IntroductionOver 5,000 cases of invasive Candida species infections occur in the United Kingdom each year, and around 40% of these cases occur in critical care units. Invasive fungal disease (IFD) in critically ill patients is associated with increased morbidity and mortality at a cost to both the individual and the National Health Service. In this paper, we report the results of a systematic review performed to identify and summarise the important risk factors derived from published multivariable analyses, risk prediction models and clinical decision rules for IFD in critically ill adult patients to inform the primary data collection for the Fungal Infection Risk Evaluation Study.MethodsAn internet search was performed to identify articles which investigated risk factors, risk prediction models or clinical decisions rules for IFD in critically ill adult patients. Eligible articles were identified in a staged process and were assessed by two investigators independently. The methodological quality of the reporting of the eligible articles was assessed using a set of questions addressing both general and statistical methodologies.ResultsThirteen articles met the inclusion criteria, of which eight articles examined risk factors, four developed a risk prediction model or clinical decision rule and one evaluated a clinical decision rule. Studies varied in terms of objectives, risk factors, definitions and outcomes. The following risk factors were found in multiple studies to be significantly associated with IFD: surgery, total parenteral nutrition, fungal colonisation, renal replacement therapy, infection and/or sepsis, mechanical ventilation, diabetes, and Acute Physiology and Chronic Health Evaluation II (APACHE II) or APACHE III score. Several other risk factors were also found to be statistically significant in single studies only. Risk factor selection process and modelling strategy also varied across studies, and sample sizes were inadequate for obtaining reliable estimates.ConclusionsThis review shows a number of risk factors to be significantly associated with the development of IFD in critically ill adults. Methodological limitations were identified in the design and conduct of studies in this area, and caution should be used in their interpretation.
NHS Diabetes, along with clinical colleagues, established a ‘Safe Use of Insulin’ e‐learning course in response to an alert from the National Patient Safety Agency and supporting data from the National Diabetes Inpatient Audit which demonstrated a worrying scale of insulin errors for in‐patients with diabetes in England. The e‐learning course has been offered freely to all health care professionals across England from June 2010. As of 16 August 2012 (26 months from module launch), there have been 83 986 health care professionals registered, with 58 188 (69%) of these having completed the module. A three‐month follow‐up evaluation was conducted inviting 8142 people who had completed the module to participate in a short web‐based survey, with responses received from 1246 (15.3%). Evaluation data showed that the course led to increased staff confidence in prescribing, handling, or administering insulin. Changes in individuals' working practice, and departmental or trust policies or procedures at NHS trusts across England were also identified. Copyright © 2012 John Wiley & Sons.
BackgroundThe aim is to improve the quality of care for patients who may be in their last three months of life who attend or are admitted to hospital in an emergency. Hospitals are an important provider of care for this group of people (Clark et al., 2014). An emergency admission may indicate underlying clinical decline. Quality of experience of care varies (Office for National Statistics., 2015). Acute admission processes are not generally designed to manage care for this group (Bailey et al., 2010). This may result in unwanted inpatient stays and/or treatments (Cardona-Morrell et al., 2016) that affect the person’s quality of (their remaining) life. Detail is important: ‘sometimes, it’s the little things that matter, and that is what you remember’ (NHS Improving Quality., 2014). This is in the background of increasing demographic related demand for palliative care (Public Health England., 2015) and associated pressure on services (Lowthian et al., 2010).MethodFour acute hospital Trusts formed a quality improvement collaborative in 2016 with expert clinical, quality improvement and patient experience advice. The methods to diagnose underlying problems and facilitate acute physician engagement included: a ‘patient/relative’ experience walkthrough, a case file review and analysis of activity data and building on existing plans for improvement/known issues. The Trusts set their own priorities for improvement.ResultsThe ‘walkthrough’ highlighted areas for improvement, eg information, signage and mortuary visiting environments. The casefile review facilitated acute physician engagement in three Trusts. These highlighted some excellent practice, which was not consistent. Recognition of dying (69% – average three Trusts); recognition clinical uncertainty of recovery (53% average 3 Trusts); non-beneficial treatment (65% average two Trusts). 60% patients who died in hospital had a prior visit to that Trust (three months) – potential missed opportunity to plan.ConclusionsThis is an important topic. Results are still emerging including an independent evaluation due in September 2017. Improvements in clinical processes (quality and reliability) depend on good engagement with acute clinicians. Quality improvement methods helped, but other enablers are often required.
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