British journal of healthcare innovations Jan 2016 by Sanjeev Agarwal

Volume 1 | Issue 1 | January 2016

British Journal of

Healthcare Innovations Improving patient care and optimising resource utilisation

In This Issue Wales Deanery in the forefront of training innovations A collaborative approach in managing hip fractures Enhanced recovery reduces transfusion rates Reconfiguration of breast surgery services A solution to NHS recruitment problems App to ensure examiner objectivity Injection snoreplasty is effective

British Journal of Healthcare Innovations

BAPIO (Wales)

Chair: Keshav Singhal

Secretary: Hasmukh Shah

BAPIO Wales Conference, 16th January 2016 – City Hall, Cardiff 1.15

Registration and coffee

1.45

Introduction and House rules Dr Hasmukh Shah Secretary BAPIO (Wales)

1.50

Chairman’s address Mr. Keshav Singhal MBE Chair BAPIO (Wales)

1.55

Inauguration and address by Prof. Mark Drakeford Minister for Health and Social services

2.05

Roadmap for NHS Wales Dr. Andrew Goodall Director General Health and Social Services & Chief Executive NHS Wales

2.25

Empowering the medical workforce (Value based leadership and patient safety) Dr. Umesh Prabhu Medical Director WWL Foundation Trust

2.45

Infections and Antibiotics Dr Chris Jones Dy. Chief Medical Officer NHS Wales

3.05

Prudent Healthcare Mr. Hamish Laing

3.25

Role of clinicians in tackling NHS waste and inefficiency Dr. Parag Singhal Director Acute Care Weston Area Health Trust Hon. Secretary BAPIO UK

4.05

Panel Discussions including audience participation Dr. Andrew Goodall, Dr Chris Jones, Mr. Hamish Laing, Dr. Parag Singhal, Dr Umesh Prabhu

Medical Director ABMU Health Board

“Getting the best out of BME medical workforce” “Recruitment and retention” “Is Hours based contract detrimental to NHS?” 4.45

Scientific papers on Innovative practises

5.45

NICE 2015 Type II Diabetes guidance Dr Atul Kalhan Consultant in Diabetes, Royal Glamorgan Hospital

6.05

NHS pensions talk Dinesh Bharwani

6.15

Summing up and Vote of Thanks Dr. Ashish Wagle Consultant anaesthetist

Wesleyan

British Journal of Healthcare Innovations Jan 2016 1(1) British Journal of Healthcare Innovations Jan 2016 1(1)

CONTENTS Injection snoreplasty – A novel approach for the treatment of snoring Developing medicines fit for the 21st century Indo-British collaboration: Reducing reliance on agency locums in the NHS Transforming Breast services in Cardiff and Vale An innovative model of care for hip fractures Enhance recovery protocols reduce transfusion rates in hip and knee replacements Wales deanery in the forefront of innovation Alcohol detox pathway: Improving efficiency through initiative for head neck cancer patients X ray teaching and assessment smart app – The Diagnoster Streamlining audiology referrals to the ear, nose and throat department (ENT):

5 10 14 18 21 24 31 33 36 39

Delivering complex therapy for Parkinson’s disease at local level:

Postoperative wound management: A step forward Integrating complementary and mainstream medicine. An innovative thought

45 49

A collaborative project to create an efficient and cost effective pathway for acoustic neuroma screening A novel & innovative concept

Editor in Chief Keshav Singhal MBE FRCS, MS(Orth), M.Ch(orth) Consultant Orthopaedic Surgeon Princess of Wales Hospital, Bridgend Chair BAPIO (Wales)

Executive editor

Parag Singhal MD,MPhil,FRCP(London) Consultant Endocrinologist & Director, Acute Services Honorary Lecturer Bristol University Honorary Secretary BAPIO UK

Editor Sanjeev Agarwal MS, DNB, FRCS(Ed), FRCS(Trauma & Orthopaedics) Consultant Orthopaedic Surgeon University Hospital of Wales, Cardiff Honorary Lecturer, Cardiff University

British Journal of Healthcare Innovations Jan 2016 1(1) British Journal of Healthcare Innovations Jan 2016 1(1)

From the Editorsâ&#x20AC;&#x2122; desk

Healthcare costs accounts for over 9% of the GDP for United Kingdom, with other countries spending between 1.3% to 19.7%. The rapid development in science and technology over the last few decades has transformed healthcare in most countries around the world.

2. To disseminate information about efficiency and cost improvements to the NHS.

While the National Health Service remains one of the best health services in the world, it is faced with multiple challenges of increasing expectation and demand on account of increased life expectancy on one hand, and resource constraints on the other hand.

4. Provide a platform for innovators and researchers to discuss and promote new research ideas.

3. To provide a platform for publishing papers on complimentary therapies, and to highlight the improvements in chronic disease that are possible with such therapies.

5. Increase the awareness of public and health care personnel to the challenges being faced by the medical profession worldwide.

The NHS five year plan laid out in October 2014 suggests a ÂŁ30 billion funding gap that needs to be overcome by 2020/21 by a two pronged strategy of an extra 2% efficiency/demand saving per annum along with staged increases in funding as the economy allows.

Getting a peer-reviewed journal ready within two months of conception of the idea is no mean feat and we are very grateful to our patrons, contributors, fellow editorial board members and our advisory board for their invaluable help and guidance in this unique venture.

In view of this, a cost effective delivery of healthcare is critical to ensuring a sustainable and long-term viable service. There are innumerable journals that highlight the advances in modern medicine dealing with basic science and clinical research. However, there are scarcely any publications championing the efficiency and demand savings that the NHS desperately needs, so as to continue to be a world class service.

We expect this journal to be of interest to a diverse group of healthcare professionals including 1. Senior NHS managers across the country 2. Department of health 3. Medical and allied professions 4. Pharmaceutical manufacturers.

Concurrently, it was also obvious that there were a large number of innovations at the local level, but these were not being adopted on a larger scale as there was no vehicle for their dissemination.

and

medical

device

5. Biomedical researchers and innovators 6. General public This journal would be published twice a year and due to an overwhelming response from the authors, we are already editing the next issue due to be published in July 2016 and look forwards to your continuing support for years to come. It is intended as an open access publication.

This journal was therefore conceptualized with the following aims 1. To showcase innovations in healthcare service delivery by publishing original articles from doctors and allied health professionals, including technical innovations.

British Journal of Healthcare Innovations Jan 2016 1(1) British Journal of Healthcare Innovations Jan 2016 1(1)

Patrons Prof. Bhikhu Parekh FRSA, DSoc.Sci, Ph.D Baron Parekh of Kingston upon Hull Fellow British Academy

Alun Cairns MP Parliamentary Undersecretary of State for Wales Lord Commissioner of HM Treasury

John Penrose MP Parliamentary Secretary Cabinet Office Lord Commissioner HM Treasury

Advisory Board Sir Paul Williams OBE, CStJ DL Non Executive Director, Natural Resources Wales Member of Ministerial advisory board for Economy, Science & Transport Gordon Bannister FRCS Professor of Orthopaedic Surgery, University of Bristol Davinder Sandhu MD, FRCS(Ed Urol) FRCS Glas & Eng. Head of School of post graduate studies and research Royal College of Surgeons of Ireland, Bahrain Arun Baksi FRCP Consultant Emeritus Physician The Arun Baksi Centre for Diabetes and Endocrinology St Maryâ&#x20AC;&#x2122;s Hospital, Newport, Isle of Wight Dr Michael Dixon LVO, OBE Chair, College of Medicine Visiting Professor, Universities of London & Westminster

British Journal of Healthcare Innovations Jan 2016 1(1) British Journal of Healthcare Innovations Jan 2016 1(1)

Editorial Board

Dr Hasmukh Shah

GP Principal, LLwynypia, South Wales

Mr Deepak Gupta

Consultant ENT Surgeon, Swindon

Mr Ravi Nannapanini

Consultant Neurosurgeon, Cardiff

Dr Sameer Srivastava

Director, Non invasive Cardiology, New Delhi,

Dr Ashish Wagle

Consultant Anaesthetist, Rhondda

Mr Sumit Goyal

Consultant Breast Surgeon, Cardiff

Ms Indu Deglurkar

Consultant Cardiac Surgeon, Cardiff

Dr Jyoti Bansal

Consultant Radiologist, Cardiff

Prof Rajiv Agarwal

Consultant Plastic Surgeon, Lucknow

Prof Tulika Chandra

Professor of Transfusion Medicine, Lucknow

Mr Khitish Mohanty

Consultant Orthopaedic Surgeon, Cardiff

Dr Sunil Mungi

Consultant Cardiologist, Peoria, US

Christine Perry

Director of Nursing, Royal Cornwall Hospital, Truro

Dr Anju Sinha

Consultant Gynaecologist, Cardiff

British Journal of Healthcare Innovations Jan 2016 1(1): 5-9

British Journal of Healthcare Innovations Jan 2016 1(1):5-9

Original Article Injection Snoreplasty – A Novel approach for the treatment of Snoring Urmil Chalishazar Abstract Snoring is a very common disorder with huge social implications. Injection snoreplasty is a technique where Sodium tetradecyl sulphate (STS) – a sclerosant substance is injected into the soft palate. It produces scar tissue to stiffen and reduce palatal flutter responsible for snoring. An observational, nonrandomised study was conducted to evaluate the effectiveness of Injection Snoreplasty in improving primary snoring. The procedure was performed on 52 patients diagnosed with primary snoring due to palatal flutter, on clinical examination. All patients received two doses of the injection at intervals of six weeks. We found significant subjective improvement in snoring reported by patients and their bed partners following injection snoreplasty. Forty five patients were followed for 6 months after the procedure. Almost two third (64%) patients reported great improvement in snoring at 3 months, which reduced to 58% at 6 months. Injection snoreplasty is minimally invasive and an effective treatment to improve primary snoring in carefully selected patients. Introduction Snoring is a major social problem affecting marital life. According to one epidemiological study, 40% of adult population in the UK snore (15 million).1 It is twice as common in men as women. Snoring is a low frequency sound produced by vibration of the upper airway mainly from the soft palate. There are other sites like the nose, adenoids, tonsils, base of the tongue and pharyngeal walls, which can cause or contribute to snoring. The common risk factors are middle age, obesity, alcohol, smoking and acid reflux.2,3 Snoring may be a manifestation of underlying sleep apnoea, which if left untreated, can have serious cardiovascular consequences.3

There are many treatments available for snoring. However, none of these treatments are without side effects nor offer a permanent cure.2 Therefore, there is a great demand for further research and long term follow up studies to determine the best method. A combination of the patient’s clinical history preferably with the partner, along with the Epworth Sleepiness Score (ESS) and Body Mass Index (BMI) can be used to screen out non-apnoeic snorers with sensitivity of 93 percent and specificity of 60 percent.3 The site/s of obstruction (in the upper airway) should be determined by clinical examination and using flexible nasal endoscopy to perform Mṻller manoeuvre. Sleep nasal endoscopy is the preferred method in the UK.

Mr. Urmil Chalishazar, Department of Ear, Nose & Throat, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, UK. Correspondence Email: ukc@sky.com

British Journal of Healthcare Innovations Jan 2016 1(1): 5-9

British Journal of Healthcare Innovations Jan 2016 1(1):5-9

expense.6 The substance produces aseptic inflammation in the sub-mucosal layer of the soft palate producing scarring and stiffening to reduce palatal vibration and snoring.7

It involves using Propofol in the anaesthetic room inducing sleep. However, there are higher cost implications with this technique. The medical treatment for snoring involves weight reduction, sleep hygiene, abstaining from alcohol and sleeping pills and treating underlying associated medical conditions such as hypothyroidism, acid reflux, rhinitis etc.

Material and methods Injection snoreplasty was performed in 52 adult patients. The diagnosis of primary snoring was made on the basis of detailed history and clinical examination. Patients were selected with tonsils size I and II (Freidman classification) and palate grade between I & III (Mallampati scoring). Patients with severe anti-social snoring without suggestion of obstructive sleep apnoea and single or predominant palatal level obstruction were offered the treatment (Table: 1). All patients were issued a pre-procedure information leaflet explaining Injection Snoreplasty. Patients with multiple drug allergies, on anticoagulants, multiple co-morbidities and pregnant women were excluded from the study. A written consent for the procedure was obtained. The procedure was performed in the outpatient clinic under topical anaesthetic using 10% xylocaine spray. 2 ml 3% Sodium Tetradecyl Sulphate (Fibrovein registered trademark STD pharmaceutical LTD, Hereford, England) was injected as described in literature.

Mandible advancement device can be helpful in patients with predominant base of tongue level obstruction. Continuous Positive Airway Pressure (CPAP) is the gold standard treatment for obstructive apnoea.2, 3 Common Surgical treatment includes correction of nasal pathology, Uvulopalatoplasty (UPPP), laser assisted palatoplasty (LAUP), and radiofrequency tissue volume reduction (RFTVR) of the soft palate, which have been developed and evolved in last several years. There are varying success rates for each of the surgical procedures but each of them have major disadvantages of high cost and significant post operative morbidity.4, 5 Injection snoreplasty was introduced by Dr. J. F. Strauss in 1943. Brietzke and Mair (2001) from Walter Reed Army Centre in Washington DC popularised injection snoreplasty, using Sodium Tetradecyl Sulphate – a sclerosant injection in the soft palate without pain and

Table 1: Patient selection criteria for Injection Snoreplasty - Body Mass Index < 30 - No history suggestive of sleep apnoea - Only/predominantly palatal obstruction - Tonsils grade I or II - Mallampati palate classification grade I-III - No Nasal pathology e.g. deviated septum, nasal polypi etc.

Figure 1: Sites of Injection in Injection Snoreplasty. ‘X’ mark shows the site of Injection

British Journal of Healthcare Innovations Jan 2016 1(1): 5-9

British Journal of Healthcare Innovations Jan 2016 1(1):5-9

scarring (average 1.8 injection per patient in Brietzke and Mair series)7. Subsequent follow ups were arranged after six weeks and six months with their partners.

One ml was given in the midline approximately 1-2 cms above the base of the uvula and 0.5 ml each on either sides of the first injection at approximately 2-2.5 cm laterally (Figure 2).

Both the patient and their partner filled out a snoring outcome survey (adapted from outcome science Inc, Boston USA) for subjective assessment of snoring improvement. Those patients who had no improvement after the procedure (two injections) were offered an alternative treatment. Results The study included 52 patients. Seven patients were excluded from the study after enrolment. Three patients did not attend follow up after first injection, two patients decided to opt for surgical treatment after the first dose of Injection Snoreplasty and two patients gained weight increasing their BMI over 30, hence excluding them from the study. The age ranged from 31 to 78 years old with mean age of 49.4 years. There were 34 males and 11 females. All the patients described this experience to be an unpleasant one. Nevertheless, the pain they experienced was only short lived. Only one patient developed an ulcer at the site of injection, requiring them to attend the Accident and Emergency department and were treated with oral antibiotics and analgesia. None of the patients reported serious complications such as airway compromise, palatal necrosis or fistula. The subjective criteria for improvement included at least 50% reduction in snoring loudness, reported by the partner on visual analogue score (VAS) and able to share the room without his/her sleep being disturbed. The additional symptomatic improvement reported by the patients were namely better quality of sleep and feeling fresh on waking up, were also considered in overall success of the procedure. Twenty nine out of forty five patients (64.4%) reported improvement in snoring at 3 months. Fifteen (33.3%) patients who had previously reported that they could not share the same room with their partner on at least 3-4 nights/week could do so after the injection snoreplasty procedure. The success rate dropped to 58% at 6 months after the procedure, comparable with most studies.8, 9,10,11,13

Figure 2: Clinical picture showing the injection snoreplasty procedure Most patients tolerated the procedure very well, only complaining of a burning/stinging sensation at the site of injection and/or feeling of a lump in their throat. They were kept in the waiting area for 20 minutes for observation after the procedure and sent home with a prescription of Difflam速 (Benzydamine hydrochloride- trade mark Meda pharmaceutical, England) topical spray. All patients were given 6 weeks follow up appointment to assess their improvement and proceed with the second dose. The second injection was split in 0.5 ml and given parallel to the first injection site to produce uniform

British Journal of Healthcare Innovations Jan 2016 1(1): 5-9

British Journal of Healthcare Innovations Jan 2016 1(1):5-9

Iseri and Balcioglu (2005) compared the results of radiofrequency (RF) versus injection snoreplasty in simple snoring. The results illustrated 87.5% and 76.7% satisfaction in snoring improvement by RF and IS, respectively.11

Discussion Snoring is a widespread disorder affecting 40% of middle aged adult population, higher incidence in men than women.1 There are enormous social implications ranging from not been able to share the room at home and on holidays to disturbing neighbours and major strain on marriage / relationship.

From current literature, the long-term results of Injection Snoreplasty are not known. However, same as with other more invasive and expensive surgical techniques like UPPP, LAUP or RFTVR (Table 2) the palatal stiffness lessens with time due to softening of the scar tissue in palate.3,4,5,12 The greatest advantage of Injection Snoreplasty over these techniques is the simplicity, reproducibility, minimal cost and very good patient compliance with comparable results.13

There are several treatment options available varying from medical to surgical. 2,5 There is generally poor compliance with non-surgical treatment namely weight reduction, CPAP, Mandible advancement device etc.5 Surgical options have certain disadvantages; significant pain and prohibitive cost being most common.5 Sclerotherapy is used in treatment of superficial varicose veins for a long time. Sodium Tetradecyl Sulphate (STS) has an excellent long term safety record. It has been used in various head and neck lesions like haemangiomas, arteriovenous malformation, glomus tumor in middle ear and cystic hygroma.

Table: 2 Result comparisons with different techniques.

In this study 3% Fibrovein® was chosen over 1% in order to increase effectiveness in volumetric tissue reduction and produce greater stiffness of the palate. The results from this study has shown that injection snoreplasty is effective in significant number of cases (64%) in reducing/abolishing snoring for at least short term, up to six months.

Procedure

Early results

UPPP

65 – 100% 60 – 90 % 50 – 85 % 64 %

LAUP RFTVR IS (our series)

Short / Medium term > 6 months to 2 years 45- 60 % 57 % 52 % 58 %

UPPP – Uvulopalatopharyngoplasty, LAUPLaser assisted uvulopalatoplasty, RFTVR – Radiofrequency tissue volume reduction, IS – Injection Snoreplasty

There are some weaknesses of this study, such a small sample size, short follow ups and no objective data pre and post procedure. However, it would have defeated the purpose of cost effectiveness of the procedure. AlJassim and Lesser in 2008 published similar results and used this technique as an investigative as well as therapeutic for habitual snoring.8 Labra et al from Mexico used injection snoreplasty in management of snoring and mild sleep apnoea (2012). They found a marked reduction in apnoea hypopnoea and snoring index.9 Similar results were produced in a Polish study by Olszewska et al after injection snoreplasty showing significant reduction in snoring duration and intensity improvement in post procedure AHI (apnoea hypopnea index).10

Conclusion This study concludes that injection snoreplasty is inexpensive, safe and a minimally invasive clinic based procedure. In carefully selected patients, it reduces snoring significantly without complications, pain and cost, involved in other surgical techniques. References 1. Davey, Marianne J. Epidemiological study of snoring from a random survey of 1075 participants. British Snoring & Sleep Apnoea Association 2004

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British Journal of Healthcare Innovations Jan 2016 1(1):5-9

Snoring. Otolaryngology- Head and Neck Surgery 2005; 133:224-28

2. Main C, Liu Z, Welch K, Weiner G, Jones SQ, Stein K. Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs. Health Technol Assess 2009; 13(3)

12. Levin, Barry C., and Gary D. Becker. Uvulopalatopharyngoplasty for snoring: Long-term results. The Laryngoscope 1994; 104.9: 1150-1152.

3. Mc Namara M. The surgical management of snoring. Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7th Ed, Gleeson M. et al (eds) CRC press 2008 : 2325–2339.

13. Brietzke, Scott E., Eric A. Mair. Injection Snoreplasty-extended follow-up and new objective data. Otolaryngology--Head and Neck Surgery 2003; 128: 605-615.

4. Sundaram S, Lim J, Lasserson TJ. Surgery for Obstructive sleep apnoea in adults (Review). The Cochrane Collaboration and published in The Cochrane Library 2005; Issue 4. 5. Savage, Christopher R., and David L. Steward. Snoring: a critical analysis of current treatment modalities. Does anything really work? Current opinion in otolaryngology & head and neck surgery 15.3 (2007): 177-179. 6. Brietzke S, Mair E. Injection Snoreplasty: How to treat snoring without all the pain and expense. Otolaryngology - Head and Neck surgery 2001; 124: 503-10 7. Poyrazoğlu, Ethem, et al. Histologic effects of injection snoreplasty and radiofrequency in the rat soft palate. Otolaryngology--Head and Neck Surgery 135.4 2006: 561-564. 8. Al-Jassim A, Lesser T. Single dose injection Snoreplasty: investigation or treatment? The Journal of Laryngology & Otology 2008; 122: 1190-93 9. Labra A, Haro-Valencia R, Huerta-Delgado A, Jimenez-Correa U, Sanchez-Narvaez F. Efficacy of Submucosal Sodium Tetradecyl Sulfate in the Soft Palate as a Treatment of the Mild Obstructive Sleep Apnea Syndrome: A Pilot Study. Sleep disorders 2012; 597684: 14 10. Olszewska E, Panek J, O’Day J, Rogowski M. Usefulness of snoreplasty in the treatment of simple snoring and mild obstructive sleep apnea/hypopnea syndrome – Preliminary report. Polish Journal of otolaryngology 2014; 68/4: 184-88 11. Iseri M, Balacioglu O. Radiofrequency Versus Injection Snoreplasty in Simple

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Commentary Developing Medicines Fit for the 21st century Hedley Rees Abstract Health-care systems are buckling under the cost and complexity of satisfying the spiralling needs of patients world-wide. A sizeable component of the challenge is the ever increasing price of medicines, coupled with the complications of adopting new technologies offering patient-specific diagnosis and therapy. The backdrop to these challenges is a pharmaceutical industry comfortable with developing new products using an approach that has not changed for over fifty years. This approach has been demonstrated to be extremely wasteful and lacking innovation productivity, the latter affliction now affectionately termed ‘the patent cliff’. This article contends that the industry’s 20th century approach toward product development will not cut the mustard in the complex world of 21st century medicine. It argues that medicines are no different to any other product intended for end-users in customer markets, such as semiconductors, automotives, aerospace or electronics. A solution is offered based upon these other sectors way of working, namely prototyping as a precursor to commercial production. We argue medical prototypes are needed to pressure test compounds, using predictive technologies, before being considered for patient administration. The second stage, commercialisation, would mandate a multi-disciplinary team assessment of the likelihood of the prototype completing the journey through the valley of death. Candidates making it through the assessment would then receive the necessary investment from the Pharma Company applying for a licence to market the product. This upfront investment is likely to be significant, but nowhere near the $2.7 billion figure banded about today. That figure is mainly the cost of failed compounds. We argue here that the approach advocated will cut the cost of drug development to a fraction of where it stands today. We conclude with suggestions on how stakeholders in heath-care systems could help facilitate this transformational change. __________________________________________________________________________________________ Hedley Rees, Managing Director Pharma Flow, & Author of “Find it, File it, Flog it”, Advisory board member at International Institute for advanced purchasing and supply. Correspondence E mail: h.rees@pharmaflowltd.com

Building the case for change We begin this analysis by making the case for changing the current model for developing medicines.

British Journal of Healthcare Innovations Jan 2016 1(1): 10-13 British Journal of Healthcare Innovations Jan 2016 1(1):10-13

In 2006, the United States Government Accountability Office produced a report (GAO-07i 49) concluding that for every 250 drugs that entered the development pipeline, only five made it to testing in humans. The other 245 failed during pre-clinical assessment. Just think about that for a moment—the mulitude of employees and contractors carrying out the pre-clinical studies, the animals involved and the cash resources burnt— ninety-five percent plus is wasted.

J. Michael Pearson, CEO at Valeant Pharmaceuticals) have been snapping up these out of patent products that found application in orphan indications ignored by Big Pharma, ramping up the prices to extraordinary levels. They have been severely chastised, of course, but it does not alter the fact that Big Pharma’s modus operandi has contributed to this worrying trend.

What should change look like?

When in clinical development, the report concludes only one of the five survivors make it to market. The other four fail for reasons many and varied. The statisitc improves—only eighty percent in the bin this time—but given the huge sums of money and people resource required to conduct such studies, it remains a horrifc cost to society, repaid through the eye watering prices of drugs today required to recover this cost of failure.

If we accept the above, we must also accept that global health-care systems, faced with their own massive issues, are being weighed down by the th Pharma industry’s 20 century methods of product development. We conclude here, consequently, that things need to change radically, by turning product development on its head, as other sectors did very successfully in the 1950s and 1960s. They had similarly been throwing their products ‘over the wall’ into the system consuming their goods, until the Japanese revolution took place. Companies such as Toyota, Honda Nissan and Matsushita led the charge to place end-user value at the forefront of their missions in life. The results were startling as we all now know.

A second, less obvious issue, is the cost and complexity locked-in during the development process. Since the absolute focus during development is clinical efficacy, little if any attempt is made to optimise the manufacturing and supply aspects—with devasting impact on the industry’s ability to remediate issues once the product is on the market. Inflated costs, shortages, compliance failures, economic adulteration, and a number of related issues have become endemic in the industry.

The same has to happen in Big Pharma, the alpha male of the industry. Healthcare professionals and the patients they serve have to become the central focus of development activites—they must be deeply involved and consulted on the indication under consideration, at the earliest stage, even before pre-clinical assessment takes place. It is not sufficient to involve only a small number of investigators, appointed by the pharma company, in trialing drugs; attrition rates in the industry prove that.

A crippling side-effect of the cost issue is Big Pharma’s propensity to drop products once outside the patent protection umbrella, on the basis that they cannot be produced economically. These products will typically have been selling for ten or more years where profits have been high, very high. Over that period, the opportunity will have existed to significantly reduce the cost to manufacture and supply those products, so that once out of patent they could still yield more than acceptable returns. Sadly, that is a wasted opportunity which Big Pharma leaves to the generics industry, working to significantly reduced economies of scale.

Once this engagment takes place and the value proposition established, prototypes must be built and pressure tested before progressing into commercial development. Maximum use of predictive technologies must be employed, using in-silico and ex-vivo techniques. These methods have moved on unrecognisably in recent years, but the industry is reluctant to apply them in any meaningful way.

If this were not concerning enough, there is one last aspect to all this that is raising its ugly head as we speak. Opportunistic businessmen (such as Martin Shkreli, CEO of Turing Pharmaceuticals and

British Journal of Healthcare Innovations Jan 2016 1(1): 10-13 British Journal of Healthcare Innovations Jan 2016 1(1):10-13

Figure 1: Alternate stages in the drug development process To achieve the above, discovery research scientists need to stay and help develop the prototypes, rather than move on to ‘discover’ new compounds, oblivious to any issues arising from their previously orphaned offspring. Only those prototypes passing muster under the scrutiny of a multi-disciplinary review team (including the HCPs), would move forward into development for end-user markets. Figure 1 shows a schematic

Comparing the current and proposed new approach, readers will notice the iterative nature of the proposed approach, whereby candidate compounds are designed, tested and optimised and then subjected to clinical validation using predictive technologies. The power of this approach lies in the depth of scrutiny each compound receives, and this process weeds out potential failures at the starting gate.

Once on the road to development for commercial markets, a ‘production system’ approach must be taken, whereby the target destination is a product in end-users hands, not the statistical end-point of a clinical trial, as it is today.

What can stakeholders do to help? It would be naïve to think this level of change would be easy; it certainly was not for the other sectors discussed above. There is also no sign of one such as Toyota’s Taiichi Ohno emerging from the ranks of Pharma CEOs. We therefore contend that it is incumbent upon health-care system stakeholders to catalyze the change. Below are some suggestions, radical in part, that may be considered as a useful starting point.

This means that a much broader range of skills, including those derived from the world of engineering, must be recruited and applied; also leadership in taking the product to market will be a single continuum, rather than a two-tier approach as it is currently. This severely challenges the industry’s historic tendency to withhold allocation of resources until the later stages of clinical trials. However, this has only come about because attrition rates are so high. The solution is to reduce the attrition, as we suggest here, rather than withdraw the resources.

Governments The underlying root cause of the issues lay in patent laws, as applied in Pharma. Patenting a molecule with no evidence that it can be converted into a medicine is ridiculous. Along with

British Journal of Healthcare Innovations Jan 2016 1(1): 10-13 British Journal of Healthcare Innovations Jan 2016 1(1):10-13

“The final message is for CEOs of Big Pharma companies. Your predecessors discovered a wonderful way to build businesses, which could not be summed up better than by repeating the words of George W. Merck:

changing these laws to require more evidence for patent registration, Governments should also seek post mortems on failed drugs to prevent predicable ‘no hopers’ being pursued. If these two things were done, it would encourage drug developers to collaborate with health-care professionals to gather the necessary evidence and avoid the failures.

“We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear. The better we have remembered it, the larger they have been!”

Regulatory authorities Regulation is vitally important to patient safety, but there is a risk that it can sometimes confuse the interface between healthcare professionals and those developing drugs. We should bear in mind that a ‘highway code’ for medicines is essential, but it doesn’t automatically lead to safe drivers. Regulators should increasingly become facilitators of interaction, rather than enforcers of rules.

We rest our case. i

http://www.gao.gov/assets/260/253726.pdf Rees, Hedley Find It, File It Flog It: Pharma’s Crippling Addiction and How to Cure It, December 3 2015

Health-care professionals Health-care professionals must begin to view themselves as the ones in control and start with a proactive rejection of sales representatives at the door, if they have not already done so. They must cease dependence on Pharma derived statistical evidence supporting one-sided marketing claims, and anything else that detracts from the patient/provider interface. They should then push for early involvement in development of the drugs they prescribe, if not themselves personally, then their professional bodies. Patients Patients should ask their doctors the dumb questions and expect sensible answers. If the answers don’t work, they should keep on with the questions. As is often said, there is no such thing as a stupid question and the few minutes of embarrassment in asking the question could avoid decades of suffering by remaining silent. They should also support their health-care professionals in pushing back on Pharma sales speak. Pharma CEOs We conclude with the only stakeholder that can make change happen, with the ending paragraphs ii from my book

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British Journal of Healthcare Innovations Jan 2016 1(1): 14-17

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British Journal of Healthcare Innovations Jan 2016 1(1): 18-20 ! "#$%$&'!()*#+,-!).!/0,-%'1,#0!2++)3,%$)+&!(,+!4567!6869:6;<45!

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British Journal of Healthcare Innovations Jan 2016 1(1): 18-20 ! "#$%$&'!()*#+,-!).!/0,-%'1,#0!2++)3,%$)+&!(,+!4567!6869:6;<45!

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British Journal of Healthcare Innovations Jan 2016 1(1): 21-23 British Journal of Healthcare Innovations Jan 2016 1(1):21-23

Original Article An innovative model of care for Hip Fractures Abhaya Gupta Abstract Hip fractures in the elderly are a major source of mortality and morbidity and impose a huge financial burden on the health service. Setting up a new Orthogeriatrician led unit to manage hip fracture patients perioperatively led to a higher quality care with reduced hospital stay and consequent savings for the NHS trust.

Introduction Hip fractures pose a major public health burden and consume signiﬁcant healthcare resources. The incidence of hip fractures is expected to rise with the ageing population and is already the second most frequent cause of hospitalisation in the older population. Hip fractures are associated with a signiﬁcant increase in morbidity and mortality for both the short-term (3 to 6 months) and the longterm (5 to 10 years). These patients are elderly with significant co-morbidities including frailty and are prone to complications.

patient care. The National Institute of Clinical Excellence (NICE) in the United Kingdom (UK) has recommended that hip fracture patients should be offered a formal acute orthopaedicor Orthogeriatric-ward-based hip fracture programme, which includes Orthogeriatric assessment. Joint acute Orthogeriatric comanagement is also endorsed by the British Orthopaedic Association and the British Geriatrics Society. Shared surgical and medical care for hip fractures is increasingly being implemented and adopted across UK hospitals and worldwide.

Although surgery is the main treatment for a fracture of the hip, the Orthogeriatrician can play a key role in holistic management of the patient’s medical co morbidities and complications during the perioperative period.

Pre-intervention Prior to July 2011, patients with hip fractures were admitted at Glangwili hospital, Carmarthen, UK under the care of one of the ten Orthopaedic Consultants. This hospital admits about 350 hip fractures per year. These patients were primarily managed by the Orthopaedics team. The traditional pathway was admission from the Emergency Department (ED) to the Orthopaedics ward, followed by surgical treatment and postoperative rehabilitation under Orthopaedics care with advice from a Geriatrician limited to a weekly consultation service. Medical problems were mainly addressed by the medical registrar on call. There was a lack of doctors in the multidisciplinary team meetings. Patients were discharged to peripheral rehabilitation hospitals if they were unable to go home. There was lack of

Hip fracture surgery is only one aspect amongst a range of conditions and complexities associated with ‘Hip fracture syndrome’. Patients with hip fractures have multiple complexities and are managed by several specialities, so there is a potential for miscommunication, delays and gaps in Abhaya Gupta Consultant Orthogeriatrician Glangwili hospital, Carmarthen SA312AF. E mail: guptaabhaya@hotmail.com

British Journal of Healthcare Innovations Jan 2016 1(1): 21-23 British Journal of Healthcare Innovations Jan 2016 1(1):21-23

* Significant reduction in the acute hospital length of stay 19.6 days vs 34 days (p<0.001).

standardised approach to fluid administration, pain management, thromboprophylaxis, falls and management of osteoporosis and common medical conditions.

* Improved assessment and management of osteoporosis 97.6% vs 95% (p=0.155).

First collaborative Orthogeriatric Acute Hip Unit in Wales (United Kingdom)

* Improved falls assessment and management 73.9% vs 5.1% (p=<0.001)

The author (AG) developed an Orthogeriatrician-led 15-bedded collaborative Acute Hip Unit in 2011 at Glangwili Hospital, Carmarthen. This was the ﬁrst of its kind in Wales (United Kingdom). The Unit is based on Acute Coronary Care and Stroke Units model, with dedicated ring-fenced beds, direct admission from the Emergency Department, standard protocols and care, staff training, and consistent senior medical cover. Fasttrack protocols and the clerking of patients using a standardised clerking proforma in the Acute Hip Unit reduce the time spent in the emergency department. An Acute Hip Unit managed by just one Geriatrician has led to the development of high-quality, structured, standardised, evidence-based care in managing the ‘medical’ issues of patients under the care of several surgeons, thereby reducing the chances of variable care. Weekly multidisciplinary meetings led by a Consultant Orthogeriatrician and increased daily medical supervision have reduced the dependency on the on-call medical registrar, allowing sick patients to be managed with earlier detection especially delirium. The Unit allows seamless preoperative and early postoperative care in the same environment. Uniquely, in the new Unit, care is shared between Orthopaedic and Medical juniors. There is improved training opportunity for orthopaedic juniors in assessing elderly patients’ comorbidity, polypharmacy, falls and osteoporosis. The nursing staff previously had an ‘orthopaedic background’ but now have a more specialised training and approach in dealing with both medical and surgical issues. Patients are provided with written information leaﬂets.

* Improved training opportunity for junior doctors at Foundation, core and higher training levels in both Medicine and Orthopaedic departments. * Improved team working and communication with patients, relatives and multidisciplinary professionals. Conclusions An Acute Hip Unit is able to address the complex challenging needs of a frail older high-risk hip fracture patient soon after admission, therefore minimising delays as well as providing structured standardised evidence-based care by trained staff. Our Acute Hip Unit provides focussed, multidisciplinary, holistic, seamless and specialized care meeting national care standards. Hip fractures are traditionally managed by surgeons but Orthogeriatricians can play a key role in providing a holistic package of care. An Orthogeriatrician-led unit such as ours, can deal with the preoperative and complex postoperative medical, social, ethical, physical, and mental health issues that are associated with the ‘hip fracture syndrome’. Hip fracture patients are among the most frail to be admitted to hospital and their outcomes could depend on how effectively their care is managed. Avoidable delay, incomplete assessment and lack of attention to issues such as co-morbidities, fluid balance and nutritional status, falls, and a lack of osteoporosis management can lead to poorer outcomes. Current models of care in several hospitals fall short of the ideal of providing optimal care for these patients. The overall length of stay for hip fractures across 180 hospitals in the UK ranges from 12.4 to 44.5 days. For this reason the traditional model where patients with hip fractures are managed primarily by the orthopaedic surgeon should be replaced by coordinated

Outcomes * Significant reduction in the time to surgery performed within 48 hours (86% vs 77%; p=0.013) *Nearly 50% patients receive local anaesthetic blocks vs 5% (p<0.001).

British Journal of Healthcare Innovations Jan 2016 1(1): 21-23 British Journal of Healthcare Innovations Jan 2016 1(1):21-23

multidisciplinary care, with the involvement of an Orthogeriatrician.

Further reading

This Acute Hip Unit and Orthogeriatrician led model of care for hospitalised hip fracture patients is feasible across many hospitals in the UK and worldwide. This model of care proves that cross-departmental working is achievable by reorganisation of existing resources available in an average district general hospital in the UK. With the rising demand for beds in acute hospitals in UK, this unit is an example of innovation in the care of hip fracture patients. The economic burden of fractures combined with limited financial sources for rehabilitation programmes supports the reorganisation and implementation of collaborative units such as ours. This new care model has the potential to reduce morbidity and mortality in the frail hip fracture population.

Gupta A. The effectiveness of geriatrician-led comprehensive hip fracture collaborative care in a new acute hip unit. J R Coll Physicians Edinb 2014; 44:20–6.

Gupta A, Havelock W. A new future for hip fracture care – Orthogeriatrician lead in an ‘Acute’ Hip Unit. Clinical Medicine 2014; Vol 14: No 6. 591–6.

Gupta A. Medical management of hip fractures and the role of the Orthogeriatrician. Reviews in Clinical Gerontology. 2012; 22 : Issue 04 . pp 261-273.

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Enhanced recovery protocols reduce Transfusion rates in hip and knee replacements Jaydeep Shah, Aashka Shah, John Gorst, Gareth Perry, Keshav Singhal. Abstract Lower limb arthroplasty is a major surgical procedure requiring blood transfusion in up to 46% cases. Blood transfusion carries its own complications apart from the resource implications and the transfusion costs can be well in excess of ÂŁ1000 per patient. Enhanced recovery protocols have been shown to reduce the length of stay and improve the pain, nausea and vomiting, but an interesting and not often highlighted benefit is the significant reduction in the transfusion rates due not using a surgical site drain, the local anaesthetic and adrenalin infiltration, changes in anaesthetic management and raising the transfusion trigger. Our study shows a marked reduction in the transfusion rates from 15% to 4%. __________________________________________________________________________________ Introduction: These procedures are associated with significant peri-operative blood loss. Transfusion rates of up to 46% have been reported using standard practice in 2004[24]. The Incidence of allogenic blood transfusion (ABT) can be as high as 32% for Primary THR and 25% for primary TKR [8,23].

Total hip replacement (THR) and total knee replacement (TKR) are the commonest, most successful and cost effective orthopaedic interventions providing reliable pain relief and improved function in patients suffering from osteoarthritis and inflammatory arthritis of hip and knee [2].

Orthopaedic hip and knee surgery has accounted for about 8% of all blood transfusions and is the leading surgical indication for transfusion in north of England [19]. It is very well established that there are clinical risks associated with blood transfusions including transfusion related lung injury, haemolytic transfusion reactions, transmission of infection, organ dysfunction, immunosuppression and increased mortality [21]. Systematic review of literature has shown that post-operative anaemia in major arthroplasty patients is associated with increased infection, increased length of stay and increased mortality [22]. Although mortality following elective THR is generally low [15], a recent large retrospective study in patients undergoing major joint surgery has confirmed the association between RBC transfusion and increased post-operative mortality [16]. These studies performed in large patient populations question the safety of blood

Typically such patients were admitted a day before surgery and stayed in the bed on the day of surgery due to patient controlled analgesia (PCA), an operative site drain, catheterization and possibly also due to nausea/vomiting. Usual mobilization was on day 1 postoperatively and the average in-patient stay varied between 7 and 10 days. _________________________________________ Jaydeep Shah Orthopaedic Consultant Aashka Shah, Medical Student John Gorst, Anaesthetic Consultant Gareth Parry, Anaesthetic Consultant Keshav Singhal Orthopaedic Consultant ABMU Health Board Email: shahjaydeep@hotmail.com

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transfusion and warrant careful evaluation of the risk/benefit ratio of ABT in the elective surgical setting [17]

a. Pre-medication pregabalin 150 mg one hour prep (reduced dose to 75 mg if patient is aged 75 or over, has renal impairment or low BMI) b. Minimize/avoid opiates, Use of short acting anaesthetics c. Intra-operatively all patients receive:

The overall cost of transfusion is difficult to calculate and includes not only the cost price of a unit of blood, but also the cost of consumables, cost of non-used cross-matched units and potentially the cost of complications. Green et al found that allogenic blood transfusion is the most expensive option for optimizing haemoglobin (US$1789 per THR patient and US$1352 per TKR patient) compared with either the use of autologous transfusion or preoperative erythropoietin[11]

    

Many strategies have been recommended and used to reduce the need for peri-operative allogenic blood transfusion. They include, preoperative haemoglobin optimization (iron loading or use of haemopoetin), decreasing intraoperative blood loss (meticulous haemostasis, using cell salvage, anti fibrinolytic agents), use of autologous transfusion and the implementation of restrictive transfusion strategies.[10].

 

1 gm IV Paracetamol A non steroidal anti-inflammatory 15-20 mg/kg Tranexamic acid iv bolus prior to tourniquet Dexamethasone 8 mg 20 mmol Magnesium Sulphate infusion during surgery (started prior to Tourniquet) and to titrate to heart rate and blood pressure. 1-2 litres of IV fluid Intra/postoperative local infiltration analgesia by the surgeon( In our institution we use 30 ml of 5% chirocaine with 1 ml of adrenalin(1:1000) diluted with 70 ml of normal saline )

For patients receiving Spinal anaesthesia: a. Pre-medication as above b. Spinal anaesthesia aiming for unilateral block whenever possible and to use minimum dose of anaesthetic to reduce urinary retention and delay in motor function.

The Enhanced recovery after surgery (ERAS) program was introduced as a structured protocol in the department of Trauma and Orthopaedics in Princess of Wales Hospital and the ABM University health board in July 2011 by the senior authors ( KS and GP) The key components of the ERAS program include involvement of multidisciplinary team from the beginning, optimization of the pre-existing medical co-morbidities, pre-operative patient education (joint school), day-of-surgery admission (DOSA), implementation of the evidence based perioperative care, preop carbohydrate loading, nonopioid multimodal analgesia, post-operative nausea and vomiting control and early mobilization and discharge.

Patients and methods: ABM health board audit committee granted the approval of this study We have compared the length of inpatient stay, day of mobilization, post-operative blood transfusion and adverse outcome for the patients undergoing hip or knee replacement over 2 years. All patients were given a diary to fill the questionnaire during their stay and the diary was collected on the day of discharge. We asked the patients to record severity of pain, nausea and vomiting, day of weight bearing mobilization and overall satisfaction. The pain was graded from 0-3

Anaesthetic management: The aim is to deliver safe and effective sedation and analgesia to the patient which does not hinder early mobilization. For patients receiving general anaesthesia

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with 0 as no pain and 3 as severe pain. We collected the data for the patients under ERAS program prospectively from July 2011 to June 2012 for a single surgeon (KS). We compared this data with the group of patients who underwent hip or knee replacement without the benefit of ERAS program (pre-ERAS) a year before (between July 2010 to June 2011). The patient notes were reviewed for both groups.

while patients who underwent uni-compartmental knee replacement, bilateral knee replacement and revision hip or knee replacement during the same time were excluded from the study. Results: 124 patients underwent hip or knee replacement or hip resurfacing during the ERAS period of which 49 underwent knee replacement, 44 hip replacements and 31 hip resurfacing. In the preERAS group we had 139 patients with 63 knee replacement, 41 hip replacements and 35 hip resurfacing.

In order to quantify the rate of ABT we also collected separate data over 3 month period which was collated with the hospital blood bank data. This includes the THR and TKR performed at both Princess of Wales Hospital and Neath Port Talbot Hospital. The data for the blood transfusion was collected between July 2012 to August 2012 for the ERAS group, and from March 2011 to May 2011 for the patients in pre-ERAS group.

Average hospital stay for ERAS patients was 4.06 days with 41.3% of patients going home on day 3 or earlier. 74.5% of patientsâ&#x20AC;&#x2122; hospital stay was less than or equal to 5 days. Average stay for TKR patients was 4.08 days, while THR patientsâ&#x20AC;&#x2122; average hospital stay was 5.4 days, slightly longer than the TKR patients. Patients undergoing hip resurfacing had average hospital stay of 3.7 days

We have included the patients undergoing total hip or total knee replacement and hip resurfacing,

Table 1 Type of surgery

ERAS Group

NON ERAS Group

TKR

THR

Hip Resurfacing

Age

ERAS Group

NON ERAS Group

<60 years

61-80 years

>80 years

Table 2

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Table 3 ERAS Group

NON ERAS Group

Average stay for all patients

4.06 days

8.14 days

â&#x2030;¤ 3 days stay

41.3%

7.55%

â&#x2030;¤ 5 days stay

74.5%

23.78%

PCA prescription with opioid analgesia was consciously avoided in the ERAS patients to allow for early mobilization and they were prescribed regular paracetamol and anti-inflammatory (where not contra-indicated) along with Pregabalin. They also had the benefit of local infiltration analgesia as compared to the pre-ERAS patients.

with the help of a walker or crutches. All patients who filled in diary mentioned that they were very satisfied with the overall management starting from the joint-school where they felt they received enough information for their operation. We collected all data retrospectively for comparing the transfusion rates. 126 patients were in the ERAS group ( 51 THR and 75 TKR) while 121 patients were in the pre-ERAS group ( 51 THR and 70 TKR)

42 out of 98 patients, who were given the diary, completed it to be included in the analysis with complete data during their stay in the hospital. 53.5% of ERAS patients had adequate pain relief, while 46.5% needed topping up with morphine. 74% of patients did not experience nausea or vomiting post-operatively while 16% experienced some nausea during their stay in the hospital. 10% experienced one or more episodes of vomiting in the post-operative period in spite of regular antiemetic drugs.

We found that the ABT rate was 15% in the preERAS group of patients (11% in TKR and 22% in THR) while it was only 4% in ERAS group (1% in TKR patients and 8% in THR patients) The following chart shows the number of patients transfused in both groups with the expected count and p value.

All patients who completed the diary walked on the day of surgery full weight bearing to the toilet

Table 4 Transfused No Pre ERAS Post ERAS Total

Total Yes

Count Expected count

102 109.2

19 11.8

121 121.0

Count Expected count

121 113.8

5 12.2

126 126.0

Count Expected count

223 223.0

24 24.0

247 247.0

Pearson Chi-Square Value=9.688 p=0.002

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Table 5 Number HIPS

KNEES

ALL

Pre

Post

Pre

Post

Pre

121

Post

126

Hb drop (95% CI) 3.42 (3.03.8) 2.27 (1.92.6) 2.92 (2.673.17) 1.68 (1.511.86) 3.14 (0.210.53) 1.92 (1.732.11)

Table 5 above shows the mean drop in the Hb level which was 3.1 g/dl in the Pre-ERAS group as compared to only 1.9 g/dl in the ERAS group. The difference of 1.2 g/dl (95% CI 0.9-1.5 and p=0.000) is statistically significant. The mean units transfused in Pre-ERAS group was 0.4 as compared

Hb drop diff (95% CI) 11.15 (0.651.66) p=0.000 1.24 (0.941.54) p=0.000 1.21 (0.941.49) p=0.000

Transfusion (95% CI) 0.52 (0.230.82) 0.19 (0.000.39) 0.26 (0.070.44) 0.026 (0.027-0.080) 0.37 (2.933.34) 0.10 (0.010.18)

Transfusion diff (95% CI) 0.33 (-0.0160.68) p=0.061 0.23 (0.0380.422) p=0.019 0.28 (0.0940.460) p=0.003

to 0.1 units for the ERAS group with a difference of 0.3 units (95% CI 0.1-0.5 and p=0.003) which is also statistically significant. It also shows Hb drop in both groups of patients with mean units transfused and confidence interval along with the p value for each group.

Postop Hb. ( Pre ERAS)

Postop Hb. ( Post ERAS)

very satisfied with their overall experience. Hip resurfacing patients on average are younger as compared to the TKR and THR patients and have less co-morbidity accounting for the faster recovery and shorter hospital stay. ERAS protocol has become routine in our hospital and most of the hospitals in UK and it is also a part of 1000 lives plus campaign of Wales Assembly government [1].

Discussion: The comparison data clearly shows that the ERAS program has improved outcomes in terms of inhospital stay, early mobilization and pain control. Almost 50% of the patients walked full weightbearing on the day of surgery. Early mobilization on the day of surgery makes the impact of surgery psychologically less stressful, imparts the sense of well being, promotes early recovery, avoids complication of the prolonged bed rest and makes early discharge possible. All ERAS patients were

It is quite evident from recent evidence that the patients with Hb concentration above 100 g/L

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should not receive ABT as it does not improve outcome in functional status and length of stay. UK guidance from the British Committee for Standards in Haematology (BCSH) and international guidance from AABB states that patients should not be transfused unless their Hb concentration is <70 g/L (or 80 g/L or unless there is a demonstrable or suspected cardiovascular risk)[18]

of a drop in the Hb which is likely due to a combination of the use of Tranexamic acid, Magnesium Sulphate local anaesthetic & adrenalin infiltration of the wound, and avoidance of postoperative drain. Strict adherence to the transfusion trigger of 8 Gm of Hb. is also important for this reduction to the transfusion rates. We therefore conclude that ERAS protocol reduces the blood transfusion rates significantly and is beneficial for patient recovery and frees up precious NHS resources.

We have shown that there is a statically significant (p=0.002) reduction in the transfusion rate, from 15% to 4% with ERAS. ERAS patients also have less

__________________________________________________________________________________________

References: 8. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB, An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint surd Am 1999;81: 2-10

1. 1000livesplus: www.1000lives.wales.nhs.uk 2. Oxford Textbook of Orthopaedics and trauma 2002

9. Pedersen AB, Mehnert F, Overgaard S, Johnsen SP, Allogenic blood transfusion and prognosis following total hip replacement: a population based follow up study. BMC Musculoskeletal disord 2009;10:167

3. National Joint Registry for England and Wales(2012) 9th Annual report. National Joint register for England and Wales, Hemel Hempstead 4. Jans O, Kehlet H, Johansson PI (2012) Transfusion related mortality after primary hip arthroplasty-an analysis of mechanisms and confounders. Vox Sang 103:301. do:10.1111/j.1423-0410.2012.0612.x

10. Spahn DR,Anaemia and patient blood management in hip and knee surgery: a systematic review of literature. Anaesthesiology 2010; 113: 482-495 11. Green WS, Toy P, Bozic KJ. Cost minimisation analysis of preoperative erythropoietin vs autologous and allogenic blood donation in total joint arthroplasty. J Arthroplasty 2010;25:93-96

5. Jones HW, Savage L, White C et al(2004) Postoperative autologous blood salvage drainsâ&#x20AC;&#x201D; are they useful in primary uncemented hip and knee arthroplasty? A prospective study of 186 cases. Acta Ortho Belg 70:466-473

12. Husted H, Hansen HC, Holm G, Bach-Dal C, Rud K, Andersen KL et al (2006) length of stay in total hip and knee arthroplasty in Denmark I: Volume, Morbidity, Mortality and resource utilization. A national survery in orthopaedic departments in Denmark. Ugeskr Laeger 168(22):2139-2143

6. Foss NB,Kristensen MT, Jensen PS et al (2009) The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery. Transfusion 49:227-234. do:10.1111/j.1537-2995.2008.01967.x

13. Schneider M, Kawahara I, Ballantyne G, Macgregor K, Garvie R et al (2009) Predictive factors influencing fast track rehabiliation following primary total hip and knee

7. Shah J, Singhal K (2012) Early results of ERAS (Enhanced recovery after surgery) in orthopaedics, The Physician 1: 28-31

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arthroplasty.Arch Orthop Trauma Surg 129(12): 1585-1917

19. Wells AW, Mounter PJ, Chapman CE, Stainsby D, Wallis IP: Where does blood go? Prospective observational study of red cell transfusion in north England. BMJ 2002;325:803

14. McDonald DA, Siegmeth R, Deakin AH, Kinninmonth AWG, Scott NB (2012) An Enhanced recovery program for primary total knee arthroplasty in the United Kingdom-follow up at one year. The Knee 19(5):525-529

20. Joy PJ, Bennet SJ. The appropriateness of blood transfusion following primary total hip replacement. Transfusion; Ann R Coll Surg Engl 2012;94:201-203

15. Pedersen AB, Baron JA, Overgaard S,et al: Short and long term mortality following primary total hip replacement for osteoarthritis: A Danish nationwide epidemiological study. J Bone Joint Surg Br 2011;93: 172-177

21. Rawn J. The silent risks of blood transfusion. Curr Opin Anaesthesiology 2008; 21: 664-668 22. Spahn DR: Anaemia and patient blood management in hip and knee surgery. Anaesthesiology 2010;113: 482-95

16. Pederson AB, Mehnert F, Overgaard S, et al: Allogenic blood transfusion and prognosis following total hip replacement: a population based follow up study. BMC musculoskedet Disord 2009;10:167

23. Guerin S, Collins C, Kapoor H, McClean I, Collins D. Blood transfusion requirement prediction in patients undergoing primary total hip and knee arthroplasty. Transfus Med 2007;17:37-43

17. Isbister JP, Shander A Spahn DR, et al: Adverse blood transfusion outcomes: establishing causation. Transfus Med Rev 2011; 25:89-101

24. Marson BA, Shah J, Deglurkar M. Blood transfusion in hip and knee arthroplasties: The end of the pre-operative group and save? European journal of orthopaedic surgery and Traumatology; doi; 10.1007/s00590-015-1597-2

18. Jeffrey L, Carson MD, Brenda J, Grossman MD et al: Red blood cell transfusion: A Clinical practice Guideline from the AABB; Clinical Guidelines; Annals of Internal Medicine 2012;157:49-58

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British Journal of Healthcare Innovations Jan 2016 1(1): 31-32

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British Journal of Healthcare Innovations Jan 2016 1(1): 33-35 British Journal of Healthcare Innovations Jan 2016 1(1):33-35

Original Article Alcohol Detox Pathway: Improving efficiency through initiative for Head Neck Cancer patients J Wall, S Hamer, S Berry

Background Abuse of alcohol is common in patients diagnosed with head and neck cancers. Historically, alcohol problems experienced by these patients have never been addressed prior to definitive surgical treatment. Sudden alcohol withdrawal can lead to escalating withdrawal symptoms and even death if unrecognized and untreated.1,2 Alcohol related problems can also lead to extended time spent post-operatively in High Dependency Units, delayed discharges and delay in the commencement of adjuvant treatment. An analysis of the gravity of the problem and input from the Alcohol Liaison team led to the development of an alcohol detox pathway. It is an initiative which has been implemented within Cwm Taf University Health Board following collaborative working between two specialties.

Patients undergoing surgical free tissue transfer and complex reconstruction for their head neck cancer could potentially face the following problems if their excessive alcohol intake and associated problems were not identified and addressed prior to surgery: Delayed wound healing.



Failure of free flap tissue transfer.3

Clotting problems.



Chest infection.



Complicated Alcohol Withdrawal.



Longer periods in ITU



Alcoholic patients in ITU have 50% mortality rate compared with 26% in non-alcoholic patients.



Poor nutrition



Lacking in motivation



Discharge issues – lack of social support



Delay in commencing post Radiotherapy/Chemotherapy.

operative

Patient screening to assess alcohol consumption was introduced using WHO recognised tool recommended by NICE (2011)4 – Alcohol Use Disorders Identification Test (AUDIT). Screening was undertaken by the Head and Neck CNS (Clinical Nurse Specialist) and those undergoing surgery identified as having alcohol dependency were referred to the ALN (Alcohol Liaison Nurse).

Methodology



Severity of dependency was determined by ALN using the Severity of Dependency Questionnaire (SADQ). A specific fixed-regime for alcohol detox was then organised, the patient admitted and detox commenced. Throughout the detox period, the ALN or the Consultant Psychiatrist could be contacted for advice regarding management problems. Immediately following completion of detox, the patient either underwent surgery at Royal Glamorgan Hospital or transferred to University Hospital Wales (for those requiring free tissue transfers).

J Wall, Head and Neck Macmillan CNS, S Hamer, Alcohol Liaison nurse S Berry. Consultant Head and Neck surgeon, Royal Glamorgan Hospital, Cwm Taf Health Board. E Mail:sandeepberry@me.com

British Journal of Healthcare Innovations Jan 2016 1(1): 33-35 British Journal of Healthcare Innovations Jan 2016 1(1):33-35

on the admitting ward in order to arrange any training/update required.

A pathway for alcohol detox was developed and introduced, all relevant staff being made fully aware of the pathway. This included nursing staff

Pathway PATIENTS DIAGNOSED WITH HEAD NECK CANCER PATIENT DISCUSSED IN THE HEAD NECK MDT

RADIOTHERAPY +/- CHEMOTHERAPY.

SURGERY

INFORM ALCOHOL CNS( EMAIL/ PHONE) OUTLINE A DETOX REGIME

INFORM VELINDRE

ADMIT WARD 8 RGH AS PER REGIME INFORM WARD STAFF

SURGERY AT RGH CONTINUE AS PER REGIME

SURGERY AT UHW PATIENT TRANSFERRED FROM RGH --- UHW AS IP LIASE WITH UHW TEAM

INFORM ALCOHOL LIAISON NURSE AT DISCHARGE TO ALLOW FOLLOW UP AT HOME/ COMMUNITY

Results

Alcohol detox pathway since its introduction has resulted in

A total of 8 patients have gone through the joint service since the initiation of the pathway Application of the principles of the RAID (Rapid Assessment, Interface and Discharge) Model by the Alcohol Liaison Team resulted in efficiency savings of £13,912 with potential for further savings by reduction of bed days spent in ITU.

 

Discussion



 

Alcohol dependency results in significant harm and is linked to numerous health conditions and social problems.5, 6 Alcohol misuse is a major risk factor for development of head and neck cancers.



Improved quality of life for patients. Addressing the clinical governance issues relating to management of alcohol dependent patients requiring surgery. Reduction of expenditure on ITU beds Reduction in potential for cancer recurrence following delay in post surgical RT Ongoing community support reduces possibility of patient relapse which would lead to further alcohol related admissions Improvement in patient experience

Conclusion

Alcohol screening for early identification of alcohol use disorders and prevention/management of alcohol withdrawal symptoms prior to surgery is vital.7-9 Once alcohol dependency has been identified, Health Care Professionals have a duty of care to address related issues otherwise they could be accused of being negligent.

Alcohol detox pathway is an innovative pathway, which to the best of our knowledge, has not been used anywhere else in Wales. Since its inception, it has improved safety and quality of life for patients undergoing surgery for head and neck cancer.

British Journal of Healthcare Innovations Jan 2016 1(1): 33-35 British Journal of Healthcare Innovations Jan 2016 1(1):33-35

References

6. Rehm J. Mathers C. Popova S. Thavorncharoensap M. Teerawattananon Y. Patra J. (2009). Global burden of disease and injury and economic cost attributed to alcohol use and alcohol-use disorders. The Lancet 373(9682): 22232233.

1. Baynard M. McIntyre J. Hill KR. Woodside J Jr. (2004). Alcohol withdrawal syndrome. Am Fam Physician, 69 (6): 1443-50. 2. Keys V. (2011). Alcohol withdrawal during hospitalisation. American Journal of Nursing, 111(1): 40-44.

7. Kuo YR. Jeng SF. Lin KM. Hou SJ. Su CY. Chien CY. Hsueh KL. Huang EY. (2008) Microsurgical tissue transfer for head and neck reconstruction in patients with alcohol-induced mental disorder. Annals of Surgical Oncology. 15(1):371-377.

3. Gallivan MD. Reiter MD. (2001). Acute Alcohol Withdrawal and Free Flap Mandibular Reconstruction Outcomes. Archives of Facial Plastic Surgery vol 3, p264-266

8. McCaffrey J, Weitzner M, Kamboukas D, Haselhuhn G, LaMonde L, Booth-Jones M. (2007). Alcoholism, depression and abnormal cognition in head and neck cancer: A pilot study. Otolaryngology-Head and Neck Surgery, 136:92-97

4. National Institute for Health and Clinical Excellence (2011) Alcohol use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence. http://www.nice.org.uk/guidance/CG115

9. Lansford CD, Guerriero H, Kocan MJ, Turley R, Groves MW, Bahl V, Abrahamse P, Bradford CR, Chepenha DB, Moyer J, Prince ME, Wolf GT, Aebersold ML, Teknos TN. (2008).

5. Owens L. (2010). How to diagnose and manage physical complications related to alcohol misuse. Nursing Times 106 (31) 19-20. .

British Journal of Healthcare Innovations Jan 2016 1(1): 36-38 British Journal of Healthcare Innovations Jan 2016 1(1):36-38

Technical Innovation

X-ray Teaching and Assessment Smart App - The Diagnoster Ila Gandhi, Mahesh Baj, Sanjay Gandhi Abstract An award winning team of academics, experienced tutors and IT professionals have developed an advanced iPhone/ iPad App called the ‘Diagnoster’, which can be used to improve X-ray interpretation skills. This tool contains carefully selected and validated high-quality radiographs arranged according to different body parts, to provide a reliable training resource. The Diagnoster also benefits from several advanced features such as in built image enhancement tools for optimum X-ray viewing. Moreover, the user receives a score of their accuracy as well as direct feedback on any mistakes.

Introduction

The availability of a tool to enable continued informal self-education in the interpretation of radiographs could enable healthcare professionals to ensure that they acquire the appropriate expertise and ensure a high standard of practice.

A very significant part in clinical practice involves interpreting radiographs. The increasing use of digital radiography enables clinicians to receive and read diagnostic radiological images from all clinical environments, both within secondary and primary care. The medical training of health professionals involves instructions on interpretation of radiographs. Despite the formal teaching, the vast majority of health professionals develop their expertise through their daily clinical practice.

The ‘Diagnoster’ The authors, each of whom have more than 25 years of academic experience have developed the Smart App called the ‘Diagnoster’. The App offers several advanced features such as in-built image enhancement tools, e.g. brightness, contrast and magnification control as well as grey scale inversion for optimum X-ray viewing. The App simulates the test format of the Royal College of Radiologists' plain X-ray interpretation examination. There is also an option to retake the test and the App shuffles the X-rays to avoid repetition of the same pictures.

Missed fractures account for 10-20% malpractice cases. A significant number of these errors could be avoided by following a systematic approach, and practice. 1-4 Ila Gandhi, Senior Pharmacist, North Bristol NHS Trust, Dr. Mahesh Baj, Consultant Radiologist, Portiuncula Hospital, Ireland Dr. Sanjay Gandhi, Consultant Radiologist, Fellow of the Higher Education Academy, UK E mail: gandhis@doctors.org.uk

Who can benefit from the Diagnoster? * Medical students and junior doctors. * Specialist Trainees Radiographers

British Journal of Healthcare Innovations Jan 2016 1(1): 36-38 British Journal of Healthcare Innovations Jan 2016 1(1):36-38

* Orthopaedic and emergency medicine nurses. * Orthopaedic and emergency medicine doctors. * Radiology specialists including Registrars and Advanced Radiography Practitioners. * Physiotherapists and any other professionals who need to review X-rays. Discussion Smart Apps are modern tools to deliver high resolution images and visually rich content. The majority of Apps can be purchased for just a fraction of the cost of traditional medical textbooks.

Figure 2 The user receives a score of their accuracy for different body regions This tool can be used in any part of the world with access to the iTunes store. This App is copyright protected and developers are considering a worldwide patent. Table 1: Summary of Key Features:  Developed by Award-winning Academic and IT Team  Advanced image controls for optimal viewing of X-rays  Images grouped by different anatomical regions, but can also be shuffled to show X-rays from random body areas  Countdown timer to simulate assessment and examination environments  Track your personal progress on each topic  Feedback of each test image

Figure 1: The Diagnoster provides feedback of each test image The Diagnoster Apps could be easily modified to teach and assess trainees in many other specialties which involve interpretation of images, such as ECG, retinal photographs and histology slides. The Diagnoster could be effectively used in the training of doctors and other health professionals, in addition to enable continued development for all practitioners within the NHS and the private sector.

Test Drive If you would like to know more about this App or view demo video on the iTunes store please visit the following Web link:

British Journal of Healthcare Innovations Jan 2016 1(1): 36-38 British Journal of Healthcare Innovations Jan 2016 1(1):36-38

itunes.apple.com/gb/app/diagnoster/id9104 79435?mt=8 Acknowledgement

Authors would like to thank IT experts Neha Baj and Deaglán Ó Meachair for their contribution to the development of this App. References 1.

Emergency Radiology - A&E and Trauma Teaching Files: Editor: Dr Sanjay Gandhi, 3rd Edition, Publisher: JMD Publishing, 2014, ASIN: B006HRMX5A Brady, A., Laoide, R. Ó., McCarthy, P., & McDermott, R. (2012). Discrepancy and Error in Radiology: Concepts, Causes and Consequences. The Ulster Medical Journal, 81(1), 3–9. Mounts J, Clingenpeel J, McGuire E, Byers E, Kireeva Y. Most frequently missed fractures in the emergency department. Clin Pediatr (Phila). 2011 Mar;50(3):183-6. Wong SJ, Robertson GA, Connor KL, Brady RR, Wood AM. Smartphone apps for orthopaedic sports medicine - a smart move? BMC Sports Sci Med Rehabil. 2015 Oct 12;7:23.

British Journal of Healthcare Innovations Jan 2016 1(1): 39-41 British Journal of Healthcare Innovations Jan 2016 1(1):39-41

Brief Report Streamlining Audiology referrals to the Ear, Nose and Throat Department (ENT): A collaborative project to create an efficient and cost effective pathway for acoustic neuroma screening Deepak Gupta, David Reed Objective:

Patient management after diagnosis may involve surveillance, surgery or gamma knife.

To audit all referrals to the ENT, from the audiology department, for asymmetric sensori-neural hearing loss and unilateral nonpulsatile tinnitus and assess safety and practicality of an efficient service redesign involving MRI requests by audiologists.

Audiologists are often the first specialist practitioner to see a patient with hearing loss or tinnitus. Various referral pathways are shown in Figure 2. Audiology to ENT referral pathway for these patients, mostly for filling an MRI request form, was felt to be inefficient. There was need to have a robust but efficient protocol. Hence an audit driven pathway redesign was put in place to prove the safety of the new pathway as audiologists had never requested radiology investigations before, and doubts had been expressed in many quarters.

Background and the Need for Change: Acoustic Neuroma is a benign slow growing tumour of the vestibular nerve and frequently presents as asymmetrical or unilateral sensorineural hearing loss and/or unilateral tinnitus (Fig 1). The incidence is about 1/100000.

Figure 1: Clinical Summary for acoustic neuroma Deepak Gupta, Consultant ENT Surgeon, David Reed, Consultant Audiologist, Great Western Hospital NHS Foundation Trust, Swindon, UK Email: mastdoc@aol.com

British Journal of Healthcare Innovations Jan 2016 1(1): 39-41 British Journal of Healthcare Innovations Jan 2016 1(1):39-41

Figure 2: Pathways for referrals. Methods

15dB interaural difference at 2 adjacent frequencies between 1 and 8KHz at octave intervals or >20dB interaural difference at one frequency between 1 and 8KHz at octave intervals.

A Prospective audit of all referrals for asymmetric sensori -neural hearing loss and unilateral non-pulsatile tinnitus from audiology to ENT from Jan 2012 to June 2015 was carried out. An audit pathway was established where the audiologists filled the MRI form according to the protocol mentioned below, ENT Consultant (DG) assessed the request and countersigned the MRI Form. Number of unnecessary MRI requests were noted, DG saw the MRI results and wrote to the patients with the result.

Results The Great Western Hospital NHS Foundation trust, Swindon audiology and ENT departments serve a population of roughly 250,000. Over a 42 month period 588 patients were managed according to the audit pathway. Only 2 unnecessary requests were seen, though lessons were taken about the ability of audiologists in explaining acoustic neuroma to the patients. To address this, a workshop was delivered to the audiologists. 9 acoustic neuromas were found.

The exclusions were: 1) Sudden sensori-neural hearing loss cases 2) Patients who cannot have MRI (metal/pacemaker/claustrophobic) â&#x20AC;&#x201C; these required CT scan and referral to ENT 3) Pulsatile Tinnitus: referral to ENT was required 4) Patient request for ENT referral 5) Patients less than 20 years required referral to ENT

To date this system has saved 588 ENT clinic appointments over 48 months, saving about ÂŁ72912 (Fig 3), shown the efficacy and safety of protocol driven direct MRI requests by the audiologists, made the process more efficient for the patients, and perhaps empowered the audiologists

Protocol for defining asymmetrical sensorineural hearing Loss: .

British Journal of Healthcare Innovations Jan 2016 1(1): 39-41 British Journal of Healthcare Innovations Jan 2016 1(1):39-41

Figure 3: Cost savings gained by new pathway Conclusions

has been accepted by the relevant departments and the new pathway has now become the norm for the hospital.

Introduction of a new pathway, as shown in Figures 2 and 3, has dramatically reduced the number of referrals to the ENT department from the audiology department. This equates to 14 extra ENT new patient slots per month for a population base of around 250,000. On a national basis, this would equate to around 240 extra ENT clinics per month, each seeing about 14 patients. Successful implementation of the pathway has led to reduced time to diagnosis, less patient visits to the hospital, and reduction in the cost of the service. The result of the audit pathway

To the best of our knowledge, only a few departments across the country - Haywood, Middleton and Rochdale NHS Trust, Southend NHS Trust and Portsmouth (J Neurol Surg B 2012; 73-A289) have adopted this approach. It is certainly not the normal practice in UK. We would suggest that universal adoption of this simple and cost effective pathway would deliver significant efficiency and cost savings to the NHS.

British Journal of Healthcare Innovations Jan 2016 1(1): 42-44 British Journal of Healthcare Innovations Jan 2016 1(1):42-44

Original Article Delivering Complex Therapy for Parkinson’s disease at Local level: A novel and innovative concept Sandip Raha Abstract Duo Dopa therapy is a valuable treatment option for patients of Parkinson’s disease who require intrajejunal Levodopa. This article details how this specialist treatment can be provided at the District Hospital Level in addition to the usual tertiary referral centre setting. Introduction

initiation as well as monitoring. In Wales, however, due to funding restrictions and paucity of access to such tertiary centres, there is a problem with accessing this service by some patients. We will attempt to show that with some innovative thinking, such therapy can be safely delivered at the District hospital level without incurring any extra funding.

Parkinson’s disease is a progressive Neurodegenerative condition affecting predominantly middle aged and elderly in Western world. As the disease progress over many years, clinicians develop professional and empathic relationship with patient and their family. Majority of these patients can be managed with oral therapy of Dopamine replacement along with transdermal delivery of medications. A small minority may require subcutaneous infusion of Apo Morphine (analogue of Morphine) which is available as pen injection or pump therapy.

Background The author has been running a Parkinson’s service in Bridgend for over 15 years And in the course of his clinical work, he has been referred a few patients needing this complex treatment of intra jejunal Duo Dopa gel instillation. Historically, there was no facility in the Health Board for this complex intervention.

There is however an even smaller minority of patients who are in late stages of their condition and have fluctuating symptoms but are still very responsive to Levodopa (gold standard for Parkinson’s disease) and can be considered for intrajejunal Duo Dopa Gel therapy via a percutaneous endoscopic jejunal (PEJ) tube and continuous pump. The intrajejunal instillation avoids the problems with swallowing medicines, variable stomach absorption and enables the drug to be safely and predictably absorbed from the jejunum.

However, as the author had been performing upper GI endoscopy and percutaneous endoscopic gastrostomy feeding (PEG) in South Wales for last 25 years, in 2005 he decided to further develop his technique and start putting PEJ tube for Duo Dopa treatment on his as well as patients referred from a neighbouring Health Board where no such facility existed. This marked a radical departure from conventional wisdom as such procedures at present are only performed in regional or tertiary centres in UK and having it available locally and being done by someone who has specialist knowledge of Parkinson’s disease as well as PEG tube insertion is unique in UK.

Traditionally in England these patients are referred to a Tertiary Neurology centre for assessment and

Sandip Raha, Consultant in Care of the Eldery, ABM University Health Board. Email: sandip.raha@gmail.com

British Journal of Healthcare Innovations Jan 2016 1(1): 42-44 British Journal of Healthcare Innovations Jan 2016 1(1):42-44

Methods

their routine follow up arrangement were left with local clinician.

Historically, when such patients were referred outside the health board, the drug funding (£30,000 per year) was preapproved, but the ongoing follow-up and management was done by the local physicians. Since the local PEJ service was set up in 2005, the decision to offer this treatment to suitable patients was taken in a multidisciplinary meeting and funding was obtained as an exceptional situation according to the All Wales Neurological commissioning guidelines.

Over last 8 years the author has performed this procedure on 7 patients and small summary of their outcome is presented. At present there are two patients still being followed up and monitored and all of them are at home being cared for by family members or support services where appropriate Discussion Duo Dopa therapy is generally offered in tertiary centres across UK leading to difficulty in accessing this service by some patients due to geographical reasons or waiting times. We have shown over a period of over 5 years that this therapy can be safely delivered in a District General Hospital setting without extra resource allocation. The ease of travel and access is well liked by the patients and the continuity of care offered by the local treating physician is appreciated for obvious reasons.

Following the patient’s admission, a Radiologist colleague inserted a naso-jejunal tube under fluoroscopic guidance, through which Duo Dopa therapy was instilled, (but without the regular Parkinson’s medication) for 24 hours as an inpatient. This allowed a detailed assessment to be carried out by the author and the specialist nurse to check the response to the therapy. Once a positive response was identified, the patient had the PEJ tube inserted in the endoscopy suite within the next 24-48 hours and the Duo Dopa pump commenced under supervision of the specialist nurse. Multiple motor and psychological assessments were performed over next 48 hours and dose of Duo Dopa adjusted according to patient’s response. Finally, the carers were instructed in the care of the PEJ tube and the use of the pump.

Rolling our concept across UK will benefit this small group of patients with severe Parkinson’s disease and help improve their quality of life.

Patients were discharged after 48-72 hours and further optimisation of their treatment was done at home by Duo Dopa specialist Nurses. A formal review was carried out by the author at one month and then every three months, while informal support by the specialist nurse continued at home. Patients outside of Health Board were seen on demand only or when tube needed changing and Figure 1: Clinical picture of Duo-dopa therapy

British Journal of Healthcare Innovations Jan 2016 1(1): 42-44 British Journal of Healthcare Innovations Jan 2016 1(1):42-44

Table: 1: Summary of patients on Duo Dopa therapy Patient

Yrs PD

57 Male

Oral medications

Duo Dopa months

Levodopa 1500mg, Rotigotine 10mg, Pramipexole 5mg, also on Apo Morphine s/c pump

Died in 2013 from unrelated causes.

71 female

Levodopa 1000mg, Ropinirole 10mg Transferred from Brecon for Duo Dopa treatment

79 female

Levodopa 500mg, Rotigotine 6mg

In a nursing home in Powys, Not on Duo Dopa now due to Dementia Died in 2013

62, male

73 Female

Levodopa 550mg, Rotigotine 6mg, Amantidine 100mg Levodopa 600mg / day, Ropinirole Mr 8mg, Amantidine 100mg, Apo Go pump 3.5mg / hr for 15 hrs previous DBS & Thalamotomy

75 female

Levodopa 700, Rotigotine 16mg

72 female

Levodopa 800mg, Rotigotine 6mg

t/t

Outcome

Patient pulled tube out twice, discontinued At home, fairly independent husband helps, Still able to use computer / Email/ Mobile indoors and out doors At home almost self caring, able to go out Lives with husband DuoDopa discontinued, as she was in a palliative stage. Died 2012

British Journal of Healthcare Innovations Jan 2016 1(1): 45-48 British Journal of Healthcare Innovations Jan 2016 1(1):45-48

Original Article Post Operative Wound Management: A Step Forward R Rammohan, L Casey, M Clarke, A Chandratreya, K Singhal Abstract Negative pressure wound therapy (NPWT) has an important role to play in the management of wounds on the surgical wards. Effective management can shorten the hospital stay of patients and help save valuable resources. This article reviews the literature on NPWT and we discuss our results showing the beneficial effect of this in our patients dresings getting completely soaked requiring their frequent change. The secretion of wound debris through the incision also carries the risk of development of bacterial infection and delayed healing. Negative Pressure wound therapy (NPWT) has been widely used to treat different open wounds with excessive discharge with impressive results. Many researchers have used the same principle in dealing with closed surgical incisions (incisional NPWT), reporting good results. This article presents a brief literature review in conjunction with our experience. ___________________________________________________________________________________ The device Our Experience We retrospectively analysed the outcome in patients who underwent NPWT using the PICO device (Smith & Nephew plc, London, UK) from March 2015 till November 2015. PICO device was applied for below mentioned indications by the Specialist Nurse in our department, either in ward or clinic setting. When possible or relevant, patient was discharged and followed up in clinic once a week for wound review and change of dressing, as and when required.

Conventional NPWT devices involve placing an open-cell foam dressing into the wound cavity or closed surgical wound and applying a controlled subatmospheric pressure (-80 to 120 mmHg) through a tubing connected the suction device. The drawbacks however are the bulky suction device, which restricts patient mobility, frequent change of canisters, and requirement of trained personnel to apply the dressing. Based on the same principle but utilising convenient innovative scaled down components, PICO (Smith and nephew, London, UK) contains a sterile dressing with pre-attached tubing to connect with a small canister-free pump that runs on common AA batteries achieving a subatmospheric pressure of about -80 mmHg. ______________________________________ R Rammohan, Specialty Doctor, Lee Casey, Trauma Clinical Nurse Specialist, Michelle Clarke, Advanced Nurse Practitioner, Amit Chandratreya, Orthopaedic Consultant, Keshav Singhal, Orthopaedic Consultant, Princess of Wales Hospital, Bridgend. CF31 Email: rammohanbangalore@gmail.com

Indications for NPWT 1. Excessive oozing from closed surgical incisions of elective arthroplasty procedures and trauma-fracture fixation procedures 2. Acute wounds of small dimensions which are expected to secrete excessive wound debris viz. haematoma debridement, small to moderate skin lacerations awaiting plastic surgery intervention or the ones which are planned for secondary healing, post operative wound dehiscence, etc.

British Journal of Healthcare Innovations Jan 2016 1(1): 45-48 British Journal of Healthcare Innovations Jan 2016 1(1):45-48

initial debridement and the wound healing achieved in an average of 1.6 weeks. The main drawbacks of our study are that this is a retrospective study, the groups are non randomised, non homogenous and lack a control group.

3. Chronic wounds e.g. chronic discharging sinus, infective wounds, small non healing ulcers. Major area of our use of PICO device has been in closed surgical wounds of elective arthroplasty patients. Most of these patients have experienced a positive outcome resulting in early discharge from hospital and the wound healing uneventfully. Three patients following primary arthroplasty developed haematoma for which they underwent surgical debridement after which the PICO dressing was changed to conventional NPWT device. The PICO usage in chronic wounds required prolonged use for an average duration of 6.2 weeks. This resulted in surgical debridement being deferred in one patient and plastic surgery intervention in another. Use in acute wounds such as haematomas, resulted in early discharge from hospital after

Discussion Negative Pressure Wound Therapy (NPWT) has dramatically changed the way a wound is managed. Since its inception the indications for its use has expanded constantly. It has been used to treat large acute traumatic wounds, chronic wounds such as pressure sores following reconstructive surgeries with great success. 1-5 Improvement in the above modality saw the provision of instillation of infected wound with fluid or antibiotic solution.6

Table 1: Summary of our results Indication

Numb Average duration of er therapy

Range

Outcome

THR

1.8 weeks (n = 11 ; one week )

1-6 weeks.

None of the patients reported any infection.

TKR

2 weeks.

1-3 weeks.

None of the patients reported any infection

Traumafracture fixation

1.5 weeks. (n = 9 ; one week)

1-3 weeks.

Except in one non compliant patient, PICO dressing application led to early discharge, with no infection reported in any.

Acute wounds

1.6 weeks (n = 4 ; two weeks)

1-2

One patient was referred for plastic surgery intervention with unknown outcome. Rest of the patients had early discharge.

Chronic wounds

6.2 weeks

1-25 (n = 1 ; 25 wks)

In one patient, PICO was changed to conventional NPWT. In one patient with ulcer over great toe, good seal could not be maintained and hence was discontinued at 6 weeks. In one patient PICO application deferred surgical debridement.

British Journal of Healthcare Innovations Jan 2016 1(1): 45-48 British Journal of Healthcare Innovations Jan 2016 1(1):45-48

in the group without iNPWT. In another randomised evaluation of iNPWT in patients undergoing total hip arthroplasty (THA) by Pachowsky et. al.8 demonstrated that the group with iNPWT had significantly decreased postoperative seromas and improved wound healing.

The latest modification in NPWT is its use in closed surgical incisions, also called by some authors as incisional NPWT (iNPWT). 7-10 Pauser et. al.11 in their randomised evaluation of iNPWT in closed surgical wounds of hip surgeries for neck femur fracture demonstrated that follow up ultrasound measurements of seroma values on post operative days 5 and 10 and the duration of wound secretion were significantly lower than the

The use of iNPWT in closed surgical wounds following total ankle arthroplasty has also demonstrated better wound healing.10

Table 2: Possible mechanisms of action of NPWT. Reduction of seroma in wounds

Pauser et al [11], Nordmeyer et al [12]

Reduction in haematoma size

Stannard et al [7]

Increased tissue perfusion and oxygenation, decreased interstitial fluid

Horch et al [13]

Reduce wound edge tension

Wilkes et al [14], Pachowsky et al [8]

Stimulation of cellular proliferation of granulation tissue

Adogwa O et al [9]

Angiogenesis

Horch et al[13], Stannard et al [7]

Conclusion Incisional NPWT in orthopaedic setting is still in its infancy. With our study, we have been able to lend support to its beneficial use in closed surgical wounds to decrease incidence of infection, promote wound healing, early discharge along with economic benefits.

Overall, the use of iNPWT results in reduced wound healing complications, 11,12 faster recovery,13,15 which we were able to demonstrate from our study as well. It has also been found that consumption of wound care material is lesser and the time utilized for wound care is shorter with use of iNPWT.11

__________________________________________________________________________________________ References

5. Greer SE, Longaker MT, Margiotta M, Mathews AJ, Kasabian A. The use of subatmospheric pressure dressing for the coverage of radial forearm free flap donor-site exposed tendon complications. Ann Plast Surg 1999;43:551–4.

1. Voinchet V, Magalon G. Vaccum assisted closure. Wound healing by negative pressure. Ann Chir Plast Esthet 1996;41:583-9 2. Fleischmann W, Strecker W, Bombelli M, Kinzl L. Vaccum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg 1993;96:488-92

6. Wolvos T. Wound instillaiton- The next step in negative pressure wound therapy. Lessons learned from initial experiences. Ostomy Wound Manage 2004;50:56-66 7. Stannard JP, Robinson JT, Anderson ER, McGwin G, Volgas DA, Alonso JE. Negative Pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2006;60:1301-6

3. Fleischmann W, Lang E, Kinzl L. Vacuum assisted wound closure after dermatofasciotomy of the lower extremity. Unfallchirurg 1996;99:283–7. 4. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563–76.

British Journal of Healthcare Innovations Jan 2016 1(1): 45-48 British Journal of Healthcare Innovations Jan 2016 1(1):45-48

complications. Int Wound J 2014;doi:10.1111/iwj.12344[Epub ahead of print]

8. Pachowsky M, Gusinde J, Klein A, Lehrl S, SchulzDrost S, Schlechtweg P, Pauser J, Gelse K, Brem MH. Negative Pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty. Int Orthop 2012;36:719-22

12. Nordmeyer M, Pauser J, Biber R, Jantsch J, Lehrl S, Kopschina C, Rapke C, Bail HJ, Forst R, Brem MH.Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care. Int Wound J. 2015 Apr 30. doi: 10.1111/iwj.12436. [Epub ahead of print]

9. Adogwa O, Fatemi P, Perez E, Moreno J, Gazcon GC, Gokaslan ZL, Cheng J, Gottfried O, Bagley CA. Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence afterlong-segment thoracolumbar spinal fusion: a single institutional experience. Spine J. 2014 Dec 1;14(12):2911-7. doi: 10.1016/j.spinee.2014.04.011. Epub 2014 Apr 21.

13. Horch RE, Munchow S, Dragu A. Erste Zwischenergebnisse der Perfusionsbeeinflussung durch Prevena: Gewebsperfusionsmessung. Z Wundheilung 2011;A 16:19-20 14. Wilkes RP, Kilpad DV, Zhao Y, Kazala R, McNulty A. Closed incision management with negative pressure wound therapy (CIM): biomechanics. Surg Innov 2012;19:67-75

10. Matsumoto T, Parekh SG. Use of Negative Pressure Wound Therapy on Closed Surgical Incision After Total Ankle Arthroplasty.Foot Ankle Int. 2015 Jul;36(7):787-94. doi: 10.1177/1071100715574934. Epub 2015 Mar 3.

15. Kaplan M, Daly D, Stemkowski S. Early intervention of negative pressure wound therapy 11. Pauser J, Nordmeyer M, Biber R, Jantsh J, using vaccum-assisted closure intrauma patients : Kopschina C, Bail HJ, Brem MH. Incisional Negative impact on hospital lenght of stay and cost. Adv pressure wound terapy after hemiarthroplasty for Skin Wound Care 2009;22:128-3 femoral neck fractures -reduction of wound __________________________________________________________________________________________

British Journal of Healthcare Innovations Jan 2016 1(1): 49-51 British Journal of Healthcare Innovations Jan 2016 1(1):49-51

Brief report Integrating Complementary and Mainstream Medicine: An innovative thought! Michael Dixon LVO, OBE Introduction Innovation is a dangerous and sometimes thankless game. Dangerous because innovators are by definition risk takers and their innovations are, invariably, ahead of their time and unproven. Thankless because once the successful innovator ceases to be an outsider others will compete to take the credit.

However, as I observed and interacted with my patients, I became aware that there was a therapeutic world beyond the confines of allopathic medicine. I realised that a large number of patients suffering from chronic and vague symptoms had no medical cure and it was obvious that in a number of cases there was a complex interplay between physical and psychological issues, which could not be treated by drugs alone. It was with this in mind that I started to explore the world of complementary therapies.

My interest in complementary medicine started well over 20 years ago with several of my patients telling me that they had greatly benefited from seeing complementary practitioners and my growing realisation that the medicine that I had learnt was too often inadequate for some patients. For instance, those with chronic tiredness, frequent minor infections, stress, irritable bowel, headaches, fibromyalgia, neck pain, eczema and a whole range of conditions where there seemed to be a significant therapeutic or evidence gap. Nor was I equipped to treat less "medicalâ&#x20AC;? problems such as a broken heart, loss of hope or selfconfidence, inability to get a job or loneliness.

Integrating complementary and mainstream medicine, as introduced in my GP practice for the past 20 plus years, has however proved to be infinitely more difficult than any of the other innovations in which I have been involved. There has been years of scepticism and at times outright hostility from the medical profession about the value of various modalities of complementary medicine. The hypothesis is that only a "quack" would want to integrate conventional (and by definition "proven") medicine with complementary (and by implication "unproven") medicine. What on earth made me do it?

Introducing complementary practitioners to my GP practice (on a subsidised paying basis) was championed by our practice patient leadership group and its wider membership of around 200 patients.

We started with the support of our patient leadership group and gradually introduced complementary therapies and now offer a Acupuncture, Homeopathy, Osteopathy, Herbal Medicine, Allergy testing, Nutrition, Massage, Alexander technique, Bowen-Feldenkrais method, counselling, Psychotherapy, Hypnotherapy, Reflexology, Physiotherapy Yoga, Reiki, & Podiatry.

Setting I am a GP principal in a semi rural practice of 12 partners and 20,000 patients. I started my practise dealing with the majority of usual problems faced in general practice. _________________________________________

We subsequently built on the publication of the Smallwood report, which supported the provision of Osteopathy, Chiropractic, Acupuncture, Homeopathic & Herbal Medicine in the NHS.

Mr Michael Dixon, LVO, OBE Culm Valley Integrated Centre For Health Willand Rd, Cullompton, Devon, EX15 1FE. E mail: christine@pitchblack.eclipse.co.uk

British Journal of Healthcare Innovations Jan 2016 1(1): 49-51 British Journal of Healthcare Innovations Jan 2016 1(1):49-51

In 2009, The National Institute of Clinical excellence also approved Osteopathy, Acupuncture, Massage & Alexander techniques formally recognising benefits of these treatments by a government body, confirming what a host of satisfied patients already knew.

led me to write a book on the subject: "The Human Effect". I have found some of their methods in mind/body medicine to be particularly powerful. Increasingly I use some of these techniques in surgery myself. This started with my attending a controversial "Cyriax" manipulation course and I have since extended my repertoire to a limited range of treatments that I have personally found to be effective such as acupressure, some herbal remedies, massage, self hypnosis, breathing techniques, self care exercises and therapeutic yoga for conditions such as neck and back pain. My patients say that they benefit from these, I have never had a complaint and it has turned me from a burnt out GP (facing human suffering and unhappiness insufficiently equipped) to a satisfied one, who still has no intention of retiring in his mid sixties. Our practice was rated as outstanding by CQC.

The medical profession has also now started realising the benefits of referring to recognised practitioners like Osteopaths, Massage therapists and Acupuncturists for problems like chronic back pain, intractable shoulder pain, and stress or posture related disorders. A large number of patients have been helped by our complementary therapists and even the most sceptical GP partners in my 12 partner practice covering almost 20,000 patients are now recommending some of the 14 different complementary practitioners to their patients. We have shown that complementary practitioners can be highly effective and that there is a demand for their services. We also believe it is safer to integrate conventional and complementary practitioners in this way because we can talk to each other - particularly important when it is well documented that only 50% patients tell their doctors that they are seeing a complementary practitioner or taking a complementary medicine. In the past year or so, our osteopath has referred me patients with giant cell arthritis, spinal secondaries and a melanoma that I would otherwise have seen much later.

Using the best of conventional and complementary medicine within an integrated approach might seem "the best of both worlds". "Not so" say opponents because they say it involves mixing one form of medicine (conventional) backed by population based evidence, with an inferior one that often does not have the same kind of evidence. This argument is perfectly valid in the treatment of a heart attack or anaphylactic shock but misses the point when it comes to everyday general practice, which is infinitely complex and subtle. This is because symptoms are often metaphors and treatment may often be effective because of its symbolic meaning. Beliefs, history, culture and mindset are all important in healing. Ignoring them is missing a trick and criticising patients that want and clinicians that offer complementary (CAM) therapies is less application of reason and more the imposition of one's own belief system on that of others. CAM therapies are also caught in a double bind because the necessary pragmatic controlled trials of cost-effectiveness have not been done (the NHS spends 0% of its research budget on them) and no one will pay for them. Consequently, they are criticised because of lack of credible research in spite of at least 25% of general practice itself being known to have no evidence base.

Complementary medicine often tips the balance from a medicalised to a more empowered patient, starting him/her on a journey of self help. By offering meditation, Tai Chi and a social prescribing facilitator, we have been able to stimulate patients into taking control of their own care and personal health, which has created virtuous circles and eventually led to patient groups and health activities that are run by patients themselves for the good of other patients. Thus integration in my GP practice has a wider agenda - that of de-medicalising and supporting self care and greater resilience. The more we can move people, where appropriate, away from being "patients" and needing conventional health services, the more available those services will be when people do need them and the more sustainable the health service will be in the long run.

So why does this particular area of innovation provoke such angry emotions from some people? Is it simply about lack of sufficient evidence? I doubt it, because every innovation starts without proper evidence and has to generate it as it goes. Is it because for some complementary therapies

On a personal level, I have learnt much from observing the healing techniques and effects of complementary practitioners - so much so that this

British Journal of Healthcare Innovations Jan 2016 1(1): 49-51 British Journal of Healthcare Innovations Jan 2016 1(1):49-51

there appears to be no clear scientific basis or theory in conventional terms? Possibly, though GPs are pragmatists not theorists and if their patients are helped then that is all that matters.

attack me on a daily basis. Stepping outside the box has led to enemies that I never wanted and to letters to my local University and colleagues in national organisations questioning my professional credibility. As I said at the beginning; innovation can be a dangerous and thankless endeavour.

I think it goes deeper. It is, I suspect, because integration is seen as an act of treason. If you train for 9 years to become a GP, what on earth are you doing fraternising and borrowing the techniques of a completely different tribe of healers, who have no medical training? Ultimately it is not about the search for truth but stamping out heresy. Integrating complementary and conventional is a particularly threatening form of heresy for some conventional medics, who may feel that patients and society owe them, and only them, the status of credible healers.

Almost a hundred years ago, my grandfather raised a loan to import one of the first tractors from the USA. He was told that they would never catch on but he died a millionaire. Today, integrated medicine, in the sense that I have used it, is accepted in medicine and medical schools in countries as far apart as the USA and Australia. My personal hope is that one day here in the UK, a much larger number of doctors and complementary therapists will be able to work together and offer their patients a wider choice of treatment approaches that will make them better able to care for them, remain healthy and reduce the burdens on the National Health Service

Our patients think differently and, for me, innovation in this field has been a case of "if you can't beat them join them". I started off with exactly the same scepticism as those who now

British Journal of Healthcare Innovations Jan 2016 1(1) British Journal of Healthcare Innovations Jan 2016 1(1

Call f o r p ap er s Br it ish Jo u r n al o f Healt h car e In n o vat io n s is a n ew an d u n iq u e jo u r n al aim ed at d issem in at in g n ew an d in n o vat iv e m o d els o f h ealt h car e p r act ise an d d eliv er y w it h t h e aim o f im p r o v in g t h e h ealt h car e q u alit y an d b r in g in g ab o u t co st ef f icien c y im p r o vem en t s. Th e Br it ish Jo u r n al o f Healt h car e In n o vat io n s in vit es o r ig in al ar t icles, au d it s, co m m en t ar ies, b r ief r ep o r t s an d r eview ar t icles o n issu es r elat in g t o in n o vat io n in h ealt h car e an d in it iat iv es t o im p r o v e t h e d eliv er y o f h ealt h car e. Th e jo u r n al is p u b lish ed t w ice a y ear . All ar t icles ar e p eer r eview ed . Fo r f u r t h er in f o r m at io n , co n t act t h e ed it o r ial t eam at : ed it o r BJHI@g m ail.co m In st r u ct io n s t o au t h o r s ar e av ailab le o n h t t p ://issu u .co m /b jh i/d o cs/in st r u ct io n s_t o _au t h o r s_b jh i.d o cx ( t in y u r l h t t p ://t in yu r l.co m /jh b n 44n )

Keshav Singhal Parag Singhal Sanjeev Agarwal

Consultants Specialising in Gastroenterology, Respiratory, Acute Medicine or Care of the Elderly Each Medical Consultant will join a team of 10 other physicians within the Medicine Department to provide continuous cover through the specialties working a 1:11 medical on-call. Respiratory work includes Outpatient Clinics, Bronchoscopies, Inpatient Respiratory referrals. Weston has a small Cardio Respiratory lab for lung function testing, overnight oximetry screening for sleep disordered breathing and a well equipped endoscopy unit with bronchoscopes.

Weston Area Health NHS Trust may be one of the smallest District General Hospitals in the UK but we are very committed to delivering the right care in the right place at the right time. We pride ourselves in being a small, friendly hospital with real drive to improve both patient care and the working environment for our staff however the town of Weston-super-Mare is one of the fastest growing towns in the South West and we are looking to increase our medical workforce to meet the needs of the local community. Weston-super-Mare is part of a rural area in North Somerset situated in an area of countryside with easy access to Bristol and Bristol International Airport. Weston is a major tourist destination with numerous festival activities nearby. Nearby Bristol and Bath offer the full range of cultural background. We have vacancies at different levels and specialties listed below and are offering competitive salaries plus relocation packages will be considered.

Trust Doctors in Emergency Medicine You will be providing direct care to patients presenting to the Emergency Department, offering supervision and hands-on training to juniors, doctors and other emergency staff. There are opportunities to attend regional training as the Trust is fully supportive towards educational development and FCEM/MCEM preparation.

Clinical Fellow Junior Doctors in General Surgery, Urology or Trauma/Orthopaedics Surgical specialties are upper GI, Colorectal and Urology and the hospital admits trauma 24/24 hours. Attendance to the Emergency Department when on-call to help manage admissions will be expected. A full range of orthopaedic cases are managed at Weston in the clinics and theatres. On-call is between 1:14 and 1:17 shared with Gynaecology, Surgery and Orthopaedics at nights and weekends. Full training will be given for this.

In Gastroenterology, you will assist with the developments in gastroenterology and endoscopy in the Trust. Demand for our services has expanded significantly in recent years, especially colonoscopy. We do not have bowel cancer screening colonoscopy but are developing a screening flexible sigmoidoscopy service in cooperation with the Bristol screening hubs. Participation in the 1:11 acute upper GI bleeding will be a requirement. The Acute Medicine team supports both the Medical Admissions Unit and short stay ward with concentration of gastroenterology inpatients in a sub-specialty ward. There is daily specialist input into the acute care of gastrointestinal disease. Within Care of the Elderly, you will have a continuing responsibility for the care of the patients in your charge and for the proper functioning of the department. You will be required to undertake a full share of the elective and emergency general medical workload, with delivery characterised by high-quality care, continuity of clinical management, appropriate clinical supervision of junior staff, clarity and timeliness of clinical communications, etc. There will also be an expectation to lead new developments in Stroke Care, Geriatology and General Medicine.

Clinical Fellows (ST3+ Registrar Equivalent) in General Medicine We are looking to appoint Clinical Fellows (registrar equivalent) Doctors in Medicine with the opportunity to work in the following Medical specialties: Respiratory, Care of the Elderly, Stroke, Diabetes and Endocrinology, Cardiology, Gastroenterology and Acute Medicine and will include participating in the General Medicine registrar rota. The Medicine Department comprises of 14 Consultants with special interests in the specialties mentioned above. There is a firm commitment to continuing professional development and the opportunity to participate in specialist clinics or procedure lists may be available.

Full job descriptions are available together with the application process at www.jobs.nhs.uk but if you have any queries please contact the Staff Services team by email to wnt-tr.recruitment@nhs.net and we will ensure that a member of the medical team contact you as appropriate. Closing date: 14 February 2016.

BENEFITS INCLUDE: ON SITE NURSERY, SUBSIDISED RESTAURANT, EMPLOYEE ASSISTANCE PROGRAMME AVAILABLE

Over the last 15 years, the PINNACLE Acetabular Cup System has been provided for more than

The CORAIL hip system celebrates 30 years in 2016, and in that time has been provided for over

patients.

patients.1

2,000,000

1,600,000

S TE M & SY P ® NACL E HI IN

S ol

u t io n

COR

AIL ® H IP

In 2015 CORAIL and PINNACLE Acetabular Cup System were awarded 10A* ratings by the Orthopaedic Data Evaluation Panel.2 National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Registry Data for the CORAIL/PINNACLE Combination Based on the 2015 Annual Report, CORAIL PINNACLE was the most implanted combination in total hip replacement across England, Wales, Northern Ireland and the Isle of Man. 3,4 Combination

Implantations

Year 3

Year 5

Year 10

CoC

32,309

1.79% (1.63%-1.95%)

2.43% (2.23%-2.65%)

3.95% (3.32%-4.71%)

CoP

12,187

1.11% (0.91%-1.36%)

1.67% (1.35%-2.06%)

2.19% (1.40%-3.41%)

MoP

36,776

1.46% (1.33%-1.61%)

1.81% (1.65%-1.99%)

3.59% (2.59%-4.96%)

* blue italics signify that fewer than 250 cases remained at risk at these time points

1. Data on file, DePuy Orthopaedics, Inc. 2. Orthopaedic Data Evaluation Panel. ODEP product ratings. Available from www.odep.org.uk [Accessed 01/10/2015]. 3. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man, 12th Annual Report, 2015. Table 3.9. Available from: www.njrreports.org.uk 4. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man, 12th Annual Report, 2015. Table 3.10. Available from: www.njrreports.org.uk depuysynthes.com

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