Views of UK melanoma patients on routine follow-up care.

Although the need for melanoma follow-up is universally accepted, there is still much debate on the duration and frequency of appointments. The UK guidelines were revised in June 2002 to streamline melanoma follow-up. Following the change in protocol, some of our patients expressed concern at the shorter duration of follow-up. We therefore polled all our active melanoma patients to obtain their views on the outpatient clinics. In particular we asked whether they would be happy to have routine follow-up in a primary care setting. In conjunction with the department of psychology, a short questionnaire was devised assessing patient satisfaction and concerns about follow-up. This was sent to all active melanoma patients in our trust. Out of 304 eligible patients currently attending outpatients, 231 (76%) completed replies were received. Ninety-eight percent of respondents found the clinics to be useful. Twenty two and a half percent felt it was difficult to attend the clinic and this was mainly due to logistical problems, i.e. hospital car parking. The majority were reassured by the clinic visits and felt it was a chance to ask questions and check for new disease. Of the 12% of respondents who had a recurrence, 52% indicated that they had detected it themselves. Sixty percent of patients would be happy to consider routine follow-up with their GP, provided they were suitably experienced and trained. A survey of 50 local GP's found that 70% would be unhappy to monitor their patients. Patients want and benefit from follow-up. However, they are an increasing burden on outpatient clinics, given the increasing incidence of melanoma. GP follow-up may be appropriate for a small subgroup of patients. This combined with shared care and practice based clinical nurse specialists may be the way forward in melanoma follow-up.     

Antenatal anaesthetic assessment of high-risk pregnancy: a survey of UK practice

BACKGROUND: Anaesthetists are frequently involved in the management of high-risk pregnancy. Antenatal referral permits time to prepare an appropriate management plan for labour and delivery. This survey looked at current methods of referral in the UK and the role of a formal clinic. METHOD: A postal questionnaire was sent to lead consultant anaesthetists of 256 UK obstetric units enquiring into methods of referral for high-risk pregnancy. RESULTS: Replies were received from 196 units (response rate 77%). Only 30% of units that responded ran a formal anaesthetic pre-assessment clinic, the remaining 70% relying on ad hoc referrals of high-risk cases. Larger units were more likely to run formal clinics. Some units wishing to introduce a formal clinic had not been able to do so because of financial constraints. CONCLUSION: Most hospitals were satisfied with current arrangements for referral of high-risk pregnancy. A mechanism for anaesthetic referral of high-risk pregnancy is vital, but in many units is not via a formal clinic.     

Evaluation of predicted and actual length of stay in 22 Scottish intensive care units using the APACHE III system. Acute Physiology and Chronic Health Evaluation

The most recent edition of the Acute Physiology and Chronic Health Evaluation provides a prediction of intensive care unit length of stay in addition to the probability of hospital mortality. Intensive care length of stay is an important determinant of intensive care costs and may be an important indicator of quality of care. Data were collected from 22 Scottish intensive care units over a 2-year period to allow comparison of actual intensive care unit length of stay with that predicted by the Acute Physiology and Chronic Health Evaluation III system. Correlation between actual and predicted stay for individual patients was poor. However, performance of the model for patients, grouped either by predicted length of stay or by intensive care unit, indicated that the model stratified patient groups appropriately while demonstrating a consistent bias. Length of stay in Scottish intensive care units was found to be consistently lower than that predicted by a model which is based on intensive care practice in the USA. Variations in severity of illness in intensive care unit populations cannot readily explain differences in intensive care unit length of stay. The availability of a model capable of predicting length of intensive care stay, based on data reflecting practice in the UK, would compliment current methods of assessing effectiveness of intensive care.     

Sedation and neuromuscular blockade in paediatric intensive care: a review of current practice in the UK

BACKGROUND: Our aim was to investigate the current practice of sedation and neuromuscular blockade in critically ill children in paediatric intensive care units (PICUs) in the UK. METHODS: A postal questionnaire was sent to all PICUs in the UK. RESULTS: The most commonly used sedative agents were midazolam in combination with morphine. Written clinical guidelines for the sedation of critically ill children were available in 45% of units. Sedation is formally assessed in 40% of units. Vecuronium is the most commonly used neuromuscular blocking agent. In the UK, 31% of critically ill children are likely to receive neuromuscular blocking agents. Depth of neuromuscular blockade is routinely assessed in 16% of patients. CONCLUSIONS: Relatively few units possess clinical guidelines for the sedation of critically ill children, and only a minority formally assess sedation levels. Where neuromuscular blocking agents are administered, sedation is frequently inadequately assessed and the depth of neuromuscular blockade is rarely estimated.     

Belastungsinkontinenz nach Prostatektomie in der Versorgungswirklichkeit

Background

In the current discussion on the operative therapy of prostate cancer, not only“if” but also“how” play a major role. Both questions are closely related as, e.g. a possible excessive therapy will result in additional suffering due to stress incontinence. For the most common, troublesome and expensive consequences of prostatectomy it is of interest to know which factors play a role in treatment reality and which could possibly be avoided.

Patients and methods

The hospital records of all patients who underwent follow-up treatment after prostatectomy in 2009 at the clinic in the spa park in Bad Wildungen-Reinhardshausen were evaluated with respect to relevant data on outcome and clinical endpoints.

Results

Of the 1,750 patients 405 (23.1?%) were continent on admission and discharge and a further 189 (10.8?%) were continent on discharge so that a total of 594 patients (33.9?%) were continent on discharge. Of the 1,155 patients (66.0?%) who were incontinent on admission and discharge, this remained the same during the rehabilitation period for 727 (62.9?%) who were diurnally incontinent and 659 (57.1?%) who were nocturnally incontinent. For 387 patients (33.5?%) the incontinence decreased during the day and for 370 (32.0?%) during the night, for 34 (3.4?%) the incontinence increased during the day and for 45 (3.9?%) during the night. An age <?60 years was advantageous for maintaining continence and in contrast >?70 years was disadvantageous. Retention of nerves showed a significant effect on maintaining continence. Statistically significant differences between the results of operative procedures and the results of the type of clinic (KKP communal, confessional and private or UK university clinic) were not observed. However, the results of maintaining continence (up to termination of rehabilitation treatment) for the 594 patients (33.9?%) was only achieved by 94 (51?%) of all 183 clinics, i.e. 78 (49.7?%) of the KKP clinics and 14 (53.9?%) of UK clinics. For the certified prostate centers of KKP and UK clinics this amounted to 17 (81?%) and 5 (83.3?%), respectively.

Conclusions

In treatment reality of follow-up treatment of patients after prostatectomy in rehabilitation clinics approximately one third (33.9?%) achieved retention of continence up to discharge. An age <?60 years was advantageous and >?70 years disadvantageous. Bilateral and unilateral retention of nerves significantly improved retention of continence. The operative procedure and type of clinic did not significantly affect the results. However, in approximately one third of patients (33.9?%) retention of continence was achieved by only approximately one half (51.4?%) of all clinics. This shows that in treatment reality, stress incontinence following prostatectomy is avoidably underdeveloped and can be demonstrably increased by suitable operative techniques for sphincter protection.     

Hospital care for adults with cystic fibrosis: an overview and comparison between special cystic fibrosis clinics and general clinics using a patient questionnaire.

BACKGROUND--Provision of medical care for adult patients with cystic fibrosis is an increasing problem as the number of patients surviving into adulthood increases. Recent reports have suggested that care is best provided in specialist centres because of longer survival. Recent changes in the National Health Service funding and delivery of service may adversely affect the provision of such a specialist service. The aim of this study was to assess the current pattern of medical service received by adults with cystic fibrosis and to compare the type of care between special cystic fibrosis and general clinics. METHODS--Confidential postal questionnaires were sent to all 1052 members of the Association of Cystic Fibrosis Adults (ACFA) comprising 59% of the UK population of cystic fibrosis patients over 15 years and 80% over 25 years of age. The response rate was 82%. RESULTS--Two thirds of patients were attending special cystic fibrosis clinics for either adults or adults and children. There were significant differences in the proportion of patients using special cystic fibrosis clinics between regions but not between social class groups. Significant differences between cystic fibrosis and general clinics were noted. Patients attending cystic fibrosis clinics were more likely to have had simple clinical investigations (blood tests, sputum culture, oxygen saturation, chest radiography, weight and lung function measurement) in the previous year. They were also more likely to have received intravenous antibiotics at home, and to have access to paramedical personnel. Patients attending cystic fibrosis clinics were taking higher doses of pancreatic enzyme supplements with respect to quantity and potency of preparation. Such patients also had less severe symptoms irrespective of social class, and were more likely to be satisfied with professional aspects of their care. Regardless of type of clinic, potential deficiencies were identified in overall medical care with omission of clinical investigations in severely affected patients and evidence of undertreated respiratory and digestive symptoms in patients with moderate and severe disease. CONCLUSIONS--This survey provides evidence that adults with cystic fibrosis attending special cystic fibrosis clinics receive more intensive care, have better symptom control, and are more satisfied with the service provided than those attending general clinics.     

Diagnosis, management and prevention of ventilator-associated pneumonia in the UK

BACKGROUND AND OBJECTIVE: Ventilator-associated pneumonia is a nosocomial infection that occurs in patients receiving mechanical ventilation for >48 h. Many aspects of its diagnosis, treatment and management are controversial. We used a postal questionnaire to survey current practice within the UK. METHODS: Questionnaire study of 207 general intensive care units in the UK. RESULTS: The response rate was 77.3%. Regarding diagnosis, 30% of units obtained specimens from the lungs invasively, while the remainder relied on tracheal aspirates. In only 28.2% of units using tracheal aspirates were results reported in a quantitative manner. A clinical suspicion of ventilator-associated pneumonia would lead to the administration of empirical antibiotic therapy in the majority of units (77.2%), opinion being almost equally divided on whether this should be mono (49.1%) or combination therapy (50.9%). Although most units received regular microbiology feedback (90.5%), the involvement of a microbiologist in the antibiotic decision-making process was variable. Antibiotics were continued for a median of 7 days (inter-quartile range 5-8.5, range 2-14 days). Compliance with the principal methods of ventilator-associated pneumonia prevention was good. CONCLUSION: There is widespread variation in the methods used for the diagnosis of ventilator-associated pneumonia within the UK. The majority of units rely on non-quantitative analysis of tracheal aspirates. This technique has a high percentage of false-positives, and suggests widespread over utilization of antibiotics. However, most agree that antibiotics should be given empirically when there is a clinical suspicion of ventilator-associated pneumonia. The widespread introduction of 'ventilator bundles' appears to have ensured that most units actively take measures to prevent ventilator-associated pneumonia.     

The current practice of tracheostomy in the United Kingdom: a postal survey

A postal questionnaire was sent to 228 intensive care units throughout the United Kingdom to determine aspects of current tracheostomy practice. From the number of units responding (n = 178, 78%), the majority (n = 173, 97%) practised percutaneous tracheostomy as opposed to open surgical tracheostomy. The Blue Rhino single dilator was the most popular technique (n = 114, 64%). Percutaneous tracheostomy is increasingly carried out under bronchoscopic guidance (n = 148, 83%); however, there remains considerable variation in the timing of tracheostomy and only 61 units (34%) have set follow-up procedures.     

Cost effectiveness of drotrecogin alfa (activated) for the treatment of severe sepsis in the United Kingdom

Drotrecogin alfa (activated) is licensed in Europe for the treatment of severe sepsis in patients with multiple organ failure. We constructed a model to assess the cost effectiveness of drotrecogin alfa (activated) from the perspective of the UK National Health Service when used in adult intensive care units. Patient outcomes from a 28-day international clinical trial (PROWESS) and a subsequent follow-up study (EVBI) were supplemented with UK data. Cost effectiveness was assessed as incremental cost per life year and per quality adjusted life year saved compared to placebo alongside best usual care. Applying the 28-day mortality outcomes of the PROWESS study, the model produced a cost per life year saved of 4608 UK pounds and cost per quality adjusted life year saved of 6679 UK pounds. Equivalent results using actual hospital outcomes were 7625 UK pounds per life year and 11,051 UK pounds per quality adjusted life year. Drotrecogin alfa (activated) appears cost effective in treating severe sepsis in UK intensive care units.     

Renal replacement therapy for acute renal failure: a survey of practice in adult intensive care units in the United Kingdom

This study surveyed current practice in adult intensive care units in the United Kingdom in three key areas of renal replacement therapy when used for acute renal failure: type of therapy used, typical treatment dose and anticoagulation.
Responses were received from 303 (99%) of the 306 intensive care units. 269 units (89%) provide renal replacement therapy for acute renal failure. Most (65%) use continuous veno-venous haemofiltration as first-line therapy in the majority of patients, though continuous veno-venous haemodiafiltration is used by 31% of units. For haemofiltration, the median typical treatment dose (interquartile range [range]) is 32 ml.kg⁻¹.h⁻¹ (28.6–35.7 [14.3–85.7]), with 49% using a treatment dose of 35 ml.kg⁻¹.h⁻¹ or greater. For haemodiafiltration, the median typical treatment dose (interquartile range [range]) is 44 ml.kg⁻¹.h⁻¹ (28.6–57.1 [21.4–120.7]), with 67% using a treatment dose of 35 ml.kg⁻¹.h⁻¹ or greater. The vast majority of intensive care units use intravenous unfractionated heparin (96%) or epoprostenol (88%) for anticoagulation. Dosage and monitoring of these two agents vary markedly between units. No units use citrate anticoagulation. These results reveal a wide variety of practice in the delivery of renal replacement therapy between intensive care units in the United Kingdom.     

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models

In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn‐specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn‐specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7–32 [0–98])% vs. 8 (1–18 [0–100])%, respectively) but in‐hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn‐specific models for patients managed on both specialist burn and general intensive care units.     

Measurement of intra-abdominal pressure in intensive care units in the United Kingdom: a national postal questionnaire study

Background. To explore the attitudes of intensivists in theUK to intra-abdominal pressure (IAP) measurement and abdominalcompartment syndrome (ACS) and to determine current practice. Methods. A postal questionnaire study addressed to the leadclinician in the intensive care unit was sent to hospitals inthe UK with a general surgical service. Results. Completed questionnaires were received from 137 ofthe 207 hospitals surveyed (66.2% response rate). Only 1.5%of the respondents (n=2) had no prior knowledge of intra-abdominalhypertension and ACS. IAP had been measured on some occasionby 75.9% (n=104) of the respondents, always by the intravesicalroute. Among those intensive care units that measured IAP, in93.2% (n=97) it was only measured when there was a suspicionof the development of ACS; 3.8% of units (n=4) measured IAPon all patients who had undergone an emergency laparotomy, and2.9% (n=3) measured IAP only in those who had undergone emergencylaparotomy associated with massive fluid resuscitation. Therewas major disparity in the frequency of IAP measurement andwhen to recommend abdominal decompression. Conclusions. Despite widespread awareness of IAH and the ACS,many intensive care units never measure the IAP. When it ismeasured, the intravesical route is used exclusively. No consensusexists on optimal timing of measurement or when decompressivelaparotomy should be performed.      

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland

IntroductionThe Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot.Methods and PatientsPatients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient’s clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment.ResultsTo date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment.ConclusionOur experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.     

A survey of interhospital transport of the critically ill child in the United Kingdom

Nineteen paediatric intensive care units were surveyed by questionnaire to provide information on the number of interhospital transfers, the experience of personal accompanying the critically ill child and the equipment available to maintain intensive care during transfer. Replies were received from 17 units. An estimated 800 transfers are performed annually. Three units routinely send intensive care staff to collect patients with an estimated 60% of transfers performed by a variety of staff from referring hospitals. Most respondents believed that existing arrangements for transfer were unsatisfactory, but only four units said that transfer may be prevented or delayed by lack of facilities. We believe that any plan to centralize paediatric intensive care in the UK should also include the means by which to transfer the patient without increasing the risk to the patient.     

Obstetric recovery practice: a survey of UK obstetric anaesthetists

BACKGROUND: The 1998 guidelines for obstetric anaesthesia services state: "postoperative care of the obstetric patient should be in accordance with that of any postoperative patient". We sought to discover whether this standard of care was provided. METHOD: A questionnaire designed to investigate recovery room practice was sent to 251 UK obstetric units. The survey took place between January and June 2003. RESULTS: The response rate was 78%. A total of 123 units (63%) had a dedicated obstetric recovery area. Midwives were exclusively responsible for postoperative parturient care in 113 units (58%) between 0900 and 1700 h and in 124 units (64%) after 1700 h. Dedicated recovery nurses were available in 59 units (30%) during the day, in contrast to 36 units (19%) after 1700 h. The level of background training ranged from no training (39%) to locally organised courses (32%), rotation through surgical areas (21%) and nationally organised English National Board courses (8%). CONCLUSION: The survey demonstrates that current obstetric recovery room practice does not always adhere to the recommended Association of Anaesthetists of Great Britain and Ireland guidelines. The provision of dedicated recovery staff or a cohort of specifically trained midwives may help to improve existing standards.     

Uncertainty and scoring systems

Estimating risks for individual patients facilitates communication with patients, relatives and colleagues, and determines whether further treatment is futile. The process of estimating risks involves mathematics (i.e. scoring systems) and human experience and expertise. Understanding how risks are estimated is important because prognostication is an integral part of any medical specialty. In the USA, such treatment limitation or withdrawal decisions were made on only 7% of all intensive care unit patients but this represented 47% of all deaths on such units. In the UK, data reported by the Intensive Care National Audit and Research Centre suggest that although treatment limitation decisions are made on only 11.8% of patients, this accounts for over 50% of deaths on intensive care. Scoring systems offer a useful adjunct in identifying futility but there are important inherent weaknesses that limit their performance. This review aims to discuss some of these limitations.     

A survey of intensive care unit visiting policies in the United Kingdom

Admission to an intensive care unit is a highly stressful event for both patients and their relatives. Feelings of anxiety, pain, fear and a sense of isolation are often reported by survivors of a critical illness, whilst the majority of relatives report symptoms of anxiety or depression while their relative was in the intensive care unit. Traditionally, infection control concerns and a belief that liberal visiting by patients’ relatives interferes with the provision of patient care have led many units to impose restricted visiting policies. However, recent studies suggest that an open visiting policy with unrestricted visiting hours improve visitors’ satisfaction and reduces anxiety. In order to determine current visiting practice and provision for relatives within intensive care units, a questionnaire was sent to the principal nurse in all units within the United Kingdom. A total of 206 hospitals out of 271 completed the survey (76%). We found that 165 (80.1%) of responding units still impose restricted visiting policies, with wide variations in the facilities available to patients’ relatives.     

Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey

OBJECTIVE: To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence-based. METHODS: In all, 410 consultant urologists practising in UK hospitals were sent a questionnaire about the management of AUR secondary to BPH. Data were collected on practice relating to initial management, trial without catheter (TWOC), the use of alpha-blockers and the follow-up. The need for a uniform guideline in the management of AUR secondary to BPH was also assessed. RESULTS: We received 270 (66%) replies, of which six were excluded because they were from subspeciality interests (e.g. paediatric urology) or had ambiguous answers; 264 (64%) were therefore available for analysis. Urethral catheterization was the initial management of choice (98%), failing which a suprapubic catheter was inserted. Two-thirds (65.5%) admitted the patient after catheterization. Most consultants initiated alpha-blockers (70.5%), with 64% (118) of these using a TWOC 2 days after starting them. One failed TWOC was an indication for transurethral resection of the prostate for 192 (72.8%), with 136 (49.8%) re-admitting the patient for surgery later. Routine follow-up after a successful TWOC was advocated by 77.3%. Just over half the respondents (52.6%) felt that there was no need for uniform guidelines in the management of AUR secondary to BPH. CONCLUSION: This survey identified a reasonable national uniformity in managing AUR secondary to BPH in the UK, but significant aspects of current practice are not evidence-based.     

National survey of palliative care in end-stage renal disease in the UK.

BACKGROUND: Palliative care for patients with end-stage renal disease (ESRD) is a neglected aspect of nephrology. We carried out this survey to establish the current pattern of provision of palliative care for ESRD in the UK. METHODS: An anonymous but numbered questionnaire concerning local palliative care provision was sent to clinical directors of all 69 UK renal units. RESULTS: All the questionnaires were returned. Only 27 (39%) units employ nursing or Professions Allied to Medicine (PAM) staff with palliative care for ESRD patients as a specified part of their role. In 19 of these units, staff spend <4 h per week concerned with palliative care and only five units have staff working for >12 h a week in this role. Fifty-five (80%) units do not have a written protocol for palliative care. Anaemic ESRD patients with an expected survival of >3 months receive blood transfusion in 59 (86%) units, intravenous iron in 61 (88%) units and erythropoietin in 63 (91%) units. Only 37 (54%) units kept a record of patients seen by the unit staff but deemed not suitable for dialysis. CONCLUSION: There is a significant variation in provision of palliative care services across the UK. In some areas, access to palliative care is restricted to patients with malignant disease, and ESRD patients are excluded.