Healthcare Safety Investigation Branch Annual Review 2018/19

Healthcare Safety Investigation Branch | December 2019 | Annual Review 2018/19

The Healthcare Safety Investigation Branch (HSIB) has published its annual review, the review includes the reflections of the HSIB’s advisory panel, along with details of their two investigation programmes and how the HSIB has met their strategic objectives.

The HSIB identifies a number of risks, these include:

• timely delivery of the national investigation programme
• an appropriate level of scrutiny, assurance and accountability necessary for an operationally independent body
• the public and health sectors’ confidence in HSIB’s good intent, rigour and independence from NHS Improvement and the Department of Health and Social Care (DHSC), and therefore
• the long-term credibility and success of HSIB.

Each chapter can also be read as a standalone report, topics covered are:

  1. Surveillance of maternal deaths
  2. Cardiovascular diseases
  3. Morbidity from breast cancer
  4. Hypertensive disorders
  5. Early pregnancy disorders
  6. Accidents
  7. Critical maternal care

The full publication is available from the HSIB 

Saving Lives, Improving Mothers’ Care 2019

Maternal, Newborn and Infant Programme: Saving Lives, Improving Mothers’ Care 2019 | 13 Dec 2019 |  Healthcare Quality Improvement Partnership

This report, the sixth MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on 549 women who died during or up to one year after pregnancy between 2015 and 2017 in the UK.

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Image source: https://www.hqip.org.uk/

In addition, it includes Confidential Enquiries into the care of women who died between 2015 and 2017 in the UK and the Republic of Ireland from cardiovascular causes, hypertensive disorders, early pregnancy conditions and accidents.

The report also includes a Morbidity Confidential Enquiry into the care of women with newly diagnosed breast cancer.

This report can be read as a single document; each chapter is also designed to be read as a standalone report: the topics covered are:

  1. Surveillance of maternal deaths
  2. Cardiovascular diseases
  3. Morbidity from breast cancer
  4. Hypertensive disorders
  5. Early pregnancy disorders
  6. Accidents
  7. Critical maternal care.

You can download the report from the Healthcare Quality Improvement Partnership

See also: Key messages Infographic 

NICE: Hypertension in pregnancy

NICE | October 2019 | Hypertension in pregnancy

NICE has updated its Clinical Knowledge Summary on hypertension in pregnancy 

Management

Full details from NICE 

National Diabetes Audit – Report 2: Complications and Mortality

This report from the National Audit of Diabetes covers complications arising from diabetes. Most cardiovascular and diabetes specific complications are covered.

Part a is divided into three main sections: cardiovascular complications, diabetes specific complications and mortality. Each section aims to address overall rates, time trends, geographical variation and hospital utilisation.

Part b investigates associations between patient characteristics and adverse outcomes. The impact of changes to lifestyle and treatment have been estimated for both the person with diabetes and diabetes services for the first time.

The reports can be downloaded here:

NIHR: Continuing an anticoagulant at home after abdominal surgery cuts thrombosis risk

NIHR | December 2019| Continuing an anticoagulant at home after abdominal surgery cuts thrombosis risk

A new NIHR Signal outlines a review of seven studies (originally published in 2009), mainly in cancer surgery, that found that 13% of patients who received anticoagulant treatment only during their hospital stay developed a clot in the deep veins or lungs, compared with 5% of those who continued with the treatment beyond discharge. There was no increased risk of bleeding complications with prolonged treatment.

This update to a Cochrane review first published in 2009 included three new randomised controlled trials, from Italy, Denmark and Japan, boosting the overall number of participants to 1,728.

The quality of the evidence in this review was moderate overall. The results are consistent with previous studies and strengthen the case for prolonged anticoagulation in an area where there is some uncertainty and variation in practice.

Abstract 

Background: This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery.

Objectives: To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS: We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA: We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (more than or equal to fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation.

Data collection and analysis: Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis.

Main results: We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I(2) = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT.We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I(2) = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis, which approached significance (M-H OR 0.30, 95% CI 0.08 to 1.11; I(2) = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I(2) = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity.
Authors’ conclusions: Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Read the full review at NIHR 

Bedtime hypertension treatment improves cardiovascular risk reduction, reports study

Hermida, R. C. et al|2019| Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial |Eur Heart J |doi: 10.3310/signal-000851

A new NIHR Signal spotlights the findings of a trial in Spain that reports that people with hypertension who took their blood pressure medications at bedtime were 45% less likely to experience a major cardiovascular outcome, such as heart attack or stroke, compared with people who took them in the morning. The large trial conducted across 40 general practices in Northern Spain assigned 19,084 adults to take their blood pressure medications either in the morning or at night. Over an average of six years, there was a clear, reduced risk for the combined outcome, with similar risk reductions for each event. The effect seemed to be mediated by the improved night-time blood pressure control, which supports previous theories on the topic.

 

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It may still be preferable to take diuretics in the morning, but for most blood pressure medications, this could be a potentially beneficial change (Source: NIHR Signal).

Aims: The Hygia Chronotherapy Trial, conducted within the clinical primary care setting, was designed to test whether bedtime in comparison to usual upon awakening hypertension therapy exerts better cardiovascular disease (CVD) risk reduction.
Methods and results: In this multicentre, controlled, prospective endpoint trial, 19 084 hypertensive patients (10 614 men/8470 women, 60.5 +/- 13.7 years of age) were assigned (1:1) to ingest the entire daily dose of >/=1 hypertension medications at bedtime (n = 9552) or all of them upon awakening (n = 9532). At inclusion and at every scheduled clinic visit (at least annually) throughout follow-up, ambulatory blood pressure (ABP) monitoring was performed for 48 h. During the 6.3-year median patient follow-up, 1752 participants experienced the primary CVD outcome (CVD death, myocardial infarction, coronary revascularization, heart failure, or stroke). Patients of the bedtime, compared with the upon-waking, treatment-time regimen showed significantly lower hazard ratio-adjusted for significant influential characteristics of age, sex, type 2 diabetes, chronic kidney disease, smoking, HDL cholesterol, asleep systolic blood pressure (BP) mean, sleep-time relative systolic BP decline, and previous CVD event-of the primary CVD outcome 0.55 and each of its single components, i.e. CVD death, myocardial infarction, coronary revascularization, heart failure, and stroke.
Conclusion: Routine ingestion by hypertensive patients of >/=1 prescribed BP-lowering medications at bedtime, as opposed to upon waking, results in improved ABP control (significantly enhanced decrease in asleep BP and increased sleep-time relative BP decline, i.e.
Full artilce available from European Heart Journal 

Transforming out-of-hospital care for people who are homeless

Housing LIN |December 2019 | Transforming out-of-hospital care for people who are homeless

An evaluation by researchers at King’s College London found that homeless inpatients have five times the rate of emergency readmission and A&E visits after discharge from hospital compared to deprived housed patients with a similar medical profile. Now a briefing paper draws on the findings of this evaluation, to demonstrate how the High Impact Change Model (HICM) can be sensitised to meet the needs of patients who are homeless, and this can contribute to meeting Better Care Fund metrics. The Homeless Hospital Discharge Fund (HHDF) funded 52 schemes to develop specialist discharge and ‘step-down’ services to tackle issues such as discharge to the street.

Transforming out-of-hospital care for people who are homeless. Support Tool & Briefing Notes: complementing the High Impact Change Model for transfers between hospital and home

Refreshing the High Impact Change Model