1074 QUALITY IMPROVEMENT PROJECT AIMED TO REDUCE THE AVERAGE NUMBER OF PATIENTS DEVELOPING CONSTIPATION ON BOURNVILLE WARD IN QEHB

Introduction

Constipation is an overlooked but frequent problem in elderly patients on geriatrics wards. The prevalence in inpatients aged over 65 years is estimated at about 50%.There are many reasons for this: reduced oral intake due to illness, delirium, immobility, and constipating drugs. If constipation is addressed correctly, we can reduce the rate of unpleasant complications and prolonged hospital stay by increasing awareness of non-laxative methods to be advocated initially to avoid worsening poly-pharmacy with side effects. Queen Elizabeth Hospital Birmingham guidelines advocates use of conservative measures. However these methods can be frequently underutilized and cause of constipation rarely considered to treat. We aimed to identify the barriers to our outcome by tackling lack of awareness, utilization of non-laxative method DRE prior to rapid relief. This included teaching sessions, MDT, posters, introducing constipation booklets.

Method

We used prospective data collection with a standardized questionnaire having a mix of descriptive and quantitative questions based on SMART Aims for the project. This was carried out once a week on alternate beds. Baseline data n44,2ndcycle n44,3rd cycle n43,4thcycle n42.With each cycle we used following interventions to improve constipation prevalence in Bournville ward i.e. individually educate patient/staff during ward rounds, MDT presentations, improve documentation of constipation causes, addition of separate educational posters for staff/patients,identification of at risk patients. Introduced Patient information booklet with documented discussion on hospital online record system.

Results

Following interventions from 1st-4th cycle inpatient constipation prevalence was reduced by 13%,Increased consideration of cause by 38%, significant increase in education by 65%,Increased use of non-laxative approach by 35%,Increased rates of DRE by 35%,reduced use of x-ray prior to DRE by 8.3%,reductions in complication rate by 9%.

Conclusion

Despite increased education, cause consideration, utilization of conservative non-laxative approaches, introduction of new constipation booklet in welcome pack to all new patients a small impact was made in reducing inpatient constipation prevalence and associated complications occurring.

135 A Quality Improvement Project Aimed to Reduce the Number of Patients on Bournville Ward Suffering with Constipation

Introduction

Constipation is exceedingly common on geriatric wards, with 20–50% prevalence. It is associated with complications; including pain, delirium and obstruction. Laxatives, often considered the solution, introduce their own side effects and increase polypharmacy especially in elderly populations. Queen Elizabeth Hospital Birmingham guidelines advocate use of conservative measures, including adequate fluid and fibre intake and increasing exercise, to prevent and treat constipation prior to use of laxatives. However, we had observed that these methods were frequently underutilised, and cause of constipation was rarely considered. We aimed to reduce the prevalence of inpatient constipation and associated complications through the introduction of teaching sessions and multidisciplinary team (MDT) discussions, focusing on staff and patient education on the recognition and conservative managements of constipation.

Method

We audited notes weekly for the recognition of constipation, appropriate bowel examination, use of conservative management including patient education and any complications. Baseline data was collected from Bournville Ward over 4 weeks (n = 44), after which, teaching sessions for all regular ward staff and weekly MDT discussion for patients recognised as constipated were introduced. Patients having not opened bowels for >2 days were targeted for early simple non-laxative interventions. A further 4-week cycle of data was collected (n = 43).

Results

Constipation was recognised in 57% of patients studied, of which 64% developed constipation during inpatient stay and 20% experienced associated complications. The introduction of teaching session and MDT reviews increased patient education, cause recognition and non-laxative methods use by 19%, 27% and 30% respectively. Constipation developed during inpatient stay and associated complications decreased by 6% and 4% respectively.

Conclusion

Despite increased patient education, cause recognition and utilisation of conservative non-laxative approaches, only a small impact was made in reducing inpatient constipation prevalence and associated complications occurring.

Patient satisfaction in telemedicine

Recent improvements in technology and telecommunications have resulted in renewed interest in telemedicine [1]. The UK’s National Health Service (NHS) Executive has recently published an ‘Information for Health’ strategy which states that ‘telemedicine and telecare will undoubtedly come to the fore as a way of providing services in the future. They have a key role to play in the Government’s plans to modernize the NHS’ [2]. Within the current climate, the future success of telemedicine will depend on patient and provider acceptance of such technologies. It is, therefore, imperative that the views and experiences of the users and providers of healthcare services are sought to enable problems to be resolved and issues addressed before telemedicine is fully implemented: ‘Information about the patients’ experiences can be an important lever for change, both highlighting where, and what sort of quality improvements are needed’ [3].

This paper provides an overview of telemedicine and patient satisfaction and considers the satisfaction studies to date. It finally discusses some of the problems in assessing patient satisfaction within telemedicine and how future studies may be improved in light of the findings. It is based upon work that is presently being carried out at the School of Health and Related Research (ScHARR) at the University of Sheffield as part of a Randomized Controlled Trial of telemedicine in dermatology, funded by the NHS Executive Research and Development Programme.

Ethical review of health service research in the UK: implications for nursing

BACKGROUND

This paper examines the current systems and structures for ethical review of health services research in the United Kingdom (UK). Past criticisms and the adequacy of recent governance arrangements for Ethics Committees in addressing these are discussed. The implications for nurses are then considered.

RATIONALE

This examination of the situation is prompted by the demand for more innovative research designs in health care evaluation, new regulations and guidance, and a climate of public anxiety regarding research conduct in the UK.

FINDINGS

The evolution of Research Ethics Committees (RECs) has been slow and resulted in a lack in consistency. Criticisms made of RECs can be categorized into four main areas. New governance arrangements for RECs have emerged as potential solutions to these criticisms. This review identifies the limitations of the new governance arrangements in addressing past criticisms because of two factors. The first is insufficient funding. The second is confusion about the confidentiality and consent requirements of clinicians working in areas where research is conducted and on whom recruitment processes often rely. The current situation regarding health research ethical review has implications for nurses, whether they are working as researchers, members of Ethics Committees or clinicians where research is conducted.

CONCLUSION

The new governance arrangements may go some way to addressing past problems. However, investment in RECs is required. It is also important to realize that maintaining ethical probity in health service research is a tripartite concern. It is reliant as it is on the actions of Ethics Committees and clinical research partners as well as those of the researchers themselves.

Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery

OBJECTIVES

(1) To determine whether pre-operative assessment carried out by an appropriately trained nurse (ATN) is equivalent in quality to that carried out by a pre-registration house officer (PRHO). (2) To assess whether pre-assessments carried out by ATNs and PRHOs are equivalent in terms of cost. (3) To determine whether assessments carried out by ATNs are acceptable to patients. (4) To investigate the quality of communication between senior medical staff and ATNs.

DESIGN

The study design was principally a prospective randomised equivalence trial but was accompanied by additional qualitative assessment of patient and staff perceptions, and an economic evaluation.

SETTING

The study was carried out at four NHS hospitals, three of which were teaching hospitals, in three NHS Trusts in Southampton, Sheffield and Doncaster.

SUBJECTS

All patients attending at one site for assessment prior to general anaesthetic for elective general, vascular, urological or breast surgery were potentially included in the study. Of 1907 patients who were randomised, 1874 completed the study with a full evaluation.

INTERVENTIONS

The intervention consisted of a pre-operative assessment carried out by either an ATN or a PRHO. Of the patients who completed the study with a full evaluation, 926 patients were randomised to the PRHO arm of the trial and 948 to the ATN arm. Three ATNs took part in the study, one from each centre, together with a total of 87 PRHOs.

MAIN OUTCOME MEASURES

Immediately following the initial assessment of a patient by a PRHO or an ATN, one of a number of clinical research fellows, all specialist registrars in anaesthetics, repeated the assessment and recorded it on a study form, together with a list of investigations required. The clinical research fellow then evaluated the competency of the initial assessor by comparing the quality of their assessment with their own. Any deficiencies in ordering of investigations and referral to other specialities were met in order to maximise patient care. Three areas of ATN and PRHO performance were judged separately, history taking, examination and ordering of tests, and each was graded into one of four categories, the most important of which was under-assessment, which would possibly have affected peri-operative management. In the case of ordering of tests, it was possible to have both over- and under-assessed a patient on different tests.

RESULTS

The pre-operative assessments carried out by the ATNs were essentially equivalent to those performed by the PRHOs in terms of under-assessment that might possibly have affected peri-operative management, although there was variation between the ATNs in terms of the quality of history taking. This may be related to the low number of patients seen at one study site. PRHOs ordered significantly more unnecessary tests than the ATNs. The substitution of ATNs for PRHOs was calculated to be cost neutral. The results of the qualitative assessment showed that the use of ATNs for pre-operative assessment was acceptable to patients; however, there was no evidence that communication between senior medical staff and those carrying out pre-operative assessments was improved by their introduction.

CONCLUSIONS

This study demonstrated no reason to inhibit the development of fully nurse-led pre-operative assessment, provided that the nurses are appropriately trained and maintain sufficient workload to retain skills. CONCLUSIONS--IMPLICATIONS FOR THE HEALTH SERVICE: ATNs provide an acceptable and efficient alternative to PRHOs for the purposes of routine pre-operative assessment. Consideration will have to be given, however, to the positions of these nurses within the surgical team, and also to their career structure. CONCLUSIONS--RECOMMENDATIONS FOR FUTURE RESEARCH: Further research is needed in the following areas: (1) the extent and type of training needed for nurses undertaking the pre-operative assessment role; (2) the use, costs and benefits of routine pre-operative testing.

General practitioners' perceptions of store-and-forward teledermatology

We studied the views of 26 general practitioners (GPs) towards store-and-forward tele-dermatology before its introduction into their practices. A postal questionnaire was developed using Likert-type questions with respondents able to explain their answers in free text. Questions related to the GPs' knowledge, perceptions and expectations of tele-dermatology, as well as their attitudes towards being part of a research trial. Most of the GPs had limited prior knowledge of tele-dermatology. They perceived its role to relate to quicker access to specialist opinions, decreased referrals, increased convenience for patients, diagnosis, and education and teaching. There was an overwhelming view that any system needed to be quick, easy to use, efficient and reliable. Concerns were expressed about being part of the clinical trial, using new technology and an increased workload. The future of tele-dermatology was thought to depend on the clinical adequacy of the system.

The patient's burden: physical and psychological effects of acute exacerbations of chronic bronchitis

In this prospective qualitative study we evaluated the subjective perspectives of the quality of life of patients with chronic bronchitis. Individuals with diagnoses which fulfilled the clinical criteria of chronic bronchitis, i.e. daily production of sputum for at least three consecutive months in two consecutive years, were recruited into four focus groups from general practices in two industrial cities. Younger patients (those of pre-retirement age) of both sexes-a significant, but frequently 'invisible' minority in this patient population-were targeted. The groups were constituted with the aim of stimulating variation in the discussions. Twenty sufferers (10 males and 10 females, ranging in age from 30 to 86 years) were eventually included in the study; there were five in each group. Group discussions were recorded and transcribed verbatim and the data were analysed thematically. It was evident from the discussions that chronic bronchitis had led to a high degree of psychological distress in the participants, particularly in relation to dependency on medication, and disruption of social and family relationships. Acute exacerbations of chronic bronchitis (AECB) were met with dread. They brought about further reductions in quality of life, increased anxieties about breathlessness, fear of atmospheric pollution and of changes in and extremes of temperature, embarrassment about coughing up phlegm in public and suspicion of medical practitioners' motives if they were unwilling to prescribe antibiotics on request. Patients' health-related behaviour and beliefs were often contradictory. For example, AECB in some patients led to increased smoking. There were also gender and age differences; for example, it was the perception of males that they received more support from their partners than did females. Younger participants appeared more distressed by AECB than older ones. The results of this study suggest that raising the standard of care for patients with chronic bronchitis requires that greater attention be paid to patients' subjective experiences of the disease.

The menstrual cycle, science and femininity: assumptions underlying menstrual cycle research

This paper examines the relationship between popular knowledge of menstruation and scientific research. It suggests that despite evidence to indicate that pre-menstrual cognitive, behavioural and emotional 'impairment' is relatively rare, the population notion that PMS routinely affects many women adversely is difficult to displace. It concludes that mainstream menstrual cycle research is subject to the influence of misogynist mythology upheld as staunchly by women influenced by patriarchy as by men. Reasons are suggested which lie in the differential power of claims to knowledge.

The ideas and experiences of pregnancy and childbirth of Asian and non-Asian women in east London

This study examined differences between the ideas and experiences of pregnancy and childbirth of Asian and non-Asian women giving birth in East London, and sources of variability in Asian women's accounts. In line with the findings of previous research, Asian women's ideas about diet in pregnancy, the gender of their children and postnatal care (e.g. the need for rest and recovery, and restrictions on their activities) were influenced by cultural beliefs and practices. However, in other ways Asian women demonstrated a strong commitment to Western maternity care. In contrast to some other studies Asian women wanted their husbands or partners present at delivery, indicating the extent to which traditional ideas are being modified. Qualitative analysis of Asian women's fuller accounts indicated that women subscribed to traditional practice as well as Western maternity care. Acculturation or familiarity with Western ideas about maternity care was associated with variability in Asian women's ideas and experiences, in line with previous research. However, in spite of frequent assumptions about its significance, religion was not associated with variability in Asian women's ideas and experiences. Parity, however, was a major variable, for Asian and for non-Asian women, suggesting that the first birth has different significance for parents than subsequent births. The implications for the provision of maternity care are discussed, especially the need to go beyond stereotypical views based on women's ethnicity or religion to consider the beliefs and preferences of women as individuals and their personal circumstances.

Understanding postnatal depression: a mother-centred approach

Research findings on the causes and correlates of postnatal depression divide into two explanatory frameworks. The clinical/medical model identifies the mothers as being 'ill', and the social science model suggests a particular vulnerability to additional social stress factors. Despite attempts to predict those women at risk, and develop preventative programmes, most treatment initiatives are reactive, which is a direct result of the inconclusive nature of available evidence. The study reported here suggests that the concept 'postnatal depression' needs to be re-examined and that rather than it being an individual illness or vulnerability, it is more akin to a normal grief reaction and part of a normal postnatal profile. It only becomes a problem when it is defined and treated inappropriately. The implications from this research lead to a new approach to understanding the mother's experience of postnatal depression, and types of counselling and support which might effectively be employed by midwives and health visitors.