Mark Welfare

Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study

Abstract Problem A large audit of colonoscopy in the United Kingdom showed that the unadjusted completion rate was 57% when stringent criteria for identifying the caecum were applied. The caecum should be reached 90% of the time. Little information is available on what units or operators need to do to improve to acceptable levels. Design Quality improvement programme using two completed cycles of audit. Setting Endoscopy department in a university linked general hospital in northeast England. Key measures for improvement Colonoscopy completion rate. Strategy for change Two audit cycles were completed between 1999 and 2002. Changes to practice were based on results of audit and took into account the opinions of relevant staff. Lack of time for each colonoscopy, poor bowel preparation, especially in frail patients, and a mismatch between number of colonoscopies done and completion rate for individual operators were responsible for failed colonoscopies. Appropriate changes were made. Effects of change The initial crude colonoscopy completion rate was 60%, improving to 71% after the first round of audit and 88% after the second round, which approximates to the agreed audit standard of 90%. The final adjusted completion rate was 94%. Lessons learnt Achievement of the national targets in a UK general hospital is possible by lengthening appointments, admitting frail patients for bowel preparation to one ward, and allocating colonoscopies to the most successful operators.

Factors associated with the development of post-infectious functional gastrointestinal diseases : does smoking play a role?

Objectives Irritable bowel syndrome (IBS) is associated with psychological stress, alterations in gut motor function and/or visceral perception. Previous studies suggest 7–32% of people develop IBS after bacterial gastroenteritis but the exact mechanisms underlying post-infectious IBS are not clear. The present studys aim was to examine the role of possible causative factors in the development of post-infectious functional gastro-intestinal disorders (FGIDs), including IBS. Methods A prospective cohort study where 122 people without a prior FGID under study and with stool-positive bacterial gastroenteritis consented to participate. The presence or not of IBS, functional dyspepsia or functional diarrhoea was diagnosed at the start and on 6-month follow-up using self-complete Rome II modular questionnaires. Demographic data, smoking, alcohol use, anxiety and depression (using the Hospital Anxiety and Depression Scale), and life events and impact (using the Life Events Survey) were collected at the start of the study. Results One hundred and seven questionnaires were returned with 25 participants (23.4%) developing a FGID and 16 participants presenting symptoms consistent with IBS (15%). Smoking was significantly associated with the development of a post-infectious FGID (odds ratio=4.8, 95% confidence interval=1.5–15.2) on regression analysis. Conclusions Post-infectious FGIDs appear to be associated with smoking. Smoking is known to moderate gut immunity in other disorders such as ulcerative colitis and Crohns disease. This study adds to increasing evidence for an organic basis to post-infectious FGIDs, perhaps moderated via inflammatory pathways.

A comparison of the discriminatory power of the Inflammatory Bowel Disease Questionnaire and the SF-36 in people with ulcerative colitis

The aim of this study was to compare the discriminatory power of a generic and a condition-specific quality of life measure (the Medical Outcomes Study Short-Form 36 (SF-36) and the Inflammatory Bowel Disease Questionnaire (IBDQ)) with respect to sub-groups defined by disease-related and other factors, in a sample of patients with ulcerative colitis. Disease activity was generally more highly correlated with IBDQ scores than with SF-36 scores. The only significant differences with respect to disease extent were in the SF-36 energy/vitality and social function domains. Age was negatively and weakly to moderately correlated with the physical domains of the SF-36 but positively though weakly correlated with scores on the IBDQ emotional domain and those domains of the SF-36 related to mental well-being. Co-existing chronic illness, even on controlling for age, was associated with significantly poorer scores on the generic measure, but had little influence on IBDQ scores. In conclusion, generic and disease-specific measures of quality of life appear to be complementary rather than interchangeable. We recommend the use of both types of measure in parallel.

The SIBDQ: further validation in ulcerative colitis patients

OBJECTIVE:The Inflammatory Bowel Disease Questionnaire (IBDQ) is an instrument that assesses quality of life in patients with inflammatory bowel disease. It has 32 items in four domains. The short form of the IBDQ (SIBDQ) was developed in Canadian Crohns disease patients for use in clinical practice. Patients with ulcerative colitis might require a different form of the SIBDQ. Our aim was to design and validate a SIBDQ for patients with ulcerative colitis and to compare this to the Crohns SIBDQ.METHODS:We recruited 122 patients with colitis as an initial sample. Using linear regression modeling, the 10 items that best predicted the total IBDQ score were identified. The colitis and Crohns versions of the SIBDQ were compared by univariate linear regression with the total IBDQ score in two other cohorts of colitis patients.RESULTS:Ten items explained 97% of the variance of the total IBDQ score in our first cohort. These were items 1 and 9 (bowel); 7, 11, 21, 30 (emotional); 2 and 10 (systemic); and 12 and 28 (social). Only three items were shared with the Crohns SIBDQ. The R2 for both SIBDQs with the total IBDQ score in the other cohorts were very high (≥0.95), although the Colitis SIBDQ showed better internal consistency.CONCLUSIONS:The development of a SIBDQ for patients with ulcerative colitis did not reveal any clear advantage over the original version of the SIBDQ. Further studies are required to determine the role of the SIBDQ in routine clinical practice.

Reconceptualizing models of delirium education: findings of a Grounded Theory study

BACKGROUND Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients. METHODS Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached. RESULTS Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patients fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patients fear. DISCUSSION These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.

The role of surgery in Clostridium difficile colitis

#### Summary points Clostridium difficile infection was cited in one of every 250 death certificates completed in the United Kingdom in 2005,1 and it has become the leading cause of death from healthcare associated infections in much of the industrialised world.2 More than 50 000 cases of C difficile infection were reported in England in 2007—a 50-fold increase since 1990.1 Pseudomembranous colitis was first described in 1935, but it took another 40 years for C difficile to be identified as the causative organism.3 4 C difficile associated disease accounts for 15-25% of antibiotic associated diarrhoea,5 and its incidence is rising. The overall prevalence in patients admitted to hospital is around 1%; it can be as high as 20% in those who stay for more than one week and 50% in those who stay for at least four weeks.6 7 This review aims to draw attention to the symptoms of C difficile infection and to summarise evidence on the indications and optimum timing of surgical intervention for C difficile associated colitis. The quality of evidence for the treatment of C difficile associated disease is poor, and the recommendations in this review are based mainly on non-randomised observational studies (level III evidence). #### Sources and selection criteria We did a PubMed search for English language articles on Clostridium difficile colitis, fulminant colitis, and surgery. Further papers were identified from the reference lists of relevant major articles. C difficile causes a wide spectrum of disease, ranging from asymptomatic colonisation of …

Responses of biomarkers of folate and riboflavin status to folate and riboflavin supplementation in healthy and colorectal polyp patients (the FAB2 Study).

Epidemiologic data suggest that increasing folate intake may protect against colorectal cancer. Riboflavin may interact with folate to modulate the effect. A double-blind randomized placebo-controlled intervention study (the FAB2 Study) was carried out in healthy controls and patients with colorectal polyps (adenomatous and hyperplastic) to examine effects of folic acid and riboflavin supplements on biomarkers of nutrient status and on putative biomarkers of colorectal cancer risk (DNA methylation and DNA damage; to be reported elsewhere). Ninety-eight healthy controls and 106 patients with colorectal polyps were stratified for the thermolabile variant of methylene tetrahydrofolate reductase, MTHFR C677T, and were randomized to receive 400 μg of folic acid, 1,200 μg of folic acid, or 400 μg of folic acid plus 5 mg of riboflavin or placebo for 6 to 8 weeks. Blood samples and colon biopsy samples were collected for the measurement of biomarkers of folate and riboflavin status. Supplementation with folic acid elicited a significant increase in mucosal 5-methyl tetrahydrofolate, and a marked increase in RBC and plasma, with a dose-response. Measures of riboflavin status improved in response to riboflavin supplementation. Riboflavin supplement enhanced the response to low-dose folate in people carrying at least one T allele and having polyps. The magnitude of the response in mucosal folate was positively related to the increase in plasma 5-methyl tetrahydrofolate but was not different between the healthy group and polyp patients. Colorectal mucosal folate concentration responds to folic acid supplementation to an extent comparable to that seen in plasma, but with a suggestion of an upper limit. (Cancer Epidemiol Biomarkers Prev 2007;16(10):2128–35)

Is lactose intolerance implicated in the development of post-infectious irritable bowel syndrome or functional diarrhoea in previously asymptomatic people?

Objective The relationship between lactose intolerance and post-infectious irritable bowel syndrome (IBS) in adults is uncertain. Bowel symptoms may persist after bacterial gastroenteritis and as post-infectious IBS. Acquired lactose intolerance may follow viral enteric infections in children. We compared the frequency of lactose intolerance after bacterial gastroenteritis in adults with and without symptoms of IBS or functional diarrhoea at 3–6-months’ follow-up. Design A prospective cohort study was conducted. Methods All subjects with bacterial gastroenteritis confirmed by stool culture from the microbiology laboratory and without prior IBS or functional diarrhoea were eligible to participate. IBS and functional diarrhoea were diagnosed via self-completed Rome II modular questionnaires. Lactose intolerance was determined from a rise in breath hydrogen and plasma glucose and symptoms. Results One hundred and twenty-eight subjects with bacterial gastroenteritis were followed prospectively, from which a smaller cohort of 42 subjects took part in this study. The cohort was comprised of 24/25 subjects who developed post-infectious IBS (n = 16) or functional diarrhoea (n = 8) (9 male, 15 female) and 18 random controls (8 male, 10 female) chosen from the group without IBS or functional diarrhoea. The mean age of the subjects was 44.4 years (range 25–76 years). In the group with functional diarrhoea or IBS, four subjects had failure of the plasma glucose to rise but none had abnormal glucose hydrogen breath tests. In the control subjects, one had a positive combined test and six had failure of plasma glucose to rise alone. No subject developed symptoms during the test. Conclusions Bacterial gastroenteritis did not cause persistent lactose intolerance in our study population. Lactose intolerance does not appear to be implicated in the aetiology of post-infectious bowel symptoms, including IBS. Advice to avoid dairy products in patients presenting with post-infectious IBS on the basis that they may have lactose intolerance appears unnecessary in patients from northern England.

Developing effective educational approaches for Liaison Old Age Psychiatry teams: a literature review of the learning needs of hospital staff in relation to managing the confused older patient.

BACKGROUND Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams. METHODS A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatricks system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes. RESULTS 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories. CONCLUSIONS The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Impact of deprivation on short- and long-term outcomes after colorectal cancer surgery

The aim of the study was to determine the association between short‐ and long‐term outcomes and deprivation for patients undergoing operative treatment for colorectal cancer in the Northern Region of England.