Showing papers by "Derek Bell published in 2007"

Trends in hospital admissions for adverse drug reactions in England: analysis of national hospital episode statistics 1998–2005

Abstract: Adverse drug reactions (ADRs) are a frequent cause of mortality and morbidity to patients worldwide, with great associated costs to the healthcare providers including the NHS in England. We examined trends in hospital admissions associated with adverse drug reaction in English hospitals and the accuracy of national reporting. Data from the Hospital Episode Statistics database (collected by the Department of Health) was obtained and analysed for all English hospital episodes (1998–2005) using ICD-10 codes with a primary (codes including the words ('drug-induced' or 'due to') or secondary diagnosis of ADR (Y40–59). More detailed analysis was performed for the year 2004–2005 Between 1998 and 2005 there were 447 071 ADRs representing 0.50% of total hospital episodes and over this period the number of ADRs increased by 45%. All ADRs with an external code increased over this period. In 2005 the total number of episodes (all age groups) was 13,706,765 of which 76,692 (0.56%) were drug related. Systemic agents, which include anti-neoplastic drugs, were the most implicated class (15.7%), followed by analgesics (11.7%) and cardiovascular drugs (10.1%). There has been a 6 fold increase in nephropathy secondary to drugs and a 65% decline in drug induced extra-pyramidal side effects. 59% of cases involving adverse drug reactions involved patients above 60 years of age. ADRs have major public health and economic implications. Our data suggest that national Hospital Episode Statistics in England have recognised limitations and that consequently, admissions associated with adverse drug reactions continue to be under-recorded. External causes of ADR have increased at a greater rate than the increase in total hospital admissions. Improved and more detailed reporting combined with educational interventions to improve the recording of ADRs are needed to accurately monitor the morbidity caused by ADRs and to meaningfully evaluate national initiatives to reduce adverse drug reactions.

Estimating trends in the burden of malaria at country level.

Abstract: National disease burdens are often not estimated at all or are estimated using inaccurate methods, partly because the data sources for assessing disease burden-nationally representative household surveys, demographic surveillance sites, and routine health information systems-each have their limitations. An important step forward would be a more consistent quantification of the population at risk of malaria. This is most likely to be achieved by delimiting the geographical distribution of malaria transmission using routinely collected data on confirmed cases of disease. However, before routinely collected data can be used to assess trends in the incidence of clinical cases and deaths, the incompleteness of reporting and variation in the utilization of the health system must be taken into account. In the future, sentinel surveillance from public and private health facilities, selected according to risk stratification, combined with occasional household surveys and other population-based methods of surveillance, may provide better assessments of malaria trends.

Initial treatment of pulmonary embolism.

Abstract: Acute pulmonary embolism (PE) is a common presentation on the acute medical take. In our previous article in Vol 6 issue 1 we discussed the diagnostic approach to this condition. This article concentrates on the treatment of PE, including guidance for treatment of PE in pregnancy and cancer. This article also discusses the role of alternative anticoagulants, thrombolysis, surgery and inferior vena caval filters.

Emergency admissions a time for action and improving patient outcomes.

Abstract: The report Emergency Admissions: A journey in the right direction? was recently published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).1 This report analysed 1800 medical and surgical patients who were admitted acutely to hospital over seven days in February 2005 and who subsequently died or were transferred to critical care within seven days of admission or died within seven days of discharge. This study, by its nature, analyses the most seriously ill subgroup of patients and, therefore, may underestimate the true extent and nature of problems that may affect care adversely. These include, for example, deficits in care provision that increase the risk of health-care-acquired infection and result in increased length of hospital stay. The report makes ten principal recommendations which can broadly be divided into issues of competency or process of care—important factors in patient care which have been apparent for many years and were, indeed, highlighted by Hippocrates. In essence, the recommendations state that acutely unwell patients should be seen promptly by a competent clinician, that documentation throughout the patient journey should be accurate and clear, that there should be diagnostic support available 24 hours per day, that patients' physiology should be monitored and that patient transfers should be minimized. The report highlights that in most of these areas the majority of patients in this severely ill group received adequate care, but in specified areas an unacceptably high proportion received suboptimal care. How will this report help improve clinical outcomes in acute care? Most, if not all, of the recommendations have been published before in a variety of previous reports.2,3 For example, one of the earliest reports, published almost a decade ago, highlighted the need for 24-hour/seven-day per week provision of diagnostic services to support acute medical admissions.2 The more recent of these reports3 covered all of the NCEPOD recommendations, with the exception of physiological monitoring which has been covered in other reports.4,5 The NCEPOD report1 highlights that in most of these areas of patient care, progress in implementing the recommendations has been, at best, slow. Before addressing why progress has been slow, we should consider whether the recommendations are themselves sufficient and which areas the report has not covered. In examining the care delivered in the acute setting, perhaps we should apply the close relative test: what would we as health-care professionals wish to happen for a close relative? The report shows that only 60% of patients had been seen by a consultant within 12 hours and this was most likely to have occurred within an assessment unit (acute medical or surgical unit) or an inpatient ward. Within 24 hours of admission, 8% had not been seen. This clearly is not acceptable, especially as the report relates to patients who, by definition, were likely to have poor outcomes. We would argue, however, that even 12 hours is too long to wait for input from a senior professional and that we should aspire to higher standards. How can this be achieved? The current levels of medical manpower would not permit a 24-hour consultant presence in the acute setting throughout the UK. We can, however, improve consultant input by working extended hours within the acute units and by ensuring that consultants are informed of all cases of clinical concern. This would require that physiological scoring is implemented uniformly, that we as consultants encourage contact by junior members of staff throughout 24 hours and, as the report reiterates, that job planning must reflect the needs of the large number of patients requiring acute care. In relation to early warning scoring systems, it is key that these are linked to clear actions and escalation policies if outcomes are to improve at point of entry to care.6,7 Acute medical and acute surgical units must be seen as defined training areas for both undergraduate and postgraduate health-care professionals in order to ensure that competencies relevant to the acute care of patients are achieved. This report covers a large number of areas but predominantly looks at the medical components of care. The delivery of high-quality acute care requires a multi-professional approach, and the roles of nursing staff and allied health professionals in both detecting and treating acute illness must be recognized and promoted. As such, staffing levels in the acute units and the level of monitoring equipment must also be adequate,8,9 but in reality they vary throughout the country. The report does not address these issues, but they are essential for all involved in assessing or redesigning acute services. The report therefore highlights that much work still requires to be done and essentially reveals that previous national recommendations have not been uniformly adopted. Why is this the case? The reasons are multifactorial and include that, until recent years, there has been little focus on acute care despite the fact it accounts for the vast majority of both medical and surgical hospital admissions. Other reasons include tensions in prioritization between unscheduled and scheduled care and between acute and specialist care. In addition, many clinicians feel uncomfortable in managing the acutely unwell and this must dictate the need for improved training programmes. Finally, staff are often required to work within systems that are inadequate and poorly organized. This reflects the lack of emphasis on acute care by both health-care professionals and senior managers. Programmes like the Emergency Services Collaborative and the Unscheduled Care Collaborative have helped emphasize the importance of improving the timeliness and quality of acute care, but this work needs to continue with an even greater emphasis on patient experience and outcomes.10 The forthcoming acute medical task force document9 re-emphasizes the recommendations of this NCEPOD report but is broader-ranging and takes a more prescriptive, whole-system approach designed to improve the care for all patients requiring acute care. We must now implement the recommendations and ensure that progress is monitored. How can this be done? First we must recognize that there is wide variation in clinical outcomes for patients in relation to the time and place that they access acute services.11,12 This is despite the fact that they may be suffering from similar illness and disease severity. We can do better. Improved care could be delivered at a local level (Trust or Health Board) if it is given the correct emphasis. Or does it require another national programme to coordinate this delivery, with quality and outcomes in acute care as the main focus? In summary, the NCEPOD report1 supports the recommendations of previous reports but perhaps could have gone further, with greater emphasis given to specific components of the recommendations. It does highlight current deficiencies and serves as a useful baseline for the necessary improvement. The importance of the report is that it serves as a timely reminder to us all. However, we must now move into an era of delivery of improved acute care with demonstrable improvement in patient outcomes—in other words it is time for action, not further reports.