National Health Service Foundation Trust Research Articles

Reducing Surgical Site Infections in Neurosurgery During the Intra-operative Phase: An Audit of National Institute for Health and Care Excellence (NICE) Guideline Adherence at a Major Trauma Centre.

Surgical site infections (SSIs) pose significant risks to patient safety and healthcare systems globally despite preventive measures. This study audits compliance with the National Institute for Health and Care Excellence (NICE) guidelines for SSI prevention during the intra-operative phase in the Neurosurgery Department at Salford Royal National Health Service (NHS) Foundation Trust. Conducted in two audit cycles from October 2022 to October 2023, the study assessed adherence to 19 key parameters aimed at minimising SSIs. Significant improvements were observed in various areas, including antibiotic prophylaxis information (from 44% to 90%) and bodywash compliance (from 14% to 80%). Compliance with skin preparation protocols also showed marked progress, with antiseptic application time improving from 12% to 80%. However, areas such as double gloving (increased from 36% to 44%) and the use of antimicrobial sutures (from 2% to 30%) indicate opportunities for further enhancement. The findings underscore the effectiveness of targeted interventions and the importance of continuous education and evaluation of surgical practices to reduce SSIs, ultimately improving patient outcomes and alleviating financial burdens on the NHS. Future audits are recommended to ensure sustained compliance and quality of care in Neurosurgery.

Corporate governance and financial performance: the case of English NHS hospitals

PurposeHospitals’ corporate governance (CG) mechanisms oversee critical operational issues and evaluate the outcomes. This paper investigates the impact of CG (i.e. board size, board independence, board expertise, board meetings, board gender diversity, CEO gender, and academic directors) on the financial performance of English National Health Service (NHS) hospitals and separately by hospital type (i.e. trusts and foundation trusts).Design/methodology/approachThe sample includes 128 NHS hospitals. The data were collected through document analysis and archival work from annual hospital reports from 2014 to 2018.FindingsThe findings indicate that board expertise, board meetings, board diversity, CEO gender, and academic directors significantly and negatively affect NHS hospitals’ financial performance. For NHS trusts, the results reveal that board expertise, board diversity, and CEO gender have a significant negative effect, while for NHS foundation trusts, only CEO gender has a significant negative impact.Originality/valueOverall, this study contributes to the literature on the healthcare system. It holds significant practical implications for hospital governance and has important implications for theories.

A Cross-Sectional Evaluation of the Virtual Outpatient Management of People With Mpox.

To report on the implementation and outcomes of a virtual ward established for the management of mpox during the 2022 outbreak, we conducted a 2-center, observational, cross-sectional study over a 3-month period. All patients aged ≥17 years with laboratory polymerase chain reaction-confirmed monkeypox virus managed between 14 May and 15 August 2022, at the Hospital for Tropical Diseases at University College London Hospitals National Health Service (NHS) Foundation Trust and sexual health services at Central North and West London NHS Foundation Trust, were included. Main outcomes included the proportion of patients managed exclusively on the virtual ward, proportion of patients requiring inpatient admission, proportion of patients with human immunodeficiency virus, and duration of lesion reepithelialization. Among confirmed cases (N = 221), 86% (191/221) were managed exclusively on the virtual ward, while 14% (30/221) required admission. Treatment for concomitant sexually transmitted infections was provided to 25% (55/221) of patients, antibiotics for other infective complications to 16% (35/221), and symptomatic relief to 27% (60/221). The median time from onset to complete lesion reepithelialization and de-isolation was 18 days (range, 8-56 days). Eleven percent (24/221) of individuals disengaged from services within 4 days of testing. The virtual ward model facilitated safe and holistic outpatient management of mpox, while minimizing admissions. This approach could serve as a model for future outbreak responses.

Cost Awareness of Anaesthetic Consumable Items Among the National Health Service (NHS) Staff and the Financial Impact on the NHS.

Background The financial burden of running the National Health Service (NHS) is high. Staff members should be aware of the cost of the equipment they use to enable efficient use of resources, reduce waste, and control spending. However, limited financial education at undergraduate and junior stages has contributed to relatively poor knowledge among healthcare workers at all levels. Anaesthetics is a speciality which uses a large amount of equipment; therefore, we aim to assess the cost awareness among staff for commonly used consumables. Furthermore, we aim to assess staff members' attitudes towards the financial and environmental impact of the equipment they use and whether this would change their practice. Methodology An electronic survey was sent to staff members from the anaesthetic department of the Medway NHS Foundation Trust during a one-month period. Respondents were asked to estimate the cost of 19 commonly used anaesthetic consumables, with an estimate categorised as correct if it was within 20% of the actual cost. At the end of the survey, there were five questions for respondents to answer regarding the financial and environmental impact of their current healthcare practice and possible alternatives. Results There were 69 respondents within the anaesthetic department from a variety of roles. Overall, only 9.37% of items were estimated correctly, with cheaper items commonly being overestimated and more expensive items being underestimated. Overall, 60% of respondents said the cost of an item would influence their use. The overwhelming majority claimed that the environmental impact was a concern, and most would favour recyclable/reusable alternatives. Conclusions Cost awareness among anaesthetic staff for commonly used equipment is poor. More education and training are necessary in this area as limited knowledge of service costs restricts the ability to make cost-efficient choices which are needed in the current NHS.

BH13 Current wig prescribing practices and financial evaluation in a National Health Service foundation trust: lessons learnt and future challenges

BH13 Current wig prescribing practices and financial evaluation in a National Health Service foundation trust: lessons learnt and future challenges

Dynamic and Transdiagnostic Risk Calculator Based on Natural Language Processing for the Prediction of Psychosis in Secondary Mental Health Care: Development and Internal-External Validation Cohort Study

BackgroundAutomatic transdiagnostic risk calculators can improve the detection of individuals at risk of psychosis. However, they rely on assessment at a single point in time and can be refined with dynamic modeling techniques that account for changes in risk over time. MethodsWe included 158,139 patients (5007 events) who received a first index diagnosis of a nonorganic and nonpsychotic mental disorder within electronic health records from the South London and Maudsley National Health Service Foundation Trust between January 1, 2008, and October 8, 2021. A dynamic Cox landmark model was developed to estimate the 2-year risk of developing psychosis according to the TRIPOD (Transparent Reporting of a multivariate prediction model for Individual Prognosis or Diagnosis) statement. The dynamic model included 24 predictors extracted at 9 landmark points (baseline, 0, 6, 12, 24, 30, 36, 42, and 48 months): 3 demographic, 1 clinical, and 20 natural language processing–based symptom and substance use predictors. Performance was compared with a static Cox regression model with all predictors assessed at baseline only and indexed via discrimination (C-index), calibration (calibration plots), and potential clinical utility (decision curves) in internal-external validation. ResultsThe dynamic model improved discrimination performance from baseline compared with the static model (dynamic: C-index = 0.9; static: C-index = 0.87) and the final landmark point (dynamic: C-index = 0.79; static: C-index = 0.76). The dynamic model was also significantly better calibrated (calibration slope = 0.97–1.1) than the static model at later landmark points (≥24 months). Net benefit was higher for the dynamic than for the static model at later landmark points (≥24 months). ConclusionsThese findings suggest that dynamic prediction models can improve the detection of individuals at risk for psychosis in secondary mental health care settings.

Ward-based in situ simulation: lessons learnt from a UK District General Hospital

IntroductionIn situ simulation (ISS) enables multiprofessional healthcare teams to train for real emergencies in their own working environment and identify latent patient safety threats. This study aimed to determine ISS...

Real-world effectiveness of upadacitinib in Crohn’s disease: a UK multicentre retrospective cohort study

BackgroundUpadacitinib is a Janus kinase inhibitor, which has recently been approved for treating Crohn’s disease. There are limited real-world studies on the outcomes of upadacitinib in Crohn’s disease.ObjectiveOur aim was...

Impact of IFRS 15 adoption on performance measurement in healthcare – the case of National Health Service Foundation Trusts

Impact of IFRS 15 adoption on performance measurement in healthcare – the case of National Health Service Foundation Trusts

Development of an enhanced scoring system to predict ICU readmission or in-hospital death within 24 hours using routine patient data from two NHS Foundation Trusts

RationaleIntensive care units (ICUs) admit the most severely ill patients. Once these patients are discharged from the ICU to a step-down ward, they continue to have their vital signs monitored...

Environmentally Sustainable Skin Surgery: Staff Perception, Attitude and Practices at a Dermatology Department in the United Kingdom

Introduction: The National Health Service (NHS) has set the goal of reaching net zero emissions by 2040. Within dermatology, minor skin surgery is particularly energy- and resource-intensive. As we approach the 1-year mark since the publication of the British Society for Dermatological Surgery (BSDS) sustainability guidance 2022, there is a need to assess dermatology staff’s awareness, attitudes and practice towards environmentally sustainable minor skin surgery. Methods: A single-centre service evaluation study was conducted at South Warwickshire University NHS Foundation Trust (SWFT). A 12-question structured questionnaire was distributed to all medical and nursing staff that undertake skin surgery (n = 14 medical and n = 5 nursing staff) between 10 and 21 July 2023, with a response rate of 11 out of 19 (58%). The skin surgery waste disposal practices were evaluated between 14 June and 11 July 2023 where the weights of waste generated from seven skin surgery lists (each lasting 4 h) involving a total of 29 procedures were evaluated using a digital scale accurate to the nearest 100 g. Results: Out of 11 respondents, 9 (82%) stated that they were aware of the BSDS sustainability guidance 2022, but only 4 (36%) respondents had read the guidance. Seven (64%) stated that they used absorbable and non-absorbable sutures for surface wound closure, whereas 4 (36%) respondents stated that they exclusively used non-absorbable sutures for surface wound closure. Eight (73%) stated that they exclusively used sterile gloves for skin surgery, and 3 (27%) stated using a mixture of sterile and non-sterile nitrile gloves depending on the situation. In the free text responses, 8 (73%) respondents stated they exclusively used sterile gloves for all skin surgery procedures, and 3 (27%) stated using both sterile and non-sterile nitrile gloves depending on the situation. Waste generated per procedure averaged 0.54 kg (0.05 kg sharps waste, 0.36 kg clinical waste, and 0.13 kg recycling waste). The recycling rate averaged 24.0%. Conclusions: Our study identified a high level of awareness of the BSDS sustainability guidance, but few had actually read the guidance itself. Staff is engaging with recycling of waste from minor skin surgery. Staff education on National Institute for Health and Care Excellence (NICE) guidance on hand disinfection in minor procedures and the BSDS sustainability guidance could further promote staff transition into more environmentally sustainable minor skin surgery practices.

Evaluating Transperineal Prostate Biopsies Performed by a New Operator: A Prospective Clinical Audit at Dorset County Hospital.

Introduction The transperineal (TP) approach for prostate biopsy offers advantages such as a low risk of infection, the ability to target lesions in difficult locations, and a rapid acquisition of proficiency. This prospective clinical audit aims to evaluate the outcomes and patient experiences of TP prostate biopsies performed by a new operator to determine the feasibility of adopting the TP biopsy as the primary method for prostate evaluations. Methods The study included all patients who underwent a TP prostate biopsy from August 1 to September 30, 2022, at Dorset County Hospital National Health Service Foundation Trust. The operator, a member of the urology team, had recently begun performing these biopsies independently after completing a four-month supervised training program and receiving approval from two consulting trainers. The biopsy technique was evaluated based on diagnostic yield and patient experience, comparing pre-procedure imaging results with histology reports and analyzing patient-completed questionnaires. Results Among the 42 patients, the cancer detection rate was 79%. The highest core positivity rate was 100% in two patients (5%), with 90% in 11 patients (26%). Of the patients, 57% showed complete agreement between magnetic resonance imaging findings and histology. A questionnaire assessing patient experience received a 64% response rate. The most common pain score reported was 2 (on a scale of 0-10), noted in 25% of patients. Most reported mild lower urinary tract symptoms (88%) and mild hematuria (85%). Of the patients, 44% rated their overall satisfaction as 10 (on a scale of 0-10), and no urinary tract infections were reported. Conclusion The findings support the adoption of TP biopsy as the primary method for prostate biopsies due to its short learning curve, high diagnostic yield, and favorable patient satisfaction. Training for new operators should be encouraged to achieve this goal.

Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: a retrospective longitudinal study

ObjectiveTo evaluate the length of stay difference and its economic implications between hospital patients and virtual ward patients.DesignRetrospective longitudinal study.SettingWrightington, Wigan and Leigh (WWL) Teaching Hospitals, National Health Service (NHS)...

Development and validation of open-source deep neural networks for comprehensive chest x-ray reading: a retrospective, multicentre study

Artificial intelligence (AI) systems for automated chest x-ray interpretation hold promise for standardising reporting and reducing delays in health systems with shortages of trained radiologists. Yet, there are few freely accessible AI systems trained on large datasets for practitioners to use with their own data with a view to accelerating clinical deployment of AI systems in radiology. We aimed to contribute an AI system for comprehensive chest x-ray abnormality detection. In this retrospective cohort study, we developed open-source neural networks, X-Raydar and X-Raydar-NLP, for classifying common chest x-ray findings from images and their free-text reports. Our networks were developed using data from six UK hospitals from three National Health Service (NHS) Trusts (University Hospitals Coventry and Warwickshire NHS Trust, University Hospitals Birmingham NHS Foundation Trust, and University Hospitals Leicester NHS Trust) collectively contributing 2 513 546 chest x-ray studies taken from a 13-year period (2006-19), which yielded 1 940 508 usable free-text radiological reports written by the contemporary assessing radiologist (collectively referred to as the "historic reporters") and 1 896 034 frontal images. Chest x-rays were labelled using a taxonomy of 37 findings by a custom-trained natural language processing (NLP) algorithm, X-Raydar-NLP, from the original free-text reports. X-Raydar-NLP was trained on 23 230 manually annotated reports and tested on 4551 reports from all hospitals. 1 694 921 labelled images from the training set and 89 238 from the validation set were then used to train a multi-label image classifier. Our algorithms were evaluated on three retrospective datasets: a set of exams sampled randomly from the full NHS dataset reported during clinical practice and annotated using NLP (n=103 328); a consensus set sampled from all six hospitals annotated by three expert radiologists (two independent annotators for each image and a third consultant to facilitate disagreement resolution) under research conditions (n=1427); and an independent dataset, MIMIC-CXR, consisting of NLP-annotated exams (n=252 374). X-Raydar achieved a mean AUC of 0·919 (SD 0·039) on the auto-labelled set, 0·864 (0·102) on the consensus set, and 0·842 (0·074) on the MIMIC-CXR test, demonstrating similar performance to the historic clinical radiologist reporters, as assessed on the consensus set, for multiple clinically important findings, including pneumothorax, parenchymal opacification, and parenchymal mass or nodules. On the consensus set, X-Raydar outperformed historical reporter balanced accuracy with significance on 27 of 37 findings, was non-inferior on nine, and inferior on one finding, resulting in an average improvement of 13·3% (SD 13·1) to 0·763 (0·110), including a mean 5·6% (13·2) improvement in critical findings to 0·826 (0·119). Our study shows that automated classification of chest x-rays under a comprehensive taxonomy can achieve performance levels similar to those of historical reporters and exhibit robust generalisation to external data. The open-sourced neural networks can serve as foundation models for further research and are freely available to the research community. Wellcome Trust.

Challenges and successes in implementing an integrated electronic patient record (HIVE) at the Manchester University National Health Service Foundation Trust, England: 1000+ legacy systems, 10 hospitals, one electronic patient record.

The Manchester University National Health Service (NHS) Foundation Trust (MFT) is one of the largest NHS Trusts in England. Historically, the Trust has had very mixed clinical record keeping, including over 1000 individual information systems. None of these health information technology systems had the full functionality of an integrated electronic patient record (EPR). MFT evolved to its current size and complexity with a vision to improve patient care in Greater Manchester by adopting a Trust-wide EPR. The EPR "Go Live" occurred in September 2022. To describe the process of EPR integration as it reflected and impacted upon MFT's health information management (HIM) teams. MFT worked through a 2-year readiness program of work. This included technical readiness, software development and migration planning. Migration of data from the approximately 1000 systems was a major undertaking, during which access to the clinical history and ongoing operational reporting needed to be maintained. Pre-implementation requirements were outlined, a change management program was implemented, and the overall implementation was managed to tight timelines. "Go Live" was achieved for the EPIC EPR product (HIVE) within MFT. Legacy systems are still in the process of being decommissioned and staff are transacting within HIVE. Significant changes in processes and reporting continue to be made, despite some challenges. The Trust delivered the single largest EPIC European "Go live." Lessons learnt continue to be identified. The impact of what the EPR means for the HIM function is described.

Design and Evaluation of an Intensive Care Unit Dashboard Built in Response to the COVID-19 Pandemic: Semistructured Interview Study.

Dashboards and interactive displays are becoming increasingly prevalent in most health care settings and have the potential to streamline access to information, consolidate disparate data sources and deliver new insights. Our research focuses on intensive care units (ICUs) which are heavily instrumented, critical care environments that generate vast amounts of data and frequently require individualized support for each patient. Consequently, clinicians experience a high cognitive load, which can translate to suboptimal performance. The global COVID-19 pandemic exacerbated this problem by generating a large number of additional hospitalizations, which necessitated a new tool that would help manage ICUs' census. In a previous study, we interviewed clinicians at the University Hospitals Bristol and Weston National Health Service Foundation Trust to capture the requirements for bespoke dashboards that would alleviate this problem. This study aims to design, implement, and evaluate an ICU dashboard to allow for monitoring of the high volume of patients in need of critical care, particularly tailored to high-demand situations, such as those seen during the COVID-19 pandemic. Building upon the previously gathered requirements, we developed a dashboard, integrated it within the ICU of a National Health Service trust, and allowed all staff to access our tool. For evaluation purposes, participants were recruited and interviewed following a 25-day period during which they were able to use the dashboard clinically. The semistructured interviews followed a topic guide aimed at capturing the usability of the dashboard, supplemented with additional questions asked post hoc to probe themes established during the interview. Interview transcripts were analyzed using a thematic analysis framework that combined inductive and deductive approaches and integrated the Technology Acceptance Model. A total of 10 participants with 4 different roles in the ICU (6 consultants, 2 junior doctors, 1 nurse, and 1 advanced clinical practitioner) participated in the interviews. Our analysis generated 4 key topics that prevailed across the data: our dashboard met the usability requirements of the participants and was found useful and intuitive; participants perceived that it impacted their delivery of patient care by improving the access to the information and better equipping them to do their job; the tool was used in a variety of ways and for different reasons and tasks; and there were barriers to integration of our dashboard into practice, including familiarity with existing systems, which stifled the adoption of our tool. Our findings show that the perceived utility of the dashboard had a positive impact on the clinicians' workflows in the ICU. Improving access to information translated into more efficient patient care and transformed some of the existing processes. The introduction of our tool was met with positive reception, but its integration during the COVID-19 pandemic limited its adoption into practice.

Study of How Adiposity in Pregnancy has an Effect on outcomeS (SHAPES): protocol for a prospective cohort study

IntroductionMaternal obesity increases the risk of multiple maternal and infant pregnancy complications, such as gestational diabetes and pre-eclampsia. Current UK guidelines use body mass index (BMI) to identify which women...

Chronic or recurrent Campylobacter enteritis in primary immunodeficiency: a UK national case-series and review of the literature.

Chronic or recurrent Campylobacter enteritis in primary immunodeficiency: a UK national case-series and review of the literature.

Adherence to vascular care guidelines for emergency revascularization of chronic limb-threatening ischemia

ObjectiveIn 2022, the National Health Service Commissioning for Quality and Innovation (CQUIN) indicator for vascular surgery, with its pay-for-performance incentive for timely (5-day) revascularization of chronic limb-threatening ischemia (CLTI), was introduced. We sought to assess its effects in terms of (1) changes in the care pathway process measures relating to timing and patient outcomes; and (2) adherence to the Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF) guidelines for patients admitted with CLTI. MethodsA retrospective before-and-after cohort study was performed from January to June 2022 of nonelective admissions for CLTI who underwent revascularization (open, endovascular, or hybrid) at Cambridge University Hospitals National Health Service Foundation Trust, a regional vascular “hub.” The diagnostic and treatment pathway timing-related process measures recommended in the PAD-QIF were compared between two 3-month cohorts—before vs after introduction of the CQUIN. ResultsFor the two cohorts (before vs after CQUIN), 17 of 223 and 17 of 219 total admissions met the inclusion criteria, respectively. After introduction of financial incentives, the percentage of patients meeting the 5-day targets for revascularization increased from 41.2% to 58.8% (P = .049). Improvements were also realized in the attainment of PAD-QIF targets for a referral-to-admission time of ≤2 days (from 82.4% to 88.8%; P = .525) and admission-to-specialist-review time of ≤14 hours (from 58.8% to 76.5%; P = .139). An increase also occurred in the percentage of patients receiving imaging studies within 2 days of referral (from 58.8% to 70.6%; P = .324). The reasons for delay included operating list pressures and unsuitability for intervention (eg, active COVID-19 [coronavirus disease 2019] infection). No statistically significant changes to patient outcomes were observed between the two cohorts in terms of complications (pre-CQUIN, 23.5%; post-CQUIN, 41.2%; P = .086), length of stay (pre-QUIN, 12.0 ± 12.0 days; post-QUIN, 15.0 ± 21.0 days; P = .178), and in-hospital mortality (pre-QUIN, 0%; post-QUIN, 5.9%). Other PAD-QIF targets relating to delivery of care were poorly documented for both cohorts. These included documented staging of limb threat severity with the WIfI (wound, ischemia, foot infection) score (2.9% of patients; target >80%), documented shared decision-making (47.1%; target >80%), documented issuance of written information to patient (5.9%; target 100%), and geriatric assessment (6.3%; target >80%). ConclusionsThe pay-for-performance incentive CQUIN indicators appear to have raised the profile for the need for early revascularization to treat CLTI, engaging senior hospital management, and reducing the time to revascularization in our cohort. Further data collection is required to detect any resultant changes in patient outcomes. Documentation of guideline targets for delivery of care was often poor and should be improved.

Impact of Digital Inclusion Initiative to Facilitate Access to Mental Health Services: Service User Interview Study.

Digital exclusion, characterized by a lack of access to digital technology, connectivity, or digital skills, disproportionally affects marginalized groups. An important domain impacted by digital exclusion is access to health care. During COVID-19, health care services had to restrict face-to-face contact to limit the spread of the virus. The subsequent shift toward remote delivery of mental health care exacerbated the digital divide, with limited access to remote mental health care delivery. In response, Camden and Islington National Health Service Foundation Trust launched the innovative Digital Inclusion Scheme (DIS). This study aimed to examine the impact of facilitating digital inclusion in mental health access. Camden and Islington National Health Service Foundation Trust implemented the trust-wide DIS for service users who were digitally excluded, that is, were without devices or connectivity or reported poor digital skills. The scheme provided access to a loan digital device (a tablet), internet connectivity devices, and mobile data, as well as personalized digital skills support. The DIS went live in October 2021 and received 106 referrals by June 2022. Semistructured interviews were conducted with 12 service users to ask about their experience of accessing the DIS. A thematic analysis identified themes and subthemes relating to the extent of their digital exclusion before engaging with the scheme and the impact of accessing a scheme on their ability to engage with digital technology and well-being. There were 10 major themes. A total of 6 themes were related to factors impacting the engagement with the scheme, including digital exclusion, relationship to the trust, the importance of personalized digital support, partnership working, device usability and accessibility, and personal circumstances. The remaining 4 themes spoke to the impact of accessing the scheme, including improved access to services, impact on well-being, financial implications, and a greater sense of empowerment. Participants reported an increased reliance on technology driving the need for digital inclusion; however, differences in motivation for engaging with the scheme were noted, as well as potential barriers, including lack of awareness, disability, and age. Overall, the experience of accessing the DIS was reported as positive, with participants feeling supported to access the digital world. The consequences of engaging with the scheme included greater perceived access to and control of physical and mental health care, improved well-being, and a greater sense of empowerment. An overview of the lessons learned are provided along with suggestions for other health care settings that are looking to implement similar schemes.