NHS Hospital Trusts In England Research Articles

Perceptions and digitalisation of outbreak management in UK health services: A cross-sectional survey

Background Global challenges arise from infectious diseases which represent significant challenges to the provision of healthcare, requiring efficient management procedures to limit transmission. Evaluating current outbreak management processes within UK healthcare services is essential for identifying strengths, weaknesses, and potential improvements. Objectives This study aimed to assess infection prevention and control (IPC) practitioners' access to outbreak management (OM) data. Secondary objectives involved determining IPC practitioners’ perceptions of outbreak management processes and the state of digitalisation of OM in the UK. Methods National cross-sectional survey data were collected to evaluate current outbreak management approaches. To supplement this, information requests were sent to the 10 largest teaching and research NHS hospital trusts in England. Findings The survey received 55 responses with 53 considered for analysis. Out of 10 NHS trusts, nine provided completed FOI responses, while one was unable to provide data. Discussion The study offers unique insights into prevailing outbreak management practices within UK health services. Although positive perceptions surround key outbreak management stages, concerns arise, including varying confidence levels in surveillance processes' robustness, efficacy of management interventions, and communication effectiveness. Conclusions The study highlights challenges with OM processes in the UK, including issues like poor surveillance and delayed outbreak detection. Positive practitioner perceptions contrast with concerns over data collection, follow-up, and limited digitalisation, relying on basic tools like Excel and Word, hindering retrospective learning.

How do hospitals respond to payment unbundling for diagnostic imaging of suspected cancer patients?

Payments for some diagnostic scans undertaken in outpatient settings were unbundled from Diagnosis Related Group based payments in England in April 2013 to address under-provision. Unbundled scans attracted additional payments of between £45 and £748 directly following the reform. We examined the effect on utilization of these scans for patients with suspected cancer. We also explored whether any detected effects represented real increases in use of scans or better coding of activity. We applied difference-in-differences regression to patient-level data from Hospital Episodes Statistics for 180 NHS hospital Trusts in England, between April 2010 and March 2018. We also explored heterogeneity in recorded use of scans before and after the unbundling at hospital Trust-level. Use of scans increased by 0.137 scans per patient following unbundling, a 134% relative increase. This increased annual national provider payments by £79.2 million. Over 15% of scans recorded after the unbundling were at providers that previously recorded no scans, suggesting some of the observed increase in activity reflected previous under-coding. Hospitals recorded substantial increases in diagnostic imaging for suspected cancer in response to payment unbundling. Results suggest that the reform also encouraged improvements in recording, so the real increase in testing is likely lower than detected.

A qualitative study of organisational response to national quality standards for 7-day services in English hospitals

BackgroundNational standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. This paper describes how a sample of NHS hospital trusts in England responded to the introduction of national standards for 7-day services (7DS), from an organisational behaviour perspective.MethodsWe conducted 43 semi-structured interviews with executive/director level and clinical staff, in eight NHS trusts that varied in size, location, and levels of specialist staffing at weekends. We explored approaches to implementing standards locally, and the impact of organisational culture and local context on organisational response.ResultsSenior staff in the majority of trusts described a focus on hitting targets and achieving compliance with the standards. Compliance-based responses were associated with a hierarchical organisational culture and focus on external performance. In a minority of trusts senior staff described mobilising commitment-based strategies. In these trusts senior staff reframed the external standards in terms of organisational values, and used co-operative strategies for achieving change. Trusts that took a commitment-based approach tended to be described as having a developmental organisational culture and a history of higher performance across the board. Audit data on 7DS showed improvement against standards for most trusts, but commitment-focused trusts were less likely to demonstrate improvements on the 7DS audit. The ability of trusts to respond to external standards was limited when they were under pressure due to a history of overall poor performance or resource limitations.ConclusionsNational standards and audit for service-level improvement generate different types of response in different local settings. Approaches to driving improvement nationally need to be accompanied by resources and tailored support for improvement, taking into account local context and organisational culture.

Real-world use and accuracy of stress echocardiography: preliminary insights from the EVAREST study

Abstract Background Stress echocardiography is a widely used, non-invasive imaging modality used to identify prognostically significant coronary artery disease. High levels of accuracy have been reported, however this is highly dependent on operator training and image quality. There are currently limited data available on the accuracy of stress echo in every day clinical practice. Purpose The EVAREST study links stress echo clinics in 30 NHS Hospital Trusts in England and therefore provides data to evaluate the performance and diagnostic accuracy of stress echo in “real-world” clinical practice. Methods Analysis was performed on the first 7415 patients recruited prospectively between 2015 and January 2020. Participants are included if they have undergone stress echo to investigate for ischaemic heart disease. Data is collected on medical history and stress echo performance. Participants are followed up for 12 months through health records and patient phone call, with all outcomes undergoing expert adjudication. A positive cardiac outcome is defined as initiation of anti-anginal medications, ≥70% stenosis on coronary angiography, revascularisation, confirmed acute coronary syndrome or cardiac-related death. Results Mean age of patients undergoing stress echo is 65±12.3 years and 56% are male. Average BMI is 28.9±5.6 kg/m2. 71.4% undergo dobutamine stress (DSE) and 28.4% exercise with <1% having a pacemaker-mediated stress. Contrast was used in 71.4% of studies. Stress echos were interpreted at time of clinic visit as positive for inducible ischaemia in 18.2% of patients. One-year outcome data is currently available for 1892 participants. Sensitivity and specificity for clinician prediction of a positive cardiac outcome was 88.7% and 94.4%, respectively. Positive and negative predictive value of stress echo was 76.4% and 97.6%, respectively. Conclusion EVAREST provides unprecedented, large-scale information on the “real world” use and accuracy of stress echo across different healthcare settings in the UK, demonstrating performance consistent with best practice. Ongoing data collection will be used to evaluate sources of heterogeneity in the predictive accuracy of stress echo and identify optimal approaches to further improve performance. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Ultromics Ltd., Lantheus Ltd.

Risk of complicated birth at term in nulliparous and multiparous women using routinely collected maternity data in England: cohort study.

ObjectivesTo determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors.DesignCohort study using linked electronic maternity records.Participants276 766 women with a singleton birth at term after a trial of labour in 87 NHS hospital trusts in England between April 2015 and March 2016.Main outcome measureA composite outcome of complicated birth, defined as a birth with use of an instrument, caesarean delivery, anal sphincter injury, postpartum haemorrhage, or Apgar score of 7 or less at five minutes.ResultsMultiparous women without a history of caesarean section had the lowest rates of complicated birth, varying from 8.8% (4879 of 55 426 women, 95% confidence interval 8.6% to 9.0%) in those without specific risk factors to 21.8% (613 of 2811 women, 20.2% to 23.4%) in those with three or more. The rate of complicated birth was higher in nulliparous women, with corresponding rates varying from 43.4% (25 805 of 59 413 women, 43.0% to 43.8%) to 64.3% (364 of 566 women, 60.3% to 68.3%); and highest in multiparous women with previous caesarean section, with corresponding rates varying from 42.9% (3426 of 7993 women, 41.8% to 44.0%) to 66.3% (554 of 836 women, 63.0% to 69.5%).ConclusionsNulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.

Reflection in practice: How can patient experience feedback trigger staff reflection in hospital acute care settings?

BackgroundPatient and staff experiences provide important insights into care quality, but health systems have difficulty using these data to improve care. Little attention has been paid to understanding how patient experience feedback can act as a prompt to reflection in practice in the clinical setting.ObjectiveWe aimed to identify the ways in which different types of patient experience feedback act as a trigger or prompt for engagement in reflection in clinical practice in acute hospital settings and identify important considerations for enhancing the value of patient experience data for reflective learning.MethodsWe conducted an ethnographic study in eight acute care units in three NHS hospital trusts in England, including 140 hours of observations and 45 semi‐structured interviews with nursing, medical and managerial staff working in acute medical units and intensive care units. The data were analysed thematically.FindingsWe distinguished between formal patient experience data sources: data purposively collected and collated to capture the patient experience of care, generally at organizational level, including surveys, complaints and comments; and informal sources of feedback on the patient experience recognized by staff alongside the formal data. We also identified patient narratives as an ‘in between’ source of data. The impact of different types of patient feedback in triggering reflection primarily depended on the extent to which the feedback was experienced as personally relevant, meaningful and emotionally salient.DiscussionPatient experience feedback is multi‐faceted, but our study suggests that all types of feedback could be harnessed more effectively to prompt reflection.

Organisational strategies and practices to improve care using patient experience data in acute NHS hospital trusts: an ethnographic study

Background Although NHS organisations have access to a wealth of patient experience data in various formats (e.g. surveys, complaints and compliments, patient stories and online feedback), not enough attention has been paid to understanding how patient experience data translate into improvements in the quality of care. Objectives The main aim was to explore and enhance the organisational strategies and practices through which patient experience data are collected, interpreted and translated into quality improvements in acute NHS hospital trusts in England. The secondary aim was to understand and optimise the involvement and responsibilities of nurses in senior managerial and front-line roles with respect to such data. Design The study comprised two phases. Phase 1 consisted of an actor–network theory-informed ethnographic study of the ‘journeys’ of patient experience data in five acute NHS hospital trusts, particularly in cancer and dementia services. Phase 2 comprised a series of Joint Interpretive Forums (one cross-site and one at each trust) bringing together different stakeholders (e.g. members of staff, national policy-makers, patient/carer representatives) to distil generalisable principles to optimise the use of patient experience data. Setting Five purposively sampled acute NHS hospital trusts in England. Results The analysis points to five key themes: (1) each type of data takes multiple forms and can generate improvements in care at different stages in its complex ‘journey’ through an organisation; (2) where patient experience data participate in interactions (with human and/or non-human actors) characterised by the qualities of autonomy (to act/trigger action), authority (to ensure that action is seen as legitimate) and contextualisation (to act meaningfully in a given situation), quality improvements can take place in response to the data; (3) nurses largely have ultimate responsibility for the way in which data are collected, interpreted and used to improve care, but other professionals also have important roles that could be explored further; (4) formalised quality improvement can confer authority to patient experience data work, but the data also lead to action for improvement in ways that are not formally identified as quality improvement; (5) sense-making exercises with study participants can support organisational learning. Limitations Patient experience data practices at trusts performing ‘worse than others’ on the Care Quality Commission scores were not examined. Although attention was paid to the views of patients and carers, the study focused largely on organisational processes and practices. Finally, the processes and practices around other types of data were not examined, such as patient safety and clinical outcomes data, or how these interact with patient experience data. Conclusions NHS organisations may find it useful to identify the local roles and processes that bring about autonomy, authority and contextualisation in patient experience data work. The composition and expertise of patient experience teams could better complement the largely invisible nursing work that currently accounts for a large part of the translation of data into care improvements. Future work To date, future work has not been planned. Study registration NIHR 188882. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Establishing the cost of implementing a performance-based, managed entry agreement for a hypothetical CAR T-cell therapy

ABSTRACTBackground: Market access stakeholders consider the adoption of Managed Entry Agreements (MEAs), however a clearly described methodology to quantify their implementation burden is not available in the public domain.Objective: To quantify the cost of implementing a performance-based MEA at the hospital level.Methods: The analysis involved a hypothetical one-off therapy targeting Acute Lymphoblastic Leukaemia. Data collection from five NHS Hospital Trusts in England captured costs by task, job band, personnel time and capital investment. We compared the administrative burden of the standard of care (SoC) to that of adopting the therapy with or without an MEA over 10 years.Findings: The 10-year cost for the activities required to support hospital payments for the target patient population in England varied as follows: for the SoC was £447,353, compared to £1,117,024 for the novel therapy with MEA, and £245,317 without MEA.Conclusions: The higher cost associated with the SoC compared to the novel therapy without an MEA, arises from the higher frequency of infusions requiring payments and the associated mandatory data capturing requirements for oncology therapies. The novel therapy with MEA presents the greatest burden due to increased frequency of monitoring in year one to compensate for the greater uncertainty in clinical data and to inform the performance-based reimbursement.

Secondary analysis of hospital patient experience scores across England's National Health Service - How much has improved since 2005?

ObjectiveTo examine trends in patient experience and consistency between hospital trusts and settings.MethodsObservational study of publicly available patient experience surveys of three hospital settings (inpatients (IP), accident and emergency (A&E) and outpatients (OP)) of 130 acute NHS hospital trusts in England between 2004/05 and 2014/15.ResultsOverall patient experience has been good, showing modest improvements over time across the three hospital settings. Individual questions with the biggest improvement across all three settings are cleanliness (IP: +7.1, A&E: +6.5, OP: +4.7) and information about danger signals (IP: +3.8, A&E: +3.9, OP: +4.0). Trust performance has been consistent over time: 71.5% of trusts ranked in the same cluster for more than five years. There is some consistency across settings, especially between outpatients and inpatients. The lowest-scoring questions, regarding information at discharge, are the same in all years and all settings.ConclusionsThe greatest improvement across all three settings has been for cleanliness, which has seen national policies and targets. Information about danger signals and medication side-effects showed least consistency across settings and scores have remained low over time, despite information about danger signals showing a big increase in score. Patient experience of aspects of access and waiting have declined, as has experience of discharge delay, likely reflecting known increases in pressure on England’s NHS.

Are acute brain injury rehabilitation guidelines applied to people with brain injury after cardiac arrest?

Relevance: The number of people surviving cardiac arrest is increasing. Associated with this, the number of people surviving with brain injury after cardiac arrest is also increasing. The long-term consequences have been likened to the long-term consequences of other causes of brain injury; which impact on quality of life for the individual and their family several years after the event. Multi-disciplinary rehabilitation is advocated for this patient group, which includes both cardiac and neurological rehabilitation. Brain injury rehabilitation guidelines exclusive to the cardiac arrest population are as yet outstanding, and it is unknown whether existing guidelines for adults with acquired brain injury of any cause, are being routinely applied. Purpose: This survey aimed to explore the current provision of acute NHS rehabilitation for adults with brain injury after cardiac arrest. The main objective was to investigate the extent to which current services met key recommendations from published literature and clinical guidelines, for brain injury rehabilitation. A secondary objective was to determine if there was a difference in adherence to these recommendations between hospital trusts with and without ´heart attack centres´; as increasing numbers of people are being treated in such centres after cardiac arrest. Methods/Analysis: A cross-sectional survey design was chosen, to provide quantitative data. A postal questionnaire was chosen as it would have the advantage of a known denominator population. A questionnaire was sent to each of the 144 acute NHS hospital Trusts in England. One physiotherapist from each trust was invited to respond. Individual guidelines were considered met if they were reported as being met ´always´ or ´almost always´ by respondents. Results: 52 questionnaires were included in the analysis; an overall response rate of 36% was achieved. A number of areas for improvement were identified, where levels of adherence were low; from initial screening and assessment - to appropriate onward referrals. No significant difference was found between responding trusts - with and without heart attack centres - in terms of guideline adherence. Discussion and conclusions: This survey has provided a ´snap shot´ of the provision of acute rehabilitation for patients with brain injury after cardiac arrest, in a number of hospital trusts across England. The results question the equity of acute rehabilitation for patients with brain injury after cardiac arrest; as adherence to guidelines varied between responding trusts, and individual trusts reported adhering to some guidelines only ´sometimes´. Further research into areas where adherence was low or varied is warranted. Added responses suggested that patient location within the trust was a factor influencing adherence to many of the guidelines, and as such it may be appropriate to review the patient pathway, with a view to improve consistency and quality of care. Impact and Implications: This study highlights the need for further guidance towards appropriate acute rehabilitation after cardiac arrest; particularly as more people are surviving cardiac arrest, and understanding how brain injury can impact on the lives of these patients and their families. Organisational support is needed to either further adopt the existing brain injury guidelines or to produce more specific guidelines for survivors of cardiac arrest. Funding Acknowledgement: Unfunded research. MSc Rehabilitation supported through CPPD contract, and staff at St George´s University Foundation Health Trust and Kingston University & St George´s University, London, Faculty of Health, Social Care and Education. Key-Words: Guidelines, Rehabilitation, cardiac arrest

Pressure ulcer and wounds reporting in NHS hospitals in England part 2: Survey of monitoring systems

This is the second of a two related papers describing work undertaken to compare and contrast Pressure Ulcer (PU) monitoring systems across NHS in-patient facilities in England. The work comprised 1) a PU/Wound Audit (PUWA) and 2) a survey of PU monitoring systems.This second paper focusses on the survey which explores differences in the implementation of PU adverse event monitoring systems in 24 NHS hospital Trusts in England. The survey questionnaire comprised 41 items incorporating single and multiple response options and free-text items and was completed by the PUWA Trust lead in liaison with key people in the organisation. All 24 (100%) Trusts returned the questionnaire, with high levels of data completeness (99.1%).The questionnaire results showed variation between Trusts in relation to the recording of PUs and their reporting as part of NHS prevalence and incident monitoring systems and to Trust boards and healthcare commissioners including the inclusion (or not) of device ulcers, unstageable ulcers, Deep Tissue Injury, combined PUs/Incontinence Associated Dermatitis, category ≥ 1 ulcers or category ≥ 2 ulcers, inherited ulcers, acquired ulcers, avoidable and unavoidable ulcers and the definition of Present On Admission. These fundamental differences in reporting preclude Trust to Trust comparisons of PU prevalence and incident reporting and monitoring systems due to variation in local application and data collection methods. The results of this work and the PUWA led to the development of recommendations for PU monitoring practice, many of which are internationally relevant.

PWE-346 Lynch syndrome and application of the rcpath colorectal cancer dataset in the united kingdom

<h3>Introduction</h3> Lynch syndrome is estimated to cause over 1,000 cases of colorectal cancer in the UK every year. Individuals that have Lynch syndrome have a lifetime risk of developing colorectal cancer or other Lynch associated cancers of &gt;35%. Yet fewer than 5% of individuals with the condition have been diagnosed in the UK. The Royal College of Pathologists (RCPath) cancer dataset (July 2014) mandates the use of immunohistochemistry or other testing for molecular features of Lynch syndrome in colorectal cancer or Lynch associated cancer patients under the age of 50, at the time of diagnosis. Performing this type of screening test for Lynch syndrome identifies those at greater risk of recurrence as well as family members at extended risk through early cascade testing. <h3>Method</h3> The strategy was developed by Bowel Cancer UK with advice from the Medical Advisory Board of the charity. We identified all NHS hospital trusts in England, health boards in Scotland and Wales and health and social care trusts in Northern Ireland. A freedom of information (FOI) request was submitted to each of these bodies in which a number of questions were asked to establish whether they were implementing the RCPath core dataset requirement, with regard to mismatch repair (MMR) testing for Lynch syndrome. As this was an FOI request respondents were required to respond within 20 working days. <h3>Results</h3> In England, 78% of trusts responded, 100% responded in Scotland and Northern Ireland; one health board in Wales did not respond. In England and Scotland 50% of hospital trusts and health boards currently do not follow the RCPath cancer dataset. 4 health boards in Wales do not, and all health and social care trusts in Northern Ireland stated they perform MMR testing to identify suspected Lynch syndrome patients. In England only 28 of those that did not perform testing stated they were intending to implement the dataset and two in Wales. Scotland is in the process of developing a nationally agreed protocol for implementation of the dataset. We found that among trusts and health boards that do test for Lynch syndrome many do not yet have in place a systematic reflex service, as mandated by RCPath. <h3>Conclusion</h3> Our findings show that the RCPath dataset may have already had some impact on the application of MMR testing for Lynch syndrome in patients diagnosed under the age of 50. However there is considerable variation in approach. We recommend that: England and Wales carry out a nationwide initiative to look at ways of delivering a consistent approach to reflex testing for Lynch syndrome; that all CCGs commission to reflect the RCPath cancer dataset thus ensuring providers are compliant with the dataset. <h3>Disclosure of interest</h3> None Declared.

Should assistant practitioners be allowed to administer medicine?

Should assistant practitioners be allowed to administer medicine?

One in six hospitals in England paying locums more than £1000 a shift

NHS hospitals in England are paying up to £2000 a shift for a locum doctor, with 16% spending more than £1000 a shift for locum cover, an investigation by the Telegraph has found.1 Based on freedom of information requests completed by 99 of the 164 hospital trusts in England, spending by NHS hospital trusts in England on agency locums is estimated to have reached £2.06bn during 2010-13. NHS Employers has estimated that around 50% of expenditure on agency staff in the NHS …

Local guidelines for the transfer of women from midwifery unit to obstetric unit during labour in England: a systematic appraisal of their quality

BackgroundA proportion of women planning to give birth in a midwifery unit will experience complications during labour that necessitate transfer to an obstetric unit. Local guidelines for the transfer of...

Assessment of the implementation of a national patient safety alert to reduce wrong site surgery

Background:In 2005, guidance on how to prevent wrong site surgery in the form of a national safety alert was issued to all NHS hospital trusts in England and Wales by...

Mortality in men admitted to hospital with acute urinary retention: database analysis

Objectives To investigate mortality in men admitted to hospital with acute urinary retention and to report on the effects of comorbidity on mortality.Design Analysis of the hospital episode statistics database...

Results of a survey of the role of multidisciplinary team coordinators for colorectal cancer in England and Wales

Over the last 6 years, multidisciplinary teams (MDTs) have been established and play a key role in organizing the delivery of cancer care in the UK. There are no published data on the roles of their co-coordinators. To seek the views of colorectal multidisciplinary team co-ordinators (MDTCs) on what they do and how they do it. Questionnaires were sent to the colorectal MDTC, or equivalent, in all 180 NHS hospital trusts in England and Wales where colorectal cancer surgery is performed. There was a 70% response rate. Seventy-one per cent of trusts now have a dedicated MDTC, whereas in 2002, only 40% had one. MDTCs generally keep their information on databases, but these differ, and are not coordinated with data entry into the national colorectal cancer database of the Association of Coloproctology of Great Britain and Ireland. In only 26 trusts does the MDTC communicate decisions to primary care, and the patients seem almost completely excluded from this process. The recently formed national MDTC Forum should grasp the opportunity of coordinating all of this well-intentioned but pluralistic activity to the benefit of patients, primary care and hospital teams. An effective MDTC with a robust database will be the key in achieving cancer waiting time targets with useful audit, thereby improving patient care.

Mortality associated with delay in operation after hip fracture: observational study

Objective To estimate the number of deaths and readmissions associated with delay in operation after femoral fracture.Design Analysis of inpatient hospital episode statistics.Setting NHS hospital trusts in England with at...