Imran Aziz

Does increasing the access to specialist respiratory team reduce the presentation and admission of acute asthma to hospital

Background and Aims: Our hospital has one of the highest rates in the North West of England for asthma admissions. The respiratory team in 2010 consisted of just one asthma specialist nurse, based off the acute site, providing a largely outpatient service. In 2014, the department gained another specialist asthma nurse and the accessibility to the service was increased with extra clinic sessions and an open access policy for patients requiring advice. The aim of our study was to review if this would influence the admission rate and presentation to the Accident and Emergency department (AE a 15% and 20% reduction respectively. For the corresponding years it was noted that the outpatient activity increased by 23%. Conclusion: We have shown that with open access to clinics we can reduce acute admissions but at a cost of more patients seen in clinics. This is preferable to acute presentations and admissions from A&E. We believe this is achieved by enabling patients to receive prompt assessment and treatment of unstable symptoms before they deteriorate, thus decreasing the need for A&E presentations and admissions, this reduces overall cost to the health service.

P202 A survey of ILD expertise availability and High Resolution Computer Tomography (HRCT) protocols used in patients with Interstitial lung disease (ILD) across hospitals in England

Introduction and aims ILD is increasingly being recognised as complex condition necessitating a multi-disciplinary approach to diagnosis and management requiring availability of a clinician and a radiologist with declared interest in ILD. HRCT is the imaging of choice used for assessment of ILD. The BTS ILD guidelines do recommend a “standard” HRCT protocol to be used in diagnosis of patients with ILD. It is however not known if there is a uniform availability of expertise within different centres in England and if “standard “HRCT protocol as recommended is being followed. Method A questionnaire was handed to radiologists with special interest in thoracic imaging working in different hospitals sites in England, at an ILD radiology conference. Questionnaires enquired about availability of ILD services and HRCT scanning technique used at their establishment. Results Of the 150 questionnaires, 100 were returned for analysis. There were responses from 39 teaching hospitals and 61 district general hospitals (DGH). Abstract P202 Table 1. Results of questionnaire given to thoracic radiologists across Hospitals in England. Question Overall “yes” Teaching Hospitals (n = 39) DGH (n = 61) p value 1) Is there a specialist thoracic radiologist? 72% 92% 59% 0.0002 2) Is there a lead clinician for ILD? 41% 59% 34% 0.0062 3) Do you have a local departmental protocol for HRCT scanning technique? 95% 95% 97% NS 4) Do you routinely perform additional expiratory phase scans during HRCT? 30% 33% 28% NS 5) Do you routinely perform HRCT in prone position ? 32% 26% 36% NS 6) Do you use image reconstruction routinely ? (only 44 responded) 77% 55% (n = 18) 92% (n = 26) NS 7) Do you use discontinuous imaging protocol? 42% 41% 43% NS 8) Do you use volume imaging protocol? 27% 21% 31% NS 9) If you use volume CT do you use “ Low Dose ” Technique? 48% 54% 44% NS Conclusions Despite increasing focus on ILD as a sub-speciality, there is still a significant difference in the provision of expert care within district general hospitals in UK for patients with ILD. This may affect the quality of care provided with potential to variability of care standards. The “standard protocol” for HRCT techniques as specified by BTS is not being followed in England. Despite recommendations from BTS, aspects of HRCT scanning technique applied were variable and influenced by local preferences and expertise. This may lead to differences in scan interpretation, diagnosis and outcomes. This gap in provision of care and variability of techniques should be bridged to ensure uniformity of care and outcomes. References NICE guidelines, June 2013; CG163 2: Thorax; 63 (Suppl V); v1-v58

P19 Worrying Trend Of Labelling Ambiguous Deaths As Pneumonia And Potential Impact On Respiratory Service In A District General Hospital

Background Pneumonia is a common cause of death recorded on death certificates. This data is used by Dr Foster to calculate hospital specific mortality rate (HSMR). However there is a general impression that pneumonia is recorded as the cause of death without confirmation. The British Thoracic Society (BTS) defines pneumonia as ‘symptoms and signs consistent with an acute lower respiratory tract infection associated with new radiographic shadowing for which there is no other explanation’ Aims Our aim was to establish if patients reported to have died of pneumonia had radiographic shadowing in accordance with the BTS definition and if they have been managed with appropriate antibiotics as per BTS guidelines 1. Methods We reviewed the case notes and chest x-rays (CXR) of 111 consecutive patients where pneumonia was stated as the cause of the death. We also investigated whether correct antibiotic therapy was used as per hospital guidelines. Results 111 patients (53 male, mean age 80.6) were given diagnosis of pneumonia on their death certificates as follows; aspiration pneumonia 20 patients, bronchopneumonia 8 patients, community acquired pneumonia 19 patients, pneumonia 44 patients and hospital acquired pneumonia 20 patients. Out of these 111 patients, 75 (67.6%) patients had radiological changes consistent with a diagnosis of pneumonia on CXR. Out of these 75 patients with radiologically confirmed pneumonia 29 (38.7%) were given incorrect antibiotics as they were treated mainly for sepsis. Conclusions Our findings show a very worrying trend of incorrectly recording pneumonia as cause of death in a third of patients, who were given pneumonia as cause of death. This would increase the HSMR for pneumonia as calculated by Dr Foster. In our opinion pneumonia as a cause of death is an easy option for many medical practitioners. Recommendations We recommend an early input by respiratory physicians for all respiratory admisssions to make sure that respiratory illnesses are managed correctly. References Thorax 2009; 64 (Supplement III) : 1–61.

AUDIT ON PLEURAL PROCEDURE IN A UK DISTRICT GENERAL HOSPITAL

Introduction: Intercostal Chest Drain (ICD) insertion is an invasive procedure indicated in certain emergency and elective scenarios. The practice is changing with more importance given to training, safety and use of ultrasound image guidance. Aims: The aim of this audit was to access current awareness & training level of junior doctors and level of practice. Methods and results: First part of audit includes questionnaire survey on awareness and competency. Of the 26 respondent, 61% were independently competent at ICD insertion, but only 9% of them performed more than 10 procedures in last one year. Only 23% of doctors had thoracic ultrasound training. In the second part, 38 consecutive cases were audited retrospectively (male = 76%, female = 24%).Pleural effusion (59%) and pneumothorax (31%) accounted for most of the indications. 38% of the procedures performed out of hours and all of them were justified. Only 68% had any form of consent documented. Majority (85%) were inserted by senior doctors (ST3+ level). Bedside Ultrasound was used in 80% of pleural effusion cases. The nursing drain observation chart was maintained in 88% cases. 8% minor immediate complication reported, no death or organ damage directly related to the procedure. Discussion: This audit has demonstrated improving safety awareness that includes, most of procedure performed by trained doctors and use of bedside ultrasound. But it has highlited lack of training at junior doctors level,including thoracic ultrasound. Following this audit we have introduced the safety check list and training programme for junior doctors including thoracic ultrasound technique. References: 1T Havelock, BTS Pleural procedure guidelines 2010. 2NPSA Rapid response Report- NPSA/2008/RRR003.

Where is the leak

In March, 2007, an 84-year-old woman came to our emergency department. She had been unwell for 3 days— with a sore throat, a sense of fullness under her chin, and exertional shortness of breath. She had hypertension, osteoarthritis, and vertigo; she had had a cholecystectomy in the 1950s, and a laparotomy, for peritonitis of unrecorded cause, in her mid-teens. We found mild fever (temperature 38°C), but standard examination of the cardiovascular and respiratory systems, and the abdomen, revealed no abnormality. However, we found palpable crepitations over the neck, and in the supraclavicular fossae. Blood tests showed a high white-cell count (24∙7×109 cells per L; neutrophil count 20∙4×109 cells per L), ESR (67 mm/h), and concentration of C-reactive protein (254 mg/L). Tests of kidney and liver function showed no abnormality of note; the serum amylase concen tration was normal. Chest radiography confi rmed the presence of subcutaneous emphysema, and also showed gas in the mediastinum. Where had it come from? The radiograph did not show free gas under the diaphragm (fi gure). CT of the chest and abdomen showed gas in the mediastinum, with extensive tracking into soft tissues—but no evidence of oesophageal rupture or pneumothorax. CT also showed retroperitoneal and mesenteric gas. The patient was transferred to a surgical unit. An exploratory laparotomy showed extensive diverticular disease of the sigmoid colon, with a small perforation, and a walled-off abscess attached to the lateral pelvic wall. The surgeons did a Hartmann’s procedure, removing the sigmoid colon and fashioning a stoma. The patient’s recovery was uneventful. When last seen, in May, 2008, she was well. Supraclavicular emphysema is typically associated with a perforated gastric or duodenal ulcer. Subcutaneous emphysema of the neck is usually a consequence of rupture of a thoracic organ. Causes include pneumothorax, oesophageal perforation, tracheo bronchial injury, surgery, and, more rarely, injury to the head and neck, or infection with gas-producing organisms, such as clostridium. Colonic disease can cause cervical subcutaneous emphysema—but, perhaps unsur pri singly, this is rare. Subcutaneous emphysema caused by colonic perforation is usually in the perineum or anterior abdominal wall. So how did our patient end up with crepitus in the neck? Meyers characterised the retroperitoneal pelvic space as comprising three compartments: the anterior pararenal space, containing parts of the duodenum, pancreas, and ascending and descending colon; the posterior pararenal space, containing blood vessels and lymphatic vessels; and the perirenal compartment, containing kidneys, ureters, and great vessels. Air from a perforated viscus could travel, via the adventitia of blood vessels, to the anterior pararenal and perirenal compartments, and thence through the diaphragmatic aortic hiatus and caval foramen to the thorax.