Pre-operative testing for pregnancy in Dublin Day Surgery Units

Background

The safety of anaesthetic agents in early pregnancy cannot be guaranteed. Certain types of surgery, particularly gynaecological, may also be dangerous. It is therefore important to ensure that, female patients are not inadvertently pregnant when undergoing elective surgery. Different hospitals have different policies and guidelines in place to determine female patients’ pregnancy status prior to elective surgery.

Aims

This study aims to evaluate practices in Ireland with regard to methods used to exclude pregnancy in premenopausal women attending for day surgery.

Methods

Postal questionnaires were sent to all consultants in Gynaecology and General Surgery. E-mail questionnaires were sent to all registrar trainees in both specialties. Letters were sent to nine Dublin teaching hospital day surgery units and followed up by telephone consultations.

Results

The overall response rate was poor at 34.3 %. Eighty per cent of respondents in the gynaecology specialty have encountered a preoperative patient with a positive pregnancy test at least once during their career versus 28.6 % in the surgical specialty. Only 35 % of gynaecology respondents would routinely inform female reproductive age patients of the need to avoid pregnancy prior to surgery versus 14.3 % in the surgical specialty. On the day of elective surgery, 90 % of gynaecologists would determine the LMP (last menstrual period) versus 35.7 % of surgeons. The policy at all nine Dublin teaching hospitals is to perform a urinary HCG preoperatively but, their policies vary as to whether the patient’s LMP, age and medical history are considered when performing a urinary HCG test.

Conclusion

It is important that, female patients are counselled appropriately regarding the importance of using adequate contraception or, abstinence in order to avoid pregnancy prior to elective surgical procedures. Our survey shows that, gynaecologists are more likely to give this advice compared to our surgical colleagues. Nevertheless, the number of gynaecologists who do this is surprisingly low (35 %). Urinary HCG is still the standard test used in most units to exclude pregnancy.     

Major otology day case surgery: viable, cost efficient and safe

Background

There has been no study or institution in Ireland promoting major ear surgery performed as a day case procedure in adults. At present, there is a strong political and financial drive for increased elective day case surgery and also a public responsibility to reduce surgical waiting times.

Methods

A prospective study of 43-day case otology patients who underwent major otological surgeries over an 18-month period in a tertiary referral center. We recorded morbidity, readmission rates and assessed the relationships between procedures performed and complications observed.

Results

We report a same day discharge rate of 88.4% with a next day readmission rate of 2.3%. We report no major morbidities and found no association between the otological procedure performed and complications observed. Furthermore, there was no statistical association between age and complications observed. We have reduced our waiting list from 9 months to 4 weeks over the 18-month period.

Conclusion

Major day case otology surgery is an acceptable alternative to an inpatient procedure with favorable discharge rates in comparison to the UK results. Day surgery in this context is safe, cost efficient and expands the surgical possibilities within our department and specialty.     

Day of surgery admission for the elective surgical in-patient: successful implementation of the Elective Surgery Programme

Background and aims

The aim of this prospective cross-sectional study was to determine the impact of (1) ring fencing in-patient general surgical beds and (2) introducing a pre-operative assessment clinic (PAC) on the day of surgery admission (DOSA) rate in a single Irish institution. The secondary aim was to analyse the impact of an increased rate of DOSA on cost efficiency and patient satisfaction.

Methods

An 18-month period was examined following ring-fencing of elective and emergency surgical beds. A PAC was established during the study period. Prospectively collected data pertaining to all surgical admissions were retrieved using patient administration system software (Powerterm Pro, Eircom Software) and a database of performance information from Irish Public Health Services (HealthStat).

Results

Ring-fencing and PAC establishment was associated with a significant increase in the overall DOSA rate from 56 to 85 %, surpassing the national target rate of DOSA (75 %). Data relating specifically to general surgery admissions mirrored this increase in DOSA rate from a median of 5 patients per month, before the advent of ring-fencing and PAC, to 42 patients per month (p < 0.0387). 100 patient surveys demonstrated high levels of satisfaction with DOSA, with a preference compared to admission one night pre-operatively. Cost analysis demonstrated overall savings of 340,370 Euro from this change in practice.

Conclusion

The present study supports the practice of DOSA through the introduction of ring-fenced surgical beds and PAC. This has been shown to improve hospital resource utilisation and streamline surgical service provision in these economically challenging times.     

Changes in the workload composition in a Plastic Surgery Unit over a 12 year period

Background

Guidelines issued by the British Association of Plastic Reconstructive and Aesthetic Surgeons suggest that the ratio of elective to emergency cases in plastic surgery units should be 2:1.

Aim

To investigate how the workload composition of a regional plastic surgery unit compared with these guidelines.

Methods

The changes in the workload composition of a regional plastic surgery unit were examined by retrospectively analysing all plastic and reconstructive surgery cases performed over 12 years (1998–2009).

Results

This time period saw a change from a 1:2 ratio of elective to trauma procedures, to the recommended ratio, at a time when the overall caseload increased by almost 40 % (3,281 procedures in 1998 to 4,529 procedures in 2009).

Conclusion

Expansion of staff numbers at consultant and non-consultant grades, and increased resources (allocated theatre sessions and outpatient clinics) were pivotal to this change.     

The impact of abdominal aortic aneurysm surgery on intensive care unit resources in an Irish tertiary centre

Background

The potential impact of surgical service reconfiguration on intensive care unit (ICU) resources needs to be assessed.

Aims

To determine the resources required to provide post-operative ICU care to patients undergoing open abdominal aortic aneurysm (AAA) repair or endovascular aneurysm repair (EVAR) at a specialist centre in the HSE South area

Methods

For 198 patients, we calculated: (1) ICU bed-days; (2) organ support required; and (3) monetary cost of ICU care.

Results

In total, 82.8 % (101/122) of patients undergoing open AAA repair required post-operative ICU care (52 emergency and 49 elective). Emergency cases required more ICU bed-days (median 4.2 vs. 1.9, p < 0.0005) and were more likely to require ventilation (odds ratio, OR 11.7, p < 0.0001), inotropes (OR 3.1, p = 0.01) or enteral nutrition (OR 23.3, p < 0.0001). Mean cost per patient was €3,956 for elective cases and €16,419 for emergency cases. No patient required ICU admission after EVAR (n = 76).

Conclusions

Open AAA surgery places significant demands on ICU resources. The planned reconfiguration of surgical services in Ireland must provide for parallel investment in ICU facilities and expertise.     

An anaesthetic pre-operative assessment clinic reduces pre-operative inpatient stay in patients requiring major vascular surgery

Background

Patients undergoing major vascular surgery (MVS) require extensive anaesthetic assessment. This can require extended pre-operative stays.

Aims

We investigated whether a newly established anaesthetic pre-operative assessment clinic (PAC) would reduce the pre-operative inpatient stay, avoid unnecessary investigations and facilitate day before surgery (DBS) admissions for patients undergoing MVS.

Patient and methods

One year following and preceding the establishment of the PAC the records of patients undergoing open or endovascular aortic aneurysm repair, carotid endarterectomy and infra-inguinal bypass were reviewed to measure pre-operative length of stay (LoS).

Results

Pre-operative LoS was significantly reduced in the study period (1.85 vs. 4.2?days, respectively, P?P?=?0.0002). No procedure was cancelled for medical reasons.

Conclusion

The PAC has facilitated accurate outpatient anaesthetic assessment for patients requiring MVS. The pre-operative in-patient stay has been significantly reduced.     

A budget impact analysis of natalizumab use in Ireland

Background

Multiple sclerosis is the commonest cause of disability in young Irish adults. Natalizumab reduces disability progression in those patients with relapsing remitting multiple sclerosis who are suitable for it. First line disease modifying therapies are given in the community and are paid for by the hi-tech drug scheme. Natalizumab is given in hospital and is paid for from the hospital??s budget. Access to natalizumab has been problematic in some Irish hospitals. A budget impact analysis was performed to look at the overall cost to the Health Service Executive of giving natalizumab.

Methods

A budget impact analysis was performed from the perspective of the Health Service Executive comparing the use of natalizumab with first line disease modifying therapies for 2009?C2011.

Results

The study showed that currently, the use of natalizumab is likely to be cost saving to the Health Service Executive overall, because some of the costs for natalizumab are borne by private insurers, whereas, all of the costs of disease modifying therapies are borne by the Health Service Executive.

Conclusions

Although the use of natalizumab is cost saving, current funding arrangements in the Health Service Executive do not allow for the transfer of money saved from drugs paid for in the hi-tech scheme, to hospitals who are supplying alternative treatments.     

Antibiotic prophylaxis for transrectal ultrasound biopsy of the prostate in Ireland

Introduction

Prostate cancer is the most common solid cancer affecting men in Ireland. Transrectal ultrasound (TRUS) biopsies of the prostate are routinely performed to diagnose prostate cancer. They are, in general, a safe procedure but are associated with a significant risk of infective complications ranging from fever, urinary tract infection to severe urosepsis. At present, there are no recommended national guidelines on the use of antibiotic prophylaxis to minimise the risk of infective complications post-TRUS biopsy.

Aim

To review the antibiotic prophylaxis for TRUS biopsy used in Irish hospitals.

Method

We used a standard telephone questionnaire to establish what antibiotic protocol is in use in each hospital.

Results

40 hospitals were contacted, of which 29 perform TRUS biopsies. In the majority of hospitals, TRUS biopsies are carried out in the radiology department. All hospitals administer antibiotic prophylaxis but there is wide variation in the protocols used. There are five different antibiotics prescribed, ciprofloxacin being the most common. Treatment protocols vary from 1 to 10?days antibiotic cover post procedure.

Conclusion

There is a lack of standardisation of antibiotic prophylaxis in Irish hospitals. There is a need for guidelines to clarify the most appropriate antibiotic, route of administration and duration of treatment.     

A multicentre analysis of troponin use in clinical practice

Background

The role of troponin quantification in evaluation of patients with suspected acute coronary syndrome is established, but with cost implications. Emerging high-sensitivity troponin and novel multi-marker assays herald further resource implications.

Aims

The objective of this study was to quantify recent trends in troponin usage and costs in a cross-section of hospitals.

Methods

A cross-sectional survey seeking data on troponin usage and costs from six tertiary referral, public access teaching hospitals for consecutive years between 2003 and 2009 was carried out.

Results

A median annual increase in the volume of troponin assays requested was identified in all six hospitals, with an average median annual increase of 6.9 % across hospitals (interquartile range 3.4, 10.1 %). This annual increase was not accompanied by a corresponding increase in volume of patients presenting to the Emergency Department (ED) with chest pain. The majority (44–67 %) of troponin requests originated in the ED of hospitals. The median annual spend on troponins per hospital was €115,612 (interquartile range €80,452, €140,918). An analysis of results of assays performed in one centre found that the majority (91 %) of troponin assays performed were in the normal range.

Conclusions

An annual increase in troponin requests without a corresponding increase in patient activity raises the possibility of increasingly indiscriminate troponin testing. The cumulative direct and indirect costs of inappropriate testing are significant. Corrective strategies are necessary to improve patient selection and testing protocols, particularly in the advent of the high-sensitivity troponin assays and novel multi-marker strategies.     

Is point of care testing in Irish hospitals ready for the laboratory modernisation process? An audit against the current national Irish guidelines

Background

The Laboratory modernisation process in Ireland will include point of care testing (POCT) as one of its central tenets. However, a previous baseline survey showed that POCT was under-resourced particularly with respect to information technology (IT) and staffing.

Aims

An audit was undertaken to see if POCT services had improved since the publication of National Guidelines and if such services were ready for the major changes in laboratory medicine as envisaged by the Health Service Executive.

Methods

The 15 recommendations of the 2007 Guidelines were used as a template for a questionnaire, which was distributed by the Irish External Quality Assessment Scheme.

Results

Thirty-nine of a possible 45 acute hospitals replied. Only a quarter of respondent hospitals had POCT committees, however, allocation of staff to POCT had doubled since the first baseline survey. Poor IT infrastructure, the use of unapproved devices, and low levels of adverse incident reporting were still major issues.

Conclusions

Point of care testing remains under-resourced, despite the roll out of such devices throughout the health service including primary care. The present high standards of laboratory medicine may not be maintained if the quality and cost-effectiveness of POCT is not controlled. Adherence to national Guidelines and adequate resourcing is essential to ensure patient safety.     

The impact of the establishment of a surgical high dependency unit on management of Abdominal Aortic Aneurysm

Background

Our ability to maintain satisfactory levels of outcome after elective abdominal aortic aneurysm (AAA) surgery is increasingly strained by rising levels of co-morbidity in the presenting population. In this study we present a comparative outcome analysis of patients undergoing elective AAA surgery 18 months before and after the establishment of a surgical high dependency unit (HDU).

Methods

The preoperative status (ASA &; POSSUM scores), operative factors and postoperative outcomes as well as duration of stay were calculated for 104 patients undergoing elective AAA repair (57 prior to the HDU opening and 47 patients afterwards).

Results

Patients undergoing surgery in the latter period had significantly higher ASA (2.5±0.06 versus 2.7±0.7; p = 0.007), overall POSSUM (33.2±0.5 versus 35.5±0.8; p = 0.02) and physiological POSSUM (16.3±0.3 versus 15.5±0.2; p = 0.048) scores than those operated on prior to establishment of the HDU (data are mean±SEM; 2-tailed p-score).The two groups had similar total lengths of hospital stay (518 versus 534 days). However, following establishment of the HDU patients occupied fewer ICU bed days (110 versus 181). This resulted in a saving of 50,750.

Conclusion

The efficiency and quality of care following elective AAA surgery can be improved by provision of HDU step-down facilities without significantly increased expenditure.     

The effect of inclement weather on trauma orthopaedic workload

Background

Climate change models predict increasing frequency of extreme weather. One of the challenges hospitals face is how to make sure they have adequate staffing at various times of the year.

Aims

The aim of this study was to examine the effect of this severe inclement weather on hospital admissions, operative workload and cost in the Irish setting. We hypothesised that there is a direct relationship between cold weather and workload in a regional orthopaedic trauma unit.

Methods

Trauma orthopaedic workload in a regional trauma unit was examined over 2 months between December 2009 and January 2010. This corresponded with a period of severe inclement weather.

Results

We identified a direct correlation between the drop in temperature and increase in workload, with a corresponding increase in demand on resources.

Conclusions

Significant cost savings could be made if these injuries were prevented. While the information contained in this study is important in the context of resource planning and staffing of hospital trauma units, it also highlights the vulnerability of the Irish population to wintery weather.     

Readability and content of patient information leaflets for endoscopic procedures

Background

Informed consent requires good communication. Patient information leaflets (PILs) may be helpful, although some PILs are too hard to read for the average patient.

Aims

We sought to examine the readability of PILs provided for patients prior to endoscopic procedures in 24 gastrointestinal and 16 respiratory departments of 24 Irish public hospitals.

Methods

Readability, measured using the Flesch Reading Ease and the Flesch–Kincaid Grade Level scores, and content of all PILs were examined.

Results

We received 61 PILs from 17 gastrointestinal and 7 respiratory departments, a response rate of 60 % (24/40). Overall, 38 (62 %) PILs met a minimum standard of a Reading Ease score of 60 or more. Only two (3 %) PILs met the optimal reading standard of being comprehensible to an average 10- to 11-year-old, while 35 (57 %) PILs would be comprehensible to an average 13- to 14-year-old. There were striking differences between PILs (and particular departments) in the amount of information given regarding potential complications—in particular, serious complications. With the exception of PILs for endoscopic retrograde cholangiopancreatography, less than half of PILs mentioned death as a possible rare outcome.

Conclusions

This study raises significant concerns about the readability and content of current Irish PILs, and it is unlikely that these issues are restricted to leaflets given prior to endoscopy. A standardised approach to developing PILs for common elective procedures, with minimum standards for readability and a uniform approach, based on current Irish legal requirements, to risk disclosure, might be helpful.     

An economic analysis of money follows the patient

Introduction

As part of the proposed changes to re-design the Irish health-care system, the Department of Health (money follows the patient—policy paper on hospital financing, 2013b) outlined a new funding model for Irish hospitals—money follows the patient (MFTP). This will replace the existing system which is predominately prospective with hospitals receiving a block grant per annum. MFTP will fund episodes of care rather than hospitals. Thus, hospital revenue will be directly linked to activity [activity-based funding (ABF)].

Theory and literature review

With ABF there is a fundamental shift to a system where hospitals generate their own income and this changes incentive structures. While some of these incentives are intended (reducing cost per case and increasing coding quality), others are less intended and less desirable. As a result, there may be reductions in quality, upcoding, cream skimming and increased pressure on other parts of the health system. In addition, MFTP may distort health system priorities. There are some feasibility concerns associated with the implementation of MFTP. Data collection, coding and classification capacity are crucial for its success. While MFTP can build on existing systems, significant investment is required for its success. This includes investment in coding and classification, infrastructure, skills, IT, contracting, commissioning, auditing and performance monitoring systems.

Conclusions

Despite the challenges facing implementers, MFTP could greatly improve the transparency and accountability of the system. Thus if the downside risks are managed, there is potential for MFTP to confer significant benefits to Irish hospital care.     

Who gets admitted? Study of referrals and admissions to an adolescent psychiatry inpatient facility over a 6-month period

Background

Child and adolescent psychiatry services have historically been neglected in Ireland, in terms of resource provision and research.

Aim

To describe referral and admission patterns to an adolescent inpatient unit in Ireland.

Methods

We studied reasons for referral and admission decisions relating to all adolescents referred to St. Joseph??s Adolescent Inpatient Unit (AIPU), Dublin in the first 6?months following its establishment in 2009.

Results

Forty-one adolescents were referred during the study period; 46?% were admitted. There was no difference between those admitted and not admitted in terms of gender (two-thirds were female), age (mean age 16.2?years), most common reason for referral (depression, in almost one-in-two) and suicidality (present in one-in-two). Amongst those referred, 46?% were resident in the primary catchment area. While a majority of admissions occurred within 5?days of referral (53?%), a significant minority were not admitted until over 20?days after referral (16?%).

Conclusions

The demographic and clinical characteristics of adolescents referred and admitted to St. Joseph??s AIPU are consistent with national and international patterns. At national level, the opening of additional beds for adolescents (such as St. Joseph??s AIPU) has had positive effects on admission patterns; our findings indicate a need to further educate referrers about referral criteria, to optimise benefits derived from these new resources. Future studies could examine the potential roles of intensive support services in the community to further maximise use of scarce resources for this patient group.     

Life after the cancer strategy: analysis of surgical workload in the general hospital setting

Background

The National Cancer Strategy heralded a major reorganisation of the delivery of cancer services in Ireland. As a result of this policy, cancer care was centralised to eight centres. The impact of this strategy on hospitals no longer providing cancer services has not been analysed to date.

Aim

The aim of this study was to examine the impact of centralisation of cancer services on surgical workload at Mayo General Hospital.

Methods

Data pertaining to all surgical procedures performed in 2007 (prior to the introduction of the National Cancer Strategy) and 2011 were obtained using the Hospital Inpatient Enquiry system. Histopathology reports and theatre registers were also analysed to ensure accuracy of the data.

Results

The numbers of elective and emergency surgical admissions during 2007 and 2011 were broadly similar (2,581 vs. 2,662). One hundred and thirty-five oncological procedures (colorectal and breast) were carried out in 2007 compared with 50 (colorectal) in 2011. This represents a 63 % reduction in cancer surgery workload following the implementation of the National Cancer Strategy. There was a concomitant increase in surgery performed for benign conditions (laparoscopic cholecystectomy and hernia repair), which coincided with the innovative introduction of 43 ring-fenced surgical in-patient beds in June 2010.

Conclusion

This study demonstrates the impact of the centralisation of cancer services on surgical workload in a non-cancer centre. Our results show that there continues to be a role for general hospitals in the provision of elective surgical services. Hospital network arrangements have the potential to facilitate such developments.     

Audit of rapid access introduction reveals high prevalence of prostate cancer in Western Region

Introduction

Men with symptoms suggestive of prostate cancer are now directly referred by their general practitioners to rapid access prostate assessment clinics (RAPACs). This service implements recommendations outlined by the National Cancer Control Programme. The RAPAC was introduced at Galway University Hospital, Galway, Ireland in June 2009, aiming to structure GP referral of patients with suspected prostate cancer to a urology service.

Aims

The aims of this study are to assess our initial experience with particular emphasis on access times, patient demographics, detection rates and treatment outcomes.

Methods

Data on all patients presenting to the RAPAC during the preliminary 2-year period have been gathered prospectively and analysed using standard parametric analysis methods.

Results

A total of 1,106 patients were reviewed at 278 clinic sessions during the initial 2-year period. The average waiting time to first clinic visit was 18 days (12–39 days). The mean age of referral to the clinic is 65 years (44–88 years). The mean PSA is 16.31 g/dL (0.4–845 g/dL). Of the 1106 patients undergoing TRUS biopsies, 503 (45.5 %) patients were diagnosed with prostate cancer. Further analysis patient demographics and cancer grading is presented in the article. Seventy-one patients (14.1 %) underwent radical retropubic prostatectomy. Sixty-seven patients (13.3 %) are being followed on an active monitoring programme, whilst 235 (56.7 %) received primary treatment with external beam radiotherapy and 68 (13.5 %) received brachytherapy.

Conclusion

This data highlight the necessity of a RAPAC to streamline the provision of prostate cancer services in the west of Ireland.     

Who goes where? A prospective study of referral patterns within a newly established primary care team

Background

Since the introduction of primary care teams, referral patterns of General Practitioners (GPs) in Ireland have not been studied.

Aims

To study the referral patterns of GPs within a primary care team (PCT) to allied health care professionals in a PCT and to secondary care. To identify indirect referral pathways. To study variation in individual GP referral patterns.

Method

Questionnaire based survey. Statistical analysis was carried out using Epi Info version 3.5.1.

Results

Of 3,166 consultations, 2,841 (89.7%) were dealt with by the GP and required no referral, 107 (3.4%) were referred within the PCT, and 218 (6.9%) were referred elsewhere. Therefore, 93.1% of consultations were managed in primary care alone. Ninety percent of GPs refer patients to the PCT. Indirect referrals constituted 17% of all outpatient referrals. Females have significantly higher referral rates than males. Referral rates of GPs in single-handed practices are higher than GPs in group practices.

Conclusions

GPs alone can manage the vast majority of presentations in general practice. Greater GP access to diagnostic and therapeutic interventions may reduce outpatient referrals. GPs in group practices may collectively have greater experience and expertise and therefore can manage more patients in primary care. There is a significant variation in referral rates between both genders.     

Managing chronic disease in Ireland: hospital admission rates and clinical outcomes in a large ulcerative colitis population

Background

Health care planning demands a detailed knowledge of the course of chronic diseases in the Irish population. This study describes hospital admission rates, medication use and outcomes in a large cohort of patients with ulcerative colitis attending a tertiary referral centre in Ireland.

Method

Four hundred and twenty-four patients who attended during the 18-year period from January 1991 to January 2009 were identified. Baseline demographics, hospital admission, medications required, extent of colitis and date of colectomy were recorded.

Results

More than half (55.4%) of the patients were managed exclusively in an outpatient setting throughout diagnosis and follow-up. Systemic corticosteroids, thiopurines and infliximab were required by 70, 29.5 and 5% of the patients, respectively. Overall 5-year colectomy rate due to failure of medical therapy was 15.8%. Independent predictors of colectomy were hospital admission at first presentation (odds ratio 3.6, p?p?Conclusions The majority of patients with colitis have an uncomplicated disease course and do not require thiopurines, biologic agents or hospital admission. Principal management at a primary care level may be appropriate in many cases. Colectomy rates at a specialist centre in Ireland compare favourably with international figures.     

Vitamin B12 status, homocysteine and mortality amongst community-dwelling Irish elders

Background

Vitamin B12 deficiency is associated with hyperhomocysteinaemia, which is associated with atherosclerosis and increased mortality. High levels of vitamin B12 have also been associated with increased mortality in certain patient populations.

Aims

We examined vitamin B12 and homocysteine status and mortality rates in a population of Irish community-dwelling elders over a 3-year period.

Methods

Prospective, community-based observational cohort study.

Results

Subjects in the highest quartile of homocysteine had increased mortality rates (14.68 vs. 7.32%, relative risk 2.09). This relationship was attenuated when controlled for the presence or absence of a history of stroke or myocardial infarction. There was no relationship between vitamin B12 status and mortality during the observation period.

Conclusion

Vitamin B12 levels are not associated with death rates in Irish community-dwelling elders. Homocysteine levels are associated with mortality and may act via the mechanism of atherosclerotic disease.