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  • Look-back Review Report

    Safety Incident Management Team (SIMT); South /South West Hospital Group (Health Service Executive (HSE), 2018-12-05)
    In September 2017 a major review of CT Scans, Ultrasounds and Chest X-Rays reported by an individual Consultant Radiologist commenced at University Hospital Kerry (UHK). This was prompted by the notification to hospital management of three Serious Reportable Events (SRE) in the category of Care Management Events where a diagnostic error was considered by the hospital's Safety Incident Management Team (SIMT) to have had a serious impact on patients through a delay in diagnosis, limiting treatment options available to them. The matter was escalated to the South/South West Hospital Group (S/SWHG) who recommended that a look-back review would be carried out. This was approved by the National Director of the Acute Hospital Division, HSE, on the 30th of August, 2017. A Group SIMT was then established, chaired by the Chief Operations Officer S/SWHG, to carry out the look-back review. Following the notification of a further Serious Incident (SI) the review was extended in October 2017 to include all images reported by the individual Consultant concerned. Therefore, the review set about auditing 46,234 images in order to identify if there was any missed pathology within the radiology reporting process; to identify if any further patients had been affected; to communicate with them in a timely and appropriate fashion, and ultimately to ensure that patients received appropriate care. The SIMT endeavoured at all times to treat patients with utmost sensitivity and honesty whilst at the same time minimising unnecessary anxiety or distress. Over the course of the look-back eleven patients were identified as having a delay in diagnosis which had an impact on their care. Four of the eleven patients have passed away over the course of the review period. The hospital and the HSE acknowledge that patients and families’ experiences were devastating for them and have had a profound and lasting effect on both the patients affected and their families. The South/South West Hospital Group, University Hospital Kerry and the Health Service Executive (HSE) would like to apologise sincerely and unreservedly to all patients and families harmed by delayed diagnoses.
  • DVD Versus Physiotherapist-Led Inhaler Education: A Randomised Controlled Trial.

    Khan, R; Yasin, F; O'Neill, S; Cahalane, E; O'Shea, R; Browne, B; Cournane, J; Rand, S; Shannon, H (2018-02-09)
    Correct technique with inhalers is vital for therapeutic effect. Efficacy of DVD inhaler instruction was investigated. Secondary aims were to examine feasibility of an inhaler technique outcome measure, and to compare knowledge and self-efficacy after DVD or individual education. This was a randomised controlled trial conducted in a regional hospital paediatric ward, involving new or existing paediatric inhaler users. Inhaler technique was assessed pre-education in existing inhaler users. Participants were then randomised to message equivalent education by DVD or individually with a physiotherapist. Inhaler technique, self-efficacy and knowledge were assessed immediately post- and three months after education. Twenty one participants received DVD or individual education. There were no significant differences between groups for technique, self-efficacy or knowledge at any time. The outcome measure was feasible for use in a research study. DVD education was equivalent to individual instruction to teach parents how to use inhalers with their child.
  • Doctors don't Do-little: a national cross-sectional study of workplace well-being of hospital doctors in Ireland.

    Hayes, Blánaid; Prihodova, Lucia; Walsh, Gillian; Doyle, Frank; Doherty, Sally (2019-03-10)
    Objectives: To measure levels of occupational stress, burn-out, work-life balance, presenteeism, work ability (balance between work and personal resources) and desire to practise in trainee and consultant hospital doctors in Ireland. Design: National cross-sectional study of randomised sample of hospital doctors. Participants provided sociodemographic data (age, sex), work grade (consultant, higher/basic specialist trainee), specialty, work hours and completed workplace well-being questionnaires (Effort-Reward Imbalance (ERI) Scale, overcommitment, Maslach Burnout Inventory) and single item measures of work ability, presenteeism, work-life balance and desire to practise. Setting: Irish publicly funded hospitals and residential institutions. Participants: 1749 doctors (response rate of 55%). All hospital specialties were represented except radiology. Results: 29% of respondents had insufficient work ability and there was no sex, age or grade difference. 70.6% reported strong or very strong desire to practise medicine, 22% reported good work-life balance, 82% experienced workplace stress, with effort greatly exceeding reward, exacerbated by overcommitment. Burn-out was evident in 29.7% and was significantly associated with male sex, younger age, lower years of practice, lower desire to practise, lower work ability, higher ERI ratio and greater overcommitment. Apart from the measures of work ability and overcommitment, there was no sex or age difference across any variable. However, ERI and burn-out were significantly lower in consultants than trainees. Conclusions: Hospital doctors across all grades in Ireland had insufficient work ability, low levels of work-life balance, high levels of work stress and almost one-third experienced burn-out indicating suboptimal work conditions and environment. Yet, most had high desire to practise medicine. Measurement of these indices should become a quality indicator for hospitals and research should focus on the efficacy of a range of individual and organisational interventions for burn-out and occupational stress.
  • Proficiency-based progression training: an 'end to end' model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study.

    Kallidaikurichi Srinivasan, Karthikeyan; Gallagher, Anthony; O'Brien, Niall; Sudir, Vinod; Barrett, Nick; O'Connor, Raymund; Holt, Francesca; Lee, Peter; O'Donnell, Brian; Shorten, George (2018-10-15)
    Background: Training procedural skills using proficiency-based progression (PBP) methodology has consistently resulted in error reduction. We hypothesised that implementation of metric-based PBP training and a valid assessment tool would decrease the failure rate of epidural analgesia during labour when compared to standard simulation-based training. Methods: Detailed, procedure-specific metrics for labour epidural catheter placement were developed based on carefully elicited expert input. Proficiency was defined using criteria derived from clinical performance of experienced practitioners. A PBP curriculum was developed to train medical personnel on these specific metrics and to eliminate errors in a simulation environment.Seventeen novice anaesthetic trainees were randomly allocated to undergo PBP training (Group P) or simulation only training (Group S). Following training, data from the first 10 labour epidurals performed by each participant were recorded. The primary outcome measure was epidural failure rate. Results: A total of 74 metrics were developed and validated. The inter-rater reliability (IRR) of the derived assessment tool was 0.88. Of 17 trainees recruited, eight were randomly allocated to group S and six to group P (three trainees did not complete the study). Data from 140 clinical procedures were collected. The incidence of epidural failure was reduced by 54% with PBP training (28.7% in Group S vs 13.3% in Group P, absolute risk reduction 15.4% with 95% CI 2% to 28.8%, p=0.04). Conclusion: Procedure-specific metrics developed for labour epidural catheter placement discriminated the performance of experts and novices with an IRR of 0.88. Proficiency-based progression training resulted in a lower incidence of epidural failure compared to simulation only training.
  • Distance as a Barrier to Melanoma Care

    McCarthy, S; Feeley, K; Murphy, M; Bourke, J F (2019-08-01)
    Our aim was to review cases of melanoma diagnosed histologically in UHK in 2016 and to compare them to cases of melanoma nationally and in Kerry. Methods For each patient we recorded age, Breslow depth, and shortest distance to travel by car and travelling time (without traffic) to the South Infirmary Victoria University Hospital (SIVUH) from their primary residence (calculated using Google maps™ (2018)). Results 20 cases of invasive melanoma were diagnosed in UHK in 2016. Of the 20 cases, 9 (45%) presented at a very advanced stage with a Breslow depth of greater than 4mm. A further 7 (35%) cases had a depth of 1.5-4mm. These patients with invasive melanoma had a mean age of 72.5 (±15). The mean shortest distance to travel from the patient’s primary residence to the SIVUH was 114.8km (±15.5) taking an average of 102 minutes (±14.6) by car. Conclusion Cases of melanoma diagnosed locally in UHK presented at an advanced stage compared to the national average. We suspect that the long distances to travel to the SIVUH pigmented lesion clinic is a barrier for these patients.
  • The Prevalence and Management of Metabolic Acidosis of Chronic Kidney Disease

    Ahmed, A.R.; Satti, M.M.; Abdalla, A.E.; Giblin, L.; Lappin, D. (Irish Medical Journal, 2019-10)
    Emerging evidence supports initiating oral sodium bicarbonate (OSB) at a serum bicarbonate (HCO3) level of less than 22mmol/L. We look to identify the prevalence of metabolic acidosis of chronic kidney disease (MA-CKD) and its management with OSB at a regional university hospital.
  • Development of an Insulin-Prescribing Chart for Paediatric Diabetes

    Finn, B.P; O’Neill, T.; Bradfield, A.; O’Sullivan, T.; Beattie, S.; O’Connell, S.M. (Irish Medical Journal, 2019-10)
    Our aim was to design a new insulin prescribing tool in compliance with the Irish Medicines Safety Network recommendations.
  • How Much Greater is Obstetric Intervention in Women with Medical Disorders in Pregnancy When Compared to the General Population?

    Keane, R.; Manning, C.; Lynch, C.; Regan, C.; Byrne, B. (Irish Medical Journal, 2019-10)
    The purpose of this study was to compare obstetric and neonatal outcomes between women attending a specialised maternal medicine service and the general obstetric population.
  • Factors Contributing to Non-Exclusive Breastfeeding in Primigravid Mothers

    Panaviene, J.; Zakharchenko, L.; Olteanu, D.; Cullen, M.; EL-Khuffash, E.L (Irish Medical Journal, 2019-10)
    We aimed to examine the factors contributing to non-exclusive breastfeeding in primigravid mothers in a large Irish tertiary maternity hospital.
  • What Stops Doctors Switching from Intravenous to Oral Antibiotics?

    Hogan-Murphy, D.; Waqas, S.; Tuite, H.; Ni Riain, U. (Irish Medical Journal, 2019-09)
    To explore doctors’ perceptions of the motivators and barriers to complying with intravenous to oral switch antibiotic guidelines in a Model 4 Irish hospital.
  • A Geospatial Analysis of Adult Major Trauma Transit Time in Dublin

    Kelly, O.; O'Reilly, M; Collins, N. (Irish Medical Journal, 2019-09)
    To estimate ambulance transit time of Major Trauma patients from scene to Emergency Department (ED) in order to inform future trauma network design.
  • A Temporal Comparative Study of Women’s Rugby Injuries Presenting to an Emergency Department

    Gilmartin, S.; Ryan, J. (Irish Medical Journal, 2019-10)
    We aimed to examine the change in injury patterns, diagnostics and treatments provided to female rugby players in an emergency department between two separate seasons ten years apart.
  • High-flow Nasal Cannulae, Bronchopulmonary Dysplasia and Retinopathy of Prematurity

    Healy, L.I; Corcoran, P.; Murphy, B.P (Irish Medical Journal, 2019-09)
    To determine if HFNC use was associated with changes in incidence of BPD and ROP.
  • Telephone Follow-Up of Mild Traumatic Brain Injury; A Feasibility Study

    Underwood, S.; Campbell, S.; Deasy, C. (Irish Medical Journal, 2019-09)
    This study investigates the prevalence of Post-Concussion Syndrome (PCS) one-year post-injury in patients that were treated for Mild Traumatic Brain Injury (mTBI) in the Clinical Decision Unit (CDU) of Cork University Hospital’s (CUH) Emergency Department.
  • Psychiatry in Ireland: A Lot Done, More to Do

    Kelly, B.D.; Department of Psychiatry, Trinity Centre for Health Sciences (Irish Medical Journal, 2019-10)
    Four decades ago, in April 1979, Time magazine printed a dramatic cover story titled “Psychiatry’s depression”, diagnosing psychiatry with “a bad case of mid-life blues” 1. The magazine pointed to a lack of knowledge about the biology of mental illness, recruitment problems into the profession, uncertainties about treatments, and the inadequacy of community care. Precisely forty years later, in April 2019, the Economist magazine, in a very similar tone, referred to “today’s crisis in the psychiatric profession” 2 and, the following month, the New Yorker cited many of the same problems again in an article about “psychiatry’s fraught history” 3.
  • Being “Mindful” of Dignity in Dying: Developing Awareness, Fostering a Psychological Understanding, and Supporting Dignified Endings-To-Life

    Hession, Natalie; Elmer, Nicola; O'Kane, Aifric; Cotter, Pádraig; Psycho-Oncology Department, St. Luke's Radiation Oncology Network (IJEPP, 2019)
    Experiencing a sense of dignity when nearing end-of-life has been shown to be very important. There are many things that hospice and palliative nurses can do to support dignified endings-to-life. This paper explores the different aspects of this process from both the perspective of the person dying and in particular the individual in the caring role. Consideration is given to the different components of experiencing dignity in dying, especially those aspects that nursing staff can influence most. The importance of a sense of dignity to people who are dying is explored using two psychological models that provide an intrapersonal and transpersonal perspective. These include the Abandonment of Self Model and the Surface-Depth Model respectively. The types of obstacles to nursing staff providing this type of care and support are reflected upon, with particular emphasis placed on the practitioner’s own personal fears and anxieties and how these may manifest within the patient-nurse relationship. The final section explores the use of mindfulness practises as a way of interacting more fully with people diagnosed with terminal illnesses to support their experience of a dignified ending-to-life. This process is termed “mindful engagement”.
  • The Role of Interventional Radiology in the Management of Obstetric and Gynaecological Haemorrhage

    O’Brien, C.; Healy, G.M.; Anglim, B.C.; O’Brien, A.; Duignan, J.; Patel, A.; Cheung, M.; Cantwell, C.P. (Irish Medical Journal, 2019-07)
    Aim We will review our experience of emergent arterial embolization used to treat haemodynamically unstable patients with obstetric and gynaecological haemorrhage. Methods This is a retrospective study of patients with haemodynamically unstable obstetric and gynaecological haemorrhage treated with emergent arterial embolization from 2010 to 2015. Results 22 patients (average age 41 (SD +/-9) years) had emergent arterial embolization. 63% had post-partum haemorrhage(PPH). 82% of cases were performed with conscious sedation and local anaesthesia. Embolization was technically successful in all cases. Embolization was clinically successful in 95% (21/22). In one case of PPH the patient represented six days later with recurrent bleeding and was treated with surgical suturing of the cervix. There were no complications or deaths. Conclusion Arterial embolization is a highly successful treatment of obstetric and gynaecological haemorrhage in unstable patients.
  • Incidence of Asymptomatic Chiari Malformation

    O’Reilly, E.M; Torreggiani, W (Irish Medical Journal, 2019-07)
    Aim The aim of this study is to define the incidence of asymptomatic Chiari malformation in an Irish population. Methods MRIs performed over 24 months were analysed. Exclusion criteria include: space occupying lesion, hydrocephalus, Chiari symptoms and inadequate views. Data were analysed to give incidence of asymptomatic Chiari and to analyze the relationship between symptom and position of the cerebellar tonsils (Chi square and Fishers exact test). Results Sample Characteristics: 147 patients (Male = 65: Female = 82), age range 15 to 93 years (M age = 53.35, SD= 16.67). 2%had a Chiari malformation (n=2). There was no significant association between symptom and tonsil position (Fishers exact test, ² (8) = 9.98, p = .23.) Conclusion This study shows an asymptomatic Chiari Malformation rate of 2%. This study supports the idea that in asymptomatic patients, a tonsil herniation of up to 5 millimeters may be an incidental and inconsequent finding.
  • Circumcision Rates after the Release of Preputial Adhesions

    Aworanti, O.M; Rasheed, F.; Aldiab, A; Mortell, A. (Irish Medical Journal, 2019-07)
    The non-retractile foreskin in children is one of the most frequent indication for referral to a paediatric surgeon in Ireland. This is probably due to parental concerns when children complain of related symptoms coupled with a misperception among some general practitioners (GP) of the natural separation process of the inner surface of the prepuce from the glans surface1,2,3. Phimosis from the Greek word ‘Ψιμoσισ’ (muzzling) generally describes the non-retractile foreskin. Phimosis is best classified as either pathological or physiological. Pathological phimosis is either due to balanitis xerotica obliterans (BXO) or due to a constricting phimotic ring that hinders retraction, both usually in the older boy. Physiological phimosis is simply the non-retractile or incompletely retractile state of the foreskin in usually asymptomatic young boys. Foreskin retraction has been established to be complete by the age of 3 years in 90% 1 and by the age of 16 years in 99% 2 of boys. During this preputial separation process, complaints such as local discomfort, ballooning of the foreskin during micturition and smegma retention cysts are common and require simple reassurance only 3. No pathologic sequelae have been attributed to these physiologic processes on assessing urine flow rates, post-void residual bladder volumes and bladder wall thickness in young boys with physiologic phimosis 3. Furthermore, as partial separation of the foreskin ensues, young boys can suffer from episodes of balanoposthitis1,3. This inflammation of the glans and prepuce (or prepuce only - termed posthitis) generally resolves with antibiotic treatment and can be prevented with improved local hygiene. Therefore, absolute and strong indications for a medical circumcision are limited to pathological phimosis due to BXO and prevention of recurrent urinary tract infections (UTI) usually in children with vesicoureteric reflux or posterior urethral valves respectively4,5
  • A Prospective Audit of Inappropriately Occupied Hospital Beds in Patients with Newly Acquired Traumatic Spinal Cord Injury

    Smith, E.; Synnott, K. (Irish Medical Journal, 2019-07)
    Aim To quantify the inappropriate bed occupancy amongst patients with traumatic spinal cord injury (TSCI) awaiting transfer of care from the acute to community. Methods A prospective audit was carried out, of all newly acquired cases of TSCI in 2017, who progressed through acute care and specialist rehabilitation. Results Forty-four patients who were audited spent a total of 3915 days occupying a hospital bed, inappropriate for their phase of care, 78 awaiting admission to specialist acute care, 3126 awaiting admission to rehabilitation and 711 awaiting discharge from rehabilitation. Conclusion Valuable health-care resources are being wasted because TSCI patients cannot move seamlessly from one phase of care to the next. This impacts negatively on the quality of care being delivered to this patient cohort.

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