The medical practice is full of challenges and complexity; and clinicians need to be vigilant all the time in their practice to appreciate unusual and rare manifestations of common clinical conditions like IDA and CD.
Transferring patients from the intensive care unit (ICU) to a general ward is commonly associated with error and adverse events, and is one of the most challenging and high-risk transitions of care. Patients discharged from ICUs often require sustained intensive multi-disciplinary team input, part of which can be provided by nurse or clinician-led outreach teams. Unfortunately, due to a lack of resources many institutions do not have such programmes. We work in one such hospital with no ICU outreach service for recently discharged patients.We noted that a disproportionate number of patients recently discharged from the ICU needed acute medical reviews by on-call evening and overnight junior doctors. Furthermore we noted that many of these patients had not been reviewed by their medical team after having arrived onto the general ward from the ICU.We aimed to foster a fundamental culture change within junior doctors to review patients within six hours of arrival onto a ward from the ICU. We introduced simple and low-cost interventions that included educational sessions for junior doctors and ward-based nurses, as well as posters that acted as visual reminders in relevant departments.Overall, the number of patients discharged from the ICU to general wards that were reviewed within six hours improved from 22% to 70% in the space of six months. In the same period, the number of patients requiring an acute medical review by the evening or overnight on-call junior doctor dropped from 14% to 0%.Whilst our project is not necessarily appropriate for many larger institutions that already have outreach teams in place, it is certainly applicable to other similar sized smaller hospitals. We hope that others who face the same inherent barriers are inspired to implement similar projects, to bring about positive change, and ultimately improve the safety of their patients.
Aim Urinary tract infection (UTI) is a common bacterial infection in children. Much controversy exists over the level of investigation required for UTI, looking for evidence of scarring and vesicoureteric reflux (VUR). In the Northern Region we follow local guidelines which involve imaging, prophylaxis and prolonged follow-up for all those with first UTI under 1 year of age. This places a heavy burden on NHS resources. NICE produced new guidelines in 2007 which results in fewer investigations being recommended in a more targeted fashion. Our aim is to identify how many episodes of VUR we would have missed had we been following NICE guidelines. Methods A retrospective study in a large district general hospital from January 1998 - April 2008, looking at all children <1 year of age who had an MCUG investigation for UTI. Notes for all with abnormal scans were reviewed to determine if they met the criteria for scan under NICE. We could then identify patients with VUR who would have been missed if we followed NICE. Results Over a period of 10 years, 368 MCUGs were done for UTI in children under 1 year, of these, 73 (19.8%) were reported abnormal. Applying NICE guidelines retrospectively, 15 of these 73 would have been recommended by NICE, 58 were therefore performed in our study that went against the NICE guidelines, all of which were abnormal to some degree. Most showed evidence of grade I or II VUR but 9 showed evidence of grade III or VI reflux. Conclusion In rationalising investigation of UTI according to NICE guidelines we would have missed 58 children with a diagnosis of VUR. Many of these have grade I or II reflux, the clinical significance of which is unclear. However there are 9 children in our cohort with Grade III or IV VUR who would have been missed. Controversy continues to remain as to whether or not the presence of primary VUR predicts renal scarring and damage but some paediatric nephrologists continue to believe there to be a causative effect between the two.
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