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Odell M.,Royal Berkshire NHS Foundation Trust
Journal of Clinical Nursing | Year: 2015

Aims and objectives: To audit ward nursing practice in the adherence to an early warning scoring protocol in the detection and initial management of the deteriorating ward patient and investigate factors that may impact on practice. Background: Hospital inpatients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, misinterpret or mismanage the signs. Rapid response systems have been implemented to address this problem. The rapid response systems consists of two phases: the afferent phase involves monitoring the patient, recognising deterioration and referring to more expert help and the efferent phase involves expert teams assessing and treating the patient. Research has tended to concentrate on the efferent phase of the process and has so far failed to show a significant impact on patient outcome. Methods: Using cardiac arrest as a surrogate marker for deterioration, patient records were retrospectively reviewed during the 12 hours prior to the cardiac arrest event. Data relating to nursing practice and adherence to the early warning scoring protocol were extracted and analysed. Findings: The findings suggest that ward nurses' monitoring of patients' observations has improved compared with earlier research, but errors in early warning scoring and nonadherence to referral protocols are still a problem. A number of potentially influential factors on nursing practice were tested, but only deterioration occurring outside normal weekdays was associated with a reduced quality of nursing adherence to protocol. Conclusions: The implementation of rapid response systems may have been an oversimplified solution to the highly complex problem of undetected patient deterioration. There are a multitude of contributory factors to the problem of noncompliance to early warning scoring protocols, and possible solutions will need to reflect the breadth, depth and complexity of the problem if we are to improve patient experience and outcome. Relevance to clinical practice: An audit of nursing practice against an early warning scoring protocol based on national recommendations and standards in the recording of and response to physiological deterioration in the ward patient has shown that vital signs recording has improved, but early warning scoring accuracy and referral to more expert help remain suboptimal. By identifying areas of suboptimal practice, strategies for education and training and service development can be better informed. More in-depth evidence on factors that may impact the quality of nursing practice has been identified. Problems with rapid response systems assumptions have been highlighted, which may facilitate the implementation of more realistic solutions for managing the deteriorating ward patient. © 2014 John Wiley & Sons Ltd. Source

Knox T.,Royal Berkshire NHS Foundation Trust
Nursing children and young people | Year: 2011

Undergoing oronasopharyngeal suction is an unpleasant experience, but the intervention may prevent the deterioration of children who cannot clear their secretions. A successful procedure requires a practitioner with appropriate knowledge, dexterity and communication skills. Thorough training should be provided and a careful risk-benefit assessment is important before suction is performed. Source

Foulkes M.,Royal Berkshire NHS Foundation Trust
Nursing standard (Royal College of Nursing (Great Britain) : 1987) | Year: 2011

Nursing metrics have been used increasingly in UK health services over the past two years to measure and improve nursing performance and to aid commissioners in linking funding to quality. This article provides an introduction to nursing metrics, including some of the nurse-sensitive indicators and the background to their development. It also provides examples of how metrics are used in practice to improve the care and experience of patients. Source

Dua J.,Royal Berkshire NHS Foundation Trust | Clayton R.,Royal Berkshire NHS Foundation Trust
Australasian Journal of Dermatology | Year: 2014

We report a unique case of ascending cutaneous lymphangitis in a 72-year-old immunocompromised man from which a newly described Nocardia species was isolated by 16S ribosomal gene sequencing. Treatment with trimethoprim-sulfamethoxazole resulted in successful resolution of symptoms. To the best of our knowledge, this is the first case report of N. veterana implicated in causing ascending cutaneous lymphangitis. © 2013 The Authors Australasian Journal of Dermatology © 2013 The Australasian College of Dermatologists. Source

Haviland J.S.,The Institute of Cancer Research | Haviland J.S.,University of Southampton | Owen J.R.,Gloucestershire Oncology Center | Dewar J.A.,Ninewells Hospital | And 13 more authors.
The Lancet Oncology | Year: 2013

Background: 5-year results of the UK Standardisation of Breast Radiotherapy (START) trials suggested that lower total doses of radiotherapy delivered in fewer, larger doses (fractions) are at least as safe and effective as the historical standard regimen (50 Gy in 25 fractions) for women after primary surgery for early breast cancer. In this prespecified analysis, we report the 10-year follow-up of the START trials testing 13 fraction and 15 fraction regimens. Methods: From 1999 to 2002, women with completely excised invasive breast cancer (pT1-3a, pN0-1, M0) were enrolled from 35 UK radiotherapy centres. Patients were randomly assigned to a treatment regimen after primary surgery followed by chemotherapy and endocrine treatment (where prescribed). Randomisation was computer-generated and stratified by centre, type of primary surgery (breast-conservation surgery or mastectomy), and tumour bed boost radiotherapy. In START-A, a regimen of 50 Gy in 25 fractions over 5 weeks was compared with 41·6 Gy or 39 Gy in 13 fractions over 5 weeks. In START-B, a regimen of 50 Gy in 25 fractions over 5 weeks was compared with 40 Gy in 15 fractions over 3 weeks. Eligibility criteria included age older than 18 years and no immediate surgical reconstruction. Primary endpoints were local-regional tumour relapse and late normal tissue effects. Analysis was by intention to treat. Follow-up data are still being collected. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779. Findings: START-A enrolled 2236 women. Median follow-up was 9·3 years (IQR 8·0-10·0), after which 139 local-regional relapses had occurred. 10-year rates of local-regional relapse did not differ significantly between the 41·6 Gy and 50 Gy regimen groups (6·3%, 95% CI 4·7-8·5 vs 7·4%, 5·5-10·0; hazard ratio [HR] 0·91, 95% CI 0·59-1·38; p=0·65) or the 39 Gy (8·8%, 95% CI 6·7-11·4) and 50 Gy regimen groups (HR 1·18, 95% CI 0·79-1·76; p=0·41). In START-A, moderate or marked breast induration, telangiectasia, and breast oedema were significantly less common normal tissue effects in the 39 Gy group than in the 50 Gy group. Normal tissue effects did not differ significantly between 41·6 Gy and 50 Gy groups. START-B enrolled 2215 women. Median follow-up was 9·9 years (IQR 7·5-10·1), after which 95 local-regional relapses had occurred. The proportion of patients with local-regional relapse at 10 years did not differ significantly between the 40 Gy group (4·3%, 95% CI 3·2-5·9) and the 50 Gy group (5·5%, 95% CI 4·2-7·2; HR 0·77, 95% CI 0·51-1·16; p=0·21). In START-B, breast shrinkage, telangiectasia, and breast oedema were significantly less common normal tissue effects in the 40 Gy group than in the 50 Gy group. Interpretation: Long-term follow-up confirms that appropriately dosed hypofractionated radiotherapy is safe and effective for patients with early breast cancer. The results support the continued use of 40 Gy in 15 fractions, which has already been adopted by most UK centres as the standard of care for women requiring adjuvant radiotherapy for invasive early breast cancer. Funding: Cancer Research UK, UK Medical Research Council, UK Department of Health. © 2013 Elsevier Ltd. Source

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