International Journal of Risk & Safety in Medicine - Volume Pre-press, issue Pre-press
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The International Journal of Risk and Safety in Medicine is concerned with rendering the practice of medicine as safe as it can be; that involves promoting the highest possible quality of care, but also examining how those risks which are inevitable can be contained and managed.
This is not exclusively a drugs journal. Recently it was decided to include in the subtitle of the journal three items to better indicate the scope of the journal, i.e. patient safety, pharmacovigilance and liability and the Editorial Board was adjusted accordingly. For each of these sections an Associate Editor was invited. We especially want to emphasize patient safety. Our journal wants to publish high quality interdisciplinary papers related to patient safety, not the ones for domain specialists. For quite some time we have also been devoting some pages in every issue to what we simply call WHO news. This affinity with WHO underlines both the International character of the journal and the subject matter we want to cover. Basic research, reports of clinical experience and overviews will all be considered for publication, but since major reviews of the literature are often written at the invitation of the Editorial Board it is generally advisable to consult with the Editor in advance. Submission of news items will be appreciated, as will be the contribution of letters on topics which have been dealt with in the journal.
Abstract: BACKGROUND: Gender dysphoria is characterised by a sense of distress because of discordance between the self-perception of gender identity and the assigned sex. Hormonal treatment of transgender males uses testosterone to induce and preserve masculinisation. OBJECTIVE: The study investigated the safety of testosterone therapy in transgender males. METHODS: The present study used a retrospective file review of transgender male subjects who were treated with testosterone (initially transdermal testosterone gel and subsequently parenteral testosterone undecanoate) for at least 18 months and had subsequently achieved a serum testosterone level within the normal range of cisgender male counterparts. Changes…in somatometric data and blood biomarkers were investigated. RESULTS: The mean testosterone serum levels after approximately 18 months of treatment were about 545 ng/dL (SD ± 94 ng/dL). There was a statistically significant rise in body mass index (𝜒d = +1.23 kg/m2 ) with a reduction in blood glucose (𝜒d = −5.33 mg/dL) as well as statistically significant increases in aspartate transaminase (𝜒d = +4.3 U/L), haemoglobin (𝜒d = +1.72 g/dL) and haematocrit (𝜒d = +4.76%). In contrast, there were no significant changes in the lipidaemic profile of the subjects. CONCLUSIONS: Treatment with testosterone is routinely used for the promotion of virilising physical changes in transgender males. However, the likelihood of adverse effects of continuous administration treatment is still unclear. This study contributed to the notion that achieving testosterone levels within the target range is a prerequisite for the safety of the gender-affirming treatment.
Keywords: Transgender persons, testosterone, evidence-based medicine
Abstract: BACKGROUND: The General Medical Council (GMC) states that all intimate examinations should have a chaperone offered. Documentation of chaperone identity, or patient’s refusal, is essential. OBJECTIVE: This project aimed to improve documentation of chaperones during intimate examination of patients based in a Surgical Admissions Unit (SAU) within a large tertiary hospital in the Southwest of the UK. METHODS: A Plan-Do-Study-Act (PDSA) cycle structure was used. Initial data collection and planning occurred in December 2019. Intervention implementation and analysis occurred from January 2020 to March 2021. Intervention 1 involved presenting results at a clinical governance meeting. Intervention…2 was information posters in the SAU and intervention 3 involved training sessions for nursing staff. Intervention 4 was editing the surgical clerking proforma. RESULTS: Prior to interventions, chaperone identity or patient’s refusal was correctly documented only 9.7% (N = 7 out of 72) of the time. Intervention 1 increased this to 34.6%. Following intervention 3 and 4, correct documentation was 25.0% and 28.6% respectively. After intervention 4 correct documentation was at 59.1%. CONCLUSIONS: Initial documentation of chaperones was poor. Interventions 1 to 3 were successful in educating clinicians how to document accurately, but engaging individuals in person was more successful than passive education through posters. Changing the proforma structure was the most successful intervention. This suggests a visual reminder for clinicians at the point of contact with the patient is the most effective way to encourage correct documentation of chaperones, improving patient care and clinical practice.
Abstract: BACKGROUND: Previous reports have shown that there are long waiting times to commence therapy in the community-based mental health programme, IAPT (Improving Access to Psychological Therapies). OBJECTIVE: This study aimed to explore both causes and potential solutions to alleviate the burden of these waits. METHODS: A Systematic Literature Review (SLR) and Semi-Structured Interviews (SSIs) were conducted to identify causes and effects of these waits. Consequently, meaningful recommendations were made and tested with the aim of improving IAPT’s waiting times. RESULTS: SLR and SSIs revealed high ‘Did Not Attend’ (DNA) rates and a lack of…support between initial appointments as being both a cause and effect of long waits. The identified issues were tackled with the development of an App design. Expert interviews and a mass survey fuelled the iterative process leading to a final prototype. Notable features included: therapist profile page, smart appointment reminders and patient timeline. Positive feedback was received from university students and ICS Digital, with scope to trial the App within Manchester CCG. CONCLUSIONS: In the long run, the App aims to indirectly shorten waiting times by addressing treatment expectations and serving as an IAPT companion along the patient journey, thus reducing anxiety and consequently DNAs.
Abstract: BACKGROUND: Since the outbreak of the coronavirus (SARS-Cov-2), wearing personal protective equipment (PPE) has become necessary. Patients’ ability to recognize staff is disrupted impacting on the relationship between healthcare worker and patient. OBJECTIVE: Assess the patients’ perspective of healthcare workers wearing PPE and its effect on communication. METHODS: Admitted Orthopaedic patients during the first wave of SARS-Cov-2 were surveyed about the experience with staff wearing PPE. In response to feedback, individual badges with large pictures and names were introduced to wear over PPE. Patient views and response to the badges was collected from surveying admitted patients.…RESULTS: Patients encountered staff wearing face masks and felt this was appropriate in the context of the pandemic. 44% responded that they would prefer staff wearing badges with names, roles and pictures more visible. Following the introduction of badges, patients were better able to recognize staff roles and remember names. Hospital staff felt this was a positive change to help improve rapport while wearing PPE. CONCLUSION: Wearing PPE affects patients’ ability to recognize individuals in a fast-paced environment such as an acute hospital. Introducing badges was an intervention based on patient feedback and an important adaptation to sustained PPE use to improve the patient’s experience.
Keywords: COVID-19, SARS-Cov-2, PPE, patients’ perception, communication
Abstract: BACKGROUND: The Nightingale North West (NNW) was a UK temporary field hospital set up during the COVID-19 pandemic. Policies and standard operating procedures were undeveloped. Visitors were permitted only in exceptional circumstances, resulting in heightened anxiety for patients and next of kin (NOK). OBJECTIVE: Recognising the importance of effective NOK communication, a quality improvement project (QIP) was undertaken to improve communication between doctors and NOK. METHOD: NOK satisfaction with communication received from doctors (scored 1–5) was the primary outcome measure and data was collected through standardised phone-calls. A wide four point (1–5) variability in satisfaction was…identified. PDSA methodology was used to introduce interventions: (1) ‘Gold standard’ for frequency of NOK updates; (2) Record date of NOK update on the doctors’ list. RESULTS: Early post-intervention data showed reduced variability in satisfaction with 82% of NOK scoring ‘4’ or ‘5’. Process measures demonstrated excellent uptake of interventions. CONCLUSION: Conclusions are limited by the project’s short time-frame but there is a promising role for these interventions in enhancing doctor-NOK communication.
Abstract: BACKGROUND: Patients in psychiatric inpatient settings are at increased risk of developing physical health complications due to the structure of inpatient wards, the metabolic side-effects of antipsychotic medications and socioeconomic factors. Robust physical health monitoring and interventions are paramount in reducing this health inequality. OBJECTIVE: To improve the quality of physical health interventions in the ward environment and empower patients to follow healthy lifestyle guidance to reduce their risk of metabolic syndrome. METHODS: Patient weight and waist circumference data were collected at baseline and weekly throughout the 8-week intervention period. A questionnaire was recorded from baseline…to week-5 to assess patient understanding. Two PDSA cycles were completed: (1) Series of weekly psychoeducation sessions and group exercise and (2) Implementation of healthy living diaries. RESULTS: Our data did not demonstrate any definitive impact upon the waist circumference and weight of participants. However, analysis of the questionnaires showed a consistent trend in knowledge improvement. CONCLUSION: Whilst our aim of reducing patient weight and waist circumference was not realised, there was a significant impact on participant’s knowledge, demonstrating a subjective benefit of our interventions. Our project also highlighted inconsistencies in physical health measurements and data collection, providing vital information for further quality improvement measures.
Abstract: BACKGROUND: In 2011 Mrs A assaulted two people, one who died. In the hours prior to the attack she made multiple attempts to gain help including attending accident and emergency, contact with an inpatient service and the police. Subsequent investigation highlighted that her risk was not well documented or understood. OBJECTIVE: This quality improvement project aimed to improve knowledge and awareness of HCR-20 risk assessments amongst mental health professionals. METHOD: The Quality Improvement approach was taken and various initiatives were introduced to improve knowledge of the location and purpose of the HCR-20 and to ensure that…these risk assessments were regularly updated. RESULTS: The results indicated that knowledge relating to the HCR-20 significantly improved amongst staff and breaches of deadlines for updating these risk assessments dramatically declined after the induction of the interventions. CONCLUSION: Including the ‘risk formulation’ and ‘scenarios’ from the HCR-20 in clients’ crisis plans, introducing training relating to the HCR-20, and including discussions relating to the HCR-20 at the beginning of CPA meetings resulted in improved MDT awareness and knowledge of the HCR-20. A broader understanding and awareness of risk factors enabled the service to move towards a culture of risk being everyone’s business.
Abstract: BACKGROUND: Advance care treatment escalation plans (TEPs) are often lost between healthcare settings, leading to duplication of work and loss of patient autonomy. OBJECTIVE: This quality improvement project reviewed the usage of TEP forms and aimed to improve completeness of documentation and visibility between admissions. METHODS: Over four months we monitored TEP form documentation using a standardised data extraction form. This examined section completion, seniority of documenting clinician and transfer of forms to our hospital electronic patient record (EPRO). We added reminders to computer monitors on wards to improve EPRO upload. RESULTS: Initial data…demonstrated that 95% of patients (n = 230) had a TEP, with 99% of TEPs recording resuscitation status. However, other sections were not well documented (patient capacity 57% completion and personal priorities 45% completion, respectively). Only 11.9% of TEPs documented consultant involvement. Furthermore, only 44% of TEPs with a do not attempt resuscitation (DNACPR) decision were uploaded. Following this, we added reminders to computer monitors explaining how to upload TEP decisions to EPRO, which increased EPRO uploads to 74%. CONCLUSION: Communication of TEPs needs improving across healthcare settings. This project showed that the use of a physical reminder can greatly improve communication of treatment escalation decisions. Furthermore, this intervention has inspired future projects aiming at making communication more sustainable through the use of discharge summaries.
Keywords: Treatment escalation plans, resuscitation, CPR, communication, advanced care planning
Abstract: BACKGROUND: Malnutrition adversely affects clinical outcomes, necessitating a prompt and accurate assessment of nutritional status on admission. A variety of tools exist to aid nutritional assessment, of which the malnutrition universal screening tool (MUST) is recommended, but remains difficult to implement in practice. OBJECTIVE: The aim of this audit was to improve the utilisation of the malnutrition universal screening tool (MUST) in the Acute Medical Unit (AMU) at Queen Elizabeth Hospital, King’s Lynn. Specifically, patients should have a completed and accurate MUST score within 6 hours of arrival to AMU and high-risk patients (MUST score ≥2) should be referred…to dieticians within 48 hours of admission. The first cycle was conducted by March 2019 and the second cycle was completed 1 year later to allow assessment of interventions actioned after the first cycle. METHODS: We conducted a two-cycle audit evaluating the MUST completion and dietician referral rate of high-risk patients (defined as MUST ≥2) on the Acute Medical Unit in a district general hospital, with the standards of 80% and 100% respectively. A questionnaire was distributed after the first cycle exploring nurses’ current experience and competence in using MUST. RESULTS: In the first cycle, MUST scores were calculated correctly in 111/150 patients (74%) and 1/9 (11%) high-risk patients were referred to dieticians. After interventions, MUST scores were calculated correctly in 77/101 patients (76%) and 2/4 high-risk patients (50%) were referred to dieticians. The nurses (n = 19) who took part in the questionnaire felt confident in MUST completion, but the average score in an objective assessment was 67%. CONCLUSIONS: As per the literature, the first cycle demonstrated the under-utilisation of MUST in clinical practice. In response, we proposed additional face-to-face training for existing staff, the inclusion of an e-learning module within the staff’s induction, and provision of ward MUST ‘troubleshooting’ booklets. MUST utilisation rates improved upon re-auditing, but not to target standards. We will need to consider potential barriers to sustainable change and implement interventions such as identification of nursing champions to overcome them.
Keywords: Malnutrition, dietetics, screening, surveys and questionnaires, quality improvement