Cardiology a Ward Rounds: in Response Outpatient Clinic in Conjunction with Out- Rationale of Using a Checklist Patient Or Community Therapy Input

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LETTERS TO THE EDITOR

Cardiology a ward rounds: In response outpatient clinic in conjunction with out- rationale of using a checklist patient or community therapy input. It was rewarding to read Garg’s vision for It is possible that any additional data to Editor – I read with great interest Herring using checklists on a cardiology ward round. support further gains after inpatient reha- et al’s professional issues paper (Clin Med Feb We would encourage medical specialties to bilitation, either by a dedicated community 2011 pp 20–2) on ward rounds and using a practise using the ward round checklists and team led by rehabilitation medicine physi- checklist to improve quality and safety. In the adapt them in accordance to their personal cians or by general practitioners with an modern NHS, there is often significant pres- practice and specialty needs. Our experience interest in stroke or neurological disability, sure on consultant staff to consolidate several has shown us that checklists are potentially would in no small measure help drive clinical duties during their clinical sessions. useful in complex processes in which errors home the message of the beneficial impact As our population is aging and people are are common, or have serious effects, or of both inpatient and outpatient input in living longer than ever before, the majority of both. It is important to make the purpose of stroke patients by all and sundry, including patients in medical wards are now elderly the checklist obvious, stick to important commisioners. The potential savings on with multiple medical issues and also social points that tend to get missed, and keep the scanty resources and the improvement of issues. This obviously creates complexity in font large! The process of error checking the quality of life of stroke patients cannot ward rounds. should not slow the pace of work and should be overemphasised. From our experience, cardiology ward be embraced by every member of the ward rounds can be divided into many facets. A round team. NOSA AKPOREHWE few examples are as follows: a) consultant-led Consultant physician ward round; b) specialist registrar (SpR)-led ROSELLE HERRING Department of Rehabilitation Medicine ward round; c) senior house officer-led ward Specialist registrar in diabetes and endocrinology Woodend Hospital round; d) consultant/SpR led board ward Worthing Hospital Aberdeen round; e) post-take ward rounds led by con- Western Sussex NHS Trust sultants; f) foundation year 1-led ward round KERSTIN AKPOREHWE GP (should not happen ideally). What reductions in dependency Cardiology is predominantly a procedure The Glen Medical Centre cost result from treatment in an Hebburn, Tyne and Wear driven specialty. Checklists will be very rele- inpatient neurological vant in various cardiac patients who get rehabilitation unit for people RAJIB PURKAYASTHA admitted for various cardiac procedures with stroke? Consultant physician ranging from ablation to percutaneous coro- Department of Rehabilitation Medicine nary intervention. This checklist could Editor – We read with keen interest, the very Woodend Hospital include vascular complications, follow-up timely study of O’Connor et al (Clin Med Aberdeen planning details and also be individualised Feb 2011 pp 40–3). It was reassuring to note for each cardiovascular procedures. the significant reduction in dependency, Checklists already exist for cardiac proce- dependency costs and improvement in In response dures in various NHS hospitals and they are functional ability as measured using the embedded in procedural pathways. They median Barthel index in stroke patients Editor – We would like to thank Akporehwe become relevant in ward rounds as patients who have undergone goal-oriented multi- et al for their interest in our study. Recently, requiring overnight stay for their procedures disciplinary inpatient neurological rehabili- we had the opportunity to investigate the will be reviewed by ward-based teams at tation. This is pertinent in the current reduction in dependency and care costs some stage. For example, post-pacemaker financial climate where commissioning of associated with a newly established goal-ori- implantation patients should have a chest X- healthcare is about to be radically trans- entated multidisciplinary community stroke ray the next day and a checklist-based system formed from primary care trusts to GP con- rehabilitation team. This team comprises will facilitate the ward team to make sure this sortia with no robust evidence, including consultant physicians in rehabilitation med- is reviewed before discharge. Overall, this pilot study, to back such a monumental icine, occupational and physical therapists, reduces complications, clinical/nursing change within the NHS. speech and language therapists, dieticians, errors and facilitates early discharge of Although the study did not mention the and psychologists. patients. It also provides one pathway com- formal follow-up of the cohort of stroke We collected data on dependency using munication between several teams involved patients in a dedicated outpatient clinic the Northwick Park Dependency Score in a patient’s care. and community therapy team after inpa- (NPDS)1 in a cohort of stroke survivors par- tient rehabilitation, we wonder if the team ticipating in the rehabilitation programme PANKAJ GARG has any data regarding further improve- (45 males, 26 females; median age 71 years, Specialist registrar in cardiology ment in physical ability or further reduc- interquartile range (IQR) 39–96 years). The Cardiology and Cardiothoracic Department tion in dependency and dependency costs median length of the rehabilitation pro- Northern General Hospital, Sheffield subsequent to follow-up in a dedicated gramme was nine weeks (IQR 8–13 weeks).

LETTERS TO THE EDITOR

Table 1. Dependency and care costs on admission and discharge. Clinical and Outcome Admission median (IQR) Discharge median (IQR) Z-score p-value scientific letters NPDS 7 (2–14) 1 (0–5) Ϫ6.842 Ͻ0.001 Letters not directly related to articles Cost of care 234 (168–564) 102 (18–168) Ϫ6.851 published in Clinical Medicine and (£ per week) Ͻ0.001 presenting unpublished original data NPDS ϭ Northwick Park Dependency Score. should be submitted for publication in this section. Clinical and scientific let- The interim analyses are presented in Diagnosis and management of ters should not exceed 500 words and Table 1 and demonstrate both substantial urinary infections in older people may include one table and up to five improvements in independence, and references. reductions in care costs. We would Congratulations to Drs Woodford and George for a well researched article on uri- strongly encourage other rehabilitation The need for dedicated dermatology nary infections in older people (Clin Med teams to collect and collate data for com- beds missioners to demonstrate the effective- Feb 2011 pp 80–3), a common diagnosis encountered during most medical takes. As ness of multidisciplinary rehabilitation Increasing pressure on inpatient beds has their article states, urine samples may be programmes. no doubt contributed to the ongoing hard to obtain in older patients due to reduction in designated dermatology beds incontinence or cognitive impairment, but RORY O’CONNOR within acute hospital trusts. Studies in misdiagnosis of urinary tract infections Senior lecturer and honorary consultant physician Scotland1 and Manchester2 have high- may result in inappropriate exposure to in rehabilitation medicine lighted an 82% and 57% reduction respec- antibiotics and delay in establishing the Academic Department of Rehabilitation Medicine tively in dedicated dermatology beds in correct diagnosis, and urine culture ‘if pos- recent years. This loss of acute beds for the CLARISSA MARTYN-HEMPHILL sible’ is advised in the appropriate clinical treatment of patients with severe skin dis- Year 5 medical student context. ease has led to a shift away from patient It would have been of interest to review CATRIONA MCNICOL admission towards management in the any evidence base, techniques or recom- Year 5 medical student community with expensive immunosup- mendations for obtaining the urine culture RORY MORRISON pressant therapies associated with poten- in this commonly encountered subset of Year 5 medical student tially serious side effects. patients. Much is written in the paediatric University of Leeds We report a study from a designated literature about collection of urine by col- 12-bedded dermatology ward at Amersham lection bags, supra-pubic aspiration, or ‘in- Reference General Hospital in Buckinghamshire, out’ catheterisation in young children who which investigated the impact of admission 1 Turner-Stokes L, Tonge P, Nyein K et al. The are not able to provide a sample easily, and Northwick Park Dependency Score (NPDS): on the Dermatology Life Quality Index it would be useful to know if these tech- a measure of nursing dependency in rehabil- (DLQI)3 of patients with skin disease. niques may also have benefit in the adult itation. Clin Rehabil 1998;12:304–18. In total, 107 patients were admitted to population. the ward over a six-month period. Fifty- four per cent (58/107) were female and GUY HAGAN 46% (49/107) male. The average age was Specialist registrar in respiratory/general medicine 53.8 years (range 16–94 years). The mean West Midlands length of stay was 13.9 days (range 2–57 days). Fifty-two per cent of admissions to the ward were planned (eg photoinvestiga- tions, eczema clearance and education) and 48% were emergency admissions (eg acute flares of eczema, psoriasis or cellulitis). The average DLQI score at time of admission was 12 (range 0–30). Three months post- discharge, the average DLQI was 6.5 with an individual average 5.8 point reduction in DLQI score (paired t test, pϭ0.0001).