The National Patient Experience Survey (2017) found lower levels of satisfaction with hospital discharge. Poor communication was the primary cause for this finding. A thorough review of the survey resulted in the identification of four key areas pertaining to discharge that patients had a knowledge deficit namely Diagnosis, Drugs, Aftercare and ‘Your’ Follow-up. This resulted in the development of the D-day mnemonic/concept. Communication is a two way process between the healthcare provider (HCP) and the patient. This facilitates shared decision making and an equal partnership that is truly person centered. Patient empowerment is prerequisite to this as proposed by the mantra ‘no decision about me, without me’ (Kings Fund, 2011). Enabling patients to participate as equal partners is a challenge for HCP’s as it conflicts with paternalism, the dominant decision making healthcare model (Coulter et al, 2008). The National Healthcare Charter (HSE, 2012) ‘its safer to ask’ encourages patients to ask questions about their care. Patient utilisation of the charter was not evident in the findings of the national patient experience survey. To this end we developed a ‘D-day patient information leaflet’ containing cue questions targeting the d-day knowledge deficits. Due to the time constraints of this project we focused on two of the four D-day knowledge deficits namely Aftercare and ‘Your’ follow-up.

Background / Problem Identified: Acute Medical Assessment Units (AMAU) were created with the main goal of providing medical patients with prompt, consultant-led decision making. According to the 2010 HSE National Acute Medicine Programme, a decision should be made regarding admission or discharge for AMAU patients (time to decision) in less than 6 hours. The aim of our Acute Medical Assessment Unit is to provide a service that enables early patient assessment and prioritisation of investigations leading to a reduced patient experience time (PET) on the emergency department floor. The AMAU will also provide an alternative pathway for follow-up in patients not requiring acute admission – with scheduled follow up of planned investigations in the AMAU clinic or Virtual Ward. Complementary investigations play a key role in decision making. Prioritisation of urgent investigations to determine acute management (Priority 2 e.g. CTPA for a suspected PE with a high Wells’ score) and less urgent investigations (Priority 3 e.g. endoscopy for gastritis) can be decided and followed-up via the AMAU. Lack of timely access to these investigations can lead to an undue delay in patient flow and obstruct potentially safe patient discharges. The Mercy AMAU was restructured in July 2020. This resulted in the addition of a fixed medical SHO, CNM2, and clerical officer; along with 2 Consultants who supervise the unit. There is additional support provided with an SHO and Medical Registrar from another team. A GP referral pathway was introduced to further expedite patient assessment in November 2020. This AMAU Audit aims to ascertain to what extent the AMAU activity reduces the number of hospital admissions that are required to facilitate access to timely investigations.

Background / Problem Identified: Since the establishment of the Speech & Language Therapy (SLT) service in MUH in 2005, internal inpatient referrals to the service have been made using paper referral forms. The paper-based referral system was audited for quality, safety and efficiency in 2018, in the context of increasing referral rates to SLT. A number of issues of concern were identified within this audit, across the domains of quality and safety, economic costs and data use/security. 1. Quality and safety issues: Delayed receipt of referrals E.g. 25% of referrals were delayed in reaching the SLT service in 2017 and this increased to 36% (267 patients) in 2018. Paper referrals often lacked essential information. These issues resulted in inaccurate and inequitable triage of referrals and provision of services, leading to delayed hospital discharge in some cases. 2. Economic costs: Opportunity costs in terms of staff time: NCHDs, SLTs, nursing staff and clerical staff time was lost in generating referrals, collecting referrals from wards, checking the status of referrals, duplicating referrals and restocking referral forms on wards. The paper referral system workflow encompassed 15 steps, from the SLT viewpoint alone. 3. Data use & security issues: Incomplete referral information limited the scope for data analysis which impacted on service audit, planning and development (Harman and Cornelius, 2017). Manual data analysis of paper forms led to inefficiency and human errors in data analysis. Hardcopy referral waiting lists were kept in storage in the SLT department, representing a data protection risk associated with storage of confidential information (Data Protection Commissioner, 2017, Health Service Executive, 2013, Burke and Weill, 2013, Harman and Cornelius, 2017, Hoyt et al., 2012). Measurement Methods / Design / Strategy: In order to address the above quality and risk issues, a health information technology solution was implemented in March 2019 in the form of an Electronic Referral system. The design and implementation of the E-referral system encompassed a number of phases, all based on the HSE change management approach; 1. Stakeholders were identified: A change in referral processes was found to affect the SLT department, ICT department, NCHDs and Consultants, ward clerks, ward CNMs, patient flow service and the hospital stores department. 2. In-house technology solutions were explored: The existing Social work E-referral system was reviewed. The Social work manager shared learning from the design and implementation phases involved in rolling out the social work E-referral system. 3. Literature review: Current literature on the implementation of internal referral systems in acute care settings was reviewed. 4. System design & end-user consultation: The NCHD committee 2017-2018 was consulted on system design in order to design a user-friendly system and to promote end user buy-in the change initiative. A member of NCHD committee with background qualifications in IT provided support to SLT and ICT department in the design of the system. The ICT department redesigned the existing social work referral system in order to capture the data required by the SLT service. 5. Education & training: Stakeholders were informed in January 2019 regarding the new system via emails to Consultants, NCHDs, CNMs and patient flow, presentations at intern education session, information handouts on wards and communication to ward clerks. 6. System testing: The E-referral system was tested on St. Finbarr’s ward for a seven day period in February 2019. Changes to the system were made by the ICT department in response to feedback from stakeholders. 7. Implementation: The E-referral system was rolled out to all clinical areas March 2019. 8. Gathering of feedback and audit. Results / Lessons learned / Limitations: A number of beneficial results were noted in practice, which echo the findings in current literature on the subject. These benefits can be described across the three areas of quality and safety improvements, economic benefits and data security and data use improvements. 1. Improvements in service quality & patient safety - Completeness and legibility of referral information enables accurate triage and equitable prioritisation of referrals, ensuring that patients are seen for SLT assessments in order of most urgent clinical need (for example, a dysphagia assessment in the case of a patient who is nil by mouth) (Kim-Hwang et al., 2010, Adaba and Kebebew, 2018, Bates and Gawande, 2003, Ash et al., 2004). - Delayed referral rates have dropped to 0%. Referrals are received immediately by the system, in chronological order and can be triaged as such (Shaw and de Berker, 2007). - Delayed hospital discharges no longer occur as a result from delays in the receipt of referrals (Bates and Gawande, 2003). - Increased numbers of patients can be seen by the SLT service as a result of the time saved by the new system. 2. Economic Benefits –hospital costs, staff time & productivity - NCHDs do not have to search for hardcopy forms on each ward. - Automated completion of demographic information and tick box options ensures that each referral takes less than 2 minutes to complete and submit. - Feedback from NCHDs on the wards is that the system is an improvement on the paper-based one, in terms of ease of use and time efficiency. - The system confirms when referrals have been submitted- NCHDs and nurses do not have to contact SLTs to check if referral was received, or submit multiple referrals. - Stores department do not have to order or deliver paper referral cards. - Ward clerks do not need to monitor and reorder stocks of referral cards for wards. - The E-referral system workflow reduces the steps required for an SLT to process a new referral to 7 steps (down from 15). - SLT time saved over the course of a year on referral processing is 65 hours, which can now be used to see 130 extra patients. This represents a cost saving of 2,340.32EU. - The system automates the process of calculating SLT response times to referrals. Time saved over the course of a year on such data analysis is 24 hours, which can now be used to see 48 extra patients. It also represents a cost saving of 864.16EU. 3. Data use & data security improvements - Complete referral information has resulted in improved scope for SLT service analysis, planning and development. - Efficiency and accuracy of data analysis has been achieved (Adaba and Kebebew, 2018, Bates and Gawande, 2003). - The system can be used as an activity management tool, as SLT response-times to referrals can be analysed automatically. - Referral data is now computerised and therefore stored on the hospital’s server, ensuring maximum security of digital information. - There is no longer a need for duplication of referral information into spreadsheets to calculate referral delay times and SLT response times to referrals, as this is automated within the new system. Conclusions / Reflections This project showcases the internal resources and skills available in MUH with which a health information technology solution can be implemented to address organisational inefficiencies, quality and safety issues (Burke, 2013). However, as a ‘frontline ownership’ model was adopted for the most part, the project developed across a two-year time period, which is a lengthy timeframe for a project of this nature. If carrying out a similar initiative, top-down project sponsorship and championing by senior management may be beneficial in securing protected resources with which to complete a similar project in a shorter timeframe. Based on the positive results on service efficiency and patient safety outlined above, there is a strong case to be made for rolling this system out across other clinical services, such as HSCP services, medical/surgical consults for inpatients and MDT referrals. Indeed, it could be used to streamline processes and collect data on operational services also, such as catering requests or requests for continuous supervision on wards. Reflection and stakeholder consultation upon completion of the project revealed a number of additional features that could be incorporated into practice, in order to maximise efficiency. For example, the E-referral system generates unique referral ID numbers. These could be quoted in the healthcare record, instead of printing and filing copies of referrals. It would also maximise transparency and accountability re the processing of referrals.

Objectives We sought to examine healthcare workers (HCWs) utilisation of formal and informal psychological support resources in the workplace during the first and third waves of the COVID-19 pandemic in Ireland. Methods A convergent mixed methods approach was undertaken. Four hundred and thirty HCWs in the Mid West and South of Ireland responded to an online survey in terms of their use of psychological support resources during Wave 1 (April/May 2020) of COVID-19. Thirty-nine HCWs undertook in depth interviews at Wave 3 (January/February 2021), and a further quantitative survey was distributed and completed by 278 HCWs at this time. Quantitative data arising at Wave 1 and Wave 3, were synthesised with Qualitative data collected at Wave 3. A Pillar Integration Process (PIP) was utilised in the analysis of the quantitative and qualitative data. Results Five pillars were identified from the integration of results. These were: a) the primacy of peer support, b) the importance of psychologically informed management, c) a need to develop the organisational well-being ethos, d) support for all HCWs, and e) HCWs ideas for developing the well-being path. These pillars encapsulated a strong emphasis on collegial support, an emphasis on the need to support managers, a questioning of the current supports provided within the healthcare organisations and critical reflections on what HCWs viewed as most helpful for their future support needs. Conclusions HCWs who utilised supportive resources indicated ‘in house’ supports, primarily collegial resources, were the most frequently used and perceived as most helpful. While formal psychological supports were important, the mechanism by which such psychological support is made available, through utilising peer support structures and moving towards psychologically informed supervisors and workplaces is likely to be more sustainable and perceived more positively by HCWs.

Background: Primary urethral carcinoma (PUC) is rare and accounts for < 1% of all genito-urinary cancers. There is a male predominance of 3:1 and a peak incidence in the 7th and 8th decades. The aetiology of this cancer is similar to penile cancer, and the human papilloma virus (HPV) is thought to be an essential factor in tumorigenesis. Urethral cancer should be diagnosed and staged with a combination of tumour biopsy, MRI, and CT with treatment involving a multimodal approach. Contemporary management emphasises phallus-preserving surgery where feasible. Case presentation: Here, we describe a case of distal urethral carcinoma, which presented as a metastatic groin mass and identifying the primary lesion proved challenging. Diagnostic flexible cystoscopy identified a tiny lesion in the navicular fossa, which was biopsied and confirmed to be a squamous cell carcinoma. The patient then underwent phallus preserving surgery, including distal urethrectomy with bilateral inguinal lymph node dissections. The final stage was pT1N1M0, and adjuvant chemotherapy was started. The distal urethrectomy involved the surgical creation of a hypospadic meatus in the midshaft of the penis. Normal voiding and sexual function were preserved. Conclusions: Urethral cancer is a rare malignancy and clinicians should bear in mind that early diagnosis of this disease can be very difficult depending on the anatomical location of the tumour. Treatment currently favours penis-preserving surgery.

In order to best treat a patient, the carer must be able to clearly see their point of view. In the case of the complexities of insulin pump therapy, physicians may not fully understand the common challenges that drive patients to non-adherence. The author undertook a three-day simulation using wearable technology to explore this experience. This form of simulation represents a simple yet effective means by which to foster cognitive empathy in undergraduate and postgraduate medical education settings alike.

Zinner syndrome was first described in 1914 and represents the triad of unilateral renal agenesis and ipsilateral seminal vesicle cyst and ipsilateral ejaculatory duct obstruction. Seminal vesicle cysts are often asymptomatic but can also present with pain, haematospermia, or other lower urinary tract symptoms. Treatment strategies include observation and surgical excision. We present the laparoscopic management of an enlarged seminal vesicle cyst, consistent with Zinner syndrome, 14 years after the initial diagnosis. A 58-year-old male patient was diagnosed with a left-sided seminal vesicle cyst while undergoing assessment for renal transplant due to progressively worsening renal function in his solitary right kidney. The otherwise asymptomatic cyst enlarged from the time of initial diagnosis in 2004 (11.3 cm × 9.7 cm × 13.1 cm) to nearly double the size in 2018 (12.8 cm × 11.9 cm × 14.2 cm). This cyst size ultimately precluded renal transplant, and the patient was referred for excision. Laparoscopic excision of the cyst was performed, histopathology confirmed seminal vesicle cyst tissue, and there has been no recurrence of the cyst to date. The patient remains active on the renal transplant waitlist. Zinner syndrome is a rare syndrome, with the seminal vesicle cysts being managed by observation or surgical excision. We report the longest documented observation of a seminal vesicle cyst, culminating in a safe and successful laparoscopic excision.

The seventh report from the National Clinical Audit of Severe Maternal Morbidity (SMM) in Ireland reports on 401 cases of SMM occurring in all 19 Irish maternity units in 2018.

The aim of this study was to understand how chaplains delivered spiritual care to staff during the Covid-19 pandemic. The researchers analyzed data collected from an International Survey of Chaplain Activity and Experience during Covid-19 (N = 1657). The findings revealed positive changes that emerged and new practices evolved around the use of technology as useful tools for maintaining contact with staff.