Gemma Housley

Trends in hospital admissions for hypoglycaemia in England: a retrospective, observational study

BACKGROUND Studies in the USA and Canada have reported increasing or stable rates of hospital admissions for hypoglycaemia. Some data from small studies are available for other countries. We aimed to gather information about long-term trends in hospital admission for hypoglycaemia and subsequent outcomes in England to help widen understanding for the global burden of hospitalisation for hypoglycaemia. METHODS We collected data for all hospital admissions listing hypoglycaemia as primary reason of admission between Jan 1, 2005, and Dec 31, 2014, using the Hospital Episode Statistics database, which contains details of all admissions to English National Health Service (NHS) hospital trusts. We calculated trends in crude and adjusted (for age, sex, ethnic group, social deprivation, and Charlson comorbidity score) admissions for hypoglycaemia; in admissions for hypoglycaemia per total hospital admissions and per diabetes prevalence in England; and in length of stay, in-hospital mortality, and 1 month readmissions for hypoglycaemia. FINDINGS 79 172 people had 101 475 admissions for hypoglycaemia between 2005 and 2014, of which 72 568 (72%) occurred in people aged 60 years or older. 13 924 (18%) people had more than one admission for hypoglycaemia during the study period. The number of admissions increased steadily from 7868 in 2005, to 11 756 in 2010 (49% increase) and then remained more stable until 2014 (10 977; 39% increase from baseline, range across English regions 11-89%); the trend was similar after adjustment for risk factors, with a rate ratio of 1·53 (95% CI 1·29-1·81) for 2014 versus 2005. Admissions for hypoglycaemia per 100 000 total hospital admissions increased from 63·6 to 78·9 between 2005-06 and 2010-11 (24% increase), and then fell to 72·3 per 100 000 in 2013-14 (14% overall increase). Accounting for diabetes prevalence data, rates declined from 4·64 to 3·86 admissions per 1000 person-years with diabetes between 2010-11 and 2013-14. We were unable to compare prevalence rates with data prior to 2010, as the populations were not comparable; data were available for all individuals prior to 2010 but only for those aged 17 years or older after 2010. With some differences across regions, from 2005 to 2014, the adjusted proportion of admissions to receive same-day discharge increased by 43·8% (from 18·9 to 27·1 same-day discharges per 100 admissions); in-hospital mortality decreased by 46·3% (from 4·2 to 2·3 deaths per 100 admissions); and 1 month readmissions decreased by 63·0% (from 48·1 to 17·8 per 100 readmissions). INTERPRETATION Over 10 years, hospital admissions in England for hypoglycaemia increased by 39% in absolute terms and by 14% considering the general increase in hospitalisation; however, accounting for diabetes prevalence, there was a reduction of admission rates. Hospital length of stay, mortality, and 1 month readmissions decreased progressively and consistently during the study period. Given the continuous rise of diabetes prevalence, ageing population, and costs associated with hypoglycaemia, individual and national initiatives should be implemented to reduce the burden of hospital admissions for hypoglycaemia. FUNDING None.

Using venous blood gas analysis in the assessment of COPD exacerbations: a prospective cohort study

Introduction Identifying acute hypercapnic respiratory failure is crucial in the initial management of acute exacerbations of COPD. Guidelines recommend obtaining arterial blood samples but these are more difficult to obtain than venous. We assessed whether blood gas values derived from venous blood could replace arterial at initial assessment. Methods Patients requiring hospital treatment for an exacerbation of COPD had paired arterial and venous samples taken. Bland–Altman analyses were performed to assess agreement between arterial and venous pH, CO2 and . The relationship between SpO2 and SaO2 was assessed. The number of attempts and pain scores for each sample were measured. Results 234 patients were studied. There was good agreement between arterial and venous measures of pH and (mean difference 0.03 and −0.04, limits of agreement −0.05 to 0.11 and −2.90 to 2.82, respectively), and between SaO2 and SpO2 (in patients with an SpO2 of >80%). Arterial sampling required more attempts and was more painful than venous (mean pain score 4 (IQR 2–5) and 1 (IQR 0–2), respectively, p<0.001). Conclusions Arterial sampling is more difficult and more painful than venous sampling. There is good agreement between pH and values derived from venous and arterial blood, and between pulse oximetry and arterial blood gas oxygen saturations. These agreements could allow the initial assessment of COPD exacerbations to be based on venous blood gas analysis and pulse oximetry, simplifying the care pathway and improving the patient experience.

Risk factors and outcome differences in hypoglycaemia-related hospital admissions A case-control study in England.

To evaluate risk factors for hospital admissions for hypoglycaemia and compare length of hospitalization, inpatient mortality and hospital readmission between hypoglycaemia‐ and non‐hypoglycaemia‐related admissions.

Exploring the Relationship between Location and Behaviour in Out of Hours Hospital Care

‘Out of Hours’ (OoH) hospital care involves a small number of doctors covering a very large number of patients. These doctors are working in stressful environments, performing complex tasks and making difficult task prioritisation decisions, yet little data exists to aid in improving the working practices or to ensure junior doctors are adequately prepared for OoH working. Historically, this has been owing to complex and expensive processes to capture this data; however recent advances in indoor positioning technologies has the potential to automate and improve the capture and availability of data that may help alleviate the burden of OoH care on at a personal and hospital level. This paper describes our work to combine cutting edge indoor positioning technologies from OoH working with and a newly deployed in-ward electronic tasking system. Here we describe data collection via traditional methods, clinical tasking systems, and indoor positioning solutions. We further describe our understanding from such data of the effect of physical layout and current working practices on task completion and time spent in transit, which ultimately may inform improvements to working practice within OoH care. Finally we discuss potential relevance to other work domains.

Accurate identification of hospital admissions from care homes; development and validation of an automated algorithm

Abstract Background measuring the complex needs of care home residents is crucial for resource allocation. Hospital patient administration systems (PAS) may not accurately identify admissions from care homes. Objective to develop and validate an accurate, practical method of identifying care home resident hospital admission using routinely collected PAS data. Method admissions data between 2011 and 2012 (n = 103,105) to an acute Trust were modelled to develop an automated tool which compared the hospital PAS address details with the Care Quality Commission’s (CQC) database, producing a likelihood of care home residency. This tool and the Nuffield method (CQC postcode match only) were validated against a manual check of a random sample of admissions (n = 2,000). A dataset from a separate Trust was analysed to assess generalisability. Results the hospital PAS was inaccurate; none of the admissions from a care home identified on manual check had a care home source of admission recorded on the PAS. Both methods performed well; the automated tool had a higher positive predictive value than the Nuffield method (100% 95% confidence interval (CI) 98.23–100% versus 87.10% 95%CI 82.28–91.00%), meaning those coded as care home residents were more likely to actually be from a care home. Our automated tool had a high level of agreement 99.2% with the second Trust’s data (Kappa 0.86 P < 0.001). Conclusions care home status is not routinely or accurately captured. Automated matching offers an accurate, repeatable, scalable method to identify care home residency and could be used as a tool to benchmark how care home residents use acute hospital resources across the National Health Service.

Assessment of discharge treatment prescribed to women admitted to hospital for hyperemesis gravidarum

Prescribing drug treatment for the management of hyperemesis gravidarum (HG), the most severe form of nausea and vomiting in pregnancy, remains controversial. Since most manufacturers do not recommend prescribing antiemetics during pregnancy, little is known regarding which treatments are most prevalent among pregnant patients. Here, we report for the first time, evidence of actual treatments prescribed in English hospitals.

Investigating the discriminative value of Early Warning Scores in patients with respiratory disease using a retrospective cohort analysis of admissions to Nottingham University Hospitals Trust over a 2-year period

Objective Early Warning Scores (EWSs) are used to monitor patients for signs of imminent deterioration. Although used in respiratory disease, EWSs have not been well studied in this population, despite the underlying cardiopulmonary pathophysiology often present. We examined the performance of two scoring systems in patients with respiratory disease. Design Retrospective cohort analysis of vital signs observations of all patients admitted to a respiratory unit over a 2-year period. Scores were linked to outcome data to establish the performance of the National EWS (NEWS) compared results to a locally adapted EWS. Setting Nottingham University Hospitals National Health Service Trust respiratory wards. Data were collected from an integrated electronic observation and task allocation system employing a local EWS, also generating mandatory referrals to clinical staff at set scoring thresholds. Outcome measures Projected workload, and sensitivity and specificity of the scores in predicting mortality based on outcome within 24 hours of a score being recorded. Results 8812 individual patient episodes occurred during the study period. Overall, mortality was 5.9%. Applying NEWS retrospectively (vs local EWS) generated an eightfold increase in mandatory escalations, but had higher sensitivity in predicting mortality at the protocol cut points. Conclusions This study highlights issues surrounding use of scoring systems in patients with respiratory disease. NEWS demonstrated higher sensitivity for predicting death within 24 hours, offset by reduced specificity. The consequent workload generated may compromise the ability of the clinical team to respond to patients needing immediate input. The locally adapted EWS has higher specificity but lower sensitivity. Statistical evaluation suggests this may lead to missed opportunities for intervention, however, this does not account for clinical concern independent of the scores, nor ability to respond to alerts based on workload. Further research into the role of warning scores and the impact of chronic pathophysiology is urgently needed.

Measuring health related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing

Introduction Research into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures. Methods and analysis This is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents ≥60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model. Ethics and dissemination The PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies.

P194 Early warning scores, too imprecise a tool in patients with respiratory disease?

Introduction Guidance from the National Institute of Health and Care Excellence in 20071 has led to the almost universal use of early warning scores (EWS) derived from vital signs observations in hospitals in the UK to highlight patients at risk of deterioration. Lack of high quality prospective studies limits our understanding of the impact of using such monitoring systems on outcomes and working patterns. No EWS has been validated in respiratory patients despite widespread use. Our aim was to examine the ability of both the locally used EWS and National Early Warning Score (NEWS) to predict patient deterioration and associated burden of escalations generated in a respiratory cohort. Methods Vital signs observations and outcomes for all admissions under the respiratory department at a tertiary referral centre between April 2015 and March 2016 were analysed. Predicted and actual escalation patterns in relation to primary endpoint of mortality were examined comparing NEWS to local EWS. Patients documented as receiving end of life care were removed from analysis. Results Over 12 months there were 165,184 observations sets during 5293 admissions, with a mean of 38 observations per admission (standard deviation 50). Occurrence of primary endpoint of in-hospital death was 6.74%. 13% of observations triggered clinical escalation to a registered nurse or beyond, with mean of 1075 per month. 112 (31%) patients who died did not trigger escalation on their final set of observations, 1 patient was escalated despite scoring below protocol threshold. Applying NEWS criteria retrospectively predicts 6 patients who died would not be escalated, while generating a mean of 12,409 escalations of vital signs observations per month to registered nurse or beyond, 1,621 in patients who went on to die in hospital. Conclusion Our data suggests that neither scoring system provides effective monitoring in patients with respiratory disease, falling short on either sensitivity or specificity for predicting in-hospital death. As more data becomes available, modelling may allow more accurate prediction systems to be developed. Reference Adam S, et al. Acutely ill adults in hospital: recognising and responding to deterioration. In NICE guidelines. Manchester: National Institute for Health and Care Excellence (NICE), 2007. Abstract P194 Figure 1 Percentage of early warning score within last observation set prior to death

P44 Chronic obstructive pulmonary disease exacerbation and respiratory acidosis: patient outcomes at 6 months

Introduction Recognition of hypercapnic respiratory failure is a vital part of the assessment and management of the patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Several studies have demonstrated that respiratory acidosis in the context of an acute exacerbation is associated with worse inpatient outcomes. Our study compares the outcomes of patients admitted with an acute exacerbation, between those with respiratory acidosis and those who had a normal pH and PaCO2 on arterial blood gas (ABG) analysis. Methods Patients requiring hospital treatment for an acute exacerbation of COPD had an ABG taken on admission. Patients were subsequently assessed for the following outcomes: inpatient mortality, outpatient mortality up to six months after discharge and hospital re-admission rates in the six months post discharge. Chi-squared test was applied to assess the relationship between respiratory acidosis and our outcomes. Results 234 patients had an admission ABG and were subsequently followed up to the point of death or six months post discharge. Patients with a PaCO2 of >6 Kpa were 2.33 times (95% CI 1.11 to 4.96) more likely to die in hospital as compared to those patients with a normal value. Patients with a lower arterial pH (<7.35) were 2.32 times (95% CI 1.07 to 4.96) more likely to die in hospital as compared to those with a pH of >7.35. The increased risk in mortality was only seen for in-hospital mortality and there was no association with death in the 6 months following discharge, hospital re-admission or re-admission for a respiratory problem. Conclusion This data supports previous studies that suggest hypercapnia and respiratory acidosis are associated with increased inpatient mortality, therefore further demonstrating the usefulness of pH and PaCO2 as prognostic markers for inpatient outcomes. However our study does suggest that patients with respiratory acidosis on admission, who survive until discharge from hospital, do not have an increased risk of six month mortality or readmission compared to those with a normal admission ABG.