IntroductionDiabetic ketoacidosis (DKA) remains a frequent and life threatening complication in type 1 diabetes. In England, more than 11% of people with type 1 diabetes had an episode of DKA in the years between 2004 and 2009. 1 Mortality rates have now fallen significantly in the last 20 years from 7.96% to 0.67%. 2 In 2010, the Joint British Societies Inpatient Care Group developed and approved guidelines on a weight-based, fixedrate intravenous insulin infusion regimen for the management of DKA in adults. 3 These were based on the systematic review of current evidence and accumulated professional experience. Some changes were made to these guidelines in 2011, 4 and they were introduced in September 2012 at a hospital in south east Wales. Junior doctors were educated about them in the educational programmes and they are also available on the trust intranet but were not a part of the junior doctor's induction. These guidelines were then audited on 24 patients between October 2012 and March 2013. Audit results obtained through personal communication showed 16% of the patients were not started on the weight-based, fixed-rate regimen. This led us to conduct a survey on junior doctors' knowledge of these guidelines. AimsOur aims were to assess junior doctors' knowledge of the weightbased, fixed-rate insulin regimen in the management of DKA in adults based on the trust protocol. MethodologyA survey was conducted on a random day of a week in July 2013 at a hospital in south east Wales. Data were collected by using a questionnaire consisting of eight questions (see Box 1) designed on the basis of the trust guidelines for DKA. This questionnaire was distributed to junior doctors working on that day (house officers, senior house officers and registrars) in medical and surgical specialties in July 2013. Consultants were excluded from this survey as more often the initial management of DKA is done by junior doctors. Data were analysed in Microsoft Excel format. ResultsThe questionnaire (Box 1) was distributed to 56 junior doctors. A total of 53 (95%) responses were received of which 34 were from medical doctors and 19 were from surgical doctors. The following results are numbered in relation to the questions posed in the questionnaire. 1. Thirty-five percent of medical and 63% of surgical doctors were not aware of the guidelines. AbstractDiabetic ketoacidosis (DKA) is a common medical emergency. In recent years a weight-based, fixed-rate intravenous insulin infusion regimen has replaced the conventional sliding scale regimen for effective management of DKA. These guidelines have come into effect from 2012 at a hospital in south east Wales.A survey was conducted to assess the junior doctors' (medical and surgical) knowledge of these guidelines as per trust protocol. The results of this survey clearly show that a significant number of doctors (35% of medical and 63% of surgical doctors) were not aware of these guidelines; 15% of medical and 22% of surgical doctors were not aware of the criteria for the diagnosis of DKA.
AimsTo identify the number of patients currently on melatoninTo determine the average duration of use of melatonin in patients under the care of S-CAMHS in ABUHBTo investigate whether behaviour interventions were tried and reinforced from time to timeTo identify any areas of improvementMethodData were collected at St. Cadoc's hospital, in January, 2021. S-CAMHS database was used. Out of total 346 patient currently being managed with pharmacological therapies, 115 (33.2%) are currently on melatonin. 57/115 were randomly selected as a sample for this this project. Patient notes and EPEX software were also used to collect information regarding the sleep management practices.ResultDuring analysis, it was noticed that within the sample, only 46 patients were actively on melatonin. Melatonin is prescribed for sleep related issues in ASD (8/46), ADHD (15/46), ASD and ADHD (10/46), ADHD and mood disorder (0/46), ASD and mood disorder (6/46), ADHD and behaviour difficulties (2/46), ASD with behaviour difficulties (1/46), mood disorder (4/46).39/46 patients are currently on melatonin for more than a year (85%). These patients also include 10 patients who have been using melatonin for 5 years or more.35 patients (76%) reported improved sleep or some benefit from melatonin.Evidence for implementation of parent-led sleep behavioural interventions:Prior to commencing melatonin- Clear evidence available for 35 patients only (76%). These interventions were however not deemed helpful by most of the service users.While prescribing melatonin- Clear evidence available for 39(85%) patients. Evidence base for melatonin was also discussed during this visit.During last follow-up visit- Evidence available for 31 patients only (67%).ConclusionMajority of patients under S-CAMHS ABUHB remain on melatonin therapy for longer than one year. Most of these patients have reported benefit from this therapy and preferred to remain on it despite being informed about evidence base for melatonin. Also, there is evidence for implementation of sleep behavioural interventions prior to prescribing melatonin, however their benefit remains unclear.Recommendations:The quality of education on sleep hygiene offered should be assessed and improved if neededFormal group sessions/workshops on sleep hygiene/parent-led sleep behavioural interventions at regular intervals might be useful in reducing the chances of long term polypharmacy or unlicensed drugsUse of outcome measures such as Child Sleep Habits Questionnaire at intervals can be helpful in identifying any improvement from educational/pharmacological interventionsS-CAMHS database (for patients actively on medications) needs a review and update
Aims and MethodConfusion in an older patient on a general hospital ward requires prompt and appropriate management. To this end, evidence-based guidelines have been produced and disseminated by Gwent Healthcare NHS Trust. An audit was carried out when it became apparent that junior doctors might not be aware of the guidelines and that their availability on the wards was limited. An action plan was generated and a second audit carried out. Our aim was to establish whether the doctors' knowledge of the guidelines and their availability on wards changed as a result of our action plan and audit.ResultsThe audit consisted of a survey of general wards at the Royal Gwent Hospital and at St Woolos Hospital to assess availability of the guidelines and a questionnaire administered to a sample of junior doctors. The guidelines were available on 17% of wards; 11% of junior doctors were aware of them. Results of the audit informed implementation of an action plan. The second audit showed a limited improvement in availability (increased to 34%) and awareness (increased to 15%) of the guidelines, with no statistically significant difference.Clinical ImplicationsApparently well-thought-out action plans may produce minimal change, but unless the audit cycle is completed this fact cannot be corroborated. In generating action plans, more consideration may need to be given to the factors that influence the spread of change in healthcare systems.
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