University Hospital Of Wales Research Articles

Using simulation for long-term bed modelling in critical care

ABSTRACT A simulation model of the University Hospital of Wales (UHW) Critical Care (CC) Department is presented. This is the first CC model that considers the impact of future demand on capacity, supporting planning decisions to build a new hospital. A combination of long-term demand trajectories and Discrete Event Simulation (DES) are used. The results suggest the unit will need at least 66 Intensive Care beds and 19 Post-Anaesthesia Care beds to fulfil predicted demand in 2040 while being at capacity less than 5% of the time. Non-critical care ward beds impact patient flow in CC, thus must be considered when planning a new hospital. This study’s findings directly impact on decision making at UHW, having informed capacity planning of the planned unit. This paper contributes by presenting an infrastructure planning project using simulation as a decision-making tool, with transferable insights applicable to the planning of other CC units.

Fertility outcomes following transsphenoidal surgery for pituitary tumours at the university hospital of wales, cardiff

Fertility outcomes following transsphenoidal surgery for pituitary tumours at the university hospital of wales, cardiff

DO WE NEED LAMINAR FLOW IN TRAUMA?

Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients.A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted.Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively.In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics.

819 Management of Maxillofacial Trauma Emergency Department Presentations in an Evolving Pandemic. Did COVID-19 Change Our Practice?

Abstract Aim Trauma encompasses a significant proportion of referrals to Oral Maxillofacial Surgery (OMFS). COVID-19 called for clinicians globally to tailor practice and follow-up patterns. Multiple government-imposed lock downs saw changes in patterns of emergency department (ED) attendances nationally. The aim of this audit was to examine the impact of COVID-19 on Maxillofacial trauma presentations, admissions, and existing practice in University Hospital of Wales (UHW). Method Data was collected using an electronic patient database “Team Talk”. Patients filtered by pathology (Soft tissue trauma, fractures) and location (ED). Annual data collected for 2019, 2020 and 2021, to compare pre-pandemic (2019), evolving pandemic (2020) and established pandemic (2021) figures. Results Trauma made up 74%, 73% and 78% of total OMFS referrals (2019, 2020, 2021). There was an 83% decrease in the number of trauma referrals between 2019 and 2020, despite UHW becoming a major trauma centre. No correlation identified between trauma presentations and lockdown events (2020) but lifting of restrictions (September 2021) showed an increase in presentations. 16.8%, 16.4% and 16.2% (2019, 2020 and 2021, respectively) of ED referrals were offered follow up follow up. Percentage of follow up appointments used for removal of sutures (ROS) decreased by 30% (2019–2020). Conclusions

CD28- Cells Are Increased in Early Rheumatoid Arthritis and Are Linked With Cytomegalovirus Status.

Objective: CD3+CD8+CD28− cells are higher in Rheumatoid Arthritis (RA). The aim of this study was to assess CD3+CD8+CD28− cells in patients with early RA and assess the effects of cytomegalovirus (CMV) seropositivity.Method: In this prospective observation study, 50 RA patients were recruited from Cardiff University Hospital of Wales (UHW) rheumatology outpatient, 25 patients with early disease (disease duration 0–6 months) and 25 patients with established disease (>2 years). These were compared with 25 healthy controls. Clinical and serological markers of inflammation were noted, and peripheral blood mononuclear cells were analyzed using flow cytometry.Results: The percentage of the CD8+CD28− T cells was increased in RA patients and was associated with disease duration. The percentage of CD8+CD28− T cells was increased in CMV positive early and established RA grouped and early RA patients in comparison to CMV negative patients (p < 0.05). There is a weak but statistically significant correlation between the percentage of CD3+CD8+CD28− cells and CRP in CMV positive RA patients (r = 0.227, p < 0.05).Conclusion: The percentage of CD8+CD28− T cells is higher in RA patients and correlates with disease duration, highlighting a potential role early in the disease process. These cells were also higher in CMV positive early RA patients which may suggest a role of CMV in disease development.

The effect of the revised WHO classification on the incidence of grade II meningioma

Introduction: A retrospective study over a three-year period at University Hospital of Wales (UHW) of the incidence of atypical cranial grade II meningioma both pre and post 2016 revision of The World Health Organisation (WHO) classification of tumours of the central nervous system.Subjects: All available histology from January 2015 to December 2017 of patients with cranial meningiomas.Method: Institutional online reporting system Welsh Clinical Portal to identify patients and view histology reports.Results: Overall 164 patient histology results were analysed (median age 59, age range 23-82, 74% females). There were 55 patients in 2015: 69.1% grade I, 29.1% grade II and 1.8% grade III. There were 109 patients in 2016/17; 68.8% grade I, 29.4% grade II, 1.8% grade III.Discussion: There is significant variability in the reported incidence of grade II meningioma, likely due to variation in local interpretation of diagnostic criteria. Neuropathologists at our institution have reported brain invasion as grade II prior to 2016. This was due to compelling published evidence that brain invasive meningiomas have recurrence and mortality rates similar to that of grade II meningioma as defined using other criteria. The new 2016 WHO criteria now recognise this specifically. As other institutions adapt to the amended 2016 guidelines we anticipate that there will be a greater consensus in line with our incidence rates of grade II meningioma.

P03-T A review of patients with possible Occipital-lobe-seizures (OLS) seen at University-Hospital-of-Wales (UHW) in 2018

Introduction Patients having experienced OLS describe their seizures as featuring bright colours, and severe blurring of their vision, occasionally ictal vomiting, deviation of the eyes, and hypersalivation with or without impairment of consciousness. OLS are thought to account for between 5% and 10% of epilepsies with photo-sensitive epilepsies occurring in 1–5% of epilepsies. Method EEG’s including prolonged, sleep deprived and video monitoring EEG’s including (where appropriate) hyperventilation and photic-stimulation were reviewed in 929 patients referred at the UHW during 2017–2018. Results Four patients were found to have evidence of occipital lobe seizures. One was a juvenile patient with suspected idiopathic occipital lobe epilepsy. One patient was found to have posterior temporal/occipital lobe abnormality on Magnetic Resonance Imaging as a result of childhood injury. MELAs and concordant occipital stroke were thought to be the cause of the third patient. The final patient has been treated intensively because of injury due to collapse. Vomiting was not a feature of any seizure semiology. Hypersalivation and spitting were observed late into the seizure of one patient (spread temporally with secondary generalization). All described visual disturbance ranging from simple colored 2-dimensional shapes in the vision to more complex kaleidoscopic manifestations. Electrographic correlate was similar comprising repetitive sharp wave discharges. Conclusion Although thought to account for 5–10% of epilepsies, we at UHW (the largest teaching hospital in Wales) found OLS accounted for a very small percentage of confirmed epilepsies.

The Impact of the Implementation of a New Selective Screening Program for Neonatal Hip Ultrasound in Cardiff and Vale University Health Board

Objective: Developmental dysplasia of the hip (DDH) is a common and preventable cause of disability. Early detection of DDH (<3 months) is associated with reduced risk of surgical treatment, hence in addition to the traditional clinical screening, NIPE guidelines advocate the use of selective screening of those with DDH associated risk factors. In 2016, Cardiff and Vale University Health Board (CAVUHB) implemented a selective screening program for DDH. This research will determine the impact and up-to-date cost effectiveness of a selective screening for DDH. Methods: A retrospective study of all patients born between 1st of January 2016 and the 31st of December 2016, who underwent ultra-sonographic screening for DDH in CAVUHB. Ultrasounds were graded using Graf’s classification, treatment outcomes were determined by patient’s records and costings were based on 2016 NHS tariffs. The research took place at the University Hospital of Wales (UHW). Results: Screening of those with risk factors for DDH, but a normal examination diagnosed 72% of all DDH cases and 38% of treated DDH cases. Screening for risk factors cost CAVUHB £98914, with a cost per favorable outcome, defined as early detection and successful treatment of DDH without surgical intervention, of £12364. The mean cost of DDH treatment of a patient missed by screening was £14431. All DDH cases were detected through breech presentation or family history risk factors. Screening only those with these risk factors is more cost effective and equally successful with a cost per favorable outcome of £9095. Conclusion: The selective screening program was successful and cost effective in detecting and treating cases of DDH. However, the screening process can be made more cost-effective without reducing DDH detection rate, by omitting statistically insignificant risk factors from the screening criteria. Early detection of DDH is important for effective treatment. CAVUHB cost-effectively reduced morbidity and potential surgical mortality within the neonatal population because of its selective screening program for DDH.

Epidemiology and outcomes of advanced necrotising enterocolitis

Background: A life-threatening gastrointestinal emergency, necrotising enterocolitis (NEC) presents commonly in neonates. It may be medically or surgically managed. The demographics of NEC patients in the University Hospital of Wales (UHW) and their long-term outcomes are largely unknown. Aims: To investigate factors associated with NEC, including methods of management, and correlate these with outcomes (mortality/discharge). Methods: A retrospective service evaluation comparing inborn and outborn infants diagnosed with NEC during a 5-year period, who were admitted to the Neonatal Intensive Care Unit (NICU), UHW. The Vermont-Oxford Network (VON) criteria determined the confirmed cases and the data was collected from the ‘BadgerNet’ database and IMPAX image viewer. Results: All infants with poor outcomes (mortality) were preterm. Most were born by emergency caesarean, had low APGAR scores and birth weights <1kg. There was a significant difference in the volume of feeds at diagnosis between the inborn and outborn cohort (p<0.01) and between those who died and those with better outcomes (p<0.05). Discussion: Most infants in UHW with NEC require surgical input, but surgery alone does not correlate directly with higher mortality. Low gestation/birthweight and larger volume of feeds at diagnosis are high contributors. Further research will expand the database and permit follow-up of the cohort post-discharge.

Lessons in speed from Formula One.

Could observing a sports team be the key to improving care in a time-critical hospital environment? Nick Evans, writing in Nursing Children and Young People, examines how a collaboration between a Formula One team and the University Hospital of Wales (UHW) generated ideas for clinicians to improve care. What similarities did the neonatal team at UHW spot between the sport and resuscitative care? And what changes did the hospital make following the collaboration?

Lessons in speed from Formula One.

A COLLABORATION between Formula One team Williams and the University Hospital of Wales (UHW) has provided clinicians with a host of ideas about how to improve care.

PWE-221 Improving the practice of nutrition therapy in the critically ill patient: Abstract PWE-221 Table 1

Introduction In 2013, the University Hospital of Wales (UHW) participated in the fourth International Critical Care Nutrition Survey, a period prevalence survey led by Daren Heyland of the Clinical Nutrition Unit, Canada. This Quality Improvement Project aims to compare nutritional practices within and across countries and to highlight strengths and weaknesses leading to practice improvement. Method Critical Care units were eligible to participate in the survey if they had a minimum of 8 beds, and enrolled a minimum of 20 patients within a set time period. Over 100 patients were screened for enrollment criteria - aged ≥ 18 years of age, mechanically ventilated with 48 h of admission and remained for ≥ 72 h in the unit. For each patient a questionnaire was completed. This included patient demographics, diagnosis, co-morbidities, clinical parameters and severity of illness scores, nutritional status, nutritional requirements, feeding route and when nutrition was commenced. Data was subsequently collected for up to 12 days for actual nutrition received from enteral and parenteral sources in addition to insulin and glycaemic control. Patient outcomes included duration of mechanical ventilation, critical care and hospital outcomes. Data was collected by 2 Dietitians and submitted using the web based data collection tool. UHW data was validated for 3 randomly selected patients, and a comprehensive report comparing our patients and practice with Critical Care units in Europe and overall worldwide was provided by the Clinical Nutrition Unit. Results 190 Critical Care Units participated in the 2013 International Survey. UHW enrolled 23 of the total 3997 patients and 243 of the 37460 days analysed. The results of UHW–s practice compared with the other units are shown in the Table 1. Conclusion UHW was ranked joint 4th in the 2013 International Critical Care Survey and is the highest achievement of any UK hospital to date. The UHW feeding protocol has been further revised as a result of this improvement project and is both evidence based and practical. UHW participated in the 2014 survey and is currently awaiting the results. Disclosure of interest None Declared.

Setting up an alcohol treatment centre

In the emergency unit at University Hospital of Wales (UHW), Cardiff, a rise in the number of patients presenting with alcohol intoxication was reducing the amount of clinical space available to, and affecting the care of, other patients. In response, an alcohol treatment centre (ATC) staffed by emergency nurse practitioners, healthcare assistants and police officers was set up and piloted for three months in the city centre to ensure that people who were severely intoxicated could be managed safely without attending the emergency unit at UHW. This article describes the collaborative approach adopted to launch the three-month pilot project and discusses findings from a review of the ATC conducted when the pilot had ended. These findings indicate that severely intoxicated patients at low or moderate risk had been diverted from the emergency unit to the ATC and that clinical care in the unit, and police and ambulance services, had improved as a result.

A Respiratory Centre and Network Model for the Management of Severe Hypoxaemic Respiratory Failure

The development of specialist respiratory centres for the management of severe refractory hypoxaemic respiratory failure is advocated based largely on three premises: 1. High volume units have better outcomes than smaller volume units.1-4 2. The provision of extra-corporeal membrane oxygenation (ECMO) in the UK is limited and patients should be selected according to need. Those patients requiring ECMO are best recognised by intensivists working in high volume centres, either following discussion with the smaller unit or following a trial of care in the high volume centre.5 3. Only larger units have what Bob Winter refers to in his editorial in the January 2011 issue of JICS as a ‘wider range of witchcraft’6 and others may know as high frequency oscillation (HFOV), and nitric oxide (NO). These may have a role as rescue therapies before a trial of ECMO. Those arguing against such logic point to the following flaws: 1. Comparing outcome of high volume to low volume units does not equate to the introduction of a policy to transfer patients failing conventional treatment. 2. Transfer of patients is already historically contentious7,8 and a second transfer for ECMO, following an initial transfer from a small unit to a respiratory centre is even more so. 3. There is a lack of compelling evidence demonstrating benefit from ECMO, HFOV, NO, and prone ventilation. To summarise, those arguing against the respiratory centre concept point to a lack of good evidence for its implementation, and worry that the real agenda is one of centralisation of services. Those arguing for respiratory centres cite the unintended consequence in the CESAR study, demonstrating that patients transferred but not receiving ECMO had better than expected outcomes.9 The document ‘The management of severe refractory hypoxia in critical care in the UK in 2010,’5 recommends that Networks implement the policy of identifying respiratory centres. In South East Wales we have had a managed clinical network for five years (SEWCCN), covering three of the seven recently created Welsh Health Boards (Aneurin Bevan, Cwm Taf and Cardiff and Vale University Health Board). Within the three Health Boards, there are five District General Hospital (DGH) critical care units which each have between 5-8 level 3 beds, and one Teaching Hospital Unit – University Hospital of Wales (UHW) – which has 14 level 3 beds (Table 1). Early in the 2009 H1N1 influenza A pandemic, it became clear that the morbidly obese and those with chronic lung disease were at greater risk of severe respiratory failure. South East Wales, with a population of 1.4 million, has a particularly high incidence of obesity10 and chronic lung disease11 related to previous industrial lung exposure, severe chronic social deprivation, and a high prevalence of cigarette smoking. We therefore expected to be particularly vulnerable to this pandemic, and set up in 2009 what would now be recognised as a ‘Respiratory Centre’ model. A series of meetings about influenza were organised by the Network to agree a way forward based on the information about H1N1 available at that time. When it became clear that ventilators planned for use to create surge capacity were not fit for the purpose of ventilating patients with severe refractory respiratory failure, the first step the Network took was to improve equipment in all units. Following discussion with the SEWCCN, the Welsh Assembly Government agreed to fund 50% of the level 3 surge capacity ventilators as intensive care unit ventilators. The second step, based upon the published experience particularly from North America and Australasia, was to develop local protocols: in Canada,12 81% of patients (n=168) were ventilated on the first day of critical care admission. Of those that required rescue therapy for hypoxia, 28% received neuromuscular blockade, 13.7% inhaled NO, 11.9% HFOV, 4.2% ECMO, and 3% prone ventilation. In Australasia 11.6% of those mechanically ventilated (n=456) received ECMO for H1N1 Hospital Number of Surge capacity Level 3 beds identified

Referrals for cataract surgery: variations between different geographic areas within a Welsh Health Authority.

The aim of the study was to identify variations in cataract presentation within three different eye units in a single health authority and to identify any correlation between cataract presentation and social deprivation indices. We also compared our patient profile and results with the UK National Cataract Audit Statistics. It was a prospective multicentre questionnaire-based project involving three hospitals: Cardiff Eye Unit--University Hospital of Wales (UHW), Royal Glamorgan Hospital--Llantristant (RGH), and Prince Charles Hospital--Merthyr Tydfil (PCH). Demographic, clinical, and socioeconomic data were collected in patients undergoing cataract surgery. Patients were also asked to fill in the questionnaire based on Berth-Petersen Visual Function Index (VF-14) indicating difficulty in performing daily living activities. A total of 112 patients were recruited in the study. Demographics were similar to National Cataract Audit. However, the percentage of patients with poor visual acuity (less than 6/60) at the time of surgery was greater at all the three hospitals compared to the national statistics. Among the three hospitals at South Wales, PCH had the lowest visual acuity in both listed and fellow eye and the lowest VF-index. Both the outpatient and surgery waiting times were longest at PCH. The population at PCH also visited their optician least frequently. Our results show significant variation in cataract presentation between the three eye units within a single Health Authority. These variations correlate well with social deprivation indices and poor use of Optometric services. Local policies are needed to redress these inequalities and raise public and professional awareness of causes of poor sight in the elderly population.

Molecular characterization of clinical and environmental isolates of vancomycin-resistant Enterococcus faecium and Enterococcus faecalis from a teaching hospital in Wales.

The present study describes the first molecular characterization of environmental and clinical isolates of vancomycin-resistant enterococci (VRE) in Wales. Over a 3-month period (May-July 2000), 134 isolates of VRE (89 Enterococcus faecium and 45 Enterococcus faecalis) were isolated from the patient environment of the University Hospital of Wales (UHW) in Cardiff, Wales, UK. In addition, over the same time-period, 24 clinical isolates of VRE (20 isolates of E. faecium and four isolates of E. faecalis) were obtained from 14 patients. All study isolates were subjected to PFGE typing and their van genotypes were determined by using multiplex PCR. The vanA PCR product (231 bp) was evident in 146 (92 %) of 158 VRE isolates; the remaining 12 isolates (8 %) were positive for the vanB gene. All isolates of E. faecalis were found to be vanA-positive. In total, 16 PFGE banding profiles (pulsotypes) were observed for environmental isolates of E. faecium, whilst eight pulsotypes were found for isolates of E. faecalis. Some of these pulsotypes were isolated from multiple sites, whereas others were more restricted in their distribution. Eleven pulsotypes were evident for clinical isolates and eight of these (representing 11 isolates) were also encountered in environmental isolates. Eleven clinical isolates of E. faecium (55 %) shared an identical pulsotype that was not detected in environmental isolates. These results demonstrate a heterogeneous environmental population of VRE and an association of certain strains with clinical isolates. Predominance of a single pulsotype (not detected in the environment) amongst clinical isolates suggests non-environmental transmission between patients.

Role of a Domiciliary Physiotherapist in the Treatment of Children with Cystic Fibrosis

Summary This article describes the contribution to patient care made by a part-time physiotherapist with domiciliary responsibilities who has worked exclusively with paediatric cystic fibrosis (CF) patients over the past nine years as a member of the CF Unit, Department of Child Health, University Hospital of Wales (UHW), Cardiff. The article outlines the physiotherapy input both to the CF clinics held at UHW and at shared-care clinics throughout Wales. It also describes the main indications for the use of the domiciliary service, its responsibilities and possible benefits.