Feasibility and evaluation of an emergency department‐based general practitioner streaming and treatment service

Rationale Offering a primary care service that can provide good quality primary care at emergency departments may reduce pressure on usual emergency department (ED) services. Aims and Objectives To evaluate the acceptability, satisfaction, and potential impacts of a co-located primary care service at an emergency department. Methods This is a prospective feasibility study and service evaluation comprising a narrative summary of activity, satisfaction, well-being, and safety, and comparisons of wait times for ED services by patient category (‘minor’, ‘majors’, ‘paediatric’ or ‘resus’) before and during the service operation. Patients and staff were asked using semistructured interview topic guides about service perception, well-being, representation within 48 h, safety concerns, and/or satisfaction. Wait times for patient categories in usual ED care service were in secondary care electronic records. Pathway changes were captured under primary care electronic records. Results Approximately 96% of general practitioner streaming and treatment (GPST) patients were seen within 1 h. There was a statistically significant reduction in ED patients with minor injuries or illnesses waiting >4 h for admission or discharge ‘breaches’ during the 3 months that GPST was operating compared with the previous 3 months (p ≤ 0.005). Wait times for other ED services did not significantly improve. A total of 769 walk-in patients received GPST consultation and 661 (86%) needed no further ED intervention. Fast discharge was a major determinant of patient satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in eligibility criteria and built environment design features. Conclusion Provision of GPST correlated with shorter waits for discharge from ED. Patient and staff experiences of GPST were positive

Testing for SARS-CoV-2 infection in care home residents and staff in English care homes: A service evaluation

Context COVID-19 is especially dangerous to older adults living in residential care. Objective To evaluate the usefulness of a nurse-led Enhanced Care Home Team (ECHT) SARS-CoV-2 testing strategy to identify resident cases early, identify typical illness presentation residents, and correctly attribute cause of death in care home settings in Norfolk, UK. Method Residents and staff received nose and throat swab tests (7 April to 29 June 2020). Resident test results were linked with symptoms on days 0-14 after test and mortality to 13 July 2020. The data collected were used to evaluate service performance. Findings Residents (n=521) and staff (estimated n=340) in 44 care homes were tested in the ECHT service. SARS-CoV-2 positivity was identified in 103 residents in 14 homes and 49 staff in seven homes. Of 103 SARS-CoV-2+ residents, just 37 had what were understood to be typical COVID-19 symptom(s). Among 51 residents without symptoms when initially tested, 13 (25%) developed symptoms within 14 days. Many SARS-CoV-2+ residents lacked typical symptoms but presented rather as ‘generally unwell’ (n=16). Of 39 resident deaths during the monitoring period, 20 (51%) were initially attributed to SARS-CoV-2, all of whom tested SARS-CoV-2+. One deceased person not initially attributed to SARS-CoV-2 tested positive through a different monitoring programme. 9% of all staff tests were positive. Implications A locally designed and integrated joint nursing and social care team approach successfully identified asymptomatic and pre-symptomatic SARS-CoV-2+ residents and staff. Being ‘generally unwell’ was common amongst symptomatic residents and indicated SARS-CoV-2 infection in older people in the absence of more ‘typical’ symptoms. The service supported correct attribution of cause of death

PPI and Scoping Review for GP at Door of Accident and Emergency services

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Sex-related differences in oncologic outcomes, operative complications and health-related quality of life after curative-intent oesophageal cancer treatment: multicentre retrospective analysis

Background: Oesophageal cancer, in particular adenocarcinoma, has a strong male predominance. However, the impact of patient sex on operative and oncologic outcomes and recovery of health-related quality of life is poorly documented, and was the focus of this large multicentre cohort study. Methods: All consecutive patients who underwent oncological oesophagectomy from 2009 to 2015 in the 20 European iNvestigation of SUrveillance after Resection for Esophageal cancer study group centres were assessed. Clinicopathologic variables, therapeutic approach, postoperative complications, survival and health-related quality of life data were compared between male and female patients. Multivariable analyses adjusted for age, sex, tumour histology, treatment protocol and major complications. Specific subgroup analyses comparing adenocarcinoma versus squamous cell cancer for all key outcomes were performed. Results: Overall, 3974 patients were analysed, 3083 (77.6%) male and 891 (22.4%) female; adenocarcinoma was predominant in both groups, while squamous cell cancer was observed more commonly in female patients (39.8% versus 15.1%, P < 0.001). Multivariable analysis demonstrated improved outcomes in female patients for overall survival (HRmales 1.24, 95% c.i. 1.07 to 1.44) and disease-free survival (HRmales 1.22, 95% c.i. 1.05 to 1.43), which was caused by the adenocarcinoma subgroup, whereas this difference was not confirmed in squamous cell cancer. Male patients presented higher health-related quality of life functional scores but also a higher risk of financial problems, while female patients had lower overall summary scores and more persistent gastrointestinal symptoms. Conclusion: This study reveals uniquely that female sex is associated with more favourable long-term survival after curative treatment for oesophageal cancer, especially adenocarcinoma, although long-term overall and gastrointestinal health-related quality of life are poorer in women

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome

Testing for SARS-CoV-2 in care home staff and residents in English care homes: A service evaluation

Background COVID-19 has especially affected care home residents. Aim To evaluate a nurse-led Enhanced Care Home Team (ECHT) enhanced SARS-CoV-2 testing strategy. Design and setting Service evaluation in care homes in Norfolk UK. Method Residents and staff received nose and throat swab tests (7 April to 29 June 2020). Resident test results were linked with symptoms on days 0-14 after test and mortality to 13 July 2020. Results Residents (n=518) in 44 homes and staff (n=340) in 10 care homes were tested. SARS-CoV-2 positivity was identified in 103 residents in 14 homes and 49 staff in seven homes. Of 103 SARS-CoV-2+ residents, just 38 had typical symptom(s) at time of test (new cough and/or fever). Amongst 54 residents who were completely asymptomatic when tested, 12 (22%) developed symptoms within 14 days. Compared to SARS-CoV-2 negative residents, SARS-CoV-2+ residents were more likely to exhibit typical symptoms (new cough (n=26, p=0.001); fever (n=24, p=<0.001)) or as generally-unwell (n=18, p=0.001). Of 38 resident deaths, 21 (55%) were initially attributed to SARS-CoV-2, all of whom tested SARS-CoV-2+. One death not initially attributed to SARS-CoV-2 also tested positive. Conclusion Testing identified asymptomatic and pre-symptomatic SARS-CoV-2+ residents and staff. Being generally-unwell was common amongst symptomatic residents and may indicate SARS-CoV-2 infection in older people in the absence of more typical symptoms. Where a resident appears generally unwell SARS-CoV-2-infection should be suspected. Protocols for testing involved integrated health and social care teams

Retaining dermatology patients in primary care using dialogues

Background: There are long patient waits for specialist care. A dermatology dialogue service between primary and secondary care (DDPS) was developed in eastern England. Primary care referrers uploaded patient images of skin conditions for review by and dialogue with consultant dermatologists to try to retain patients in primary care rather than be referred to secondary care.   Methods: Evaluation of service performance with respect to specific targets including reduction in secondary care wait list growth in the period April 2021-March 2022 inclusive. Service activity was summarized with respect to speed of resolution, case counts and dispositions. Clinician and patient satisfaction were canvased with structured questionnaires. Actual new referral counts were compared to projections based on historical data. Wait list growth was compared to other specialisms and other commissioning areas. Wait times to receive first treatment were monitored.   Results: Over 3300 patients were enrolled, > 90% of dialogues were resolved within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Wait list growth to see dermatology in the commissioning area was smaller for dermatology than other large specialisms, and mostly smaller growth than dermatology wait lists commissioned by other NHS commissioners. Negative impact on the urgent priority (cancer pathway) wait list could not be observed. Conclusions: The DDPS was satisfactory to clinicians and patients and coincided with smaller dermatology wait list growth than might otherwise have been expected

Feasibility and evaluation of an emergency department-based GP streaming and treatment service

RATIONALE: Offering a primary care service that can provide good quality primary care at emergency departments may reduce pressure on usual ED services.  AIMS AND OBJECTIVES: To evaluate acceptability, satisfaction and potential impacts of a co-located primary care service at an emergency department. METHODS: This is a prospective feasibility study and service evaluation comprising narrative summary of activity, satisfaction, wellbeing and safety, comparisons of wait times for ED services by patient category (‘minors’, ‘majors’, ‘paediatric’ or ‘resus’) before and during the service operation. Patients and staff were asked using semi-structured interview topic guides about service perception, well-being, re-presentation within 48 hours, safety concerns and/or satisfaction. Wait times for patient categories in usual ED care service were in secondary care electronic records. Pathway changes were captured under primary care electronic records. RESULTS: Approximately 96% of GPST patients were seen within one hour. There was a statistically significant reduction in ED patients with minor injuries or illnesses waiting > 4 hours for admission or discharge ‘breaches’ during the 3 months that GPST was operating compared to the previous 3 months (p=<0.005). Wait times for other ED services did not significantly improve. 769 walk-in patients received GPST consultation and 661 (86%) needed no further ED intervention. Fast discharge was a major determinant of patient satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in eligibility criteria and built environment design features. CONCLUSION: Provision of GPST correlated with shorter waits for discharge from ED. Patient and staff experiences of GPST were positive