Kirklandside Hospital

Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people's assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.

BACKGROUND: Difficulties in the recruitment of adults with intellectual disability (ID) to research studies are well described but little studied. The aim of this study was to investigate the difficulties in recruiting to a specific research project, in order to inform future recruitment to ID research. METHODS: Individual semi-structured interviews were held between September 2009 and May 2010 with people who had been involved as intermediaries in recruitment to the research project. These were transcribed verbatim and were independently analysed by two researchers using the Framework approach, who then agreed upon the key emerging themes. RESULTS: Ten interviews were analysed. A number of themes arose, including participant factors (interview anxiety, difficulties in understanding the concept of research, worry about negative feedback), the importance of the researcher (using a personal approach, meeting potential participants prior to recruitment) and motivators [enjoyment of the research interview (participant), obtaining a medical assessment (carer)]. The themes were then used to generate strategies to improve recruitment to ID research: these include the research team applying a more personal approach, developing the recruitment process to allow for multiple meetings with potential participants, and considering motivators for both participants and carers. CONCLUSIONS: This study has used the experiences of intermediaries to identify strategies for improving recruitment to future ID research. This has implications in terms of both time and money. However, successful recruitment is essential to ID research, and we hope that the study will be used by ID researchers to review and improve their recruitment processes.

OBJECTIVE: To evaluate longitudinally the effectiveness of a cooking programme on self-reported confidence about cooking skills and food consumption patterns in parents of young children. DESIGN: An evaluation of cooking programmes delivered by National Health Service (NHS) community food workers using a single group pre-test/post-test repeated measures design. A shortened version of a validated questionnaire at baseline, post intervention and 1-year follow-up determined confidence in cooking using basic ingredients, following a simple recipe, tasting new foods, preparing and cooking new foods on consumption of ready meals, vegetables and fruit. SETTING: Deprived communities in Ayrshire and Arran, Scotland. SUBJECTS: Parents of nursery age children, 97 % were female and <45 years old. RESULTS: One hundred and two participants had completed baseline and post-intervention questionnaires. Forty-four participants contacted by telephone completed a follow-up questionnaire. In participants who completed all questionnaires (n 44), median confidence in four aspects of cooking increased significantly from baseline to post intervention (P < 0·001) but was retained at 1-year follow-up only for following a simple recipe and preparing and cooking new foods. Improved food consumption patterns were reported from baseline to post intervention (ready-meal consumption reduced from 2-4 times/week to 1 time/week, P < 0·001; vegetable consumption increased from 5-6 times/week to 1 time/d, P < 0·001; fruit consumption increased from 5-6 times/week to 1 time/d, P < 0·001) and remained at 1-year follow-up. CONCLUSIONS: The cooking programmes appeared to improve cooking confidence and food consumption patterns in the target group and some of these changes were retained after 1 year.

Accessible summary It can be hard for everyone if someone they care for dies. People with a learning disability may need extra support when someone they know dies. Care staff may not always know what to do to help. This study found that 1 day of training helped care staff to know more about how people might feel and how to support them. We do not know how long this training was helpful to staff for. Summary This study aimed to investigate whether a 1‐day training course improved support staff knowledge about bereavement and grief in people with a learning disability. A questionnaire based, mixed design was used. Forty‐eight participants were randomly assigned to one of two equal groups. A staggered design allowed for group 2 to act both as a control group and to receive training. Within‐ and between‐group comparisons were made. Training significantly improved staff knowledge in all the areas measured. An analysis of staff knowledge at 1 month after training was not possible due to a low response rate. A short training course was successful in significantly increasing the knowledge of paid carers about issues relating to bereavement for people with a learning disability. The clinical and ethical implications of the study are discussed along with limitations and suggestions for further research.

It is becoming increasingly important for clinicians to justify the treatment approaches they use. This study illustrates one way of measuring therapeutic effectiveness in a small group of learning disabled individuals who frequently demonstrated aggressive or intimidating behaviours. The use of a self‐report measure, the Provocation Inventory (PI) to monitor change, can be easily implemented in everyday clinical practice. The PI allowed for responses to be categorised and consequently pre‐ and post intervention responses could be compared. Changes recorded using the PI were ambiguous in terms of ‘improvement’, although staff reports indicated group work to have been effective to some extent. The use of formal outcome measurements represents good clinical practice. Despite some limitations in the PI, some useful recommendations for its future use are documented.

Jean Howieson describes how her research dissertation study revealed how to improve care outcomes for these patients

A quasi-experimental trial, yielding 30 data points per system, was carried out to investigate the influence of component parts on the overall performance of urinary sheath systems. Information was obtained on the effect of changing both the sheath and leg-bag. Data from the trial was supported by accurate stock-taking analysis over two periods of 4 weeks' duration when alternative systems were used in a clinical setting. Results suggest that leg-bag design profoundly influences the performance of urinary sheaths. A significant difference in the performance of two urinary sheaths in the presence of the same leg-bag was also observed. The significance of the findings for nursing practice is discussed since the optimum performance, from the components tested, was a 'hybrid' system. A continuing line of investigation is suggested whereby improvements in the composition of urinary sheath systems could be made from nursing research.

BACKGROUND: Poor communication between healthcare professionals is recognised as accounting for a significant proportion of adverse patient outcomes. In the UK, the General Medical Council emphasises effective handover (handoff) as an essential outcome for medical graduates. Despite this, a significant proportion of medical schools do not teach the skill. OBJECTIVES: This study had two aims: (1) demonstrate a need for formal handover training through assessing the pre-existing knowledge, skills and attitudes of medical students and (2) study the effectiveness of a pilot educational handover workshop on improving confidence and competence in structured handover skills. DESIGN: Students underwent an Objective Structured Clinical Examination style handover competency assessment before and after attending a handover workshop underpinned by educational theory. Participants also completed questionnaires before and after the workshop. The tool used to measure competency was developed through a modified Delphi process. SETTING: Medical education departments within National Health Service (NHS) Lanarkshire hospitals. PARTICIPANTS: Forty-two undergraduate medical students rotating through their medical and surgical placements within NHS Lanarkshire enrolled in the study. Forty-one students completed all aspects. MAIN OUTCOME MEASURES: Paired questionnaires, preworkshop and postworkshop, ascertained prior teaching and confidence in handover skills. The questionnaires also elicited the student's views on the importance of handover and the potential effects on patient safety. The assessment tool measured competency over 12 domains. RESULTS: Eighty-three per cent of participants reported no previous handover teaching. There was a significant improvement, p<0.0001, in confidence in delivering handovers after attending the workshop. Student performance in the handover competency assessment showed a significant improvement (p<0.05) in 10 out of the 12 measured handover competency domains. CONCLUSIONS: A simple, robust and reproducible intervention, underpinned by medical education theory, can significantly improve competence and confidence in medical handover. Further research is required to assess long-term outcomes as student's transition from undergraduate to postgraduate training.

An investigation was carried out on six hospitalized elderly male urinary incontinent patients for 21 days to test three urinary sheath systems by means of a quasi-experimental trial, incorporating crossover. Observations were made, and recorded, of detachment or leakage in systems and of skin condition round the shaft of the penis. Results suggest that two of the systems differ significantly in their performance and that performance of the urinary sheath was probably the limiting factor in overall performance. Incidence of skin problems, and other problems within systems, were minimal. It was also observed that patients differ significantly in their suitability for the application of sheath systems. This observation was made at two time intervals. A further line of investigation is suggested to test the effect of components, other than sheaths, on performance of systems.

Jean Howieson and Karen Clarke explain how they developed accessible information resources on screening programmes for people with learning disabilities

With oral cancer on the rise,1 dentists and their teams have a vital role in ensuring early detection and informing patients of the risk factors. Early detection is associated with …

Around 300 delegates attended the recent annual conference of Scottish Action on Dementia held in Glasgow’s City Halls. Roger Watson reports

An attempt has been made to evaluate colistin sulphate in the treatment of specific intestinal infections. Ninety three patients were treated with the antibiotic comprising 48 cases of specific E. coli infection and 45 cases of Shigella. Eradication of the infecting organism was achieved in these two groups in 39 (81.25%) and 33 (73.3%). No problems were associated with administration of colistin and toxic effects were not seen. Considering the fact that six negative daily dismissal swabs were taken as criterion of cure, the results obtained compare very favourably with other antibiotics. The necessity of the treatment of E. coli gastro-enteritis is discussed and the good results obtained with colistin would suggest it to be an appropriate choice of antibiotic. The findings in all groups would suggest that colistin is a very useful antibiotic in the treatment of specific intestinal infections.

1. The oral absorption and the rate of loss from the body of radioactive iron were measured by whole-body monitoring in patients with functioning renal homografts. The incorporation of radioactive iron into erythrocytes was also measured. 2. The results were compared with corresponding values in normal subjects and in non-dialysed and dialysed patients with chronic renal failure. 3. The mean oral absorption and incorporation into erythrocytes of radioactive iron was intermediate between that of normal subjects and of both non-dialysed and dialysed patients with chronic renal failure. 4. The mean rate of loss from the body was not significantly different from that in normal subjects and non-dialysed patients with chronic renal failure but it was significantly less than that in dialysed patients.

The concept of quality in nursing care rests on its mcasureahility. Roger Watson investigates

SUMMARY Primary hyperparathyroidism (PHPT) is the presence of hypercalcaemia with an elevated or inappropriately normal parathyroid hormone level. In clinical psychiatry this is often detected on routine blood investigations. This article aims to help mental health professionals understand the relevance of PHPT to psychiatry and offers some guidance about further management of patients presenting with this endocrine abnormality in mental health settings. PHPT can be associated with both mental and physical health problems in some individuals, making it a crucial diagnosis that should not be overlooked.

Are cotsides used for the benefit of patients or staff? Roger Watson and Margaret Brunton describe how focusing on restraint helped bring the cotsides down in a continuing care unit in Scotland

Roger Watson describes the formulation of guidelines for the treatment of pressure sores, based on available knowledge

Good practice is the link between care planning and cost effective delivery of care, according to Roger Watson

Purpose The purpose of this paper is to investigate the use of the Mental Health (Care and Treatment) (Scotland) Act 2003 for people with learning disabilities in Scotland, in the context of the recent commitment by the Scottish Government to review the place of learning disability (LD) within the Act. Design/methodology/approach All current compulsory treatment orders (CTO) including LD as a type of mental disorder were identified and reviewed. Data was collected on duration and type of detention (hospital or community based) for all orders. For those with additional mental illness and/or personality disorder, diagnoses were recorded. For those with LD only, symptoms, severity of LD and treatment were recorded. Findings In total, 11 per cent of CTOs included LD as a type of mental disorder. The majority of these also included mental illness. The duration of detention for people with LD only was almost double that for those without LD. A variety of mental illness diagnoses were represented, psychotic disorders being the most common (54 per cent). Treatment was broad and multidisciplinary. In all, 87 per cent of people with LD only were prescribed psychotropic medication authorised by CTO. Originality/value There has been limited research on the use of mental health legislation for people with learning disabilities. This project aids understanding of current practice and will be of interest to readers both in Scotland and further afield. It will inform the review of LD as a type of mental disorder under Scottish mental health law, including consideration of the need for specific legislation.