Betsi Cadwaladr University Health Board Research Articles

Impact of first-line dalbavancin for cellulitis on hospital admissions and costs: a case series

BackgroundMany patients with cellulitis are treated with oral antibiotics as outpatients, but some require hospital admission for intravenous antibiotics. During the coronavirus disease 2019 pandemic, Betsi Cadwaladr University Health Board (BCUHB) in Wales approved use of dalbavancin as first-line intravenous antibiotic from April to December 2020 to facilitate early discharge and prevent hospital admission. ObjectivesTo report cost savings and admission avoidance through first-line intravenous use of dalbavancin for cellulitis in one health board in Wales. Patients and methodsPatients with cellulitis who presented to the emergency department (ED) or medical assessment unit (MAU) at BCUHB's two hospitals between April and December 2020 were identified for treatment with dalbavancin, because they had not responded to oral antibiotics or their initial presentation warranted intravenous antibiotics. Patients received 1500mg dalbavancin by intravenous infusion according to prescribing information and were sent home without being admitted. Outcomes were admission within 30 days of dalbavancin and cost savings from avoiding admission. Results31 patients were treated with dalbavancin for cellulitis in the ED or MAU. No patient was admitted within 30 days of receiving dalbavancin. Use of dalbavancin is estimated to have saved 248 bed-days over the study period, with an estimated saving of $120,444.23 based on avoidance of admission. The cost of dalbavancin for these 31 patients was $69,959.08, giving an overall cost saving of $50,485.15 ($1,529.95 per patient). ConclusionsPrescribing dalbavancin as first-line intravenous antibiotic for cellulitis prevents admission, saving bed-days and admission-related costs.

Snuffbox Versus Wrist Radiocephalic Arteriovenous Fistulas: 10 Years Experience.

Background The wrist radiocephalic arteriovenous fistula (RCAVF) is the initial suggested procedure for establishing hemodialysis vascular access (HVA) in the most distal site of the upper limb. The anatomical snuffbox arteriovenous fistula (SBAVF) is barely utilised, despite its remote location. In this study, we aimed to analyse and compare the results of SBAVF and RCAVF in terms of their maturity, patency, and failure rates. Methodology This descriptive, retrospective study compared outcomes between SBAVF and RCAVF in terms of maturation, patency, and failure. All patients with chronic kidney disease who attended and underwent either procedure at Betsi Cadwaladr University Health Board between 2013 and 2023 were studied. Results In a period of 10 years, 179 patients were included. Overall, 102 (57%) were male and 77 (43%) were female, with a male-to-female ratio of 1.3:1. Wrist radiocephalic fistula was the dominant type of surgery done in 76% (n = 136), while the snuffbox radiocephalic fistula was done in fewer than 24% (n = 43) of patients. Most patients underwent a successful arteriovenous (AV) fistula (n = 105, 58.7%), in contrast to 67 patients whose fistulas failed. There was a significant relationship between fistula failure and complications (p = 0.000). There was no significant effect of the fistula site, hypertension, diabetes, cardiac diseases, smoking, peripheral vascular disease, or central vein stenosis on the failure of the AV fistula (p = 0.127, 0.534, 0.510, 0.397, 0.017, 0.68, and 0.371, respectively). Conclusions The snuffbox AV fistula is a suitable and feasible first choice for patients on hemodynamic therapy.

Effect of Peri-Operative Blood Transfusion on Short and Long-Term Mortality Rates in Elderly Patients With Neck of Femur Fractures: A Retrospective Study.

Introduction The current reported mortality rate for elderly neck of femur fractures (eNOFF) is relatively high in the UK. eNOFF patients commonly suffer from associated cardiovascular co-morbidities and tend to have fragile physiological states and poor physiological reserves. Although some studies have shown a potential link between blood transfusion and mortality in eNOFF patients, there is no general consensus on this matter. Therefore, our study aims to explore the possible association between blood transfusion and length of hospital stay (LOHS) as well as short- and long-term mortality rates in eNOFF patients by reviewing the practice of blood transfusion. Methods This retrospective study was conducted at Wrexham Maelor Hospital, which is part of the Betsi Cadwaladr University Health Board (BCUHB), Wales. The study included patients who were 65 years of age or older and presented with neck of femur fractures. Only patients who required surgical intervention were included, and those managed non-operatively were excluded from the study. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, New York, United States).Furthermore, unpaired t-tests and log-rank (Mantel-Cox) tests were performed to compare the groups that received blood transfusions. Results During the study period, a total of 501 eNOFF patients were included in the primary cohort of the study, with a mean age of 81 years (ranging from 65 to 102). The majority of the patients were female (n=340). Of the 501 patients, 79 (15.8%) received a blood transfusion during their treatment.Around 52.9% of the eNOFF patients were categorized as American Society of Anesthesiologists (ASA) III, but there was no statistically significant difference in the requirement of blood transfusion between patients in ASA III, II, and IV categories, as compared to ASA I. Additionally, the mean time to surgery was higher in patients who received a blood transfusion (35.8 hours), and this difference was statistically significant (p=0.035). Moreover, the average LOHS after surgery for eNOFF was longer in patients who needed peri-operative blood transfusion (22 days), and this difference in the means was statistically significant (p=0.022).At the one-year post-surgery mark, mortality was higher in the transfused group (33%), and long-term five-year mortality rates were also higher in this group (63.2%). Conclusion Peri-operative blood transfusion may confer certain benefits in the management of eNOFF ptients. However, it should not be regarded as a panacea for improving long-term outcomes. The decision to administer blood transfusion must be made on a case-by-case basis, with careful assessment of individual clinical indications, and the potential risks and benefits taken into consideration. To achieve optimal clinical outcomes, close monitoring and follow-up of eNOFF patients, both in the short-term and long-term, are essential.

Pharmacist named one of Wales' 'changemakers' for work on healthcare sustainability

A pharmacist from Bangor in north Wales has been celebrated as one of 100 of the country’s ‘changemakers’, by Wales’ outgoing Future Generations commissioner. Yasmina Hamdaoui, pre-operative assessment pharmacist at Betsi Cadwaladr University Health Board (BCUHB), was recognised in the Future Generations Changemaker 100 list for her work on sustainability in healthcare. Hamdaoui and colleagues […]

Pharmacies report three-fold increase in patients seeking emergency medicine

Community pharmacies in North Wales saw a more than three-fold increase in patients seeking emergency medicine in December 2022, figures from a local health board show. In a press release from Betsi Cadwaladr University Health Board (BCUHB), published on 27 January 2023, the board said there had been a 345% increase in the number of […]

The "Right" to refuse treatment.

The "right" of an adult patient with capacity to refuse treatment has been very well recognized by the courts over the years. Recently, it was the central issue in this recent case, PH (by his litigation friend, the Official Solicitor) v Betsi Cadwaladr University Health Board ([2022] EWCOP 16). This paper briefly reviews the case and goes on to present the author's views on the general "right" to refuse treatment and the meaning of "right" in the expression, "the right to refuse treatment". It then points out other relevant matters worth noting.

INSIGHT: Evaluation of the Year Four Psychological Medicine Student Placements at HMP Berwyn, North Wales

AimsBackground: Although social determinants of health (SDOH) are to some extent incorporated within preclinical medical education, little validated educational methodology exists to provide guidance on how to integrate teaching about SDOH within the competency-based training of medical students’ clinical years. This is potentially important. The COVID-19 pandemic has highlighted the importance of SDOH, and social determinants have become topical, with increasing discussion in journals about equity, inequality, and sustainability. Sir Michael Marmot's 2020 review has highlighted these issues. Consequently, the evaluation of medical students’ experience of prison placements is an interesting area to investigate. This will help us to explore their understanding of SDOH, and implications of gained knowledge for their future practice. Aims: This study explores changes in year four psychological medicine students’ knowledge and attitude towards SDOH during prison placements.MethodsA mixed-methods study between Sep 2021 to Apr 2022 recruiting all year four medical students on their psychiatry placement in North Wales. Data collection involves baseline and mid-placement questionnaires and end-of-placement individual interviews to explore their understanding of SDOH.Thematic analysis will be used to describe students’ reflection on placement satisfaction; explore impacts on trainee doctors and supporting staff; make suggestions to improve placement structure in the future; and evaluate the utility of placements in prison.ResultsData collection is in progress. However, early indications suggest that students view these placements favourably and find them a helpful learning experience. Preliminary results will be reported at the conference.ConclusionWe are hopeful that this evaluation will suggest a way forward to raise awareness about SDOH during clinical placements and will give these students confidence in working with socially excluded populations in the future.Implication for practise, policy and researchFindings of this study may provide exploration of means of capacity building and training with improved knowledge of the SDOH in partnership between the medical school, the local health board and the prison.We have developed systems and processes to raise awareness of social factors to be considered by medical students in their future practice. These can guide further development of such placements at HMP Berwyn and in other prisons.This research was funded by Betsi Cadwaladr University Health Board and sponsored by Bangor University in North Wales, UK.

Audit of the quality and content of discharge summaries from mental health inpatient units across Betsi Cadwaladr University Health Board

AimsOur aim was to carry out an audit of summaries sent from inpatient psychiatric units across North Wales (namely Heddfan in Wrexham, Ablett in Rhyl, and Hergest in Bangor), against recommendations from ‘Standards for Inpatient Mental Health Services’ (RCPsych 2014) and PRSB Mental Health Discharge guidelines (2018).MethodAblett summaries are typed onto and electronically sent through the Welsh Clinical Portal (WCP) directly to the GP. Hergest and Heddfan both have their own templates which are then sent to the GP and filed in the case notes. Data were collected from both sources. The first audit cycle used 25 discharges selected at random from the male and female open wards in each site (n = 75 summaries). Data were collected over 3 months time using the audit proforma.ResultAll mandatory headings are automatically inputted into the WCP summary used in Ablett therefore documentation was 100% for information such as patient name, DOB, and GP Details. Documentation of allergies was poor across 3 sites, particularly in Hergest, in which there was no mention of allergy status in 96% of summaries. Only 13% of Ablett summaries and 0% of Hergest summaries reach the GP on the day of discharge, however, 100% of summaries from Heddfan do, possibly due to their method of ‘discharge notification’. The date and location of discharge were documented in 84% of Heddfan summaries, 100% of Hergest summaries, and 100% of Ablett summaries. This implies that this heading is already incorporated into the templates for the 2 sites which scored 100%. In the Ablett, medication was documented in 88%, but we found that in 49% of discharge summaries, the medication was the only field filled in! In these cases, the GP may not even know why the patient had been admitted. This is clearly unacceptable. Risk history is poorly documented across the sites, with 0% in Hergest and Heddfan, and 12% in Ablett. 0% of summaries across the Health Board mentioned crisis contacts. 0% of summaries in Heddfan and Ablett contained details of the patient's care coordinator.ConclusionOur audit has identified a lack of psychiatry-relevant headings in the discharge summaries, particularly for those working in Ablett.

Lack of community pharmacies commissioned for COVID-19 vaccinations is 'a ticking time bomb', say sector leaders

Four pharmacies in north Wales have begun vaccinating patients against COVID-19, amid warnings from sector leaders that the lack of pharmacy involvement in the programme is a “ticking time bomb”. The four pharmacies currently offering COVID-19 vaccinations are all from the Fferyllwyr Llŷn Cyf multiple in Betsi Cadwaladr University Health Board, Community Pharmacy Wales (CPW) […]

More than 30 community pharmacies in Wales now offer a COVID-19 vaccination service

Four health boards across Wales have commissioned more than 30 community pharmacies to provide COVID-19 vaccinations, nearly double the number reported by The Pharmaceutical Journal in April 2021. As of 29 November 2021, Aneurin Bevan University Health Board, Betsi Cadwaladr University Health Board, Cardiff and Vale University Health Board and Swansea Bay University Health Board said […]

JPO Editor's Comments

Independent Paediatric Physiotherapist (Formerly Superintendent and Clinical Specialist Paediatric Physiotherapist at Child Development Centre), Betsi Cadwaladr University Health Board, Bangor, Gwynedd, United Kingdom [email protected] Disclosure: The author declares no conflict of interest. Author states no funding was received.

Prescribing trends over time by non-medical independent prescribers in primary care settings across Wales (2011–2018): a secondary database analysis

IntroductionAs of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary...

Evaluation of a Framework for Safe and Appropriate Prescribing of Psychoactive Medications in Prison

Background: The widespread use of drugs in prisons leads to avoidable deaths and a poor living environment. The contribution of psychoactive prescription drugs to this problem has received little attention in prison policy and at individual prescriber level. To the best of our knowledge this is the first study to evaluate a framework for safe and appropriate prescribing of psychoactive prescription drugs in a prison setting. Methods: A medicines optimisation framework was developed based on principles of good prescribing. It was initiated on the opening of HMP Berwyn in February 2017. During the study period, all prisoners at HMP Berwyn were transferred from other prisons. The safety and appropriateness of psychoactive medications were evaluated de novo on reception at HMP Berwyn and during follow up, using the medicine optimisation framework. Data was collected retrospectively from the online prison database. Key outcomes were proportion of unsafe and inappropriate prescriptions. Findings: 1941 men arrived at HMP Berwyn between February 2017 and December 2018. 32·6% (634/1941) were on a prescribed psychoactive medication. Overall 75·2% (477/634) required a prescription change due to appropriateness or safety concerns. 46·5% (295/634) received changes at reception despite having already undergone medicines reconciliation at their previous prison. 43·7% (277/634) received changes at follow up, most commonly in those who had no prior risks identified at reception. Interpretation: Inappropriate and unsafe prescribing of psychoactive medications is occurring in prisons despite mandatory medication reviews. Ongoing monitoring is required to reduce the risk from these medications. A medicines optimisation framework such as this could be adopted across other prisons in England and Wales to help contribute to risk reduction from drug use in prisons. Appropriately modified, a similar framework might help reduce inappropriate and harmful prescribing in hospitals and in the community. Funding Statement: Betsi Cadwaldr University Health Board. Declaration of Interests: Dr. Bebbington reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Dr. Lawson reports I contributed to the design of the medicines optimisation framework, completed some of the drug reviews, and completed data collection. I am the Medical Director of Gables Medical (Offender Health) Ltd which is contracted to provide primary care services to HMP Berwyn. Dr. Nafees reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Prof. Robinson reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Prof. Poole reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Ethics Approval Statement: As this study uses an anonymised routinely collected dataset, the Betsi Cadwaldr University Health Board (BCUHB) (NHS) research and development department recommend that the project is exempt from ethics approval. This project is registered with the BCUHB Clinical Audit and Effectiveness office.

12 Month Review Of Lipid / Cholesterol Testing Throughout North Wales (Betsi Cadwaladr University Health Board) – An Adjunct For Familial Hypercholesterolaemia (Fh) Case Finding

12 Month Review Of Lipid / Cholesterol Testing Throughout North Wales (Betsi Cadwaladr University Health Board) – An Adjunct For Familial Hypercholesterolaemia (Fh) Case Finding

Predicting psychosis admission rates in Wales using neighbourhood deprivation

BackgroundSocioeconomic deprivation has been identified as a risk factor for psychosis and admission rates for psychosis are higher in deprived areas than more affluent areas. However, social gradients exist in many mental health conditions and it is unclear if this relationship is particularly important for psychosis.
 ObjectivesThe present study assesses whether there is a stronger relationship between the socioeconomic deprivation of an area and its rate of psychiatric admissions for psychosis than there is for other mental health diagnoses.
 MethodsWe linked a large dataset of routinely recorded psychiatric admissions from the Welsh National Health Service to small area indices of socio-economic deprivation (the Welsh Index of Multiple Deprivation). Poisson generalised linear mixed effects models were applied to stratified admission count data to test whether the relationship between deprivation and admission rates was stronger for psychosis admissions than for non-psychosis admissions. Data from Betsi Cadwaladr University Health Board (19,437 patients) were used as a discovery sample and an analysis protocol was pre-registered before being applied to data from the rest of Wales (116,641 patients).
 FindingsIn both samples, admission rates were higher in more deprived areas. In the discovery sample, this relationship was stronger for psychosis admissions than for other types of admission. However, in the larger replication dataset, this was not the case and the social gradient in admissions was equivalently steep for the two diagnosis categories.
 ConclusionsAlthough socio-economic deprivation was a risk factor for admission with psychosis, it is not a stronger risk factor for psychosis than for other psychiatric categories. Theoretical accounts of the relationship between psychosis and poverty should focus on factors common across mental health, rather than factors specific to psychosis.

Hip fracture in the elderly multidisciplinary rehabilitation (FEMuR) feasibility study: testing the use of routinely collected data for future health economic evaluations

BackgroundHealth economic evaluations rely on the accurate measurement of health service resource use in order to calculate costs. These are usually measured with patient completed questionnaires using instruments such as the Client Service Receipt Inventory (CSRI). These rely on participants’ recall and can be burdensome to complete. Health service activity data are routinely captured by electronic databases.The aim was to test methods for obtaining these data and compare with those data collected using the CSRI, within a feasibility study of an enhanced rehabilitation intervention following hip fracture (Fracture in the Elderly Multidisciplinary Rehabilitation: FEMuR).MethodsPrimary care activity including prescribing data was obtained from the Secure Anonymised Information Linkage (SAIL) Databank and secondary care activity (Emergency Department attendances, out-patient visits and in-patient days) directly from Betsi Cadwaladr University Health Board (BCUHB), North Wales, UK. These data were compared with patient responses from the CSRI using descriptive statistics and the intraclass correlation coefficient (ICC).ResultsIt was possible to compare health service resource use data for 49 out of 61 participants in the FEMuR study. For emergency department (ED) attendances, records matched in 23 (47%) cases, 21 (43%) over-reported on electronic records compared with CSRI and five participants (10%) under-reported, with an overall ICC of 0.42. For out-patient episodes, records matched in only six cases, 28 participants over-reported on electronic records compared with CSRI and 15 (12%) under-reported, with an overall ICC of only 0.27. For in-patient days, records matched exactly in only five cases (10%), but if an error margin of 7 days was allowed, then agreement rose to 39 (66%) cases, and the overall ICC for all data was 0.88.It was only possible to compare prescribing data for 12 participants. For prescribing data, the SAIL data reported 117 out of 118 items (99%) and the CSRI only 89 (79%) items.ConclusionsThe use of routinely collected data has the potential to improve the efficiency of trials and other studies. Although the methodology to make the data available has been demonstrated, the data obtained was incomplete and the validity of using this method remains to be demonstrated.Trial registrationTrial registration: ISRCTN22464643 Registered 21 July 2014.

Utilizing an automated patient contact notification service/high LDL alert system – following secondary care/hospital attendance in north Wales (Betsi Cadwaladr University Health Board) – a 12 month review

Utilizing an automated patient contact notification service/high LDL alert system – following secondary care/hospital attendance in north Wales (Betsi Cadwaladr University Health Board) – a 12 month review

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR).

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking. To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation. Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study. Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge. Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area. Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions. The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers. Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported. Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure. Current Controlled Trials ISRCTN22464643. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Improving Care for Bariatric Dental Patients in North Wales.

This paper presents the experiences of Betsi Cadwaladr University Health Board, North Wales, UK in improving facilities, access and quality of care for bariatric dental patients. It includes the multi-stakeholder audit of existing practice which informed those improvements. Public health competencies illustrated: needs assessment; development and implementation of oral health strategies; oral health improvement; development of clinical pathways; improving patient safety; clinical and public engagement; addressing inequalities.

HCA award winner's passion and enthusiasm shine through.

A healthcare assistant who significantly improved care for people with learning disabilities through an individualised, gentler approach to taking blood has been recognised with a prestigious RCNi Nurse Award. Cemlyn Roberts, who works for Betsi Cadwaladr University Health Board in Wales, won the RCN Healthcare Assistant award category.