Hypertrophic cardiomyopathy: a common disease with a good prognosis. Five year experience of a district general hospital.

The manifestations and workload in a district general hospital cardiac unit of 39 unselected cases of hypertrophic cardiomyopathy over a five year period are reported. The "typical" form with asymmetrical septal hypertrophy and a gradient was found in only one third of patients, serious ventricular arrhythmias were probably no more common than in the general population, and no deaths occurred during a relatively short follow up (mean 3.1 years). It is concluded that although hypertrophic cardiomyopathy occupies a not insignificant proportion of cardiac workload, unselected cases presenting to a district general hospital represent a relatively mild disease without a grave prognosis.     

A psychiatric ward in an African district hospital.

In most African district hospitals there are no separate facilities for psychiatric patients. Aformer general medical officer describes how a ward for these patients was set up at a rural district hospital in Zimbabwe using the already available resources.The effects on the psychiatric care at the hospital and the district are illustrated by two case reports. It is concluded that psychiatric care integrated in primary healthcare, with due regard for the cultural aspects and with cooperation of local healers is feasible, provided that it is supported by additional diagnostic and treatment facilities at the district hospital.     

Correcting a block?: successful experience of a small British pacing centre

The establishment of a local permanent pacemaker service in a district general hospital increased the pacemaker implantation rate from 22 per million population per year to 152 per million population per year over the first 6 years of the service. Forty eight per cent of patients were referred by general practitioners and 52% by hospital specialists. Single chamber demand pacing (VVI) was used exclusively. Indications for pacing and complications were comparable to those of specialist cardiac centres. Management of symptomatic bradycardia by cardiac pacing in the United Kingdom may be facilitated by further development of small pacing centres.     

Correcting a block?: successful experience of a small British pacing centre.

The establishment of a local permanent pacemaker service in a district general hospital increased the pacemaker implantation rate from 22 per million population per year to 152 per million population per year over the first 6 years of the service. Forty eight per cent of patients were referred by general practitioners and 52% by hospital specialists. Single chamber demand pacing (VVI) was used exclusively. Indications for pacing and complications were comparable to those of specialist cardiac centres. Management of symptomatic bradycardia by cardiac pacing in the United Kingdom may be facilitated by further development of small pacing centres.     

The Medical Emergency Team (MET): a model for the district general hospital

Background : Most hospitals have a Cardiac Arrest Team, activated after cardiopulmonary arrest. The Medical Emergency Team (MET) is a newer concept, encompassing a proactive response to a wide range of emergencies with the aim of preventing irreversible organ failure and cardiopulmonary arrest.
Aim : To describe the application of the MET model to the district general hospital, the spectrum of clinical conditions encountered, outcomes and administrative problems.
Method : Data regarding each MET activation was collected prospectively.
Results : The MET responded to 68 calls to 63 patients in 12 months. The mean age was 60.4 years (range: neonatal to 94 years). The most common conditions leading to MET activation were chest pain (19.1%), cardiopulmonary arrest (14.7%), seizures (14.7%) and respiratory distress (13.2%).
Conclusion : This paper demonstrates that the application of the MET model to the district general hospital improves the process of patient care. We are unable to conclude whether the MET alters morbidity or mortality for hospital inpatients.     

Audit of work-load of physicians with a special interest in respiratory medicine

A 6-month prospective survey was undertaken to assess the work-load of two consultant general physicians with special interest in respiratory medicine, one in a teaching hospital (TH) and the other in a district general hospital (DGH). The two firms dealt with similar numbers of inpatients of whom half had non-respiratory disease. Eighty per cent of the outpatient work of both firms was respiratory disease. The TH firm saw more referrals from other consultants and referred more patients, especially to other physicians. Practical procedures performed, the proportion of patients seen by the consultant at first attendance and the range of both respiratory and general medical conditions seen by the two firms was similar.     

A diagnostic service for eliciting carotid sinus hypersensitivity and vasovagal symptoms in a district general hospital

AIM: to describe the technical, diagnostic and logistical problems encountered in a syncope and falls clinic in a district general hospital. METHODS: we have reviewed 157 consecutive patients and the problems encountered in their assessment at the clinic. RESULTS: 143 patients (91%) completed assessment, which included head-up tilt and carotid sinus massage. We reached a diagnosis in 75 of these (52%). Difficulties with continuous blood pressure monitoring caused testing to be abandoned in four cases and caused considerable delay (up to 30 min) in 45% of the rest. Eight patients (5%) refused consent for carotid sinus massage and two others had neurological sequelae. Some patients fulfilled diagnostic criteria on testing but remained asymptomatic, making an attributable diagnosis difficult. This was most noticeable with vasodepressor carotid sinus hypersensitivity. The limited facilities in a district general hospital and the time-consuming nature of the testing resulted in a considerable delay between referral and assessment (58 days +/- 25.9), which may adversely affect diagnostic yield. CONCLUSIONS: syncope clinics have a role in the assessment of elderly people with recurrent syncope and unexplained falls. Enthusiasm for this approach has to be tempered with an awareness of the limitations of the tests involved and an appreciation of the logistical problems likely to be encountered in a district hospital.     

综合医院结核病专科门诊对结核病防治工作的作用

目的　评价综合性医院结核病专科门诊设置对结核病防治工作的作用。方法 分析2003、2005年闵行区疾病预防控制中心报表资料和2005年闵行区各结核病专科门诊登记资料。结果 2004年闵行区在3所综合性医院各增设了1个结核病专科门诊。和2003年相比,2005年闵行区确诊肺结核病例增加118%、其中外来病例增加190%;痰涂片阳性率由31.6%上升到42.4%,治愈率由83.3%到81.7%。结论 综合性医院开设结核病专科门诊提高结核病人的发现率同时,治愈率未见下降,对结核病防治工作起到了明显的促进作用。     

Audit of HIV partner notification in a district general hospital

We evaluated partner notification for HIV in a district general hospital over a two-year period. The majority of current partners were notified and 60% were found to be HIV-positive. No previous partners were successfully notified. We make recommendations intended to improve the rate of notification and testing.     

The effect of a coordinator on cardiac rehabilitation in a district general hospital

The purpose of this study was to compare the recorded evidence for cardiac rehabilitation (CR) before and after the appointment of a CR coordinator in a large district general hospital in the north of England. An audit proforma was used to collect data recorded in the case notes of 200 patients admitted to hospital during this period with the diagnosis of first myocardial infarction. Recorded CR activity was significantly higher (P<0.001) following the appointment of a CR coordinator, and when the patient was under the care of a cardiologist rather than a general physician (P<0.001). The main differences in activities related to the provision of a personal rehabilitation plan, education, counselling and exercise, and referral for invasive diagnostic tests. Little difference was evident in relation to risk factor assessment, exercise assessment and psychological assessment and treatment.     

The socioeconomic burden of hospital acquired infection

Adult inpatients in common specialties who developed hospital acquired infection (HAI) remained in hospital 2.5 times longer, incurred hospital costs almost three times higher, and incurred higher general practitioner, district nurse, and hospital costs a     

Electrophysiology in a district general hospital.

OBJECTIVE--To investigate the feasibility of performing electrophysiological studies at a district general hospital and to evaluate the importance of such studies in the management of patients with suspected arrhythmias. DESIGN--Retrospective study of patients having had electrophysiological studies during a three year period. SETTING--District general hospital. SUBJECTS--93 patients (50 men, 43 women, mean age 45.9 years) with suspected arrhythmias. RESULTS--The patients were divided into two groups according to symptoms. Group 1 (34 patients) presented with syncope. Group 2 (59 patients) presented with palpitation. All had previously undergone non-invasive investigations. All had had multiple hospital admissions and outpatient attendances. In group 1 nine patients with no documented arrhythmias had inducible ventricular tachycardia and three of six with suspected bradyarrhythmias had ventricular tachycardia. Fourteen patients had suspected ventricular arrhythmias before electrophysiological studies, which were confirmed in all, four receiving automatic implantable cardioverter defibrillators. Electrophysiological studies were used to guide drug treatment in all patients. Group 2 consisted of 32 patients with reentrant supraventricular tachycardia and 15 with ventricular tachycardia; 12 had no documented arrhythmias. In those with supraventricular tachycardia, accessory pathways were identified in all. In 23 patients drug treatment (guided by electrophysiological studies) was successful. In nine, drug treatment guided by electrophysiological studies were ineffective and radiofrequency ablation was successful. In 15 patients with ventricular tachycardia and palpitations, 10 had their drugs changed after electrophysiological studies and their ventricular tachycardia was suppressed. In five patients electrophysiological studies showed that ventricular tachycardia was unsuppressed and they were referred for an operation or implantation of an automatic cardioverter defibrillator. In 12 patients with no documented arrhythmias electrophysiological studies identified significant arrhythmias in six. There were no complications. CONCLUSIONS--Diagnostic electrophysiological studies can safely and effectively be performed in a district general hospital. These studies are especially effective in investigating patients with syncope, and also provide a strategy for future arrhythmia management.     

Geriatric follow-up by home visits after discharge from hospital: a randomized controlled trial.

The aim of this prospective, randomized and controlled trial was to carry out and evaluate a model for follow-up by home visits after discharge from hospital of persons aged 75 years or more. The trial was a feasibility study in which hospital staff, district nurses, and general practitioners already working within the hospital and the primary health sector participated, with changes in the usual organization. On the day after their discharge from hospital, 163 patients were visited in their homes by the district nurse. Two weeks later, they were evaluated at home by their general practitioner. For 181 control patients, discharge took place according to the usual procedures. Endpoints were evaluated one year after discharge. Significantly more patients from the control group had been admitted to nursing homes as compared with the trial group (25/10, p < 0.05); the control patients stayed 2700 days at institutions, the trial group 1950 days. It is proposed that this simple and practicable follow-up routine be introduced in connection with discharge of elderly persons from hospital.     

Inappropriate hospital utilization for long-stay patients in southern Taiwan

This study examined the inappropriate utilization of hospital services under the National Health Insurance (NHI) program. The study population consisted of long-stay inpatients who stayed longer than 30 days in acute care hospitals located in southern Taiwan. The study hospitals included four medical centers, six regional hospitals, and 21 district general hospitals. The survey of patients was conducted in January and May of 1996 using the Acute Care Hospital Long-stay Questionnaire developed by the research team. Excluding subjects with missing values and abnormal length of stay, 536 long-stay patients were included in the analysis. Among these, 196 patients (36.6%) were classified as having an inappropriate stay, while 340 patients (63.4%) had an appropriate stay. Of the long-stay patients in medical centers, 32.2% were inappropriate stays; this figure was 45.4% for regional hospitals and 43.3% for district general hospitals. There were significantly higher proportions of inappropriate long-stay patients in regional and district general hospitals than in medical centers. In conclusion, this study confirms the existence of inappropriate hospital bed days, which may be due to patient characteristics, hospital factors, and NHI payment schemes. If the NHI program can provide incentives to long-stay patients who no longer need acute care to move, patients' utilization behaviors might change and hospital discharge plans could be modified for more efficient utilization of hospital beds.     

Teaching evidence-based medicine skills can change practice in a community hospital

OBJECTIVES: Several studies have evaluated whether evidence-based medicine (EBM) training courses can improve skills such as literature searching and critical appraisal but to date, few data exist on whether teaching EBM skills and providing evidence-based resources result in change in behavior or clinical outcomes. This study was conducted to evaluate whether a multifaceted EBM intervention consisting of teaching EBM skills and provision of electronic evidence resources changed clinical practice. DESIGN: Before/after study. SETTING: The medical inpatient units at a district general hospital. PARTICIPANTS: Thirty-five attending physicians and 12 medicine residents. INTERVENTION: A multicomponent EBM intervention was provided including an EBM training course of seven 1-hour sessions, an EBM syllabus and textbook, and provision of evidence-based resources on the hospital network. MEASUREMENTS AND MAIN RESULTS: The primary outcome of the study was the quality of evidence in support of therapies initiated for the primary diagnoses in 483 consecutive patients admitted during the month before and the month after the intervention. Patients admitted after implementation of the EBM intervention were significantly more likely to receive therapies proven to be beneficial in randomized controlled trials (62% vs 49%; P= .016). Of these trial-proven therapies, those offered after the EBM intervention were significantly more likely to be based on high-quality randomized controlled trials (95% vs 87%; P= .023). CONCLUSIONS: A multifaceted intervention designed to teach and support EBM significantly improved evidence-based practice patterns in a district general hospital.     

Methotrexate for Crohn's disease: experience in a district general hospital

Controlled trials have demonstrated the efficacy of methotrexate (MTX) in the induction and maintenance of remission in patients with luminal Crohn's disease, but its use outside of specialist centres remains limited. We present a case series of 24 patients treated with parenteral MTX in a district general hospital. Patients received an induction course of 25 mg weekly for 16 weeks, followed by maintenance doses of 15 mg weekly. Nineteen patients achieved remission during the induction period. Of these, 10 were maintained in remission for more than 12 months. In total, there were six relapses within 1 year and five drug withdrawals due to side effects during the observation period. Of the six relapses, three required surgical intervention (with two of these re-starting methotrexate postoperatively) and three were recommenced on maintenance MTX after a short period at an increased dose. Our results are similar to outcomes achieved in large, randomized, controlled trials and indicate that MTX can be used safely and effectively for the treatment of refractory Crohn's disease in the district general hospital setting.     

Coordination between a district hospital and a reference hospital: evaluation of chest disease care models

Specialised medical care at district hospitals has not been thoroughly defined. Respiratory care data from 2008 in Barbanza and Cee hospitals (Galicia, Spain), were analysed to evaluate different approaches, as they are both similar. Barbanza hospital has a chest diseases clinic run by specialist doctors from the reference hospital three days per week, while Cee hospital is operated by the staff on site. In both cases hospitalisation is the responsibility of the Internal Medicine department. Data was provided by the administrative departments of each hospital and the regional government. Average CDM4 stays were similar for both district hospitals; however, they were lower than in the reference hospital. Charlson scores and re-admissions a month after discharge were similar in both. Barbanza's hospital carried out more functional explorations, both at the centre (957 spirometries vs 21; P<.0001) and at the reference hospital (214 volume/diffusion tests vs 99; P<.001). CPAP treatments were more prevalent in the Barbanza area (3.9 vs 2/1,000 habitants; P<.0001). No differences were found in oxygen therapy and home mechanical ventilation. Mortality due to respiratory disease in 2007 was similar in both regions. Data suggests that in a district hospital scheme supported by chest disease consultants and outpatient clinics gives easier access to specialised, comprehensive and probably, higher quality care than district hospitals without them.     

Short-acting general anaesthesia facilitates therapeutic ERCP in frail elderly patients with benign extra-hepatic biliary disease

AIMS AND OBJECTIVES: To ascertain whether therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for benign biliary disease in frail elderly patients with comorbid conditions can be safely undertaken in a district general hospital, and whether the procedure is facilitated by the use of short-acting general anaesthesia. SETTING: District general hospital in South East England. DESIGN OF STUDY: Clinical study of 25 consecutive patients with benign biliary disease. METHODS: Describes the process of bile duct clearance by therapeutic ERCP under short-acting general anaesthesia in 25 patients with co-morbidity aged > or = 80 years and gives details of the general anaesthesia and monitoring. RESULTS: Twenty-two patients had their bile ducts successfully cleared locally and one patient was stented for a benign biliary stricture. The ampullae of two other patients were lying within diverticula, which hindered cannulation and only pancreatograms were obtained; one of the patients had a successful bile duct clearance at a tertiary centre, the other refused further intervention. Complications (melaena, bronchopneumonia and a Clostridium difficile infection) occurred in two patients (8%). There was no morbidity associated with the anaesthesia, and no mortality occurred within 30 days of the procedure. CONCLUSIONS: Bile duct clearance by therapeutic ERCP can be safely carried out in frail elderly patients in a district general hospital and the process is facilitated by the use of short-acting general anaesthesia. The importance of optimizing the patient's condition before ERCP, and not overfilling the pancreatic duct, is highlighted.     

Tuberculosis patient care decentralised to district clinics with community-based directly observed treatment in a rural district of South Africa.

SETTING: A rural district of the Northern Province, South Africa. OBJECTIVES: To measure the effect of decentralisation of a tuberculosis service in a rural area on treatment outcomes. DESIGN: An intervention study that measured treatment outcomes of patients attending district clinics for tuberculosis treatment and compared these with outcomes of patients attending the district hospital. RESULTS: Over the 4-year period 1992-1995, 928 patients were admitted to the tuberculosis unit of the district hospital. In the initial pre-intervention phase, the best estimate of completed treatment for all 503 cases was 61%, and for 206 new smear-positive patients it was 67%. The intervention process established a tuberculosis control programme with directly observed treatment for all patients, and training and supervision of clinic staff. Ninety per cent of all patients had community-based supporters. For most patients, cure was not proven, but assuming success from completion of and proven adherence to treatment, successful outcomes for new smear-positive cases rose to 82% for decentralised (clinic) treatment, and 88% for those patients who lived in the district but attended the hospital for treatment. CONCLUSIONS: These findings suggest that district clinics can achieve the same good results as the hospital. It is recommended that tuberculosis control needs a dedicated co-ordinator at district level to manage the necessary infrastructural and staff resources.