Implementing a standardised discharge analgesia guideline to reduce paediatric post tonsillectomy pain.

OBJECTIVES: To reduce readmission for pain control post-paediatric tonsillectomy. INTRODUCTION: Paediatric tonsillectomy is a common procedure in the UK. Uncontrolled pain at home is a common reason for re-admission and therefore adequate analgesic control following paediatric tonsillectomy is vital for a smooth post-operative recovery. Analgesic regimens at a district general hospital in England were audited and a standardised protocol was subsequently implemented. METHODS: A retrospective audit from September 2014 to August 2015 was completed. Discharge analgesic regimens and readmission rates post-tonsillectomy for recurrent tonsillitis in 2-17 year-old children were studied in a large general hospital in the United Kingdom. A standardised weight-based algorithm was used to dose scheduled regular paracetamol for 2 weeks. Second cycle prospective audit ran from December 2015 to November 2016. RESULTS: In cycle 1, 151 children (mean age, 7.9 years) underwent tonsillectomy for tonsillitis, 25 (16.6%) of whom were readmitted. 12 (7.9%) experienced postoperative haemorrhage, 13 (8.6%) required pain control, and one (1.2%) had infection. The discharging analgesic regimen varied widely and often included purchase of over-the-counter ibuprofen and paracetamol. In cycle 2, 118 children (mean age, 8.8 years) underwent tonsillectomy, 17 (14.4%) were readmitted; 12 (10.2%) had post-operative haemorrhage, 0 needed pain control, 5 (4.2%) had other problems. There was a significant reduction in readmission for pain control (p = 0.0027) from 7.3% to 0% in the study. There was no significant change in overall readmission rate (16.6%-14.4%) or postoperative haemorrhage rate (8.9% overall). DISCUSSION: Analgesia prescription post tonsillectomy varies widely and over the counter prescriptions of ibuprofen and paracetamol is based on age rather than weight with patients receiving inadequate analgesic doses. A readily available standardised postoperative analgesic protocol can significantly reduce readmission rates for pain control following paediatric tonsillectomy.

Implementation of a combined Cardiopulmonary Resuscitation and Treatment Escalation Plan document in a District General Hospital.

Documentation of appropriate escalation of treatment was identified as a problem for junior doctors and Critical Care Outreach Nurses at Musgrove Park Hospital. An audit of resuscitation and escalation documentation of all wards found that of the patients who were not for Cardiopulmonary resuscitation (and therefore not for full escalation of care), 78.4% had no documentation of the appropriate level of escalation of treatment should they deteriorate. The majority of junior doctors had experienced cases where they felt that inappropriate treatment had been given, where no escalation plan was documented. Using several Plan, Do, Study, Act (PDSA) cycles, drawing tools used in other trusts and departments, and the views of clinicians, we developed a treatment escalation plan (TEP) tool, to be included in the resuscitation form. This included consideration of referral to critical care, ward based non-invasive ventilation, and appropriate use of intravenous or oral antibiotics. This then prompted the responsible clinician to consider and document appropriate escalation of treatment. The CPR-TEP form was trialed using a quasi-experiment design allowing the aim to be tested using two groups - intervention and control. All patients in the intervention group were not for CPR and therefore had their TEP-CPR form filled in fully (n=68). The control group consisted of patients who were not for CPR but who did not have a TEP form filled in (n=36). The appropriateness of OOH (out of hours) treatment in those patients who experienced clinical deterioration was judged by questionnaire-based feedback from the in-hours team the following morning. Levels of inappropriate treatment between the two groups were compared to test the aim. At the end of the study period, questionnaire feedback indicated that 11.1% of patients in the group with the new CPR-TEP document had received inappropriate OOH care compared to 44.4% of patients in the group without the document. Using the TEP alongside resuscitation documentation prompts the responsible clinician to consistently consider and document the appropriate escalation of care for their patient, improving communication with the out of hours team and appropriate escalation of care in the event of patient deterioration.

Eye problems on expeditions.

BACKGROUND: Visual loss in the wilderness setting is at best disabling and at worst potentially fatal. However many physicians have a poor knowledge of ophthalmology and the basic skills that could be applied in situations away from definitive care. METHOD: This paper is intended for physicians, interested non-medical people and expedition operators as a practical guide to the treatment and prevention of eye problems on expeditions. RESULTS: Some of the eye conditions described in this paper are unique to the high altitude setting, such as high altitude retinopathy and some could happen in any environment, such as trauma, dry eyes and contact lens problems. As with any aspect of an expedition, preparation is vital to prevent and avoid eye problems. It is therefore important that pre-existing ocular conditions are known about and appropriate drugs and equipment are available in expedition first aid kits. CONCLUSIONS: In the event of a visual problem, it is always better to be cautious and evacuate a patient rather than a risk a sight-threatening complication. However this paper should provide a non-ophthalmologist with the skills to treat the eye conditions described.