Improving the safety and effectiveness of urgent and emergency care.

Delays and waiting in urgent and emergency care (UEC) services are causing avoidable harm to patients and affecting staff morale. Patients are often having a poor experience of using UEC services, increasing stress and anxiety for both their families and themselves, delaying their recovery. Despite the constraints of available permanent staffing, funding and competing NHS priorities, changes along the whole UEC pathway in and out of hospital, admitted and non-admitted pathways need to be made safe, timely and accessible, to provide clinically appropriate care for patients. Changes in clinician behaviour, culture, and training toward the management and sharing of clinical risk differently along the whole UEC pathway are also required. Modifying operational processes with a focus on patients in different UEC settings will improve productivity, flow and the patient experience. There is a need to do things differently rather than continuing as we are and expecting a different result to unlock the perennial UEC crisis.

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.

BACKGROUND: Over 138,000 patients are discharged to hospital wards from intensive care units (ICUs) in England, Wales and Northern Ireland annually. More than 8000 die before leaving hospital. In hospital-wide populations, 6.7-18% of deaths have some degree of avoidability. For patients discharged from ICU, neither the proportion of avoidable deaths nor the reasons underlying avoidability have been determined. We undertook a retrospective case record review within the REFLECT study, examining how post-ICU ward care might be improved. METHODS: A multi-centre retrospective case record review of 300 consecutive post-ICU in-hospital deaths, between January 2015 and March 2018, in 3 English hospitals. Trained multi-professional researchers assessed the degree to which each death was avoidable and determined care problems using the established Structured Judgement Review method. RESULTS: Agreement between reviewers was good (weighted Kappa 0.77, 95% CI 0.64-0.88). Discharge from an ICU for end-of-life care occurred in 50/300 patients. Of the remaining 250 patients, death was probably avoidable in 20 (8%, 95% CI 5.0-12.1) and had some degree of avoidability in 65 (26%, 95% CI 20.7-31.9). Common problems included out-of-hours discharge from ICU (168/250, 67.2%), suboptimal rehabilitation (167/241, 69.3%), absent nutritional planning (76/185, 41.1%) and incomplete sepsis management (50/150, 33.3%). CONCLUSIONS: The proportion of deaths in hospital with some degree of avoidability is higher in patients discharged from an ICU than reported in hospital-wide populations. Extrapolating our findings suggests around 550 probably avoidable deaths occur annually in hospital following ICU discharge in England, Wales and Northern Ireland. This avoidability occurs in an elderly frail population with complex needs that current strategies struggle to meet. Problems in post-ICU care are rectifiable but multi-disciplinary. TRIAL REGISTRATION: ISRCTN14658054.

Harm Reduction and Moral Desert in the Context of Drug Policy.

The target of my discussion is intuitions lay people have about justice in the context of drug policy-intuitions that take on a more or less moral-desert-based shape. I argue that even if we think desert is the right measure of how we ought to treat people, we ought still be in favour of Harm Reduction measures for people who use drugs. Harm Reduction measures are controversial with members of the public, and much of the opposition seems to come from something like an appeal to a desert conception of justice-the notion that a just state of affairs is one in which everybody gets what they deserve, no more, no less. A recent study, for example, found that 'moral outrage' predicts a preference for prevalence reduction (criminal sanction, etc.) over Harm Reduction. The thinking seems to be that, since drug use is wrong, letting people who use drugs suffer and/or die as a consequence of their use is just. Aiding their health and safety, while perhaps compassionate, is unjust. I argue that there is a bad desert fit between using drugs and suffering avoidable harm even if using drugs is morally wrong. Many of the possible harms of drug use are socially/policy driven, and much problematic drug use is context dependent, not cleanly attributable to the decisions of the person who uses drugs. This means that even if drug use is wrong, people who use drugs deserve Harm Reduction policies, at minimum.

Improving junior doctor medicine prescribing and patient safety: An intervention using personalised, structured, video-enhanced feedback and deliberate practice.

AIMS: This research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video-enhanced feedback and deliberate practice, undertaken at the start of four-month sub-specialty rotations. METHODS: Three prospective, non-randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break-even analysis evaluated cost-effectiveness. RESULTS: There was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI -0.068 to -0.001). The break-even analysis demonstrates cost-effectiveness for the intervention. CONCLUSION: Simulated clinical encounters using personalised, structured, video-enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost-effective with potential to reduce avoidable harm.

Factors associated with early mortality in non-small cell lung cancer patients following systemic anti-cancer therapy: A 10 year population-based study.

OBJECTIVES: To investigate how clinical, demographic and treatment-related factors in non-small cell lung cancer (NSCLC) patients impact the risk of mortality in the 30 days following receipt of systemic anti-cancer therapies (SACT), and undertake a comprehensive review of the treatment decisions and experiences of a real-world population. MATERIALS AND METHODS: We reviewed NSCLC patients receiving SACT from 2005 to 2014, and captured in the Glans-Look Lung Cancer Database, which contains demographic, clinical, pathological, treatment and outcome data. The 30-day post-SACT mortality rate was calculated, and regimen changes in the last 14 days of life were identified. Univariate analysis and multivariate logistic regression were used to identify demographic, tumor and treatment-related factors that correlated with mortality risk. RESULTS: 1044 patients receiving ≥ 1 cycle of SACT in 2005-2014 were identified. 233 (22.3%) deaths occurred ≤ 30 days following SACT receipt; 32 (13.7%) of which had new SACT regimens ≤ 14 days prior to death. Risk of 30-day mortality and regimen changes at the end of life increased in association with being male [OR: 1.48 (1.12-1.95), p = 0.005], advanced disease at diagnosis [OR: 1.85 (1.19-2.88), p = 0.006], palliative-intent treatment [OR: 6.75 (3.88-11.77), p < 0.001], and use of EGFR-targeting agents [OR: 4.5 (3.27-6.18) p < 0.001]. Risk of early mortality decreased for never-smokers [OR: 0.62 (0.41-0.95), p = 0.028], and those receiving SACT in more recent years (2010-2014) [OR: 0.65 (0.49-0.86), p = 0.002]. CONCLUSION: Our findings identified several factors that affected the risk of early mortality in NSCLC patients following SACT. These results from a representative population provide insights regarding the benefits and risks of SACT and can serve to inform clinical and palliative best practices.

Prevention of dehydration in hospital patients.

Dehydration is widely linked to increased risk of mortality in patients who are acutely unwell, and it also increases the risk of further illness. Despite being recognised nationwide as a cause for concern, 45% of hospital patients will become dehydrated upon admission, suggesting that more needs to be done to prevent dehydration. The use of bedside water devices allows patients to drink freely without assistance. Access to these can reduce a patient's length of stay in hospital and minimise the risk of developing a urinary tract infection. However, further research is needed to fully assess the impact of having such devices at the bedside.

Prevention of dehydration in hospital inpatients.

BACKGROUND: The adverse effects of dehydration in hospital inpatients can be severe, resulting in morbidity and even mortality. This study examined the ability of surgical patients in a district general hospital to undertake the seemingly minor but critically important task of taking on oral fluids using the conventional, hospital-supplied, water jug and glass. METHODS: Surgical patients receiving oral fluids were interviewed on two occasions. A questionnaire assessed the patient's capacity to use the water jug and recorded his or her experience. The patient's ability to use jugs with varying volumes of water was then observed. RESULTS: Some patients simply could not physically lift the conventional jug of water and often went thirsty; 42% of patients could not reach the jug of water at the time of interview; 31% of patients found the simple task of pouring a glass of water difficult, very difficult or impossible. CONCLUSION: Patients need their individual requirements to be assessed and their preferences addressed on admission to hospital, by means of a fluid-assessment chart. Alternative methods of hydration should also be considered. Education and training on the importance of hydration remain key. These small changes could improve patient hydration and independence, thus preventing avoidable harm.