higher overall dependency levels, problems with mobility and continence and need for care of wounds, catheters or colostomies were more frequent in residents admitted from hospital or nursing or residential homes than in those admitted from their own home. The 70 responding general practitioners varied widely in the numbers of residents on their lists and in their visiting patterns. The 16 general practitioners providing medical care for entire nursing homes were significantly more likely than the other general practitioners to visit routinely.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of nursing home patients on general practitioners' workload.

BACKGROUND: Although the number of people in nursing homes has risen substantially in recent years, the shift of responsibility into general practice has rarely been accompanied by extra resources. These patients may be associated with a higher general practitioner (GP) workload than others of similar age and sex. AIM: To assess the GP workload associated with nursing home residents and its associated costs. METHOD: All nursing home residents aged over 65 years and registered with nine Nottinghamshire practices during one year were matched with patients living in the community for general practice, age, and sex. Data were collected retrospectively for both groups on key workload measures. Costs for the workload measures were calculated using published estimates. RESULTS: Data were collected for 270 pairs of patients. Nursing home patients had more face-to-face contacts in normal surgery hours, telephone calls, and out-of-hours visits. The mean workload cost per month of a nursing home patient (assuming that one patient was seen per visit) was estimated to be 18.21 Pounds (10.49 Pounds higher than the cost of controls). A sensitivity analysis demonstrated that potential savings in visiting costs associated with increasing the numbers of patients seen per visit were 27% for one extra patient seen per visit and 44% for four extra patients. CONCLUSION: Nursing home residents were associated with higher workload for GPs than other patients of the same age and sex living in the community. Our costings provide a basis for negotiating suitable reimbursement of GPs for their additional work.

Reproducibility and accuracy of pulmonary artery pressure measurement in supine and lateral positions.

The reproducibility and accuracy of pulmonary artery (PA) pressures in supine versus side-lying positions were compared in two groups of intensive care unit (ICU) patients. Side-lying measurements were reproducible, accurate, and clinically acceptable for surgical ICU patients, but not for medical ICU patients. The inconsistency was partly explained by the reference points used for transducer releveling in lateral positions. Surgical ICU used the fourth intercostal space and dependent midaxillary line; medical ICU used the fourth intercostal space and sternum. Reversing the leveling procedure in each ICU reduced surgical unit accuracy to an unacceptable level; medical unit accuracy was increased but was still too low for clinical acceptance. Further research is needed to identify appropriate anatomic reference points for transducer releveling in the side-lying position and to clarify which patient groups may be safely monitored by using this position.

Injectate temperature: effects on thermodilution CO measurements.

The present study has confirmed the findings of other research and indicates that current technology permits accurate CO determination using room temperature injectate. Some patients, especially those with high output, temperature, or blood pressure, may continue to require iced injectate measures to ensure accuracy; more research is needed here. Room temperature measures may be less reproducible than iced. Several ways of compensating for this have been suggested, depending on the technology available. At present, these methods are preferable to using a correction formula based on regression analyses.

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE: To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN: Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING: 20 general practices in one family health services authority. SUBJECTS: Patients of 75 years and over in 20 general practices. RESULTS: Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS: The way health checks were performed varied greatly, both in their organisation and the practices' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.

Arthrodesis of the proximal interphalangeal joint affected with septic arthritis in 8 horses.

Arthrodesis was performed to treat septic arthritis of the proximal interphalangeal joint of 8 horses. Records of the horses were reviewed to determine outcome and possible factors that influenced success or failure. All horses were female. Seven horses had 1 joint treated and 1 horse was treated for bilateral pelvic limb involvement. The duration of sepsis before surgery ranged from 1 to 66 days. Bone lysis and production was radiographically apparent in 7 horses before surgery. Six horses had multiple bacterial organisms cultured from bone or synovial tissues; 2 horses had single isolates identified. After aggressive curettage, arthrodesis was accomplished with 3 parallel screws in 1 horse, 2 divergent narrow dynamic compression plates in 3 horses, and a single broad dynamic compression plate in 4 horses. Casts were applied to all horses for 1 to 6 weeks. Four horses survived to successful brood mare status. Four horses were euthanized during hospitalization because of continued discomfort or complications of sepsis. Arthrodesis of the proximal interphalangeal joint affected with septic arthritis appears to be an acceptable alternative to euthanasia for some horses.

Randomised controlled trial of thermostatic mixer valves in reducing bath hot tap water temperature in families with young children in social housing.

OBJECTIVES: To assess the effectiveness of thermostatic mixing valves (TMVs) in reducing bath hot tap water temperature, assess acceptability of TMVs to families and impact on bath time safety practices. DESIGN: Pragmatic parallel arm randomised controlled trial. SETTING: A social housing organisation in Glasgow, Scotland, UK. PARTICIPANTS: 124 families with at least one child under 5 years. INTERVENTION: A TMV fitted by a qualified plumber and educational leaflets before and at the time of TMV fitting. MAIN OUTCOME MEASURES: Bath hot tap water temperature at 3-month and 12-month post-intervention or randomisation, acceptability, problems with TMVs and bath time safety practices. RESULTS: Intervention arm families had a significantly lower bath hot water temperature at 3-month and 12-month follow-up than families in the control arm (3 months: intervention arm median 45.0°C, control arm median 56.0°C, difference between medians, -11.0, 95% CI -14.3 to -7.7); 12 months: intervention arm median 46.0°C, control arm median 55.0°C, difference between medians -9.0, 95% CI -11.8 to -6.2) They were significantly more likely to be happy or very happy with their bath hot water temperature (RR 1.43, 95% CI 1.05 to 1.93), significantly less likely to report the temperature as being too hot (RR 0.33, 95% CI 0.16 to 0.68) and significantly less likely to report checking the temperature of every bath (RR 0.84, 95% CI 0.73 to 0.97). Seven (15%) intervention arm families reported problems with their TMV. CONCLUSIONS: TMVs and accompanying educational leaflets are effective at reducing bath hot tap water temperatures in the short and longer term and are acceptable to families. Housing providers should consider fitting TMVs in their properties and legislators should consider mandating their use in refurbishments as well as in new builds.

Inequalities in hospital admission rates for unintentional poisoning in young children.

OBJECTIVE: To determine the relationship between deprivation and hospital admission rates for unintentional poisoning, by poisoning agent in children aged 0-4 years. DESIGN: Cross sectional study of routinely collected hospital admissions data. SETTING: East Midlands, UK. PARTICIPANTS: 1469 admissions due to unintentional poisoning over two years. MAIN OUTCOME MEASURE: Hospital admission rates for unintentional poisoning. Incidence rate ratios (IRRs) comparing hospital admission rates for poisoning in the most and least deprived electoral wards. RESULTS: Children in the most deprived wards had admission rates for medicinal poisoning that were 2-3 times higher than those in the least deprived wards (IRR 2.49, 95% CI 1.87 to 3.30). Admission rates for non-medicinal poisoning were about twice as high in the most compared to the least deprived wards (IRR 1.77, 95% CI 1.19 to 2.64). Deprivation gradients were particularly steep for benzodiazepines (IRR 5.63, 95% CI 1.72 to 18.40), antidepressants (IRR 4.58, 95% CI 1.80 to 11.66), cough and cold remedies (IRR 3.93, 95% CI 1.67 to 9.24), and organic solvents (IRR 3.69, 95% CI 1.83 to 7.44). CONCLUSIONS: There are steep deprivation gradients for admissions to hospital for childhood poisoning, with particularly steep gradients for some psychotropic medicines. Interventions to reduce these inequalities should be directed towards areas of greater deprivation.

General practice health checks of elderly people: a county-wide survey.

All general practices in Nottinghamshire were sent a questionnaire to examine the organisation and structure of their annual health checks for elderly people. The results indicated that 99% of responding practices offered checks, yet nearly one quarter estimated that under 50% of their elderly population actually had a check. Many practices had no system for following up old people who did not respond to an invitation for a check. Practices with smaller numbers of elderly people were more likely to estimate high response rates to invitations for a check and more likely to follow-up those who did not respond. The findings are discussed in relation to the reasons why many elderly people do not receive their annual health check.

Changes in the role of general practitioners in child health surveillance.

BACKGROUND: Changes in their Contract in 1990 gave general practitioners the opportunity to become more involved in child health surveillance. This study aimed to describe and compare child health surveillance services provided by general practitioners before and after the changes of the 1990 GP contract. METHODS: A questionnaire was sent to all general practices within the Nottingham Health Authority area in 1990, and this process was repeated in 1994, ascertaining the services provided for child health surveillance. Outcome measures were: the reported provision of services, keeping of records and facilities for following up non-attenders. Also recorded were the training and qualifications of general practitioners and their attitudes towards child health surveillance. RESULTS: Response rates were 62% in 1990 and 80% in 1994. More practices were involved in the provision of child health surveillance services in 1994, more held a baby clinic and more reported having a recall system for non-attenders. There was little change in the training or qualifications of GPs in child health between 1990 and 1994. In 1994, there was evidence of GPs meeting regularly with Health Visitors. There remained a small number of practices who were not interested in child health surveillance. CONCLUSION: The 1990 GP contract appears to have increased the provision of child health surveillance services by GPs and improved liaison with Health Visitors in general practice.

Characteristics of patients aged 75 years and over who are discharged from hospital without district nursing support.

To investigate the state of health and needs of over-75-year-olds discharged from hospital and not referred to the District Nurse Service, patients in this age group who were discharged from hospital, who returned to their own or a relative's home and were not referred to the District Nurse Service were interviewed by Health Visitors during their normal post-discharge visit. Assessment was by a questionnaire on details of discharge, statutory, voluntary and informal support, physical status, disability level, ability to self-care and mental status. It was found that there was wide variation in timing of Health Visitors' post-discharge visits, and most patients had had some contact with their GP before this visit. Almost half the patients were discharged from General Surgery or surgical specialties. Most patients were fairly healthy but a minority had severe disabilities. Physical status, disability level and ability to self-care were related to age and sex of the patient, with older patients and women having poorer health status. Women had poorer mental status than men. It is concluded that the wide variety in health status and needs of this group of patients suggest that they should be taken into account in the planning of new discharge procedures. Closer links between the hospital, community teams and general practice are suggested.

The care of people over 75 years old after discharge from hospital: an evaluation of timetabled visiting by Health Visitor Assistants.

The objective of this study was to evaluate a programme of timetabled visiting by Health Visitor Assistants (HVAs) to patients over 75 years old who were recently discharged from hospital. An outcome evaluation examined whether patients benefited in measured health status and use of services over the year of the programme. A randomly selected group of patients (the intervention group) who were allocated to the programme of visiting were compared with an equal-sized randomly selected group of patients (the control group) who had no timetabled visiting. A process evaluation examined the actions taken by HVAs during their visits and related the actions taken to patients' measured health status and other characteristics. No overall benefit from the programme of visiting was found in the outcome evaluation. There was wide variation in the numbers of actions recorded for different patients. Numbers of HVAs' actions were related to patient's health status and sex, with more actions being initiated for those in poorer health and women. Neither age nor whether the patient lived alone were found to be related to numbers of HVAs' actions. It was concluded that the lack of demonstrated overall benefit and the wide variation in actions taken on patients' behalf suggest that this type of service cannot be recommended for all discharged patients over 75 years. Poor health at the time of discharge is recommended as a first choice of measure for need of support. Exchange of information between general practice and hospital about previous dependency may aid the identification of patients who need post-discharge support.

Is there a role for computerized decision support for drug dosing in general practice? A questionnaire survey.

OBJECTIVE: To determine: (i) whether general practitioners have difficulty with drug dosing; (ii) what information sources they currently use to help them with drug dosing; (iii) their views on the potential value of decision support software for drug dosing. DESIGN: Questionnaire survey. SETTING: Nottingham, U.K. PARTICIPANTS: 263 general practitioners (GPs). RESULTS: The response rate was 78% (263/336). Most GPs reported difficulties with drug dosing for children, the elderly and patients with renal impairment. Compared with 'patients in general', GPs had particular difficulties in drug dosing for these specific groups (P < 0.001). Paper-based formularies were the most common source of information for help with drug doses. Nevertheless, most GPs had positive views on the potential usefulness of computerized decision support. CONCLUSION: GPs commonly have problems in drug dosing for certain groups of patients. The development and use of computerized decision support might help GPs in these situations.