The impact of current peri-operative care on outcomes for patients with hip fracture

Background: Fragility hip fractures among the elderly constitute a significant global public health problem. The disease is devastating for both patient and the family, often resulting in reduced mobility (disabling), increased reliance on others, diminished health and quality of life, and sometimes death. Thirty-day and one-year mortality rates are high. Postoperative morbidity and ‘delayed discharges’ are frequently cited with an average length of hospital stay of 19.5 days. Aim: This project aimed to assess impact of current perioperative care on patient outcome after hip fracture surgery. Methods: A systematic review was performed to identify currently available risk stratification tools used in hip fracture patients. The NHFS and SORT scoring tools were evaluated and recalibrated. A mixed methods study to identify public (patients, relatives and healthcare professionals) perceptions on factors delaying discharge was conducted and a cohort follow up study of 341 patients to develop and validate a Hip Fracture postoperative morbidity survey tool (HF-POMS). Results and conclusion: The NHFS and SORT performed better than other risk stratification tools in the literature; however, they both needed further validation. Five key factors of importance identified by the public affecting LOS were; medical conditions (both prefracture comorbidities and postoperative complications), age and frailty, the recovery process (mobility and rehabilitation) psychological aspects and social factors. A 12- domains validity tool (HF-POMS) was developed with kappa interrater reliability of 0.68. High morbidity presence was seen in the following domains; renal, assisted ambulation, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent LOS of 3.08 days (95% CI 0.90 – 5.26, p= 0.005) and 15.81 days (95% CI 13.35 – 18.27, p = 0.001) respectively. The average LOS was 16.9 days. The HF–POMS is a reliable and valid tool for measuring immediate postoperative complications in hip fracture patients. Many patients remained in hospital for non-medical reasons

Maternal smoking and the risk of still birth: systematic review and meta-analysis

BACKGROUND: Smoking in pregnancy is known to be associated with a range of adverse pregnancy outcomes, yet there is a high prevalence of smoking among pregnant women in many countries, and it remains a major public health concern. We have conducted a systematic review and meta-analysis to provide contemporary estimates of the association between maternal smoking in pregnancy and the risk of stillbirth. METHODS: We searched four databases namely MEDLINE, EMBASE, Psych Info and Web of Science for all relevant original studies published until 31(st) December 2012. We included observational studies that measured the association between maternal smoking during pregnancy and the risk of stillbirth. RESULTS: 1766 studies were screened for title analysis, of which 34 papers (21 cohorts, 8 case controls and 5 cross sectional studies) met the inclusion criteria. In meta-analysis smoking during pregnancy was significantly associated with a 47% increase in the odds of stillbirth (OR 1.47, 95% CI 1.37, 1.57, p  <  0.0001). In subgroup analysis, smoking 1-9 cig/day and ≥10 cig/day was associated with an 9% and 52% increase in the odds of stillbirth respectively. Subsequently, studies defining stillbirth at ≥ 20 weeks demonstrated a 43% increase in odds for smoking mothers compared to mothers who do not smoke, (OR 1.43, 95% CI 1.32, 1.54, p  <  0.0001), whereas studies with stillbirth defined at ≥ 24 weeks and ≥ 28 weeks showed 58% and 33% increase in the odds of stillbirth respectively. CONCLUSION: Our review confirms a dose-response effect of maternal smoking in pregnancy on risk of stillbirth. To minimise the risk of stillbirth, reducing current smoking prevalence in pregnancy should continue to be a key public health high priority

The effect of intravenous iron on erythropoiesis in older people with hip fracture

Background Anaemia following hip fracture is common and associated with worse outcomes. Intravenous iron is a potential non-transfusion treatment for this anaemia and has been found to reduce transfusion rates in previous observational studies. There is good evidence for its use in elective surgical populations. Objective To examine the impact of intravenous iron on erythropoiesis following hip fracture. Design Two-centre, assessor-blinded, randomised, controlled trial of patients with primary hip fracture and no contra-indications to intravenous iron. Method The intervention group received three doses of 200 mg iron sucrose over 30 min (Venofer, Vifor Pharma, Bagshot Park, UK) on three separate days. Primary outcome was reticulocyte count at day 7 after randomisation. Secondary outcomes included haemoglobin concentration, complications and discharge destination. Eighty participants were randomised. Results There was a statistically significantly greater absolute final reticulocyte count in the iron group (89.4 (78.9–101.3) × 109 cells l−1 (n = 39) vs. the control (72.2 (63.9–86.4)) × 109 cells l−1 (n = 41); P = 0.019; (mean (95% confidence intervals) of log-transformed data). There were no differences in final haemoglobin concentration (99.9 (95.7–104.2) vs. 102.0 (98.7–105.3) P = 0.454) or transfusion requirements in the first week (11 (28%) vs. 12 (29%); P = 0.899). Functional and safety outcomes were not different between the groups. Conclusions Although intravenous iron does stimulate erythropoiesis following hip fracture in older people, the effect is too small and too late to affect transfusion rates. Trial Registry Numbers: ISRCTN:76424792; EuDRACT: 2011-003233-34

Anaesthesia workload measurement devices: qualitative systematic review

Background: Management of mental workload is a key aspect of safety in anaesthesia but there is no gold standard tool to assess mental workload, risking confusion in clinical and research use of such tools. Objective: This review assessed currently used mental workload assessment tools. Methods: A systematic literature search was performed on the following electronic databases; Cochrane, EMBASE, MEDLINE, SCOPUS and Web of Science. Screening and data extraction were performed individually by two authors. We included primary published papers focusing on mental workload assessment tools in anaesthesia. Results: A total of 2331 studies were screened by title, 32 at full text and twenty - four studies met the inclusion criteria. Six mental workload measurement tools were observed across included studies. Reliability for the Borg rating scales and Vibrotactile device were reported in two individual studies. The rest of the studies did not record reliability of the tool measurements used. Borg rating scales, NASA-TLX and task oriented mental work load measurements are subjective, easily available, readily accessible and takes a few minutes to complete. However, the Vibrotactile and Eye-tracking methods are objective, require more technical involvement, considerable time for the investigator, and moderately expensive, impacting their potential use. Conclusion: We found that, the measurement of mental workload in anaesthesia is an emerging field supporting patient and anaesthetist safety. The self - reported measures have the best evidence bas

Reducing failure to rescue rates in a paediatric in‐patient setting: A 9‐year quality improvement study

Aim: To identify and quantify Failure to Rescue (FtR) episodes from emergency events at a large children’s hospital and understand the impact of targeted interventions on reducing FtR. Methods: A quality improvement approach was adopted. From 2011 – 2019 all emergency event calls were systematically reviewed prospectively to identify FtR episodes. Root-cause analysis was performed to identify practice deficiencies. The Plan-Do-Study-Act fundamentals were used. Results: A total of 520 (100%) emergency events were reviewed, with yearly mean of 58 events (SD 13, range 41- 81). Cardiac arrest events were the most common 132 (25.8%). Out of the total 132 (100%) cardiac arrest events, 116 (88%) occurred in paediatric critical care unit and only 16 (12%) occurred in general paediatric wards. Three hundred and twelve (60%) of the events were observed in children who had been inpatient for > 48 hours. Observed FtR figures over the nine years was characterised by high rate of 23.6% in 2011 when the project commenced followed subsequently by a sharp decrease after interventions and remained at 2.5% or below for the last six years.Conclusion: Identifying rates of FtR events from routinely collected emergency events data can be used as a patient safety measure to identify emergency concerns. This enables progressive dynamic problem solving through delivery of strategic targeted interventions. The proposed interventions outlined in this quality improvement study have application to critical care nursing as mechanisms for reducing in-hospital unplanned admissions to paediatric critical care

Maternal smoking and the risk of still birth: systematic review and meta-analysis

BACKGROUND: Smoking in pregnancy is known to be associated with a range of adverse pregnancy outcomes, yet there is a high prevalence of smoking among pregnant women in many countries, and it remains a major public health concern. We have conducted a systematic review and meta-analysis to provide contemporary estimates of the association between maternal smoking in pregnancy and the risk of stillbirth.METHODS: We searched four databases namely MEDLINE, EMBASE, Psych Info and Web of Science for all relevant original studies published until 31(st) December 2012. We included observational studies that measured the association between maternal smoking during pregnancy and the risk of stillbirth. RESULTS: 1766 studies were screened for title analysis, of which 34 papers (21 cohorts, 8 case controls and 5 cross sectional studies) met the inclusion criteria. In meta-analysis smoking during pregnancy was significantly associated with a 47% increase in the odds of stillbirth (OR 1.47, 95% CI 1.37, 1.57, p

Prediction of 30-day mortality after hip fracture surgery by the Nottingham Hip Fracture Score and the Surgical Outcome Risk Tool

The care of the elderly with hip fractures and their outcomes might be improved with resources targeted by the accurate calculation of risks of mortality and morbidity. We used a multicentre national dataset to evaluate and recalibrate the Nottingham Hip Fracture Score and Surgical Outcome Risk Tool. We split 9,017 hip fracture cases from the Anaesthesia Sprint Audit of Practice into derivation and validation data sets and used logistic regression to derive new model co-efficients for death at 30 postoperative days. The area (95% CI) under the receiver operator characteristic curve of 0.71 (0.67 0.75) indicated acceptable discrimination by the Nottingham Hip Fracture Score and acceptable calibration fit (Hosmer–Lemeshow test), p = 0.23, with a similar discrimination by the Surgical Outcome Risk Tool, 0.70 (0.66–0.74), which was miscalibrated to the observed data, p = 0.001. We recommend that studies test these scores for patients with hip fractures in other countries. We also recommend these models are compared with case-mix adjustment tools used in the UK

Pressure injury and risk in the inpatient paediatric and neonatal populations: a single centre point-prevalence study

Introduction: Prevention and management of pressure injury is a key nurse-sensitive quality indicator. From clinical insights, pressure injury effects hospitalised neonates and children, however it is unclear how prevalent this is. The aim of this study was to quantify prevalence of pressure injury, assess skin integrity risk level, and quantify preventive interventions in both neonatal and child inpatient populations at a large children’s hospital in the UK. Methods: A cross-sectional study was undertaken, assessing the skin integrity of all children allocated to a paediatric or neonatal bed in June/July 2020. A data collection tool was adapted from two established pressure ulcer point prevalence surveys (EUPAP and Medstrom pre-prevalence survey). Risk assessment was performed using the Braden QD scale.Results: Eighty-eight participants were included, with median age of 0.85 years [range 0-17.5 years), with 32 (36%) of participants being preterm. Median length of hospital stay was 11 days [range 0 – 174 days]. Pressure ulcer prevalence was 3.4%. The majority of participants had at least two medical devices, with 16 (18.2%) having more than four. Having a medical device was associated with increased risk score of developing pressure injury (odds ratio [OR] 0.03, 95% Confidence Interval [CI] 0.01 – 0.05, p = 0.02). Most children (39 (44%)) were reported not having proposed preventive measures in place aligned to their risk assessment. However, for those that did , 2 to 4 hourly repositioning was associated with a risk reduction on pressure damage (OR 0.13, 95% CI 0.03 – 0.23, p = 0.01).Conclusion: Overall, we found a low prevalence of pressure injury across preterm infants, children and young people at a tertiary children’s hospital. Accurate risk assessment as well as availability and implementation of preventive interventions are a priority for healthcare institutes to avoid pressure injury

Risk scoring models for predicting peri-operative morbidity and mortality in people with fragility hip fractures: qualitative systematic review

Rationale: Accurate peri-operative risk prediction is an essential element of clinical practice. Various risk stratification tools for assessing patients’ risk of mortality or morbidity have been developed and applied in clinical practice over the years. This review aims to outline essential characteristics (predictive accuracy, objectivity, clinical utility) of currently available risk scoring tools for hip fracture patients. Methods: We searched eight databases; AMED, CINHAL, Clinical Trials.gov, Cochrane, DARE, EMBASE, MEDLINE and Web of Science for all relevant studies published until April 2015. We included published English language observational studies that considered the predictive accuracy of risk stratification tools for patients with fragility hip fracture. Results: After removal of duplicates, 15,620 studies were screened. Twenty-nine papers met the inclusion criteria, evaluating 25 risk stratification tools. Risk stratification tools considered in more than two studies were; ASA, CCI, E-PASS, NHFS and O-POSSUM. All tools were moderately accurate and validated in multiple studies; however there are some limitations to consider. The E-PASS and O-POSSUM are comprehensive but complex, and require intraoperative data making them a challenge for use on patient bedside. The ASA, CCI and NHFS are simple, easy and inexpensive using routinely available preoperative data. Contrary to the ASA and CCI which has subjective variables in addition to other limitations, the NHFS variables are all objective. Conclusion: In the search for a simple and inexpensive, easy to calculate, objective and accurate tool, the NHFS may be the most appropriate of the currently available scores for hip fracture patients. However more studies need to be undertaken before it becomes a national hip fracture risk stratification or audit tool of choice

Engaging the nursing workforce to achieve a culture of excellence: Nottingham Children’s Hospital ANCC Pathway to Excellence® Journey

High-quality nursing care is linked to improved patient experience and patient outcomes, so having work environments that nurture a culture of nursing excellence is fundamental to delivering high-quality patient care. The American Nurses Credentialing Center (ANCC) runs the Pathway to Excellence programme, an international accreditation recognising healthcare organisations that provide nurses with a positive and safe practice environment in which they can excel. In 2020, Nottingham Children’s Hospital became the first children’s hospital in Europe to gain Pathway to Excellence accreditation, demonstrating that it has developed a culture of nursing excellence and a positive environment for nurses to work in. This article describes the hospital’s journey towards accreditation. Crucial to its success were strategic planning, transformational leadership and using a change management approach, as well as effective staff engagement guided by the ADKAR model for change, an acronym representing five individual outcomes in terms of awareness, desire, knowledge, ability and reinforcement