Research by staff affiliated to Mercy University Hospital

Recent Submissions

  • Impact of Frailty on Healthcare Outcomes after Cardioembolic Ischaemic Stroke Due to Atrial Fibrillation.

    O'Caoimh, Rónán; Morrison, Laura; Hanley, Marion; McManus, Caoimhe; Donlon, Kate; Galvin, Patricia (2024-02-27)
  • A novel video compendium of real surgical patient interactions for medical students

    O'Brien, Stephen J.; Reardon, Michelle; McGreal, Gerald; Stephen J. O'Brien, Michelle Reardon, Gerald McGreal Department of Surgery, Mercy University Hospital, Grenville Place, Cork, Ireland; Department of Surgery, School of Medicine, University College Cork, Ireland (Elsevier BV, 2023-08)
    Objective: To develop a novel video compendium of real surgical patient interactions as a tool for medical student education and to evaluate our institutional experience of its usefulness. Design: Prospective development of a video compendium of real surgical patient interactions. Setting: Single university affiliated hospital in Cork, Ireland. Participants: Patients with illnesses relevant to the surgery curriculum and students from an Irish medical school. Results: Videos were recorded of the clinical interaction between a consultant surgeon and patients, capturing focused history taking and/or clinical examination, with an associated set of explanatory notes. Fifty videos were developed with a tiered release to the clinical year medical students, via their virtual learning/education platform. Three hundred and eleven students responded to the questionnaire across 3-student year groups (311/585–53 %). Fifty-two percent of students did not have their clinical rotations affected by the COVID-19 pandemic. >90 % of students agreed that the videos helped history taking and clinical examination technique. >80 % of students agreed that the accompanying text slides reinforced key points and helped with understanding difficult topics. Eighty-five percent of students reported that the videos increased exposure to surgical patients and pathology. Eighty-five percent of students rated their experience as at least 4 out of 5. Conclusions: This online educational compendium bridged a gap for students with limited clinical exposure during the COVID-19 pandemic, and has become an important resource for all clinical students. Our novel engagement with real patients sets this compendium apart from resources which use actors.
  • An analysis of suspected urinary tract infections in older adults: Time to stop the dip!!

    Jones, William; O'Connor, Kieran; William Jones and Kieran O'Connor, Geriatric Medicine, Mercy University Hospital, Grenville Place, Cork, Ireland. (2023-06-29)
    Background: Urinary Tract Infections (UTI) is the most commonly diagnosed infection in older adults. Despite this however studies show it is a diagnosis which is often made excessively and inappropriately. Clinicians often suspect a UTI due to vague non-specific symptoms, such as change in mental status, without sufficient local urinary tract symptoms i.e.dysuria, increased frequency or urgency. This is compounded by high rates of asymptomatic bacteriuria in older adults. This means that in an older adult, if urine testing is unnecessarily ordered, bacteria can be detected as an incidental finding even if no UTI is present. High rates of asymptomatic bacteriuria and inappropriately testing for bacteriuria, without sufficient clinical signs and symptoms can be problematic. It may result in clinicians frequently misdiagnosing UTI or inappropriately attributing a nonspecific finding such as fever or confusion to a UTI. This can promote inappropriate antibiotic prescribing which may promote antibiotic resistant bacteria and unnecessarily expose older adults to side effects of these medications. Incorrectly attributing a patient’s presenting complaint to a UTI can hinder the patient's care as it delays discovering the most appropriate cause of the patient's condition. In September 2021, HSE Antimicrobial Resistance and Infection Control (AMRIC) issued a position statement where they clearly outlined that in the absence of signs of symptoms of UTI, use of dipstick analysis should be avoided. This included those patients presenting with altered mental status and behavioural changes without urinary symptoms. They also state that dipstick analysis should not be used in those over 65 to assess UTI.. Strategy: The aim of the project was: To determine and quantify if dipstick urinalysis is conducted in those over 65 years old to assess UTI in contradiction to HSE guidance; To assess the relationship between clinical presentation and the diagnosis of a UTI; To assess if UTI are diagnosed in individuals in absence of clinical features of UTI; To characterise population of older adults diagnosed with a UTI in the hospital. The population reviewed was adult in-patients aged over 65 years old in the Mercy University Hospital (MUH) between January 2019 to June 2022 who had urine culture (MSU) sent to the microbiology laboratory. We audited a samples using a stratified random sampling strategy to get a spread of cases over the period. All selected cases had a retrospective chart review to determine the signs and symptoms when the MSU was ordered & to examine whether there were other indications of infection or systemic inflammatory response (SIRS). The patients co-morbidities, relevant laboratory results and relevant medication were recorded. The prescription sheet was examined to determine whether antibiotics were prescribed. The medical and nursing records were reviewed to clarify whether a urine dipstick was used in the assessment of possible UTI. For each case it was recorded whether a UTI was diagnosed by the primary team. For each case a determination was made based on recorded signs, symptoms, and laboratory results whether a) there was evidence of infection, & b) whether there was evidence to support a UTI as the diagnosis. The appropriateness of doing dipstick urinalysis was assessed using the AMRIC position statement 2021 as the standard. Results: There was a high use of dipstick urinalysis with 73.8% of cases having a urinary dipstick analysis performed as part of the assessment of possible UTI. In 25% of cases a UTI was “diagnosed” by the primary team. However, only 16.7% had any of the primary symptoms of UTI such as increased frequency, urgency or dysuria. Urine dipstick and MSU were frequently requested for patients with falls (20.2% of cases) and acute altered mental health state (22.6% of cases). The AMRIC statement specifically highlights that altered mental state should not trigger the use of urine dipstick. There was a statistically significant relationship between dipstick urinalysis being conducted and a UTI being “diagnosed”, even when accounting for LUTS as a confounding variable.(p=0.01). Falls, acute AMS and new urinary incontinence were not associated with the diagnosis of a UTI. Haematuria, flank pain, pungent urine and suprapubic pain alone without dysuria was not associated with diagnosis of a UTI. Retrospective accurate diagnosis of UTI is difficult but our project would be in keeping with previous studies showing a high level of incorrect UTI diagnosis and inappropriate antimicrobial therapy (Silver 2009). There is a significant cost to the Mercy University Hospital is inappropriately requested MSU. There was a total of 12,357 MSU over the 42 month period assessed in this project. That equates to nearly 300 samples in the microbiology laboratory each month. Only 16.7% of our cases had potential UTI symptoms. Therefore, potentially up to 250 MSU samples a month maybe inappropriate. Conclusions: Dipstick urinalysis is conducted at high rates in older adults in the Mercy University Hospital despite HSE guidance to the contrary. This is associated with increased likelihood of UTI being diagnosed inappropriately. Urinalysis testing was not associated with any specific clinical presentation suggesting it is conducted broadly in a more routine fashion rather than for specific indications. A very high level of MSU samples are requested with a low level of UTI diagnosis. It is unclear but likely that urinalysis results are driving MSU samples. There is cost saving by improving the use of appropriate dipstick urinalysis and more focused MSU samples. There is a need for more education on diagnosis of UTI in older people and the appropriate use of urine dipstick testing in hospital. References: Silver SA, Baillie L, Simor AE. Positive urine cultures: A major cause of inappropriate antimicrobial use in hospitals? .Can J Infect Dis Med Microbiol. 2009;20(4):107-111. doi:10.1155/2009/702545. Position Statements: Use of Dipstick Urinalysis for assessing evidence of Urinary Tract Infection In Adults, Antimicrobial Resistance and Infection Prevention and Control (AMRIC) clinical programme. v1. August 2021
  • Audit of "Patient Discharge Plan" checklist for older adults in the acute setting

    Power, Sarah; Sarah Power, Bed Management Unit, Mercy University Hospital, Grenville Place, Cork, Ireland. (2023-06-29)
    Problem identified: The National Inpatient Experience Survey (NIES) conducted in the Mercy University Hospital in 2022 exposed poor quality of information sharing with patients and their families upon discharge. Discharge planning for elderly patients can reduce readmission rates and hospital length of stay (NICE 2018, Goncalves-Bradley et al. 2016). A reduction in days spent in hospital results in reduced cost of care (Goncalves-Bradley et al. 2016). Individualised discharge plans for inpatients improves patient and healthcare provider satisfaction (Goncalves-Bradley et al. 2016). Eighty percent of discharges from an acute hospital setting are considered simple and predictable (NICE 2018). For this reason, failure to communicate effectively is found to be the main cause of simple discharges being delayed (NICE 2018). Discharge planning is not standardised across healthcare settings in the NHS (NICE 2018); however, the Nursing and Midwifery Board of Ireland (NMBI) have set documentation standards in Irish hospitals (NMBI 2015). HIQA (2012) National Standards for Safer Better Healthcare promote sharing of timely and relevant information between the multidisciplinary team and services upon discharge. A Patient Discharge Plan checklist facilitates this in the acute setting. The HSE (2014) sets out nine steps to effective discharge planning in the National Guideline for Quality and Patient Safety. Step eight refers to “Use a discharge checklist 24‐48 hours before discharge” (HSE 2014). Discharge checklists are advised to enhance effective communication between the patient, members of the multi‐disciplinary team, hospital, primary and community service providers (HSE 2014). A discharge checklist can communicate actions taken and those still outstanding (HSE 2014). A re-audit of Patient Discharge Plans within the Careful Nursing Document was conducted. Design: Retrospective review of Healthcare Records (HCR) on 8 medical/surgical wards within 24-72 hours of patient discharge. Tool: NMBI Documentation Discharge Planning Metrix tool. Six indicators included. Collected by 1 person using the data collection tool which was piloted initially. Timeline: Seven consecutive days, 31st January – 7th February 2023. Inclusion/Exclusion Criteria: Include patients 65 years old and older. Quantitative data collected from checklist with some free text in Discharge Care Plan to supplement. Exclude day cases, patients who died and patients taking HCR to another clinical setting. Sample: Consecutive snapshot sampling. 36 HCR audited, approximately half of that week’s total Older Adult (OA) discharges (average of 70-75 OA discharged/week in MUH). Standard: HSE (2014) National Guideline for Quality and Patient Safety. 100% compliance to checklist completion required. Permission: Granted by ADON Bed Management and Quality and Risk Department in MUH. Discussed with Nursing Practice and Development (NPDU) and Discharge Planning Sub-Committee seeking to improve NIES result. GDPR and anonymity were upheld. Medical records number, date of birth and discharge destination recorded. Code sheet used. Results: 100% compliance with all 6 indicators was only achieved in 3 of 36 (8%) of audited HCR. There was 58% compliance with pre-discharge checklist completion (Indicator 1) which increased to 75% completion of Day of Discharge Checklist section (Indicator 2) highlighting discrepancies in timely documentation (see Figure 3). Sixty-three percent compliance with Standard 3 has disimproved since July 2022 audit where 72% compliance was noted. This audit used the same tool but general population over one week. Recommendations: Revise effectiveness/efficiency/conduciveness of discharge planning checklist documentation with the Documentation Committee and Nursing Practice and Development Unit. Make alterations to documentation/checklist and PPPG using feedback (HSE 2016 & Powell et al. 2015). Utilise Documentation Champions on the wards to remind clinicians (Powell et al. 2015). Use findings to focus ward-based education sessions with staff nurses on checklist areas requiring improvements (Powell et al. 2015). Limitations: Convenient snapshot sample method used may not represent the overall compliance. Current reduced nurse staffing levels and seasonal overcrowding of service may have allowed bias. Conclusions; Re-audit should be planned post checklist review and education delivery (approx. 6 months) rather than NMBI (2015) recommendation of annually. Since this audit in February 2023, Discharge Planning sub-committee have progressed with revising the Discharge Planning Checklist with the Documentation Committee and NPDU. Recommendations have been made to alter the information required to be more patient friendly. These alterations are due to go to print in June 2023. The findings of the audit will be utilised going forward to roll out education with new checklists on the wards to staff nurses and CNMs via Documentation Champions, the sub-committee and NPDU. A change in nursing practice is being implemented with the new checklists which includes nursing staff photocopying the checklist for each patient. The patient will take this checklist copy home upon discharge as a source of person-centred information with contact details of community supports and treatment plans outlined. The aim is that each ward will have photocopying facilities and each staff nurse/CNM will have access to this. This project is ongoing.
  • The development of an online resource for OPAT patient education to enhance OPAT patient experience: a collaborative project with a local third level education institution

    Fiona Guidera, CNS OPAT, Mercy University Hospital, Grenville Place, Cork, Ireland ; Liz Forde, cANP OPAT, Cork University Hospital, Cork, Ireland; Deirdre McCann, Creative Digital Media Course Co-ordinator, Cork College of Further Education (Douglas Street Campus), Cork, Ireland; Arthur Jackson, Infectious Disease Consultant, Cork University Hospital, Cork, Ireland. (2023-06-29)
    Background: To start on the OPAT service, a shared decision-making process between provider and patient involves providing an overview of the OPAT service including the options available. With the advent of COVID, wearing facemasks interrupted effective communication making assessments and shared decision making more difficult for patients. As there were no visitors, additional phone calls to carers were needed to complete a holistic assessment. This has resulted in more time consuming assessments. In addition, there was no relevant OPAT online resource available to which we could refer patients and their relatives. Objective: To develop an on-line resource to provide both patients and carers with an overview of the service, an introduction to team members, the OPAT options available and the OPAT process. This resource would prepare patients and carers for their OPAT discharge, manage their expectations and enhance their experience. Methods: A survey of patients and community intervention team nurses assessing patient information needs was completed. Under the SPARK Covid Call, OPAT Clinical Nurse Specialists supported by the Infectious Disease Consultant OPAT Clinical Lead were successful in their application for funding of development of an online resource for patients and received funding in April 2021. The agreed purpose would be to provide patients and carers with an overview of the service, an introduction to team members, the OPAT options available, the OPAT process. resource would reflect the national programme and not be site specific so that there was potential for it to be adopted nationally. An additional suggestion was to approach third level institutions locally to collaborate with to develop the resource. Supported by MUH Nursing Management, in June 2021 we approached Cork College of Further Education, Douglas Street Campus who embraced the project as an innovative learning experience for their second year Creative Digital Media Course students. From September 2021 to May 2022, there was engagement between students, OPAT CNSs and college teams. The project included script writing, storyboarding, dry run interviews on-site, three final video recordings, a voice-over recording with animation, creation of graphics followed by animation and editing. Students worked on this project to include in their portfolio, using their current level of knowledge and skills. Resources available to the college students where limited for example, no script prompting equipment were used, which made this part of the project challenging for all involved. The students and college teachers found the involvement in the project a very beneficial learning experience to see what it would be like working with real clients and the college would like to work on projects like this again in the future. The completed online resource includes an animated information video with voice over and three separate videos with an ID consultant and OPAT nurses explaining the OPAT service: "OPAT-Your Path Home"– A short animation; OPAT - Before You Go Home – Video; OPAT -When You Go Home - Video; OPAT – Role of Infectious Disease Consultant – Video. This inter-professional project developed in collaboration with College of Further Education has produced high quality, but simple videos explaining the OPAT service to enhance the patient experience. Available to service users via the hospital websites. In addition, this collaborative initiative between HSE and Cork College of Further Education won the Further Education category of the Cork Lifelong Learning Awards for "Innovative Inter-agency Lifelong Learning Endeavours" that contribute to community and society.
  • "You happy enough with it doctor?": learning from missed opportunities for communication that takes place during health care professionals and patients

    Richards, Helen L; Fortune, Donal G; Lyons, L; Curtin, Y; Hennessey, Derek B; Helen L. Richards, Department of Clinical Health Psychology, Mercy University Hospital, Cork, Ireland; Department of Urology, Mercy University Hospital, Cork, Ireland; Department of Psychology, University of Limerick, Limerick, Ireland. Donal G. Fortune, Department of Psychology, University of Limerick, Limerick, Irelan. L. Lyons, Department of Urology, Mercy University Hospital, Cork, Ireland. Y. Curtin, Department of Clinical Health Psychology, Mercy University Hospital, Cork, Ireland. Derek B. Hennessey, Department of Urology, Mercy University Hospital, Cork, Ireland. (2023-06-29)
    Background: Patients use emotional hints to communicate rather than direct questions, during some procedures. Healthcare professionals who are task orientated and may miss these. It is the goal of this study to examine the communication that takes place between patients and healthcare providers (HCPs) during surveillance cystoscopy for non-muscle invasive bladder cancer (NMIBC) to improve doctor patient communication. Measurement Methods: Participants were 57 patients with a diagnosis of NMIBC attending for surveillance cystoscopy and 10 health care professionals (HCPs). Cystoscopy procedures were audio-recorded and transcribed verbatim. Two approaches to analysis of transcriptions were undertaken: (1) a template analysis; and (2) Verona Coding Definitions of Emotional Sequences. Results: Communication during cystoscopy generally comprised of ‘social/small talk’, ‘results of the cystoscopy’ and ‘providing instructions to the patient’. Emotional talk was present in 41/57 consultations, with 129 emotional cues and concerns expressed by patients. Typically patients used hints to their emotions rather than stating explicit concerns. The majority (86%) of HCPs responses to the patient did not explicitly mention the patient’s emotional concern or cue. Urology trainees were less likely than other HCPs to provide space for patients to explore their emotional concerns (t=-1.78, p<0.05). Conclusions: Emotional communication was expressed by the majority of patients during cystoscopy. While all HCPs responded to patients’ emotional communication, there were a number of missed opportunities to improve communication. Urologists need to be aware that patients use these cues and hints to communicate. Urologists need to identify and respond appropriately to the emotional cues to improve communication with patients.
  • Managing the end of life needs of frail, older adults in the community: the role of a hospital based community outreach team for older people

    Alcock, Megan; Hayes, Mary; O'Sullivan, Catherine; O'Connor, Kieran; Megan Alcock, Mary Hayes, Catherine O’Sullivan, Kieran O’Connor, Older Person Services, Mercy University Hospital, Grenville Place, Cork, Ireland. (2023-06-29)
    Background: Ireland has the longest life expectancy in the European Union (84 years of age for women, 81 years of age for men). However, most adults face chronic disease and dependency in the years prior to death. Frail, older adults often suffer from chronic pain, depression and/or anxiety and falls, which are often underassessed and undertreated. Older adults living with significant care needs require a healthcare workforce that can help provide support to those living in the community, with significant responsibility falling onto families. Our current healthcare systems are designed around periods of acute illness and are ill equipped to care for the needs of multimorbid and frail adults with chronic and worsening mobility, cognition and function. In addition, these patients are more likely to spend significant amounts of time in acute hospitals nearing the end of their lives, not without significant risk and often with poor outcomes and costly health care expenditure in the period just prior to death. Twenty years ago, Joanne Lynn and David Adamson authored Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age. They showed three main trajectories of chronic illness and their relationship to level of function over time, chronicling the way we die today. The first trajectory follows a period of short decline followed by death, seen often in patients with malignancy. The second trajectory is seen by people living with COPD or heart failure and is characterized by intermittent exacerbations over a longer period of increasing dependency followed by death. Finally, the third trajectory is one of ‘prolonged dwindling’ often seen in patients with dementia, stroke and frailty. The uncertain trajectories associated with chronic organ failure and prolonged dwindling make advanced care planning and care management paramount. Patient centred care that integrates the preferences and needs of both patients and families is important throughout life but especially at the end of life. As patients near the end of their lives, clinicians have a responsibility to acknowledge this and incorporate patient’s wishes into their care plans. Patients often have an increase in the frequency of hospitalization, and this can be used as a time to have serious illness discussions regarding goals of care. While it’s not feasible for all patients to die at home (or in a nursing home), hospital deaths are generally considered undesirable as a quality measure. According to The Irish Longitudinal Study on Aging (TILDA), Ireland has a high proportion of hospital deaths, indicating inadequate community and home care supports. Recognizing patients who are likely to benefit from supportive and palliative care approaches in the community with a goal to die at home can be done using a combination of tools and based on advanced care planning discussions. Methods: The Department for Older Persons Services at the Mercy University Hospital recognised many in-patients with advanced chronic disease and advanced frailty who had multiple recurrent hospitalisations towards the end of their life. There is a deficit of specialist supports in the community to help patients, families and primary care services deal with some of the complex issues of advanced chronic disease and frailty management. The existing community palliative care services do not have specific expertise in the presentations with advanced frailty. Those patients with a prolonged dwindling trajectory towards death are particularly difficult to manage in the community for existing palliative care and primary care services. Due to the deficit in existing services, in 2021, our department for Older Persons Services allocated a team consisting of both medical and nursing expertise staffed by a Registrar and Advanced Nurse Practitioner in Frailty, under the governance of the existing consultants in geriatric medicine, to form an outreach service. Inpatients who appear nearing end of life who have expressed wishes to avoid further hospitalization and to die at home are identified during their admission. These are often patients with multi-morbidity who have had multiple admissions. They have frailty syndromes such as falls, delirium or reduced mobility. In addition, patients known to the Geriatric Medicine Department who are no longer able to attend regular clinic due to a deterioration in mobility and are largely housebound are also often referred for home visits in the community by the outreach team. Home visits are designed to support the transition of care from inpatient to home but also the transition to a more supportive and palliative approach. A first home visit usually takes place within 24 hours of hospital discharge to identify any potential challenges. Visits include a discussion of the hospitalization, medication review, assessment of the home environment and family members are given the opportunity to ask questions. We provide education on end of life, trying to anticipate needs and often see patients and families through periods of deterioration until they stabilize again in a ‘new normal’ or begin the process of active dying. Families and carers are given a telephone number with any concerns weekdays between 9 am and 5 pm. We have access hospital diagnostics and planned admission where required. We communicate with Public Health Nurses, General Practitioners and the Community Palliative Care Team at Marymount University Hospital and Hospice. Results: Families and carers supporting loved ones who wish to avoid further hospitalization and die at home benefit from combined medical and nursing support & specialist expertise the team brings. We regularly address concerns including delirium, falls, noncognitive symptoms of dementia, insomnia, constipation and impaction, urinary retention, pressure ulcers, oral care and infection. There are multiple transitions associated with end of life and common concerns relate to dysphagia, decreased oral intake, managing symptoms at end of life with oral and transdermal medications and signs of active dying. Case studies in our poster illustrate patients who were able to avoid hospitalization over periods of several weeks to several months and were able to die at home in accordance with their wishes. Conclusions: Addressing end of life for multimorbid patients living with severe frailty is a significant challenge for healthcare systems worldwide. Hospital admission is an ideal time to begin conversations regarding goals of care and initiate advanced care planning. Advanced care planning is an active process over time & requires support and expertise. For those patients with advanced chronic disease and frailty who want to die at home, having access to experienced medical and nursing input with significant gerontological expertise has been invaluable. The expertise of the team support patients and families navigate a complex system and can help individuals to die in their preferred place of death and avoid unnecessary hospital admission. This initiative by the older person’s service embodies the values of the Mercy University Hospital. The service with a high level of excellence with complements from patients, families and general practitioners. It is a true service of team spirit where the outreach team work together with hospital colleagues and community colleagues to the common goal of following the patients’ wishes. Our community outreach team for older people show justice in honouring the rights of the patient & providing a patient centred service that avoids costly unnecessary in-patient care. The service shows respect to the patients wishes and with compassion supports patients towards the end of their life.
  • Adapting stroke rehabilitation during the COVID-19 pandemic: Exploring the experiences of patients and families of an Early Supported Discharge telerehabilitation programme

    Hartigan, Irene; Condon, M.; O'Regan, L.; Pope, L.; Healy, Liam; O'Caoimh, Rónán; Barrett, A; Rónán O'Caoimh, Department of Geriatric and Stroke Medicine, Mercy University Hospital, Grenville Place, Cork (Knowledge Enterprise Journals, 2023-07-17)
    Purpose: To describes stroke survivors (SS) and carer’s experiences of an Early Supported Discharge (ESD) programme delivered via telerehabilitation during the COVID-19 pandemic. Methods: Purposive sampling was conducted to recruit stroke survivors and carers who participated in telerehabilitation with a regional ESD team. Semi-structured interviews were conducted online. Interviews were transcribed and coded. Qualitative data analysis was conducted. Results: Eleven people were recruited including individual stroke survivors (n=4), carers (n=1) and family dyads (n=3). Four major themes were identified: (1) Channels of communication and enabling relationships (2) The importance of the daily rehabilitation routine, (3) Hands-off training and technology, (4) Virtual and non-tactile reality. Open channels of telecommunication were central to ensuring continuity of care and imparting information and education. Conclusion: Despite the implications of the COVID-19 pandemic, most participants described positive experiences of ‘virtual and non-tactile’ video enabled rehabilitation. Telerehabilitation enabled stroke survivors and therapists to build relationships which fostered engagement and supported rehabilitation. Further work is required to examine upscaling telerehabilitation use beyond the pandemic and to better understand key factors regarding patient selection.
  • The development of an online resource for OPAT patient education to enhance OPAT patient experience: a collaborative project with a local third level education institution

    Forde, Liz; Guidera, Fiona; McCann, Deirdre; Jackson, Arthur; Liz Forde, cANP OPAT, Cork University Hospital; Fiona Guidera, CNS OPAT, Mercy University Hospital; Deirdre McCann, Creative Digital Media Course Co-ordinator, Cork College of Further Education (Douglas Street Campus); Arthur Jackson, Infectious Disease Consultant, Cork University Hospital (2023-05-18)
    Background: To start on the OPAT service, a shared decision-making process between provider and patient involves providing an overview of the OPAT service including the options available. With the advent of COVID, wearing facemasks interrupted effective communication making assessments and shared decision making more difficult for patients. As there were no visitors, additional phone calls to carers were needed to complete a holistic assessment. This has resulted in more time consuming assessments. In addition, there was no relevant OPAT online resource available to which we could refer patients and their relatives. Methods: Under the SPARK Covid Call, OPAT Clinical Nurse Specialists supported by the Infectious Disease Consultant OPAT Clinical Lead were successful in their application for funding of development of an online resource for patients and received €2000 in April 2021. The agreed purpose would be to provide patients and carers with an overview of the service, an introduction to team members, the OPAT options available, the OPAT process. This resource would enhance their experience and manage expectations. Conditions of the funding were that the resource would reflect the national programme and not be site specific so that there was potential for it to be adopted nationally. An additional suggestion was to approach third level institutions locally to collaborate with to develop the resource. Supported by Nursing Management, in June 2021 we approached Cork College of Further Education, Douglas Street Campus who embraced the project as an innovative learning experience for their second year Creative Digital Media Course students. From September 2021 to May 2022, there was engagement between students, OPAT CNSs and college teams. The project included script writing, storyboarding, dry run interviews on-site, three final video recordings, a voice-over recording with animation, creation of graphics followed by animation and editing. Results: The completed online resource includes an animated information video with voice over and three separate videos with an ID consultant and OPAT nurses explaining the OPAT service: “OPAT-Your Path Home” – A short animation; OPAT - Before You Go Home – Video; OPAT -When You Go Home - Video; OPAT – Role of Infectious Disease Consultant – Video. Conclusion: This inter-professional project developed in collaboration with College of Further Education has produced high quality, but simple videos explaining the OPAT service to enhance the patient experience. In addition, this collaborative initiative between HSE and Cork College of Further Education won the Further Education category of the Cork Lifelong Learning Awards for “Innovative Inter-agency Lifelong Learning Endeavours” that contribute to community and society.
  • Metabolic Syndrome in Adults Receiving Clozapine; The Need for Pharmacist Support.

    Hurley, Kathleen; O'Brien, Sinead; Halleran, Ciaran; Byrne, Derina; Foley, Erin; Cunningham, Jessica; Hoctor, Fionnuala; Sahm, Laura (2023-01-24)
    People who are diagnosed with treatment resistant schizophrenia (TRS) are likely to have clozapine as a therapeutic management option. There is a high prevalence of metabolic syndrome in patients receiving clozapine. To mitigate against this, monitoring of weight, waist circumference, lipid profile, glycated haemoglobin (HbA1c), fasting blood glucose (FBG) and blood pressure (BP) is recommended. The aims of this study were to examine the prevalence of metabolic syndrome and whether any variables were correlated with its development, and to highlight any opportunities for the pharmacist to offer support. This study was conducted in an urban hospital and its associated Clozapine Clinic in Cork, Ireland. A retrospective audit assessed the prevalence of metabolic syndrome using the International Diabetes Federation (IDF) criteria. Patients were eligible for inclusion if they were aged 18 years or more, registered with the Clozapine Clinic, and had the capacity to provide informed consent. All data were entered into Microsoft® Excel ® (Microsoft Corporation) and further statistical analysis was undertaken using R, t-tests, Fisher's Exact Test and Mann-Whitney U tests as appropriate, and p ≤ 0.05 was considered statistically significant. Of 145 patients (32% female; mean age (SD) 45.3 (±11.7) years; 86.2% living independently/in family home), nearly two thirds (n = 86, 59.3%) were diagnosed with metabolic syndrome. The mean age of participants with metabolic syndrome was 44.4 years (SD = 10.8), similar to the 46.6 years (SD = 12.8) for those without. Variables that were identified to be statistically significantly associated with metabolic syndrome included waist circumference, weight, triglycerides, high density lipoprotein-cholesterol (HDL-C), BP, FBG and HbA1c. The high incidence of metabolic syndrome in this patient population highlights the need for continued physical health monitoring of these patients to ameliorate the risk of developing metabolic syndrome.
  • Metabolic Syndrome in Adults Receiving Clozapine; The Need for Pharmacist Support.

    Hurley, Kathleen; O'Brien, Sinead; Halleran, Ciaran; Byrne, Derina; Foley, Erin; Cunningham, Jessica; Hoctor, Fionnuala; Sahm, Laura (2023-01-24)
    People who are diagnosed with treatment resistant schizophrenia (TRS) are likely to have clozapine as a therapeutic management option. There is a high prevalence of metabolic syndrome in patients receiving clozapine. To mitigate against this, monitoring of weight, waist circumference, lipid profile, glycated haemoglobin (HbA1c), fasting blood glucose (FBG) and blood pressure (BP) is recommended. The aims of this study were to examine the prevalence of metabolic syndrome and whether any variables were correlated with its development, and to highlight any opportunities for the pharmacist to offer support. This study was conducted in an urban hospital and its associated Clozapine Clinic in Cork, Ireland. A retrospective audit assessed the prevalence of metabolic syndrome using the International Diabetes Federation (IDF) criteria. Patients were eligible for inclusion if they were aged 18 years or more, registered with the Clozapine Clinic, and had the capacity to provide informed consent. All data were entered into Microsoft® Excel ® (Microsoft Corporation) and further statistical analysis was undertaken using R, t-tests, Fisher's Exact Test and Mann-Whitney U tests as appropriate, and p ≤ 0.05 was considered statistically significant. Of 145 patients (32% female; mean age (SD) 45.3 (±11.7) years; 86.2% living independently/in family home), nearly two thirds (n = 86, 59.3%) were diagnosed with metabolic syndrome. The mean age of participants with metabolic syndrome was 44.4 years (SD = 10.8), similar to the 46.6 years (SD = 12.8) for those without. Variables that were identified to be statistically significantly associated with metabolic syndrome included waist circumference, weight, triglycerides, high density lipoprotein-cholesterol (HDL-C), BP, FBG and HbA1c. The high incidence of metabolic syndrome in this patient population highlights the need for continued physical health monitoring of these patients to ameliorate the risk of developing metabolic syndrome.
  • Validation of the Risk Instrument for Screening in the Community () among Older Adults in the Emergency Department.

    O'Caoimh, Rónán (2023-02-20)
    Although several short-risk-prediction instruments are used in the emergency department (ED), there remains insufficient evidence to guide healthcare professionals on their use. The Risk Instrument for Screening in the Community (RISC) is an established screen comprising three Likert scales examining the risk of three adverse outcomes among community-dwelling older adults at one-year: institutionalisation, hospitalisation, and death, which are scored from one (rare/minimal) to five (certain/extreme) and combined into an Overall RISC score. In the present study, the RISC was externally validated by comparing it with different frailty screens to predict risk of hospitalisation (30-day readmission), prolonged length of stay (LOS), one-year mortality, and institutionalisation among 193 consecutive patients aged ≥70 attending a large university hospital ED in Western Ireland, assessed for frailty, determined by comprehensive geriatric assessment. The median LOS was 8 ± 9 days; 20% were re-admitted <30 days; 13.5% were institutionalised; 17% had died; and 60% (116/193) were frail. Based on the area under the ROC curve scores (AUC), the Overall RISC score had the greatest diagnostic accuracy for predicting one-year mortality and institutionalisation: AUC 0.77 (95% CI: 0.68-0.87) and 0.73 (95% CI: 0.64-0.82), respectively. None of the instruments were accurate in predicting 30-day readmission (AUC all <0.70). The Overall RISC score had good accuracy for identifying frailty (AUC 0.84). These results indicate that the RISC is an accurate risk-prediction instrument and frailty measure in the ED.
  • Troponin testing in the emergency department in MUH

    Yates, Stephanie; Barden, Eithne; Healy, Anne; Dairiam, Samuel; Sharma, Abhishek; White, Cáit; Stephanie Yates, Eithne Barden, Cáit White, Biochemistry Laboratory/Pathology IT, Mercy University Hospital, Grenville Place, Cork, Ireland; Anne Healy, Samuel Dariam, Abhishek Sharma, Emergency Department, Mercy University Hospital, Grenville Place, Cork, Ireland (2021-09-30)
    Background / Problem Identified: Chest pain is one of the most common reasons for people attending the emergency department (ED). As there are many causes of chest pain, the physician has the responsibility of ruling out serious and potentially life threatening conditions such as acute myocardial infarction (MI), aortic dissection or pulmonary embolism (PE). Acute Coronary Syndrome (ACS) is one of the most common presentations in acute hospital settings. Cardiac troponin (TnI) is the preferred biomarker for the detection of myocardial injury. High sensitivity assays can detect elevated levels of TnI (above the 99th percentile of an apparently healthy reference population) within 3 hours after the onset of chest pain. It is particularly of value for the cohort of patients who have ACS, without typical features. For example diabetic patients, the very elderly or those with asymptomatic ACS. However if troponin is used incorrectly and without true clinical context then it can be elevated in a number of non cardiac conditions which can lead to a false clinical diagnosis, inappropriate workup and an increased patient stay in hospital. It was felt that an excessive amount of troponin tests were being requested especially in the ED so an audit was carried out to examine patterns of troponin requesting and to determine if troponin tests are requested appropriately from the ED in MUH and if the timings of the repeat requests were appropriate.
  • Exploring the impact of over requesting of laboratory tests in biochemistry, MUH and devising a demand management strategy to reduce costs without compromising patient care and safety

    Yates, Stephanie; Barden, Eithne; White, Cáit; Stephanie Yates, Eithne Barden, Cáit White, Biochemistry Laboratory/Pathology IT, Mercy University Hospital, Grenville Place, Cork, Ireland (2020-07-07)
    Like many other areas of the health care sector, there is increasing pressure being put on medical laboratories to cut costs and eliminate wastefulness, while still maintaining and improving standards and expanding test repertoire. As a result many laboratories are turning to demand management as a way of cutting excess costs. It is estimated that up to 25% of pathology investigations are unnecessary indicating a significant potential waste. The aim of demand management is to control the appropriateness of tests that are requested. There are 3 main categories used when trying to achieve demand management; (1) Pre laboratory. This involves educating and engaging with requestors with regards to testing, examining the test repertoire available and also the withdrawal of obsolete tests. (2) Within laboratory. This is largely based around using minimum retest interval rules to prevent duplicate testing. (3) Post laboratory. This involves liaising with clinical teams to review the influence of test results on patient care.
  • S.A.F.E. huddle in the emergency department

    Fitzgerald, Shona; O'Donnell, Barbara; Healy, Anne; McLoughlin, Darren; Shona Fitzgerald, Barbara O'Donnell, Anne Healy, Darren McLoughlin, Emergency Department, Mercy University Hospital, Grenville Place, Cork, Ireland. (2022-06-23)
    Background / Problem Identified: A high volume of patients with undifferentiated diagnoses attend the Emergency Department complicated by high acuity and risk of deterioration. This risk increased during the pandemic when the department was divided into single rooms for isolation reducing the level of visual observation. The challenge was keeping these patients safe behind the closed doors. We needed to enhance communication within the multidisciplinary team to create a safer environment for both staff and patients. The issue of unrecognised deterioration or failure to escalate is identified as a risk to patient safety.
  • Comparison of sodium levels between GEM 5000 Blood Gas Analysers and Abbott c8000 Architect Analyser in patients admitted to ED in MUH

    Yates, Stephanie; Barden, Eithne; Louw, Michael; Lagali, Angeline; Stephanie Yates, Eithne Barden, Michael Louw, Angeline Lagali, Biochemistry, Mercy University Hospital, Grenville Place, Cork, Ireland. (2022-06-23)
    Background / Problem Identified: Sodium is the major cation of extracellular fluid; it plays an essential role in the normal distribution of water and in the maintenance of osmotic pressure in extracellular fluid compartments. Here in MUH, sodium levels are reported using the GEM 5000 Blood Gas Analyser, as a point of care test in the ED. They also form part of a renal panel and are reported in the Biochemistry lab using the c8000 Abbott Architect, using whole blood and serum/li-heparin samples respectively. The c8000 uses Integrated Chip Technology (ICT), Ion Selective Electrode, diluted (Indirect) to measure sodium, whereas the Gem 5000 uses potentiometric sensors to measure sodium (Direct). Hypo and Hypernatremia are the most common electrolyte disorders. Therefore precise and reliable sodium measurements are crucial for correct treatment of the patient. In recent years, several studies have showed a discrepancy in sodium levels between direct and indirect methods. In general, clinicians consider the two methods to be interchangeable and there is a lack of awareness of the associated discrepancy between methods.
  • Multidisciplinary quality improvement plan: Introduction of use of Passy Muir speaking valve in line with mechanical ventilation in patients with tracheostomy in ICU setting in MUH

    Ferris, Finola; O'Sullivan, Keith; Murphy, Dervla; Marshall, Teresa; O'Mahony, Michellle; O'Croinin, Donall; Hanna, Elaine; Friel, Tara; Finola Ferris, Speech & Language Therapy Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Keith O'Sullivan, Physiotherapy Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Dervla Murphy, Physiotherapy Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Teresa Marshall, Department of Nursing, Mercy University Hospital, Grenville Place, Cork, Ireland; Michelle O'Mahony, Anaesthesia Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Donal Ó CróinÍn, Anaesthesia Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Elaine Hanna, Department of Nursing, Mercy University Hospital, Grenville Place, Cork, Ireland; Tara Friel, Speech & Language Therapy Department, Mercy University Hospital, Grenville Place, Cork, Ireland (2022-06-23)
    Background / Problem Identified: What is a tracheostomy tube? A tracheostomy tube is an artificial airway inserted through the neck into the trachea to allow a more direct access for ventilation. What is a Passy Muir speaking valve? A Passy Muir speaking valve is a one-way valve which can be placed over the end of tracheostomy hub to redirect airflow into the upper airways when the tracheostomy cuff is deflated, allowing air to flow through vocal folds and facilitating verbal communication in patients with tracheostomy. What is mechanical ventilation? Mechanical ventilation is the technique through which gas is moved towards and from the lungs through an external device connected directly to a patient. What is involved in using a speaking valve in line with mechanical ventilation? Speaking valves can be used in line with ventilators but requires deflation of tracheostomy cuff to allow leaked expiratory air to travel through the vocal folds to facilitate speech. This has implications in measuring expired tidal volume and potential loss of lung volume. Project Background: Increased numbers of patients requiring tracheostomy in last 2 years in MUH. More complex cohort of patients requiring tracheostomy with prolonged length of weaning from mechanical ventilation and protracted ICU stay. Implications of protracted ICU admission: - significant impact to patient with increased risk of ICU delirium - psychological impacts to patient including frustration, anxiety, low mood, poor engagement with rehabilitation. - increased morbidity. - impacts negatively on patient flow and bed management. - high financial cost to MUH - impacts on staff morale. Current practice in MUH: Speaking valves are utilised in patients with tracheostomy who have weaned from mechanical ventilation but have not yet been decannulated (tracheostomy tube removal). This results in a period when patients are conscious, alert and unable to communicate verbally. Practices in larger critical care facilities have progressed to use of speaking valves in line with ventilators (SVILV). Benefits of speaking valve: Benefits of speaking valve (on ventilated/non-ventilated patients) are well recognised. These include restoration of speech, improved swallow function and reduced aspiration risk. Benefits of SVILV: Benefits include primarily earlier restoration of verbal communication. In addition, it can expedite weaning from mechanical ventilation by re-establishing physiological PEEP (Positive End Expiratory Pressure) which improves arterial oxygenation, improved secretion management by enabling a stronger, more effective cough and increased end expiratory lung impedance.
  • Compliance with venous thromboembolism protocol in surgical patients in Mercy University Hospital quality improvement project

    Shehata, Danny; Cagney, David; McGreal, Gerald; Danny Shehata, David Cagney, Gerald McGreal, Vascular Surgery, Mercy University Hospital, Grenville Place, Cork, Ireland. (2021-09-30)
    Background / Problem Identified : 63% of all venous thromboembolic (VTE) events occur in the hospital setting, of which 70% may be preventable with appropriate VTE prophylaxis. Local and national quality improvement initiatives have led to development of a generic VTE prophylaxis protocol for hospital inpatients which can be found on page 3 of the hospital drug kardex. This quality improvement project aims to assess and improve the compliance amongst Non-Consultant Hospital Doctors (NCHDs) with completion of the VTE Protocol and as well as the appropriate prescription of VTE prophylaxis amongst surgical patients in Mercy University Hospital.
  • A large upper abdominal mass in an adolescent with high Ca 19.9: a case report.

    O'Connell, Robert M; O'Sullivan, Adrian (2022-04-27)
    Mucinous cystic neoplasms of the liver are uncommon cystic lesions of the liver, most commonly seen in women in the fifth decade of life. We present a case of a 16-year-old girl with an incidentally discovered abdominal mass while undergoing a tonsillectomy. Investigation revealed a multiloculated, septated 17 × 17 × 11 cm cystic lesion arising from the left lobe of the liver, with displacement of the remaining upper abdominal viscera. Serum Ca19.9 was significantly elevated at 2256 U/ml (range 0–37), but other bloods including liver function tests, alphafoetoprotein and carcinoembryonic antigen were within normal limits. We proceeded to open formal left hemi-hepatectomy. Histology was consistent with a diagnosis of mucinous cystic neoplasm with low-grade intra-epithelial neoplasia.
  • Ageing well at home: advice to help you age well in your community [updated September 2022]

    Moloney, Elizabeth; Gillman, Ciara; O’Brien, Gillian; Mercy University Hospital, Grenville Place, Cork (Mercy University Hospital, Cork Kerry Community Healthcare, 2022-09)
    The aim of this booklet is to help you age well and avoid becoming frail through general health and wellbeing advice. COVID-19 has made it more difficult to engage in normal social and physical group activities. We have had to adapt our lifestyles and regular social connections. This booklet reflects the hope we all feel as normal routines return. Included is information about a range of activities, services and agencies available in your community to help you age well. As healthcare workers, we want to support you to live well at home. By remaining active and engaged in your local community, you can delay the onset of frailty. This booklet encourages you to look after your health and wellbeing and to feel positive about the future. Now is the time to invest in your physical and mental health so you can reap the benefits in years to come.

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