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Nurse-led approach to standardising the management of iron-deficiency anaemia, achieving the 2-week cancer pathway targets and reducing hospital admissions: practicalities and learnings from a success story 护士主导的缺铁性贫血规范化管理方法,实现2周癌症通路目标和减少住院:实用性和成功案例的经验教训
IF 2.6 Q2 Medicine Pub Date : 2023-11-20 DOI: 10.1136/flgastro-2023-102438
Pauline Reid, Kev Patterson, Emma McCulloch, Laura Walsh, Amal Murshid, William Kinsella, Andrew Moore, Thomas Skouras, Philip J Smith
The most significant and common cause of anaemia is iron deficiency, which occurs when iron absorption cannot meet the body’s demands due to growth, pregnancy, poor nutrition, malabsorption or blood loss. It is estimated that in the UK 11% of the adult population have iron-deficiency anaemia (IDA) and investigation is essential to exclude significant pathology as the underlying cause. It has been shown that IDA is responsible for 57 000 hospital admissions in the UK, and at least 10% of gastroenterology referrals per annum. IDA is a major red flag symptom for gastrointestinal cancer. At the Royal Liverpool University Hospital, a dedicated nurse-led IDA service was developed in 2005 to help alleviate the clinical pressures created by the two week suspected cancer referral pathway. With the success of this service, investigation and management of IDA has been extended to referrals from accident and emergency, with the aim of reducing hospital admissions and to investigating and optimising iron replacement therapy in preoperative patients. Delivering this as a nurse consultant-led service was proposed by the gastroenterology medical team who felt that, as a clinical problem with well established, published investigative algorithms, IDA would be suitable for management in a dedicated nurse-led clinic. This article will focus on the strategies employed to achieve sufficient resources and clinic capacity to run this service effectively, develop strong nurse education and training, and the development of agreed investigation pathways. A robust results review process, with rapid management of abnormal results, was established with timely discharge for those patients with normal results. Optimisation of iron replacement therapy and verification of sustained haematological response was prioritised as this was identified as being poorly managed across all specialties. A process for ongoing audit of results was included to show the success of the service and highlight areas for redesign. Here, we demonstrate the effectiveness of our nurse-led IDA service and suggest it as the basis for other IDA services in the UK and beyond.
贫血最重要和最常见的原因是缺铁,当铁的吸收不能满足身体的需要时,由于生长、怀孕、营养不良、吸收不良或失血。据估计,在英国,11%的成年人患有缺铁性贫血(IDA),调查是必要的,以排除重大病理作为潜在原因。研究表明,IDA负责英国57000例住院病例,每年至少有10%的胃肠病学转诊。IDA是胃肠道癌的主要危险症状。在皇家利物浦大学医院,一个专门的护士主导的IDA服务于2005年开发,以帮助减轻两周的疑似癌症转诊途径所造成的临床压力。由于这项服务的成功,对缺铁的调查和管理已扩展到事故和急诊的转诊,目的是减少住院人数,并调查和优化术前患者的铁替代疗法。胃肠病学医疗团队提出以护士顾问为主导的服务方式提供这种服务,他们认为,作为一个具有完善的、已发表的调查算法的临床问题,IDA将适合在专门的护士领导的诊所进行管理。本文将重点介绍为获得足够的资源和诊所能力来有效地开展这项服务,发展强有力的护士教育和培训以及发展商定的调查途径所采用的策略。建立了一个强有力的结果审查过程,对异常结果进行快速管理,对结果正常的患者及时出院。优化铁替代疗法和验证持续的血液学反应是优先考虑的,因为这在所有专业中都被认为管理不善。包括一个持续审计结果的过程,以显示服务的成功并突出需要重新设计的领域。在这里,我们展示了护士主导的IDA服务的有效性,并建议将其作为英国及其他地区其他IDA服务的基础。
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引用次数: 0
Unusual cause of a radiological subdiaphragmatic air-fluid level 放射性膈下气液面异常原因
Q2 Medicine Pub Date : 2023-11-14 DOI: 10.1136/flgastro-2023-102562
Rex Wan-Hin Hui, Arthur Ho-Cheung Tang, Lok-Ka Lam, Wai-Kay Seto, Siu-Yin Wong, Man-Fung Yuen
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引用次数: 0
Inflammatory Bowel Disease Disability Index is a valid and reliable measure of disability in an English-speaking hospital practice and predicts long-term requirement for treatment escalation 炎症性肠病失能指数是英语医院实践中有效和可靠的失能指标,并预测治疗升级的长期需求
Q2 Medicine Pub Date : 2023-11-10 DOI: 10.1136/flgastro-2023-102428
Darragh Storan, Edel McDermott, Jenny Moloney, Lisa Keenan, Roisin Stack, Juliette Sheridan, Glen Doherty, Garret Cullen, Louise McHugh, Hugh E Mulcahy
Objective The Inflammatory Bowel Disease Disability Index (IBD-DI) was developed according to WHO standards and has been validated in population-based cohorts. However, there are limited data on its relationship to various psychosocial and economic variables or its relevance to hospital clinical practice. The study aims were to determine the validity and reliability of the IBD-DI in an English-speaking hospital out-patient population and to evaluate its association with short and long-term disease activity. Design/Methods 329 subjects were enrolled in a cross-sectional and longitudinal study assessing the IBD-DI and a range of quality of life, work impairment, depression, anxiety, body image, interpersonal, self-esteem, disease activity, symptom scoring scales in addition to long-term outcome. Results The IBD-DI had adequate structure, was internally consistent and demonstrated convergent and predictive validity and was reliable in test–retest study. Disability was related to female sex (p=0.002), antidepressant use (p<0.001), steroid use (p<0.001) and disease activity (p<0.001). Higher IBD-DI scores were associated with long-term disease activity and need for treatment escalation in univariate (p<0.001) and multivariate (p=0.002) analyses. Conclusion The IBD-DI is a valid and reliable measure of disability in English-speaking hospital populations and predicts long-term requirement for treatment escalation.
炎症性肠病失能指数(IBD-DI)是根据世卫组织标准制定的,并已在基于人群的队列中得到验证。然而,关于其与各种社会心理和经济变量的关系或其与医院临床实践的相关性的数据有限。本研究的目的是确定IBD-DI在英语医院门诊人群中的有效性和可靠性,并评估其与短期和长期疾病活动的关系。设计/方法329名受试者参加了一项横断面和纵向研究,评估IBD-DI和一系列生活质量、工作障碍、抑郁、焦虑、身体形象、人际关系、自尊、疾病活动、症状评分量表以及长期结果。结果IBD-DI结构合理,内部一致,具有收敛效度和预测效度,在重测研究中可靠。残疾与女性性别(p=0.002)、抗抑郁药使用(p= 0.001)、类固醇使用(p= 0.001)和疾病活动性(p= 0.001)有关。在单变量分析(p= 0.001)和多变量分析(p=0.002)中,较高的IBD-DI评分与长期疾病活动性和需要升级治疗相关。结论IBD-DI在英语医院人群中是一种有效、可靠的残疾测量方法,可以预测治疗升级的长期需求。
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引用次数: 0
Challenge of achieving truly individualised informed consent in therapeutic endoscopy 在治疗性内窥镜检查中实现真正个性化知情同意的挑战
Q2 Medicine Pub Date : 2023-11-08 DOI: 10.1136/flgastro-2023-102545
Philip Berry, Sreelakshmi Kotha
Objective Guidance covering informed consent in endoscopy has been refined in the UK following the obstetric case of Nadine Montgomery, and in light of updated General Medical Council guidance. All risks likely to be material to the patient must be explored, as well as alternatives to the procedure. Despite this, departments and endoscopists still struggle to meet the current standards. In this article, we explore the challenges encountered in achieving individualised consent in therapeutic endoscopy through real-life scenarios. Methods Five realistic therapeutic endoscopy (hepatobiliary) scenarios are described, followed by presentation of possible or ideal approaches, with references related to existing literature in this field. Results The vignettes allow consideration of how to approach difficult consent challenges, including anxiety and information overload, urgency during acute illness, failure to disclose the risk of death, the role of trainees and intraprocedural distress under conscious sedation. Conclusions The authors conclude that a high degree of transparency is required while obtaining consent for therapeutic endoscopy accompanied by full documentation, involvement of relatives in nearly all cases, and clarity around the presence of trainees who may handle the scope. A greater focus on upskilling trainees in the consent process for therapeutic endoscopy is required.
根据纳丁·蒙哥马利(Nadine Montgomery)的产科病例,并根据最新的总医学委员会指南,联合王国修订了关于内窥镜检查知情同意的指南。所有可能对患者产生重大影响的风险,以及手术的替代方案,都必须加以探讨。尽管如此,各部门和内窥镜医师仍在努力达到目前的标准。在这篇文章中,我们探讨了通过现实生活场景在治疗性内窥镜检查中实现个性化同意所遇到的挑战。方法介绍五种现实的肝胆内镜治疗方案,然后介绍可能的或理想的方法,并参考该领域的现有文献。结果这些小片段考虑了如何处理困难的同意挑战,包括焦虑和信息过载、急性病期间的紧迫性、未能披露死亡风险、受训者的作用和有意识镇静下的术中窘迫。作者得出结论,在获得治疗性内窥镜检查的同意时,需要高度的透明度,并伴有完整的文件,几乎所有病例都有亲属参与,以及可能处理内窥镜的受训者在场的透明度。需要更加注重在治疗性内窥镜检查的同意过程中提高受训者的技能。
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引用次数: 0
European Crohn’s and Colitis Guidelines on sexuality, fertility, pregnancy and lactation: a guideline review 欧洲关于性、生育、妊娠和哺乳的克罗恩病和结肠炎指南:指南综述
Q2 Medicine Pub Date : 2023-11-06 DOI: 10.1136/flgastro-2023-102534
Jennifer Phillips, Ann Jane Archer, Alice Lagnado, Morgan O’Flaherty, Aileen Fraser, Ruth Carr
The European Crohn’s and Colitis Organisation has recently published the third version of the European Consensus on reproduction in inflammatory bowel disease. Here, we summarise their key recommendations.
欧洲克罗恩病和结肠炎组织最近发布了第三版关于炎症性肠病生殖的欧洲共识。在这里,我们总结了他们的主要建议。
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引用次数: 0
Novel, nurse-led early postdischarge clinic is associated with fewer readmissions and lower mortality following hospitalisation with decompensated cirrhosis 新颖的、由护士主导的早期出院后临床与再入院率和失代偿性肝硬化住院后死亡率降低相关
Q2 Medicine Pub Date : 2023-11-06 DOI: 10.1136/flgastro-2023-102489
Benjamin Giles, Kirsty Fancey, Karen Gamble, Zeshan Riaz, Joanna K Dowman, Andrew J Fowell, Richard J Aspinall
Objective Patients hospitalised with decompensated cirrhosis have high rates of early unplanned readmission. Many readmissions are avoidable with secondary preventative strategies, but patients are often readmitted prior to outpatient review. To address this, we established a novel, nurse-led early postdischarge (EPD) clinic delivering goal-directed care for cirrhosis complications and evaluated the impact. Methods Retrospective cohort study comparing outcomes in 78 patients seen in the EPD clinic with 91 phenotypically matched controls receiving standard, consultant hepatologist care. Follow-up for 12 months from index admission with endpoints including survival, time to readmission, number of readmissions and healthcare burden. Results Median time to readmission was 51 days in controls and 98 days in the intervention group (p<0.01). The intervention cohort had significantly fewer readmissions at 30 days (12% vs 30%, p<0.01) and 90 days (27% vs 49%, p<0.01) but not significantly at 12 months (58% vs 68%, p=0.16) with an overall reduction in bed day usage of 29%. Mortality for the control group was 4% at 30 days with no deaths in the intervention group. There were significantly fewer deaths in the intervention group at 90 days (5% vs 15%, p<0.05) and 12 months (22% vs 41%, p<0.01). Conclusions Following an index hospitalisation with decompensated cirrhosis, goal-directed postdischarge care can be effectively delivered by specialist nurses, prior to outpatient review by hepatologists. This model was associated with significantly fewer readmissions, lower bed day usage and a reduced mortality. Our data suggest such models of care deserve wider implementation and further evaluation.
目的失代偿期肝硬化患者早期意外再入院率高。许多再入院可以避免与二级预防策略,但患者往往再入院之前门诊审查。为了解决这个问题,我们建立了一个新颖的,由护士领导的早期出院(EPD)诊所,为肝硬化并发症提供目标导向的护理,并评估了其影响。方法回顾性队列研究,比较78例EPD门诊患者和91例表型匹配的对照组接受标准的肝病专科医生治疗的结果。从指数入院开始随访12个月,终点包括生存、再入院时间、再入院次数和医疗负担。结果对照组再入院时间为51天,干预组再入院时间为98天(p < 0.01)。干预组在30天(12% vs 30%, p= 0.01)和90天(27% vs 49%, p= 0.01)的再入院率显著降低,但在12个月(58% vs 68%, p=0.16)时再入院率不显著降低,总卧床日使用率减少29%。对照组30天死亡率为4%,干预组无死亡病例。干预组在90天(5% vs 15%, p<0.05)和12个月(22% vs 41%, p<0.01)的死亡率显著减少。结论:在失代偿性肝硬化患者住院后,专科护士可以在肝病专家门诊复查之前有效地提供目标导向的出院后护理。该模型与再入院率显著降低、床日使用率降低和死亡率降低有关。我们的数据表明,这种护理模式值得更广泛的实施和进一步的评估。
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引用次数: 0
Tailoring follow-up endoscopy in patients with severe oesophagitis 重度食管炎患者的量身定制随访内镜检查
Q2 Medicine Pub Date : 2023-11-02 DOI: 10.1136/flgastro-2023-102485
Rebecca K Grant, William M Brindle, Caitlyn L Taylor, Edward J Rycroft, Oluwadara Oyewole, Sarah C Morgan, Eleanor F Watson, Atul Anand, Norma C McAvoy, Ian D Penman, Nicholas I Church, Kenneth C Trimble, Colin L Noble, John N Plevris, Gail S M Masterton, Rahul Kalla
Objective We aimed to investigate the clinical utility of follow-up oesophagogastroduodenoscopy (OGD2) in patients with severe oesophagitis (Los Angeles grades C or D) through evaluating the yield of Barrett’s oesophagus (BO), cancer, dysplasia and strictures. Second, we aimed to determine if the Clinical Frailty Scale (CFS) may be used to identify patients to undergo OGD2s. Design/method Patients in NHS Lothian with an index OGD (OGD1) diagnosis of severe oesophagitis between 1 January 2014 and 31 December 2015 were identified. Univariate analysis identified factors associated with grade. Patients were stratified by frailty and a diagnosis of stricture, cancer, dysplasia and BO. Results In total 964 patients were diagnosed with severe oesophagitis, 61.7% grade C and 38.3% grade D. The diagnostic yield of new pathology at OGD2 was 13.2% (n=51), new strictures (2.3%), dysplasia (0.5%), cancer (0.3%) and BO (10.1%). A total of 140 patients had clinical frailty (CFS score ≥5), 88.6% of which were deceased at review (median of 76 months). In total 16.4% of frail patients underwent OGD2s and five new pathologies were diagnosed, none of which were significantly associated with grade. Among non-frail patients at OGD2, BO was the only pathology more common (p=0.010) in patients with grade D. Rates of cancer, dysplasia and strictures did not vary significantly between grades. Conclusion Our data demonstrate that OGD2s in patients with severe oesophagitis may be tailored according to clinical frailty and only be offered to non-frail patients. In non-frail patients OGD2s have similar pick-up rates of sinister pathology in both grades of severe oesophagitis.
目的通过评估Barrett食管(BO)、肿瘤、发育不良和狭窄的发生率,探讨重度食管炎(洛杉矶分级C级或D级)患者随访食管胃十二指肠镜(OGD2)的临床应用价值。其次,我们的目的是确定临床虚弱量表(CFS)是否可以用于确定接受OGD2s的患者。设计/方法选取2014年1月1日至2015年12月31日期间在洛锡安NHS诊断为OGD1指数(OGD1)的严重食管炎患者。单因素分析确定了与成绩相关的因素。患者根据虚弱程度和狭窄、癌症、发育不良和BO的诊断进行分层。结果重度食管炎964例,其中C级61.7%,d级38.3%。OGD2新发病理诊断率为13.2%(51例),新发狭窄(2.3%),发育不良(0.5%),癌(0.3%),BO(10.1%)。共有140例患者出现临床虚弱(CFS评分≥5),其中88.6%的患者在回顾时死亡(中位为76个月)。共有16.4%的体弱患者接受了OGD2s治疗,并诊断出5种新的病理,但没有一种与分级显著相关。在OGD2的非虚弱患者中,BO是d级患者中唯一更常见的病理(p=0.010)。癌症、发育不良和狭窄的发生率在不同级别之间没有显著差异。结论我们的数据表明,严重食管炎患者的OGD2s可根据临床虚弱度量身定制,仅适用于非虚弱患者。在非虚弱的患者中,OGD2s在两级严重食管炎的险恶病理中有相似的上升率。
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引用次数: 0
Twitter debate: should upper gastrointestinal bleeding training and certification be formalised? 推特辩论:上消化道出血培训和认证应该正式化吗?
Q2 Medicine Pub Date : 2023-10-28 DOI: 10.1136/flgastro-2023-102549
Vivek Chand Chand Goodoory, Allan John Morris, Andrew M Veitch
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引用次数: 0
Time to treat the climate and nature crisis as one indivisible global health emergency 是时候将气候和自然危机视为一个不可分割的全球卫生紧急事件
Q2 Medicine Pub Date : 2023-10-25 DOI: 10.1136/flgastro-2023-102569
Chris Zielinski
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引用次数: 0
Developing a generic business case for an advanced chronic liver disease support service 为晚期慢性肝病支持服务开发通用商业案例
Q2 Medicine Pub Date : 2023-10-24 DOI: 10.1136/flgastro-2023-102530
Mark Wright, Sarah Willmore, Sumita Verma, Anita Omasta-Martin, Humraj Sahota, Wendy Prentice, Amelia Jane Stockley, Fiona Finlay, Julia Verne, Ben Hudson
Introduction Liver disease deaths are rising, but specialist palliative care services for hepatology are limited. Expansion across the NHS is required. Methods We surveyed clinicians, patients and carers to design an ‘ideal’ service. Using standard NHS tariffs, we calculated the cost of this service. In hospitals where specialist palliative care was available for liver disease, patient-level costs and bed utilisation in last year of life (LYOL) were compared between those seen by specialist palliative care before death and those not. Results The ‘ideal’ service was described. Costs were calculated as whole time equivalent for a minimal service, which could be scaled up. From a hospital with an existing service, patients seen by specialist palliative care had associated costs of £14 728 in LYOL, compared with £18 558 for those dying without. Savings more than balanced the costs of introducing the service. Average bed days per patient in LYOL were reduced (19.4 vs 25.7) also intensive care unit bed days (1.1 vs 1.8). Despite this, time from first admission in LYOL to death was similar in both groups (6 months for the specialist palliative care group vs 5 for those not referred). Conclusions We have produced a template business case for an ‘ideal’ advanced liver disease support service, which self-funds and saves many bed days. The model can be easily adapted for local use in other trusts. We describe the methodology for calculating patient-level costs and the required service size. We present a financially compelling argument to expand a service to meet a growing need.
肝病死亡人数正在上升,但肝病专科姑息治疗服务有限。全国医疗服务体系的扩张是必要的。方法对临床医生、患者和护理人员进行调查,设计一种“理想”的服务。使用标准的NHS关税,我们计算了这项服务的成本。在提供肝病专科姑息治疗的医院中,比较了临终前接受专科姑息治疗的患者和未接受专科姑息治疗的患者在生命最后一年(LYOL)的患者水平成本和病床利用率。结果对“理想”服务进行了描述。成本是按最小服务的总时间等价物计算的,可以按比例扩大。从现有服务的医院来看,接受专科姑息治疗的患者在LYOL方面的相关费用为14,728英镑,而没有接受姑息治疗的患者则为18,558英镑。节省下来的钱超过了引入这项服务的成本。每位LYOL患者的平均住院天数减少(19.4 vs 25.7),重症监护病房的住院天数减少(1.1 vs 1.8)。尽管如此,从LYOL首次入院到死亡的时间在两组中相似(专科姑息治疗组为6个月,而非转诊组为5个月)。结论:我们已经为“理想的”晚期肝病支持服务提供了一个模板商业案例,该服务可以自我资助并节省许多住院天数。该模型可以很容易地适用于其他信托机构的本地使用。我们描述了计算患者水平成本和所需服务规模的方法。我们提出了一个经济上令人信服的论点来扩展服务以满足日益增长的需求。
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引用次数: 0
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Frontline Gastroenterology
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