Oxford University Hospitals Research Articles

Evidence-based Medical Leadership Development: A Systematic Review

1Alexander Mafi, 2Oscar Lyons, 3Robynne George, 4Joao Galante, 5Thomas Fordwoh, 6Jan Frich,7Jaason Geerts
 1University of Oxford, UK, 2University of Oxford, UK, 3Royal United Hospital Bath NHS Trust,4Oxford University Hospitals NHS Trust, UK, 5University of Oxford, UK, 6University of Oslo,Norway, 7Canadian College of Health Leaders, Ottawa, Canada
 
 Health systems invest significant resources in leadership development for physicians and other health professionals. Competent leadership is considered vital for maintaining and improving quality and patient safety. We carried out this systematic review to synthesise new empirical evidence regarding medical leadership development programme factors which are associated with outcomes at the clinical and organisational levels.
 117 studies were included in this systematic review. 28 studies met criteria for higher reliability studies. The median critical appraisal score according to the Medical Education Research Study Quality Instrument for quantitative studies was 8.5/18 and the median critical appraisal score according to the Jonna Briggs Institute checklist for qualitative studies was 3/10. There were recurring causes of low study quality scores related to study design, data analysis and reporting. There was considerable heterogeneity in intervention design and evaluation design. Programmes with internal or mixed faculty were significantly more likely to report organisational outcomes than programmes with external faculty only (p=0.049). Project work and mentoring increased the likelihood of organisational outcomes. No leadership development content area was particularly associated with organisational outcomes.
 In leadership development programmes in healthcare, external faculty should be used to supplement in-house faculty and not be a replacement for in-house expertise. To facilitate organisational outcomes, interventions should include project work and mentoring. Educational methods appear to be more important for organisational outcomes than specific curriculum content. Improving evaluation design will allow educators and evaluators to more effectively understand factors which are reliably associated with organisational outcomes of leadership development.

Automated quantification of epicardial adipose tissue on CCTA via deep-learning detection of the pericardium: clinical implications

Abstract Background Epicardial adipose tissue (EAT) is a visceral fat deposit within the pericardial sac which surrounds the heart myocardium and coronary arteries. EAT volume has been demonstrated to be strongly associated with the development and prognosis of cardiovascular diseases, but its measurement is subjective and challenging in practice. Purpose To develop a deep-learning approach for automated segmentation of EAT from routine CCTA scans, that could assist clinical interpretation of CCTA. Methods A deep-learning method using a 3D Residual-U-Net neural network architecture for 3D volumetric segmentation of CCTA data was created. The network was trained on a diverse sample of 1900 CCTAs, each manually segmented by a single expert, drawn from the UK sites of the Oxford Risk Factors And Non-invasive imaging (ORFAN) Study. Three iterations of feedback learning were used to fine tune the algorithm for the segmentation of the whole heart within the bounds of the pericardium. In each iteration, the machine analysed sets of 100–250 unannotated CCTAs unseen by the machine which were then corrected by experts. EAT volumes were calculated by automated thresholding of adipose tissue (−190HU through −30HU) from within the bound of the pericardial segment (Figure 1). The network was then applied to 817 unseen CCTAs from US sites of the ORFAN Study. These scans were also segmented for ground truth by two experts blind to all other data. Comparisons between machine vs expert total pericardial volume and EAT volume were made using Lin's concordance correlation coefficient (CCC). The algorithm was then applied externally in 1588 CCTAs from the SCOTHEART trial (UK), and the EAT volume was automatically calculated for each case. Cross-sectional associations between standardised EAT volumes and prevalent AF and CAD were performed. Results Within both the internal (UK ORFAN sites) and external (USA ORFAN sites) validation cohorts correlation between human and machine segmented total pericardium and EAT was excellent, with CCC of 0.97 for both volumes (external validation cohort shown in Figure 2A). Utilising SCOTHEART CCTAs with automatically segmented EAT volumes, a multivariable-adjusted logistic regression model accounting for risk factors of age, sex, BMI, hypertension, diabetes mellitus, valvular disease, and previous heart surgery found that EAT volumes were significantly associated with prevalent AF, with odds ratio (OR) per 1 SD increase of EAT volume of 1.20 (95% CI, 1.06 to 1.44; P=0.03). A similar model for prevalent CAD, adjusted for age, sex, BMI, hypertension, non-HDL cholesterol, diabetes mellitus, and coronary artery calcium score resulted in an OR per 1 SD increase of EAT volume of 1.26 (95% CI, 1.10 to 1.45; P=0.001) (Figure 2B). Conclusion Highly accurate, reproducible, and instantaneous EAT volume quantification is possible utilising deep-learning detection of the whole human heart within the pericardial sac. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): British Heart FoundationNational Institute for Health Research - Oxford University Hospitals Biomedical Research Centre Figure 1Figure 2

Relative benefits of extracorporeal shockwave lithotripsy (ESWL) compared to observation in acute renal colic

Miss Catherine Lovegrove1,2Mandy Spencer1Prof Ben Turney1,2Ms Naomi Neal1
 1 Department of Urology, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK2 University of Oxford Nuffield Department of Surgical Sciences, Oxford, Oxfordshire, UK
 
 Background NICE guidance recommends patients with renal colic be offered surgical treatment, including extracorporeal shockwave lithotripsy (ESWL), within 48 hours if pain is uncontrolled or stones unlikely to pass. We compared outcomes for ureteric stone passage after ESWL with those of observation to ascertain the relative benefits of ESWL.
 Methods We collected data on stone location, size and number of ESWL treatments required prospectively over 18 months. Stone passage was confirmed radiologically. Data were compared with MIMIC, a multi-centre collaborative study examining spontaneous stone passage after observation alone.
 Results 166 patients had ESWL for ureteric stones. Median size was 6.5mm (IQR 5.0-8.0mm). 57.2% (N=95) were proximal stones. Smaller stones required fewer treatments (P=0.003). Patients with a ureteric stone <5mm required median 1.0 ESWL treatments (IQR 1.0-2.0). Ureteric stones 5-7mm had median 1.0 treatments (IQR 1.0-2.0) and stones >7mm median 2.0 treatments (IQR 1.0-2.0). Compared to MIMIC, patients with ESWL for stones <5mm were 11% more likely to achieve stone clearance (100.0% vs 89.0%, P=0.001). ESWL for 5-7mm stones had 28.1% greater clearance compared to observation (77.1% vs. 49.0%, P<0.001) and ESWL for stones >7mm 21% greater likelihood of clearance (50.0% vs. 29.0%, P<0.001). Proximal ureteric stones were 16.4% more likely to pass with ESWL than observation (68.4% vs 52%, P=0.02). Distal stones showed similar passage with ESWL (77.5%) and observation (83.0%), P=0.43.
 Conclusions Proximal ureteric stones and those >5mm stones benefit most from ESWL. Results aid identification of patients whose stones are less likely to pass and warrant urgent review to consider ESWL.

Association of Increased Body Mass Index and Waist to Hip Ratio with Kidney Stone Disease: a prospective analysis of 493,410 UK Biobank participants

Catherine E Lovegrove1,2 – catherine.lovegrove@nds.ox.ac.ukThomas Littlejohns3- thomas.littlejohns@ndph.ox.ac.ukNaomi Allen3- naomi.allen@ndph.ox.ac.ukSarah A Howles1,4- sarah.bounds@doctors.org.ukBenjamin W Turney 1,2- ben.turney@nds.ox.ac.uk
 1 Department of Urology, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK2 University of Oxford Nuffield Department of Surgical Sciences, Oxford, Oxfordshire, UK3 University of Oxford Nuffield Department of Public Health, Oxford, Oxfordshire, UK4 Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
 
 Objectives To investigate the relationship between measures of adiposity and risk of incident kidney stone disease.
 Patients and methods The UK Biobank is a prospective cohort study of ~500,000 participants whose height, weight, BMI, waist circumference, hip circumference, waist:hip ratio (WHR), total fat mass, fat-free mass, body-fat percentage and percentage truncal fat were measured at enrolment with linkage to medical records. ICD-10 and OPCS codes were used to identify individuals with a new diagnosis of nephrolithiasis from 2006-2010. Individuals with a history of kidney stones or incomplete data were excluded. Multivariate Cox-proportional hazard models were used to assess associations between anthropometric measures and incident kidney stones.
 Results From the UK Biobank, 493,410 individuals were identified for inclusion; 3,466 developed a kidney stone during the study period. Increasing weight, BMI, waist and hip circumferences, WHR, and body and truncal fat were associated with increased risk of incident kidney stone disease. However, after adjustment for BMI, only waist circumference and WHR remained significantly associated with risk of nephrolithiasis. In overweight patients, high (men 94-102cm, women 80-88cm) waist circumference or WHR (men >0.9, women >0.85) conferred >40% increased risk of stone formation.
 Conclusion This study indicates that android fat distribution is independently associated with increased risk of developing nephrolithiasis. Kidney stone disease is known to be associated with hypertension, cardiovascular disease, and diabetes, all of which are linked to android body shape. Our findings provide insight into anthropometric risk factors for stone disease, will facilitate identification of patients at greatest risk of stone recurrence, and will inform prevention strategies.

1134 Incidence of Bile Acid Diarrhoea Post-Cholecystectomy - A Single Centre Cohort

Abstract Aim Bile acid diarrhoea (BAD) can occur as a result of enterohepatic circulation interruption following cholecystectomy. Although up to 57.2% of patients are reported to develop post-cholecystectomy diarrhoea, this is not always because of BAD. The aim of this study was to determine the incidence of post-cholecystectomy BAD diagnosis and evaluate the current practices. Method This study was conducted as part of BADCAP study. The electronic records of patients underwent cholecystectomy operation at Oxford University Hospitals between January 2013 and December 2017 were retrospectively analysed. Records were matched with patients who underwent 75SeHCAT testing during the same time period. A positive 75SeHCAT testing was defined as a seven-day retention time of < 15%. Results A total of 4327 patients underwent cholecystectomy operation. 2.05% (N = 89) investigated for diarrhoea by 75SeHCAT. Alongside 75SeHCAT, 69.7% (N = 62) had colonoscopy, 37.1% (N = 33) had CT abdomen and pelvis and 3.4% (N = 3) had MRCP/MRE. Gender wise statistics revealed females were 74.5% (N = 73) and males were 19.1% (N = 17). Median time from cholecystectomy to 75SeHCAT test was 780 days (SD +/-510 days). 70.8% (N = 63) had a positive 75SeHCAT test for BAD. IBD was confirmed in 2.2% (N = 2). Conclusions A small number of patients were investigated and only 1.5% were diagnosed with post-cholecystectomy diarrhoea. There was a significant time delay from operation to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher and clinicians need to have an increased awareness of this condition. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.

647 Management of Malignant Upper Urinary Tract Obstruction

Abstract Background Malignant Upper Urinary Tract Obstruction (MUUTO) is a common emergency presentation. These are often complex patients and require multiple specialty input to make time-critical decisions. There are currently no national guidelines for the management of MUUTO, a review was conducted to assess the management and outcomes of MUUTO. Aim To agreed and review a pathway for patients with MUUTO in order to streamline patient care and to review the management. Method The pathway was devised by several consultants at Oxford University Hospital. Through retrospective data collection, the outcomes over six months were reviewed. Results Over the six-month period 49 interventions were performed for MUUTO; 44 Percutaneous Nephrostomy (PCN) and five cystoscopies with retrograde ureteric stents (RUS). Patients were admitted to urology in 45% of cases and oncology in 39%. The obstruction was located above the pelvis in 16 (33%) of the cases and within the pelvis in 25 (51%). The most common cancers causing obstruction were bladder cancer (41%), prostate (16%), and colorectal (14%). MDT advice was sought in 63% of cases. The mean time from diagnosis to the intervention was four days. Of the five retrograde inserted ureteric stents, four were unsuccessful and the patients proceeded to PCN. At the conclusion of data collection, 26 (53%) patients had died. Discussion The most striking findings were the high failure rate of RUS and the overall poor prognosis of MUUTO. As such this review suggests that more patients should proceed directly to PCN for decompression.

Incidence of symptomatic image-confirmed venous thromboembolism in outpatients managed in a hospital-led COVID-19 virtual ward.

Incidence of symptomatic image-confirmed venous thromboembolism in outpatients managed in a hospital-led COVID-19 virtual ward.

We need a clear strategy on vaccination.

The outcome of a consultation on mandatory COVID-19 vaccination for health and social care staff must result in a standard approach being taken nationwide, argues Sam Foster, Chief Nurse, Oxford University Hospitals.

14-year trends and resistance patterns of blood and cerebrospinal fluid cultures in children under three years old

Bacterial infections are a major cause of UK paediatric hospitalisations, yet longitudinal data on causative organisms or antimicrobial resistance are scarce. This retrospective analysis describes trends in blood and cerebrospinal fluid (CSF) cultures and resistance patterns in children under three years old from a large UK centre. All culture results, and resistance data for Gram-negative rods (GNR) in blood cultures, collected between January 2005 and December 2018 were extracted from Oxford University Hospitals NHS Foundation Trust microbiology database. Of 49,298 samples, 6.7% of blood and 3.1% of CSF cultures were positive for bacterial growth; 2.3% and 1.1%, respectively grew pathogens. Number of cultures taken increased over time; the proportion growing pathogens declined. Resistance of GNR to first-line antimicrobials was 9.3% to gentamicin (neonatal units), and 17.1% and 25.8% to ceftriaxone (paediatric ED and wards respectively). Resistance to any two of ceftriaxone, ciprofloxacin, gentamicin, or meropenem was ≤6% in both areas. The proportion of positive cultures declined over time. Resistance of GNR to empirical antimicrobials were observed, but resistance to a second agent were lower. Our study informs clinician decisions on when, and to which antimicrobials, to escalate if a child is not improving on empirical therapy.

Meeting patients' mental health needs.

Sam Foster, Chief Nurse, Oxford University Hospitals, considers how nurses can provide better care to people with mental health conditions, who are often in a vulnerable position and require compassionate treatment.

NHS trusts must continue to tackle racism.

Although the latest report on workforce equality shows positive changes, some improvements are marginal and the issue must be kept high on the agenda, says Sam Foster, Chief Nurse, Oxford University Hospitals.

General Versus Regional Anaesthesia for Lower Limb Arthroplasty and Associated Patient Satisfaction Levels: A Prospective Service Evaluation in the Oxford University Hospitals.

IntroductionLower limb arthroplasty is performed under general anaesthesia (GA) or regional anaesthesia (RA). There is increasing evidence of the surgical and anaesthetic benefits of RA. National Institute for Health and Care Excellence (NICE) guidelines advise using either but highlight a lack of data comparing outcomes of RA and GA for these procedures. We conducted a service evaluation, prospectively analysing elective orthopaedic cases performed at the Nuffield Orthopaedic Centre, Oxford, UK from 19/11/2018 to 03/04/2019. We aimed to compare data on anaesthetic assessment, intra-operative parameters and patient satisfaction for RA and GA cases.MethodsWe selected elective patients, aged above 18, undergoing total hip, total knee or unilateral knee arthroplasties. Prospective quantitative and qualitative data were collected using two forms. Firstly, anaesthetists completed a case report recording demographic data, intra-operative details and reason for anaesthetic choice. Secondly a questionnaire gathered patient satisfaction data. This was analysed using descriptive statistics and presented in tables.ResultsData for 132 patients were collected over the service evaluation period. After exclusion, 99 patients were included for final analysis; 59 underwent GA and 40 had RA. GA was used predominantly due to patient preference (74.6%). RA was used primarily due to anaesthetic preference (75%); most commonly due to speed of list and duration of operation. Overall patients had low pain scores (0.3/10) and high pre-operative anxiety levels (4.6/10) regardless of anaesthetic.ConclusionOur results show high patient satisfaction with GA and RA for lower limb arthroplasty; however, pre-operative anxiety was common for both. Patient preference and comfort influenced choice of anaesthesia, highlighting the importance of pre-operative counselling and education to facilitate shared decision making, leading to favourable post-operative outcomes.

Let's get the work-life balance right.

If the NHS embraces the new work practices it has adopted in the pandemic, it will improve staff wellbeing and retention, says Sam Foster, Chief Nurse, Oxford University Hospitals, and become an excellent employer.

Understanding safety culture.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on the question of what makes a pro-safety 'culture' within an organisation, and how it can be developed.

Optimal resection rate for lung cancer in the UK: how high should we go?

BackgroundThe optimal resection rate for institutions managing early-stage primary lung cancer is not known. Whether the prognosis of patients who do not proceed to operation is determined by their comorbidities...

Can we reduce the risk of burnout?

Sam Foster, Chief Nurse, Oxford University Hospitals, considers the concerns raised regarding staff shortages, excessive workloads and burnout, exacerbated by the COVID-19 pandemic.

A Mother on Trial-Best Interests and the Conflict of Maternal Instincts: Oxford University Hospitals NHS Foundation Trust and Z (by Her Litigation Friend, The Official Solicitor) [2020] EWCOP 20.

A Mother on Trial-Best Interests and the Conflict of Maternal Instincts: Oxford University Hospitals NHS Foundation Trust and Z (by Her Litigation Friend, The Official Solicitor) [2020] EWCOP 20.

It's time to change the way we work.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on how the pandemic has changed work practices and suggests that refocusing priorities can not only improve staff wellbeing but also productivity and competition.

Delirium – are we doing enough prevention and basic management in acute settings?

AimsTo identify the prevalence of delirium and/or dementia on complex medicine wards.To assess the use non-pharmacological prevention and management options in these patients.BackgroundDelirium, a common hospital syndrome, is often multi-factorial. So, the management needs not only treating a reversible cause but also minimising the factors that could increase the risk of developing delirium, or worsen its course.The Scottish-Intercollegiate-Guidelines-Network (SIGN) and National-Institute-for-Health-and-Care-Excellence (NICE) guidelines outline non-pharmacological factors to reduce the risk of developing delirium, and for its management once established.These factors include orientation, ensuring patients have their glasses and hearing aids, promoting sleep hygiene, maintaining optimal hydration and nutrition, early mobilisation, appropriate lighting and providing cognitively stimulating activities.MethodSIGN, NICE and local guidelines were used to develop a checklist of core non-pharmacological factors that minimise the risk of developing delirium and help in its management. Adherence to recommendations from these guidelines was thus evaluated in 4 Complex Medical Units of The John-Radcliffe Hospital (Oxford University Hospitals NHS Foundation Trust), cross sectionally. The data were collected by interviewing nursing staff on the wards, assessing the ward environment, reviewing nursing charts and electronic patient records.ResultThere were 57 patients aged >65 years across all four wards, with average percentages of delirium and dementia patients being 46% and 34%, respectively. Nurses were unsure about their patients having hearing or visual aids in 41% and 29%, respectively. On all four wards there was no clear signage, no digital clock, no calendar, and earplugs were not offered. Overall, the use of non-pharmacological recommendations was sub-optimal across a number of items. After a month, when the notes were reviewed, it was found that 18 out of those 57 patients had passed away (32%) and the average length of stay for delirium/dementia patients was way more than the other patients during that admission.ConclusionWe found high rates of delirium and dementia and a lack of consistent use of recommended non-pharmacological strategies for their management. Better adherence to these could help shorten length of stay and improve patient outcomes.Recommendations for patients with/at risk of delirium: –Bedside board for each patient with the name of the ward/hospital, picture of the named nurse.–Ensuring visible clock/calendar.–Non-pharmacological delirium management checklist to be added to the daily nursing notes.Emphasis on visual/hearing aids and daily reorientation. –Appropriate lighting in the bays.–Offer earplugs if not sleeping at night.

Unintentional consequences of artificial intelligence in dermatology for patients with skin of colour

Recently, there have been concerns that dermatology resources and education lack sufficient material regarding patients with skin of colour(SOC) in the Western world.1 In the UK, we have an increasingly diverse population, of which 14% have non-Caucasian skin types, necessitating a shift in our educational focus to reflect our changing environment in order for dermatologists to feel comfortable managing conditions in SOC.2.