English National Health Service Trusts Research Articles

Complications and Healthcare Costs Associated With the First Year Following Colostomy and Ileostomy Formation: A Retrospective Study.

The purpose of this study was to evaluate clinical and economic outcomes during the first year following ostomy formation. Single-center retrospective audit. The sample comprised 200 patients who underwent surgery leading to ileostomy or colostomy at a large English National Health Service (NHS) Trust. Clinical complications, medicine prescriptions, and interactions with healthcare services were reported over 12 months postsurgery, and interactions with the NHS were matched to the closest NHS unit cost to determine mean patient cost. The most common ostomy-related surgical site complications were high output (35.0%; n = 70), followed by moderate/severe peristomal skin complications (24.5%; n = 49) and bleeding (23.5%; n = 47). Ostomy management-related complications included general difficulties with ostomy management (50.0%; n = 100) and leakage-related mild peristomal skin issues (48.5%; n = 97). Clinical complication rates were highest in the first quarter following ostomy formation, except parastomal hernia, which increased in incidence over time. Ileostomy patients more frequently experienced high output, acute renal failure, and ostomy management-related complications and had increased length of inpatient admission. However, healthcare resource use was high in both groups, with a median of 13 inpatient admission days and 12 outpatient contacts overall within the first year. Mean cost per patient was £20,444.60 (US $26,018.41); 90.5% of these costs were attributed to ostomy-related factors. Patients are likely to experience at least one clinical complication following intestinal ostomy formation and have multiple interactions with the NHS. While a number of complications are more frequent in patients with ileostomies, both groups experienced considerable costs within the first year following surgery associated with ostomy management and recovery.

Pharmaceutical industry payments to NHS trusts in England: A four-year analysis of the Disclosure UK database.

Although hospitals are key health service providers, their financial ties to drug companies are little understood. We examine non-research pharmaceutical industry payments to English National Health Service (NHS) trusts-hospital groupings providing secondary and tertiary care. We extracted data from the industry-run Disclosure UK database, analysing it descriptively and using the Jonckheere-Terpstra test to establish whether a statistically significant time trend existed in the median values of individual payments. We explained payment value and number per trust with random effects models, using selected trust characteristics as predictors. Drug companies reported paying £60,253,421 to 234 trusts, representing between 90.0% and 92.0% of all trusts in England between 2015 and 2018. As a share of payments to all healthcare organisations, the number of payments rose from 38.6% to 39.5%, but their value dropped from 33.0% to 23.6%. The number of payments for fees for service and consultancy and contributions to costs of events increased by 61.5% and 29.4%. The median payment value decreased significantly for trusts overall (from £2,250.8 to £1,758.5), including those with lower autonomy from central government; providing acute services; and from half of England's regions. The random effects model showed that acute trusts received significantly more money on average than trusts with all other service profiles; and trusts from East England received significantly less than those from London. However, trusts enjoying greater autonomy from government did not receive significantly more money than others. Trusts also received significantly less money in 2018 than in 2015. NHS trusts had extensive pharmaceutical industry ties but were losing importance as payment targets relative to other healthcare organisations. Industry payment strategies shifted towards events sponsorship, consultancies, and smaller payments. Trusts with specific service and geographical profiles were prioritised. Understanding corporate payments across the health system requires more granular disclosure data.

A survey and stakeholder consultation of Independent Domestic Violence Advisor (IDVA) programmes in English maternity services

BackgroundHealthcare-based Independent Domestic Violence Advisors (hIDVA) are evidence-based programmes that provide emotional and practical support to service users experiencing domestic abuse. hIDVA programmes are found to improve health outcomes for service users and are increasingly delivered across a range of healthcare settings. However, it is unclear how hIDVA programmes are implemented across maternity services and the key facilitators and barriers to their implementation. The aim of this study was to identify; how many English National Health Service (NHS) Trusts with maternity services have a hIDVA programme; which departments within the Trust they operate in; what format, content, and variation in hIDVA programmes exist; and key facilitators and barriers of implementation in maternity services.MethodsA national survey of safeguarding midwives (Midwives whose role specifically tasks them to protect pregnant women from harm including physical, emotional, sexual and financial harm and neglect) within all maternity services across England; descriptive statistics were used to summarise responses. A World Café event (a participatory method, which aims to create a café atmosphere to facilitate informal conversation) with 38 national key stakeholders to examine barriers and facilitators to hIDVA programme implementation.Results86/124 Trusts (69%) with a maternity service responded to the survey; 59(69%) of respondents reported that they had a hIDVA programme, and 47(55%) of the hIDVA programmes operated within maternity services. Key facilitators to implementation of hIDVA programmes included training of NHS staff about the hIDVA role and regular communication between Trust staff and hIDVA staff; hIDVA staff working directly from the Trust; co-creation of hIDVA programmes with experts by experience; governance and middle- and senior-management support. Key barriers included hIDVA staff having a lack of access to a private space for their work, insecure funding for hIDVA programmes and issues with recruitment and retention of hIDVA staff.ConclusionsDespite hIDVA programmes role in improving the health outcomes of service users experiencing domestic abuse, increased funding and staff training is needed to successfully implement hIDVA staff in maternity services. Integrated Care Board commissioning of acute and mental health trust services would benefit from ensuring hIDVA programmes and clinician DVA training are prioritised.

Prevalence of electronic screening for sepsis in National Health Service acute hospitals in England

Sepsis is a worldwide public health problem. Rapid identification is associated with improved patient outcomes—if followed by timely appropriate treatment.ObjectivesDescribe digital sepsis alerts (DSAs) in use in English National Health...

A qualitative study exploring the influence of a talent management initiative on registered nurses' retention intentions.

The aim of this study is to explore the influence of a talent management scheme in an English National Health Service (NHS) Trust on registered nurses' retention intentions. The retention of nurses is a global challenge, and talent management initiatives can play a role in improving retention. Talent management in its broadest sense is a way in which an organization recruits and retains the workforce that it needs to optimize the services it delivers. In this qualitative study, eight in-depth semi-structured interviews were conducted with registered nurses who had participated in a talent management initiative, at an English acute NHS Trust. Data were collected in July 2019. The talent management initiative influenced positive retention intentions. Retention of nurses was facilitated by the creation of networks and networking. Networks and networking can be viewed as a form of social capital, which was a facilitating factor for positive retention intentions for nurses. Talent management initiatives for nurses should be developed and directed to include the building of networks and networking to enable development of social capital. Although this talent management scheme is within the NHS, the issue of nursing retention is global. Application of learning from this paper to other health care systems is possible.

Smoking Cessation Support for Pregnant Women Provided by English Stop Smoking Services and National Health Service Trusts: A Survey.

Reducing smoking rates in pregnancy continues to be a public health priority. Given a recent UK government policy change resulting in The National Health Service (NHS) making a significant new contribution to cessation support in pregnancy in England, in addition to that of Local Authorities (LA), an up-to-date assessment of national support offered to pregnant women is needed. LA Stop Smoking Service (SSS) managers and representatives from maternity services in NHS Trusts were invited to participate in an online survey in autumn 2020. Topics included service configuration, staffing, practitioner consultations and treatments offered. The survey response rate was 66% (99/151) of LAs and 68% (95/140) of Trusts. Most LAs provided smoking support for pregnant smokers (78%), whereas under half (43%) of NHS Trusts did. Combination nicotine replacement therapy, i.e., a combination of a patch and short-acting product, was offered by LAs (92%) and Trusts (95%) and most commonly for 12 weeks duration, at 53% and 50%, respectively. Similar national online training was undertaken by those supporting women, with the majority undertaking the specialist pregnancy-specific module: LAs 60% and Trusts 79%. However, clinicians were reported to deliver specialist stop smoking support in over 50% of Trusts, whereas this was reported in only 16% of LAs. In England, both LA and NHS Trusts are currently delivering similar stop smoking support to pregnant women. Having nationally recognised treatment programmes and training allows for the delivery of consistent, evidence-based smoking cessation to pregnant women in different healthcare settings.

Airborne protection for staff is associated with reduced hospital-acquired COVID-19 in English NHS trusts

IntroductionThe rate of hospital-acquired coronavirus disease 2019 has reduced from 14.3% to 4.2% over the last year, but substantial differences still exist between English National Health Service (NHS) hospital trusts.MethodsThis study assessed rates of hospital-acquired infection (HAI), comparing NHS hospital trusts using airborne respiratory protection (e.g. FFP3 masks) for all staff, as a marker of measures to reduce airborne spread, with NHS hospital trusts using mainly droplet precautions (e.g. surgical masks).Results/discussionThe use of respiratory protective equipment was associated with a 33% reduction in the odds of HAI in the Delta wave, and a 21% reduction in the odds of HAI in the Alpha wave (P<0.00001). It is recommended that all hospitals should prioritize airborne mitigation.

Improving mental health care transitions through information capture during admission to inpatient mental health services: a quality improvement study

BackgroundMany interventions aim to improve the transition from ward to community at the time of discharge, with varying success. Guidelines suggest that discharge planning should begin at admission, but in reality this is ideal rather than standard practice. We aimed to develop a novel information capture tool during admission that facilitates and accelerates discharge.MethodsA quality improvement study to develop, implement and evaluate a novel tool that improves information capture upon admission to acute mental health wards within a single English National Health Service (NHS) trust. We developed the tool by synthesising existing evidence and working with multi-agency and multi-disciplinary professionals in two co-design workshops. During implementation the tool was piloted on three wards. Ethnographic observations (145 h) and interviews (45) were used to evaluate the implementation of the tool across the three wards. Thematic synthesis was used to consolidate the findings.ResultsThe tool developed considerably as the process evolved. The finished product is a list of 10 information categories that should be captured from external agencies upon admission to hospital to facilitate discharge planning to community settings. Reported advantages of the tool were: (1) facilitating confidence in junior staff to legitimately question the suitability of a patient for an acute ward (2) collecting and storing essential information in a single accessible place that can be used throughout the care pathway and (3) collecting information from the services/agencies to which patients will eventually be discharged.ConclusionsImproving the quality of information at admission has the potential to facilitate and accelerate discharge. The novel tool provides a framework for capturing this information that can be incorporated into existing information systems. However, the introduction of the tool exacerbated complex, fragile distributed team dynamics, highlighting the importance of sociocultural context in information flow transitional interventions within distributed teams.

Serious incidents in testicular torsion management in England, 2007–2019: optimizing individual and training factors are the key to improved outcomes

To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and 'near misses'. The secondary objective was to identify areas suitable for impactful quality improvement initiatives to be undertaken by National Health Service (NHS) healthcare providers nationally. This was a retrospective record review and analysis, carried out in four phases. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12-year period to the Strategic Executive Information System database. Clinical reviewers established the incident population (Phase 1), were trained and piloted the feasibility of using the London Protocol (Phase 2), applied the protocol and themed the identified contributing factors linked to adverse events (orchidectomies) and near-misses (Phase 3), and reviewed the evidence for improvement interventions (Phase 4). Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were near misses. Factors contributing to all incidents were: individual staff/training (38%); team (18%); work environment (16%); task and technology (14%); and institutional context (13%). Subgroup analysis of incidents resulting in orchidectomies vs near misses demonstrated a different pattern of factors, with individual staff/training factors significantly more prominent: individual/training (88%); work environment (8%); and task and technology (1%). No evidenced improvement interventions were found in the literature. This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near-miss incidents in patients presenting with testicular torsion. In England, a significant number of orchidectomies occur annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and (in the longer term) more exposure of trainees and medical students to urology to improve the testicular salvage rate.

The Role of Maternity Services in Reducing the Prevalence and Cost of Perinatal Depression and Anxiety during COVID-19 in England

In 2020 the novel coronavirus outbreak (COVID-19) was declared a global pandemic. Pregnant women have been recognised as a group specifically at risk during this time due to the impact that the COVID-19 infection may have on the health of the birthing person and the unknown impact of vertical transmission to the fetus. Pregnant women also have a recognised risk of perinatal mental health problems including depression and anxiety. The aim of this paper is to summarise the impact of the COVID-19 pandemic and associated infection control measures on perinatal depression and anxiety in England, the cost of the additional impact and the role of English National Health Service (NHS) trusts and maternity services in reducing the impact and cost. Studies including systematic reviews and meta-analyses have found a 3 to 5 fold increase in perinatal depression and anxiety during the COVID-19 pandemic compared to non-pandemic times. This increased prevalence, if also seen in England, is at a potential cost to society of £10.6 billion for depression and £6.9 billion for anxiety, including a cost to the health care sector of £649 million and £1.7 billion respectively. Health care Trusts and maternity services have an important role to play in reducing this cost, not just in providing maternity care, but also in monitoring the health of the population and referring onwards where needed. Modest improvements in the availability of social support including improved partner involvement during pregnancy and labour and support given by health care staff during maternity care have the potential to reduce the risk of perinatal depression and anxiety. Signposting to and provision of perinatal mental health services, particularly for women at risk, is also likely improve outcomes for birthing people and their infants and hence to reduce the total cost to society of perinatal mental health problems.

A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery

BackgroundRandomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes.MethodsA cross-sectional questionnaire was administered to surgeons and nurses in August–October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013–15.Results218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management.ConclusionsStandardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

Implementation of high-throughput non-invasive prenatal testing for fetal RHD genotype testing in England: Results of a cross-sectional survey of maternity units and expert interviews.

BackgroundPreviously, routine antenatal anti‐D prophylaxis (RAADP) was administered to all RhD‐negative mothers to reduce the risk of sensitisation in the UK's National Health Service (NHS). If the baby is RhD‐negative, RAADP is not required. In 2016, the UK National Institute for Health and Care Excellence (NICE) recommended non‐invasive prenatal testing (NIPT) for fetal RHD genotype as a cost‐effective option to guide RAADP.ObjectivesTo evaluate the implementation of high‐throughput NIPT for fetal RHD genotype in maternity units in England by addressing research recommendations from the NICE. These were to reduce uncertainty around the resource use and cost of staff training, management of samples and results and record‐keeping, as well as resultant changes to antenatal or post‐partum care and performance of NIPT.MethodsA cross‐sectional survey was developed and sent to clinicians at 39 English NHS Trusts in May 2018. Qualitative interviews with seven individuals were conducted to explore missing or contraindicatory data. Qualitative findings were supplemented with NIPT test results (April 2017 to February 2019) from English hospitals.ResultsStaff reported that training took up to 30 minutes. There were no extra costs associated with sample management or additional appointments. Extra time required for record‐keeping and management of test results was balanced later in the patient pathway. The antenatal pathway was not changed in the Trusts surveyed. The survey revealed that four post‐partum scenarios were being used within English NHS Trusts. The frequency of inconclusive NIPT results was 4.3%.ConclusionNIPT for fetal RHD genotype can be implemented without consuming substantial extra resources through incorporation into an existing patient pathway.

A 16-year Longitudinal Cohort Study of Incidence and Bacteriology of Necrotising Fasciitis in England

BackgroundNecrotising fasciitis (NF) is a rapidly progressive, destructive soft tissue infection with high mortality. The primary aim of this study was to evaluate the incidence and mortality of NF amongst patients admitted to English National Health Service (NHS) hospitals. The secondary aims included the identification of risk factors for mortality and causative pathogens.MethodsThe Hospital Episodes Statistics database identified patients with NF admitted to English NHS Trusts from 1/1/2002 to 31/12/2017. Information on patient demographics, co-morbid conditions, microbiology specimens, surgical intervention and in-hospital mortality was collected. Uni- and multivariable analyses were performed to investigate factors related to in-hospital mortality.ResultsA total of 11,042 patients were diagnosed with NF. Age-standardised incidence rose from 9 per million in 2002 to 21 per million in 2017 (annual percentage change = 6.9%). Incidence increased with age and was higher in men. Age-standardised mortality rate remained at 16% over the study period, while in-hospital mortality declined. On multivariable analysis, the following factors were associated with increased risk of in-hospital mortality: emergency admission, female sex, history of congestive heart failure, peripheral vascular disease, chronic kidney disease and cancer. Admission year and diabetes, which was significantly prevalent at 27%, were not associated with increased risk of mortality. Gram-positive pathogens, particularly Staphylococci, decreased over the study period with a corresponding increase in Gram-negative pathogens, predominantly E. coli.ConclusionThe incidence of NF increased markedly from 2002 to 2017 although in-hospital mortality did not change. There was a gradual shift in the causative organisms from Gram-positive to Gram-negative.

Perceived stress and professional quality of life in nursing staff: How important is psychological flexibility?

ObjectivesNurses are at high risk of chronic stress. Tailored, evidence-based stress-management interventions may minimise absenteeism and staff turnover, whilst at the same time promoting good quality patient care. Current literature for nurse-focused stress-management interventions is varied in quality, with little focus on data-driven intervention development. This study explores how process measures related to Acceptance and Commitment Training (ACT) are associated with perceived stress and professional quality of life in nurses, in order to guide intervention development. DesignA cross-sectional, online psychometric survey was implemented using LimeSurvey software. MethodsOne-hundred and forty-two nurses were recruited from various specialties across four English National Health Service (NHS) Trusts. Questionnaires assessed demographic and work-related sample characteristics, ACT processes (mindfulness, acceptance, cognitive defusion, self-as-context, values and committed action), and four work-related wellbeing outcomes (perceived stress, burnout, compassion fatigue and compassion satisfaction). Correlation and regression models were used to analyse data. ResultsAll six ACT processes negatively correlated with perceived stress, burnout and compassion fatigue, and positively correlated with compassion satisfaction (all p < .05). In regression models, these same processes explained significant variance for all outcomes (R2 range = 0.36-0.61), above and beyond that explained by socio-demographic and work-related factors. Acceptance (β range: -.25 to -.55), mindfulness (β range: -.25 to -.39), and values-based processes (β range: -.21 to -.36) were frequent independent contributors to work-related wellbeing. ConclusionsThis study demonstrates that the ACT framework provides a promising platform from which to develop nurse-focused stress-management interventions. Interventions focusing on acceptance, mindfulness, and values-linked processes may be most effective.

Adherence to antibiotic guidelines and reported penicillin allergy: pooled cohort data on prescribing and allergy documentation from two English National Health Service (NHS) trusts.

ObjectiveTo investigate documentation of antimicrobial allergy and to determine prescribing adherence to local antibiotic guidelines for inpatients with and without reported penicillin allergy treated for infection in a National Health Service (NHS) context.SettingData were collected at two English hospital NHS trusts over two time-periods: June 2016 and February 2017.DesignCohort study. Trust 1 data were sourced from prospective point prevalence surveys. Trust 2 data were extracted retrospectively from an electronic report.ParticipantsInpatients treated for urinary tract infection (UTI), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and skin and soft tissue infection (SSTI). Data on allergy were collected, and antibiotic selection assessed for adherence to trust guidelines with differences between groups presented as adjusted ORs.ResultsA total of 1497 patients were included, with 2645 antibiotics orders. Patients were treated for CAP (n=495; 33.1%), UTI (407; 27.2%), HAP (330; 22%) and SSTI (265; 17.7%). There were 240 (16%) patients with penicillin allergy. Penicillin allergy was recorded as allergy (n=52; 21.7%), side effect (27; 11.3%) and no documentation (161; 67.1%). Overall, 2184 (82.6%) antibiotic orders were guideline-adherent. Adherence was greatest for those labelled penicillin allergy (453 of 517; 87.6%) versus no allergy (1731 of 2128; 81.3%) (OR 0.52 (95% CI 0.37 to 0.73) p<0.001). Guideline-adherence for CAP was higher if penicillin allergy (151 of 163; 92.6%) versus no allergy (582 of 810; 71.9%) (OR 0.20 (95% CI 0.10 to 0.37) p<0.001). There was no difference in adherence between those with and without penicillin allergy for UTI, HAP or SSTI treatment.ConclusionsA relatively high proportion of patients had a penicillin allergy and two thirds of these had no description of their allergy, which has important implications for patient safety. Patients with penicillin allergy treated for CAP, received more guideline adherent antibiotics than those without allergy. Future studies investigating the clinical impact of penicillin allergy should include data on adherence to antibiotic guidelines.

Financial performance of English NHS trusts and variation in clinical outcomes: a longitudinal observational study

ObjectivesTo examine the association between financial performance as measured by operating margin (surplus/deficit as a proportion of turnover) and clinical outcomes in English National Health Service (NHS) trusts.SettingLongitudinal, observational study...

Processes in an Experience-Based Co-Design Project With Family Carers in Community Mental Health

Experience-based co-design (EBCD) is a service design strategy that facilitates collaborative work between professional staff and service users toward common goals. There is a lack of published examples of it in relation to family carer engagement within a mental health context, and little research exploring the mechanisms behind successful implementation. The aim of this study was to explore the processes that facilitated EBCD with carer involvement. The study adopted a grounded theory–informed approach involving interviews with 16 participants of an existing EBCD project in an English National Health Service (NHS) trust, reflecting multiple stakeholders. EBCD can be thrown off track in two ways: conflict and getting “bogged down.” Leadership by project and design-group leaders could return group cohesion and maintain project momentum. The developed model reflects key processes. Future research should examine EBCD projects with similar ranges of stakeholders and in contexts with different levels of organizational change.

What role could further implementation of ERAS across elective orthopaedic and spinal procedures play in helping to ease the current NHS capacity challenges?

Objectives: The National Health Service (NHS) in England is currently under severe capacity and economic pressures. Within acute NHS hospitals, the demand for beds from emergency admissions is resulting in increased waiting times and cancellations of non-urgent surgical operations, such as orthopaedic and spinal procedures. Enhanced Recovery after Surgery (ERAS) has been proven to reduce length of stay across a range of orthopaedic procedures. This analysis aimed to assess the extent to which the further implementation of ERAS could affect bed capacity on a national scale. Methods: Data on average length of stay (LOS) for elective (non-trauma) orthopaedic and spinal procedures were analysed from 131 English NHS trusts over the last available 12 months (October 2016-September 2017) using hospital episode statistics (HES) sourced from Dr Foster. Procedures were organised through Office of Population Censuses and Surveys (OPCS) classification of intervention and procedures codes (OPCS-4). A Pareto analysis was undertaken to understand which procedures have the greatest impact on LOS and demand for hospital beds. This was further analysed by removing day case surgeries and then stratifying LOS by number of days stay. Results: 598,823 surgical procedures were analysed. 376,690 procedures were removed due to being day cases and then the following 97,884 stayed 1-2 days, 68,655 stayed 3-4 days and 55,594 stayed longer than 5 days. Of the 55,594 procedures who stayed more than 5 days, 80% of these cases were total hip replacement (THR), total knee replacement (TKR), total shoulder replacement (TSR), total ankle replacement (TAR), revision total hip replacement (REV THR), revision total knee replacement (REV TKR) and lumbar spinal procedures. A conservative estimate of reducing all procedures over 3 days by one day would result in 124,249 days bed saving per year across the NHS, or 948 bed days per hospital. Conclusion: The procedures that make up 80% of all elective orthopaedic and spinal surgeries where patients stay in hospital for longer than three days should be a priority for future ERAS implementation. Application of ERAS principles to these procedures is feasible and safe. Reducing LOS in these procedures may have a considerable benefit to the capacity and financial problems that the NHS is currently facing.

Is ERAS now the routine standard care in English NHS Hospitals for total hip replacement and total knee replacement?

Objectives: For total hip replacement (THR) and total knee replacement (TKR), Enhanced Recovery after Surgery (ERAS) pathways have reduced length of stay (LOS) to 1-3 days for unselected patients and outpatient surgery is possible. Although the evidence base supports routine 1-3 day discharge, we hypothesise that this is not a reality for most National Health Service (NHS) patients. The NHS has considerable economic and capacity challenges. Reducing LOS for high volume procedures in line with published best practice could provide highly significant efficiency benefits. We aimed to assess if ERAS is now the routine standard care in English NHS hospitals for THR and TKR by using LOS as a proxy indicator. Methods: Data on average LOS following THR and TKR were analysed from 131 English NHS trusts from Oct 2016-Sept 2017 using hospital episode statistics sourced via Dr Foster. The relative risk (RR) of a long LOS was calculated, which considers contributing exposure factors to staying longer than expected in hospital. Results: 52,271 THR and 62,666 TKR superspells were analysed. Mean national LOS for the 12 months analysed was 4.81 for THR and 4.77 for TKR. There was wide variation in the RR of patients having a long LOS across providers. The mean national RR of a long LOS for THR was 115.31 (range 44.74-273.45), which is significantly higher than the benchmark of 100. 17 trusts have a significantly lower number of long stay patients compared to 50 trusts with a higher number of long stay patients than expected. The mean national RR of a long LOS for TKR was 120.38 (range 46.11–258.04), which is significantly higher than the benchmark of 100. 15 trusts have a significantly lower number of long stay patients compared to 55 trusts with a higher number of long stay patients than expected. Conclusion: Mean LOS for both THR and TKR is appreciably greater in NHS hospitals than reported in the ERAS literature. There is a wide variation in the case-mix adjusted RR of a long LOS across trusts. This demonstrates that exemplar sites exist and are achieving outcomes in line with ERAS literature; however this is not a reality across the majority of trusts. As the data is case-mix adjusted and there is a wealth of evidence and clinical expertise in ERAS, it is likely that either external catalysts or a more strategic national implementation of best-practice is required for quality improvement to occur. Disclosure of Interest: None declared.

Complex regional pain syndrome acute care pathways in England: Do they exist and what do they look like?

Introduction Complex Regional Pain Syndrome is a condition with a high degree of morbidity and health costs to the National Health Service (NHS), characterised by persistent pain, sensory, motor, trophic and autonomic signs and symptoms. The British Orthopaedic Association (BOA) and the Royal College of Physicians (RCP) have recommended treatment guidelines and care pathways for the management of acute Complex Regional Pain Syndrome. The objective of this scoping exercise was to use Freedom of Information (FOI) requests to ascertain whether NHS Trusts in England had such pathways and what they looked like. Methods FOI requests were sent to 126 English NHS Trusts on 9 March 2017 on behalf of the Complex Regional Pain Syndrome Clinical and Research Network UK, asking: “What does your acute Complex Regional Pain Care Syndrome pathway look like?” Results Replies were received by 95 NHS Trusts and of these 84 had relevant services but (82%) had no pathway or agreed initial management. Conclusions It appears to be common for no acute care pathway to exist for CRPS in NHS Trusts in England despite it being a domain in BOA national guidelines. The Royal College of Physicians guidelines also recommend integrated MDT care. Consequentially, BOA and Royal College of Physicians standards in acute CRPS management are not yet being followed in most acute NHS Trusts in England providing trauma care. Where there is a pathway agreed, it is rarely integrated and truly multidisciplinary.