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Weight loss surgery could boost the UK economy by £1.3 billion

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Better training and prompt action are needed to prevent unnecessary acute care deaths

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Doctors have a duty to provide leadership to the NHS

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Doctors will be key to meeting the financial challenges set by Osborne’s spending review Doctors must become more involved in the financial affairs of their trusts because they will be key to meeting the challenges set by George Osborne’s November spending review, says Paul Healy, Senior Economic Adviser, NHS Confederation. Savings in the next five years will be around transformation and where we put resources. Clinicians will need to have a much greater role in these decisions to ensure they have the right impact on patient care,” he told the Acute & General Medicine conference. He was commenting on research commissioned by the Department of Health which shows that nearly three quarters of clinicians feel they are rarely or never involved in financial decisions affecting their organisations and over half do not believe they are involved in

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Hands-on training zones highly rated by delegates keen to hone essential skills This year the hands-on training workshops at Acute & General Medicine grew to cover more areas of expertise and were more popular than ever with delegates who came along to learn about the latest technology and procedures or simply to refresh essential skills. Full feature continued page 4 and 5

financial decisions that affect their service or team. Mr Healy said doctors described the current financial pressures as the worst they have ever experienced, most expected financial pressures to increase significantly over the coming year and most thought being an NHS leader had become more difficult over the last 12 months. The majority of frontline staff said they made decisions while distracted, stressed and tired.

The survey, conducted by the the NHS Confederation and the Academy of Royal Colleges, found that six in ten clinicians did not know the costs of their service or the price paid for their service. Although most clinicians understood financial incentives or payment mechanisms, such as Commissioning for Quality and Innovation (CQUIN), national tariff prices and block payments, they said were uncertain whether these mechanisms impacted on their behaviour.

f CONTINUED ON PAGE 2

Paul Healy, Senior Economic Adviser, NHS Confederation

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Contents Weight loss surgery could boost the UK economy by £1.3 billion. 2 Better training and prompt action are needed to prevent unnecessary acute care deaths. 3 Hands-on training zones highly rated by delegates keen to hone essential skills. 4-5 Exhibitor Spotlight. 6 Top tips for managing change in a changing NHS. 7 AGM Conference Poster Zone. 8-9 Doctors have a duty to provide leadership to the NHS. 10 @AGMConfUK 2015 Show Snapshot. 11 Recruitment Board. 12

Delegate bookings:

Martin Houlihan 0207 348 1845 07773 020179 m.houlihan@closerstillmedia.com

Editorial team:

Francesca Robinson Freelance Journalist fran.robinson8@gmail.com Mike Broad HospitalDr Editor www.hospitaldr.co.uk

If you're interested in exhibiting:

Yemi Ibidunni 0207 348 4907 yemi.ibidunni@closerstillmedia.com Dan Assor 0207 348 5757 d.assor@closerstillmedia.com

ORGANISED BY

Mr Healy said the research, part of the Decisions of Value project, indicated that the best way to improve decisionmaking was to develop the culture of an organisation rather than making structural changes and that behaviour

Issue 14

January 2016

and relationships were more important than rules and standards.

making, supportive environments and larger networks of peer support.

Other factors needed to improve decision-making were: stronger clinical and financial rapport, greater patient involvement, deeper values-based behaviour, information driven decision-

“This will take time to develop and the system needs to focus on how to empower clinicians to contribute to decision-making,” he said.

Bariatric surgery was also more cost effective than slimming drugs. Research showed that after three years the cost of taking Orlistat, the only slimming drug available in the UK, added up to more than is spent on bariatric surgery. Five years after taking slimming drugs 90% of patients would have put the weight back on.

onset of new diabetes and had a marked impact on patients with current diabetes resulting in 60% of all patients with type 2 diabetes coming off all their medications after surgery.

Weight loss surgery could boost the UK economy by £1.3 billion If a quarter of obese patients had bariatric surgery the UK economy would benefit to the tune of £1.3 billion within three years, even after the cost of the surgery, a leading obesity expert told Acute & General Medicine. Rachel Batterham, Professor of Obesity, Diabetes and Endocrinology, University College London, said this was the conclusion of a 2010 Office of Health Economics report, which estimated that 1.1 million people are eligible for bariatric surgery. The savings would come from the drugs needed to treat obesity and diabetes and additional tax gained from people returning to work.

MAIN SPONSOR

Weight loss surgery was safe and effective and worked by altering appetite and food preferences. It changed a person's biology by resetting their bodyweight set point and the brain’s response to food cues. It restored leptin and insulin sensitivity and altered the gut microbiome composition. It reduced hunger and appetite and the reward value of food. Weight loss surgery achieved a 30% decrease in all-cause mortality 7-8 years after surgery, prevented the

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But these patients needed lifelong follow-up and there were cases of iron folate, B12 and vitamin D deficiency and, rarely, even beriberi and night blindness. Lifelong monitoring and nutritional replacement therapy for these patients was essential and they had to sign up to that at the outset. “We have to remember however this is not about disease numbers and money, it is about patients. Bariatric surgery, particularly for young people, transforms lives. Even the patients who have complications say they would do it again in a heartbeat to get the weight loss,” said Professor Batterham.

Sponsorship Statement AGM is for healthcare professionals only. The seminars at AGM have been brought to you by Closer2Medical in association with our partners and sponsors. The views and opinions of the speakers are not necessarily those of Closer2Medical or of our partners and sponsors. AGM’s association partners have helped develop the programme. Sponsors have not had any input into the programme except where an individual session states it is sponsored. The session topic and speaker have been developed by each sponsoring company.

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Better training and prompt action are needed to prevent unnecessary acute care deaths Junior doctors need more training to improve their ability to identify the deteriorating, unwell medical patient, Dr Paul Frost, Consultant in Intensive Care Medicine, University Hospital of Wales, told the Acute & General Medicine conference. Since 2005 numerous National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reports have identified inadequate care of patients ending up in intensive care because of delayed recognition and poor management of their symptoms. The majority of patients were seen by junior doctors but the evidence that was available on the competency of juniors to deal with these patients was alarming. One study questioning 185 juniors on 12 acute care topics revealed that: 36% did not know the normal minimum urinary output expected in an adult; 23% could not correctly describe the role of a bag attached to a non-rebreathing oxygen mask and 18% did not know the maximal

deliverable oxygen concentration using a non-rebreathing (reservoir) oxygen mask. Dr Frost said he was also concerned about the “explosion” in recent years in the number of acute care courses marketed for postgraduates. “This is very, very worrying. The inference that you can draw from this is first of all there is a clear training need, there's a training gap. These courses are very resource intense yet there is no evidence that they have in any way improved clinical outcomes for patients. These courses have continued while we have also had serial reports from NCEPOD pointing out time and time again that care is poor.” Improving outcomes for deteriorating patients depended on good teamwork and activation of National Early Warning Score (NEWS) systems, he said. Despite NICE recommending the use of NEWS systems in the UK studies showed that many often fell down because observations were not done or were done inaccurately and scores were miscalculated. Even if observations were done properly and scores calculated accurately responses may still not be activated or if

Dr Paul Frost, Consultant in Intensive Care Medicine, University of Wales

activated would still be inadequate. Other studies showed that sometimes NEWS activation did not happen because of a silo mentality where doctors on the wards mistrusted the opinions and interventions of colleagues on the ICU. Dr Frost said colleagues should not to see the ICU as “some sort of black hole” where patients went and did not come out or came out many weeks later. “It's essential that if we going to improve outcomes for these patients we need to be working much more collaboratively together and it's essential that colleagues come and give their opinions as to the treatment and trajectory of illness of patients even if they are under the care of intensive care doctor,” he said.

Be alert for MERS CoV and Chikungunya in the UK warns travel health expert at Acute & General Medicine UK studies show that acute care physicians are failing to ask up to a fifth of patients with a fever about their travel history, travel health specialist Dr Victoria Johnston told Acute & General Medicine. Patients don't always volunteer their travel history and the problem is that we often don't ask,” she said. Dr Johnston, Consultant, Hospital for Tropical Diseases, University College London Hospital, said current infections to be on the alert for included MERSCoV and Chikungunya. There was a current outbreak of MERSCoV, a novel coronavirus, in the Middle East. First identified in 2012, there is growing evidence that this virus is passing from camels to humans. To date there have been 1600 laboratory confirmed cases with 575 deaths, a high mortality rate.

There was 1 case in the UK in 2012 and 3 in 2013. In Korea recently there was a reasonable sized outbreak after one traveller returned from the Middle East and attended hospital resulting in 86 further cases, 36 deaths and 16,000 people requiring monitoring for 14 days. “There is no reason to think that also couldn't happen here,” warned Dr Johnston. The incubation period for MERS CoV is 5 days but can be 2-13 days. Patients will present with a flulike illness: fever, cough, be short of breath and may have diarrhoea and vomiting. “You need to be thinking about testing people with a respiratory infection and a travel history at the front door not a few days into their admission. Infection control will be key to preventing an outbreak in the UK,” she said. Chikungunya is another infection to look out for. Dr Johnston said this is a concern for the UK because their travel health hotline has been receiving increasing calls from from GPs with

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Dr Victoria Johnson, Consultant, Hospital for Tropical Diseases, University College London Hospital

patients saying they have got chicken disease and asking what it is. Chikungunya is a mosquito borne RNA alphavirus, which has been increasing in incidence in Latin America. Most people have a febrile illness and extreme myalgic-type pains and polyarthralgia and 50% of people will have a rash. Most cases will get better with time, reassurance, NSAIDs and a short course of steroids. Occasionally the might need further intervention. Patients with moderate to severe symptoms of chronic arthralgia would warrant a referral.

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What @AGMConfUK 2015 delegates said…

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Issue 14

January 2016

Hands-on training zones highly rated by delegates keen to hone essential skills

“All the skills training has been very good. I've done ALS but I haven't done NIV or ultrasound before so it was a great opportunity to have a go. I found it very useful.” Dr Colleen Fletcher, F2, Barts Health NHS Trust.

“I’ve come along to the hands-on training as a break from the lectures and also because it’s a practical skill I want to revise. I'm ultrasound trained but I haven't used it in several years and now I’m planning to get an ultrasound machine for my department.” Tina OHara, Consultant in Acute Medicine, Buckinghamshire Healthcare NHS Trust.

“I have found the skills training very informative and I've learned a lot. It has reinforced what I already know and refreshed my skills. The trainers were very friendly and really helpful.”

j CONTINUED FROM PAGE 1 Visitors to the ultrasound, acute skills and non-invasive ventilation training zones took part in interactive workshops run by experts teaching skills they could put to use immediately back on the wards.

Ultrasound Skills Zone In the Ultrasound Skills Zone delegates were guided through six demonstration stations covering critical care and emergency medicine scenarios. Alistair Wood, Sales Manager of GE Healthcare, which sponsored the zone, said: “We had a small stand last year just to test the water. I came alone with a few bits of kit and I was swamped. This year we have run four stations there were queues to register and we were fully booked within half an hour. Next year we will be coming back with eight workstations. “Point of care ultrasound is a growing area and this conference is ideal for it because you've got physicians from all the care areas – respiratory, renal, intensive care, acute medicine, accident and emergency and general practice – all areas

where ultrasound can be used. Image quality is going up, prices are coming down and it's becoming easier to use so the interest in ultrasound is phenomenal.”

Non-Invasive Ventilation Visitors to the Non Invasive Ventilation demonstration zone, sponsored by Philips, were able to experience hands-on application of NIV for respiratory failure. Demonstrations covered acute NIV for Type I and Type II respiratory failure and NIV for acute Type I cardiogenic respiratory failure. Lisa Plummer, a respiratory physiotherapist who organised the 45 minute sessions said: “The aim of the workshops was to give clinicians handson experience with non-invasive ventilators and to give them a clear understanding of where they would use it, how they would use it and what outcomes could be achieved. “NIV is very popular in medicine at the moment particularly for COPD and cardiology patients. Delegates spent quality time learning about it in our sessions and were asking some great questions. People were tuning the

questions to their particular areas of medicine and learning about the practical applications which would enable them to apply the principles to the machines they have got in their hospitals.” Gareth Gilday, sales account manager, Philips, said: “We had a fantastic response, a lot of our sessions were been fully booked. It has been a real eye opener for us to discover the numbers of people who want to come along and learn a bit more about NIV. We've had a real mixture of delegates visit us from foundation doctors and registrars to consultants and locums. They have told us this is something they haven't had much training for and that it has been a great opportunity to learn more about it.”

Acute Skills Zone The Acute Skills Zone run by medical education charity ALSG, provided essential life-saving skills training for the fourth year at Acute and General Medicine. For the first time they offered 45 minute MedicALS training, skill stations in basic and advanced airway, intraosseous access and infusion and neurological examination as well as some new e-modules.

Zaheer Mohammed, A&E Registrar, Ipswich Hospital.

“The NIV training was very good. Our NIV machine is very old and the last time I went to use it it was missing some bits. So I needed an update. We also need a New machine in my department as well. So I thought it would be a good idea to come along and learn how to use it.” Kerry Whitwell, Consultant, Royal Free Hospital.

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Jenny Antrobus, Operations Director, ALSG, said the basic airways and advanced airways stations had been the most popular training sessions over both days of the conference. “This is something that is really useful for acute physicians. We do offer the station on all our courses and although it is quite a basic skill some people don't get the opportunity to practice it very often. The intraosseous access and infusion station and the neurological examination station were also very busy. “Our training instructors are all highly qualified and we have had some really great feedback from delegates with a

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lot of them scoring us five out of five. We have had a real mix of delegates in the sessions - quite a few SHOs, plus nurses, consultants, GPs and medical students. Although they get life support training doctors are very busy people and seem to be welcoming the opportunity to refresh their skills and earn some CPD points while they take a break from the lectures. “Providing this training at Acute and General Medicine has given us an opportunity to raise our profile and promote a whole range of courses in our portfolio. People enjoy the sessions and we like to come.”

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One's to watch! Exhibitor Spotlight throughout the UK. We are at the forefront of raising the standards throughout our industry, working 24 hours a day on call, supporting our doctors and clients, building trusted professional partnerships.

Think Vitals ThinkVitals is an intuitive clinical observations app that enables clinicians to electronically capture patient’s vital signs, dynamically calculate NEWS scores and detect and manage sepsis. ThinkVitals has been developed in association with Chelsea and Westminster Hospital by ThinkShield, a company with 10 years experience providing IT healthcare services and solutions.

Yeovil Hospital Healthcare Yeovil Hospital is a pioneering organisation that is already delivering recognisable change to the way healthcare is delivered. Chosen as a Vanguard site by NHS England, and among only 52 projects in the country, we are developing a more effective, collaborative, and patient centred NHS.

Choose South Cumbria It’s an exciting time for the NHS in South Cumbria, as part of ‘Better Care Together’, one of the first ‘Vanguards’ receiving support from the new NHS Transformation Fund. This means a future full of opportunities: developing new models of care, innovative ways of working, new roles and career progression.

East Lancashire Hospitals East Lancashire Hospitals NHS Trust is an integrated healthcare provider located in Lancashire, North West England offering high quality healthcare for a population of 530,000. We employ 7,000 staff, provide 996 inpatient beds and treat 600,000+ patients in our five hospital and numerous community facilities.

Bayer is pleased to support this event as manufacturers of one of the first novel agents (NOACs) to be indicated for the treatment and prevention of many thromboembolic diseases. Bayer has a proud history in thrombosis research and continues to develop effective and safe treatments for patients and clinicians alike.

NC Healthcare is a specialist medical recruitment agency successfully supplying locum doctors to the NHS

MDU The MDU is a not-for-profit organisation wholly dedicated to our members’ interests, providing expert guidance, personal support and robust defence in addressing medico-legal issues, complaints and claims. We provide high quality, specialised medico-legal advice, 24 hours a day, 7 days a week.

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and private healthcare organisations

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Top tips for managing change in a changing NHS Many significant and complex change management programmes grind to a halt because of their failure to produce the hoped-for results, Acute and General Medicine delegates learned in a talk on managing change. The research indicates that failure is not necessarily due to poor technical solutions, it is the result of poor project planning and change management. Managing the change process and transition is fundamental to the success of any change project, Jennifer Scott-Reid, Managing Director Scott-Reid Solutions Ltd, explained.

and a SWOT (strength weaknesses opportunities and threats) analysis. 2. Create a guiding coalition: Make sure there is a powerful group of people with leadership, communication and analytical skills, credibility and authority, guiding the change. 3. Develop a vision and strategy: Clarify how the future will be different from the past and how you will make the future a reality then create a vision to help the change effort and develop strategies to achieve that vision. 4. Communicate the change vision: Make sure as many other people as possible understand and accept the vision of the strategy and have a guiding coalition role model of behaviour with respect to the staff.

These were her top tips for 5. Empower broad-based action: managing change, based on John Remove as many barriers as possible and alter systems or structures that P Kotter’s eight stage process: 1. Establish a sense of urgency: It may be helpful to do a PEST (political, economic, social and technologies)

undermine the change vision.

6. Generate short-term wins: Create invisible wins as successes as much as you can.

Jennifer Scott-Reid, Managing Director, Scott-Reid Solutions Ltd.

7. Consolidate gains and produce more change: Press harder and faster, don’t let up, consolidate improvements and sustain the momentum for change. 8. Anchor new approaches in the culture: Hold on to the new ways of behaving and make sure they succeed and become that part of the new culture.

@AGMConfUK #agmconfuk /AGMConference

Acute & General Medicine

High quality care is key to preventing avoidable COPD admissions In some areas up to one third of medical admissions are due to exacerbations of COPD and some are avoidable so it is important that these patients are triaged correctly at the front door of the hospital, Dr Rod Lawson, Consultant Respiratory Physician, Sheffield Teaching Hospital NHS Trust, told Acute and General Medicine delegates. Patients with acute exacerbations of COPD should have an early review by a senior clinician in the emergency department. Some will need life-saving treatments in hospital while other treatments can be delivered at home. The first assessment may not be accurate and if the patient does not respond to treatment they may need to

be reassessed for other conditions such as cardiac disease or cancer. Patients with COPD who suffer from acute exacerbations have a mortality rate of about 15 per cent in hospital and continue to be at high risk of mortality post discharge. However studies show that some patients with COPD are long term survivors and about 30 per cent are still alive after five years. With careful management even patients with severe disease can enjoy a good quality of life. Patients with comorbidities are more likely to die and so comorbidity is important in predicting poor outcomes, said Dr Lawson. A low eosinophil count is a poor prognostic indicator in COPD. Eosinophils are more usually associated with asthmatic inflammation but recent research has been studying the link between eosinophils and COPD. Evidence shows that supported discharge of patients with COPD is effective. Up to 40% of patients can be sent home although 10% may be

readmitted. However studies show that around of one third of patients say they don't feel well enough or confident enough to leave hospital even though they been admitted and treated.

middle-class that when we get heartsink patients coming in we have a tendency to give up on them. In fact these are the patients we should be targeting to make a difference,” he said.

There are also issues with deprivation. One study has shown that patients from a deprived area admitted to hospital are far less likely to be invited back for follow-up. “There is something about us as doctors who are predominantly

It is also important that patients are treated by skilled staff. Studies have shown that patients treated by high quality staff and with psychological support have better outcomes, concluded Dr Lawson.

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MEET OUR 5 WINNERS Aamir Shamsi, FY2, Frimley Park Hospital/Kingston Hospital Poster Zone Category: Audit & Quality Improvement Introduction: Blood tests are important indicators of a patient’s health. Bloods are marked as “Urgent” if they need to be reported within the next few hours to determine next stage of management. However a large proportion of samples are not taken by the phlebotomy service. As a result, the doctors or nurses have to take the blood themselves resulting in tests reported much later causing the potential for treatment delay, doctors having to work overtime and an increased burden on the on-call teams to chase blood results. Aim: Using PDSA and LEAN methodology, we aimed to highlight the deficiency of the multidisciplinary blood taking process and develop solutions that will enable 60% of urgent bloods requested not completed by phlebotomy service to be sent off by 1300 in order for them to be reported with enough time to act upon within 2 months. Results: 48% of bloods requested by 0830hrs were taken by phlebotomists and of the remaining samples, only 37% were taken by a doctor or nurse before 1300hrs. From surveying the clinical staff we devised a multidisciplinary solution that was cost neutral and pragmatic: teams to discuss which bloods are urgently needed and a visual status using a magnetic blood bottle image next to the patient’s name that needed bleeding for doctors and nurses to act upon if not initially done so by a phlebotomist. With these interventions, either a doctor or a nurse successfully took 80% of remaining bloods before 1300hrs that had not been completed by the phlebotomy service: a significant increase from 37% (p=0.0005). Conclusion: Decreasing the number of urgent blood requests and utilising a visual symbol to quickly identify which patients need bleeding will help to ensure patients are managed effectively in a time frame that is appropriate for their medical team to deliver the best care possible.

Ashraf Kamour, Consultant Physician, North Manchester General Hospital Poster Zone Category: Acute Medicine Case Reports Introduction: D-dimer assay has shown to have a negative predictive value up to 94% in suspected cases of venous thromboembolism (VTE) (1). Using the Well’s scoring system to help guide clinical probability, when applied to low risk patients a negative D-dimer assay raises the negative predictive value to 99% (2, 3). Well established in routine clinical practice as a cost effective way of excluding VTE in such patients, this mantra is rarely questioned. We present a case which raises doubt over our reliance on Ddimer assay in low risk patients. The case: A 52-year-old man presented with collapse and haemodynamic instability. Preceding this was a three-day history of progressive dyspnoea and productive cough. An arterial blood gas demonstrated severe hypoxaemia, raised inflammatory markers in

blood test, with no convincing evidence of lung pathology on chest radiograph. Electrocardiogram showed right bundle branch block and T wave inversion in leads V1 to V3. Troponin I was markedly raised. The patient was initially treated for severe community acquired pneumonia and non-ST elevation myocardial infarction. On next day review, the chest radiograph did not seem to correlate well with the ongoing high oxygen requirements. In view of this, and the initial presentation, the question of pulmonary embolism was raised, and despite of a normal D-dimer assay (using turbidimetric immunoassay) in context of a Well’s score of zero, a computerised tomography pulmonary angiogram was performed which demonstrated large bilateral segmental pulmonary emboli. Conclusion: This case illustrate that negative D-dimer in patient with low clinical probability does not completely exclude VTE. Further research is required to examine the incidence and the causes of false negative D-dimer assay in this cohort of patients. Meanwhile physicians should not substitute clinical judgment, and to proceed to a more definitive diagnostic test if suspicion remain high. References: 1 Bounameaux H, de Moerloose P, Perrier A, Reber G. Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: an overview. Thromb Haemost 1994; 71:1. 2 Wells PS, Anderson DR, Bormanis J, et al. Application of a diagnostic clinical model for the management of hospitalized patients with suspected deep-vein thrombosis. Thromb Haemost 1999; 81:493. 3 Aschwanden M, Labs KH, Jeanneret C, et al. The value of rapid D-dimer testing combined with structured clinical evaluation for the diagnosis of deep vein thrombosis. J Vasc Surg 1999; 30:929.

Edward Norris-Cervetto (Helen Witney and Francoise Ticehurst), Registrar in Emergency & Prehospital Medicine, Emergency Department, Wexham Park Hospital, Slough Poster Zone Category: Service Innovation - Admissions Avoidance Aim: Reduce the amount of time and stress involved in ED doctors and specialties negotiating each admission over the phone without increasing admission rates. Method: Frimley Park NHS Trust took over Wexham Park Hospital in Autumn 2014 and implemented the “Frimley Admissions Policy” for Emergency Department referrals. Under this new policy, the senior doctor in the Emergency Department decides all admissions to hospital specialties using agreed referral pathways. ED doctors simply inform specialties of their decision and specialties must then see the patient physically before specialty seniors can continue to admit, discharge or refer to another specialty themselves. We compared a 23 week period (April – Sept) in 2014 and 2015 to see the effect of the new admission policy on admission rates and the 4h target.

Results: Prior to the new policy, the 4h (95%) target was only met 7/23 weeks (average 91.5%). A year later and despite a 5% greater attendance rate, the target was met 18/23 weeks (average 96.7%). Admission rates remained identical before (29.7 ± 1.6 %) and after (29.7 ± 1.1 %) the new policy. At a human factors level, the new policy has also resulted in the busy medical registrar being bleeped far less often (admissions are added automatically to their electronic list), specialty juniors no longer fearing being told off for “accepting” a certain patient (the decision is taken by the ED) and ED doctors no longer wasting time having to “persuade” specialties to accept a patient. Conclusion: The Frimley Admission Policy has contributed to improved 4h target performance, reduced the time spent by doctors negotiating admissions and seen no increase in admission rates despite increased attendances to the Emergency Department. We recommend this model is adopted more widely throughout the UK.

Jaimie Henry, Foundation Year 2 Doctor, Chelsea and Westminster Hospital NHS Trust Poster Zone Category: Audit & Quality Improvement Agents for Change: Can a novel education programme improve undergraduate engagement in NHS Management and Leadership?

J. Henry, R. Najim; M. Najim; R. Rabee; D Cox; S. Singh. Chelsea and Westminster Hospital NHS Trust, London Introduction: The NHS is facing increasing challenges and the need for doctors who can lead change has never been greater (1). Research shows that good NHS management affects patient care positively, while poor leadership can be catastrophic (1, 2, 3, 4). Importantly, patient outcomes and overall performance improves when doctors engage in leadership (5). However to do so effectively, medical professionals require leadership skills – at all levels. The Medical Leadership Competency Framework (MLCF) has laid out a structure for the development of these skills. Despite this, there is no overall consensus and little engagement at undergraduate level. Aim: Our aims were to evaluate the impact of a 3-tier undergraduate workshop programme, on students’ knowledge and attitude towards NHS management and leadership. This was complemented by the implementation of a supervised Quality Improvement Project (QIP). Methos: 42 medical students in their third year were enrolled onto 3 workshops delivered to cover a range of topics based on the MLCF. Knowledge improvement was assessed by a fifteen question single best answer test and attitudes assessed by a 25 question, five- point Likert scale, both conducted pre-and postintervention. This was supplemented with qualitative data from focus groups. Results: 37 (88%) students completed all three skills sessions. Focus groups demonstrated a general opinion towards a desire for further training in both skills and theory; a lack of clarity in how to act upon and deliver change was emenant. Average score on the knowledge test rose from 5.67 to 7.75 post-intervention, with an average increase of 2.08 (SD 2.58, p < 0.05). Likert scores demonstrated a significant change in attitude towards the positive in nearly all areas.

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January 2016

educational efforts) is effective, replicable by non-experts and acceptable to undergraduate medical students. References: 1 Darzi AV, Our NHS, our future: NHS next stage review. Interim Report, Department of Health, 2007. 2 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationary office. 2013. 3 Rowling E, The King’s fund. Leadership and engagement for improvement in the NHS: together we can: the King’s Fund leadership review, 2012. 4 Tooke J. Aspiring to excellence: final report of the independent inquiry into modernising medical careers. Medical Schools Council, 2008. 5 Goodall AH, Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73:535–9.

Sabrina Hasnaoui, Locum SHO, Musgrove Park Hospital, Taunton and Somerset NHS Trust Poster Zone Category: Audit & Quality Improvement Do age adjusted D-dimers work in an acute hospital setting? Aim: D-dimer levels increase with age1. The ADJUST PE study showed the reference range for elderly patients can be safely adjusted to reduce unnecessary investigations2, but these changes have not yet been approved by test manufacturers. This audit explored whether an age adjusted D-dimer reference range could reduce the need for imaging without missing any venous thrombotic events in Musgrove Park Hospital. Method: A retrospective 12 month sample of 574 patients, aged 50-100 with a D-dimer result between 0.5-1 ugFEU/ml were analysed. The D-dimer assay used was the Siemens INNOVANCE® D-Dimer Assay. The D-dimer range was adjusted using the algorithm age/100 (ugFEU/ml) generating the new threshold for a negative result. Patients with a new negative D-dimer were reviewed to see if they had further investigation for pulmonary embolism (PE) or deep vein thrombosis (DVT). Outcome: Of 574 patients 298 had a negative age adjusted D-dimer, and 111 had further investigation. Of these, one patient had a negative VQ scan. 79 of 80 patients had a negative CTPA (positive CTPA patient had a ‘likely’ pretest probability of having a PE, i.e high Wells score, therefore the D-dimer was inappropriately applied). 29 out of 30 patients had a negative Doppler scan, the one patient had a possible calf DVT. Conclusion: Our results support the use of age adjusted D-dimer. No PE’s were missed when applying negative age adjusted D-dimer with Wells score. There was one missed below knee DVT of uncertain significance (not seen on follow-up scan). Although a retrospective study, a large sample (111) was used for INNOVANCE® Assay. These findings could support the use of age adjusted D-dimer, reducing imaging costs, increasing resource availability and reducing risks and complications from imaging. References: 1 Righini M, Goehring C, Bounameaux H, Perrier A. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med. 2000;109(5):357-361 2 Righini M, Van Es J, Den Exter P et al AgeAdjusted D-Dimer Cutoff Levels to Rule Out Pulmonary EmbolismThe ADJUST-PE Study JAMA. 2014;311(11):1117-1124

Conclusion: Providing supplementary skills and knowledge based tuition to Quality Improvement Projects (or similar MCLF

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January 2016

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POST SHOW EDITION / 9

12th November, 10:30-12:00

All 2015 Poster Zone Submissions: Session Summary P1

Sabrina Hasnaoui, Musgrove Park Hospital, Taunton and Somerset NHS trust

Alison Eastaugh, The Royal Wolverhampton Hospital

Anastasia Theodosiou, Sarah Young, Southampton General Hospital

Testing Times: Improving HIV testing at Charing Cross Hospital

Andy Levy, University of Bristol and University Hospitals Bristol NHS Foundation Trust

Development of a device to reduce IV line tear-out and improve patient comfort

Dr Christopher Woods, Clinical Trials Units, Castle Hill Hospital, HEYH Trust

Audit Location - Diana Princess of Wales Hospital, NLAG NHS Trust

Herbert, F; Williams, R and Orme, A; University Hospitals Bristol NHS Foundation Trust, Bristol, UK

Improving pre-emptive prescribing to relieve patient symptoms occurring out-of-hours

Dr S. Hewitt, Dr I. R. Davies & Dr A. Thuraisingam, Arrowe Park Hospital

Management of acute upper gastrointestinal bleeding at Wirral University Teaching Hospital (WUTH)

J. Henry, R. Najim; M. Najim; R. Rabee; D Cox; S. Singh. Chelsea and Westminster Hospital NHS Trust, London

Agents for Change: Can a novel education programme improve undergraduate engagement in NHS Management and Leadership?

p10

Greenland J, Alawneh J. Bedford Hospital

Acute Neurology Service in a District General Hospital

p11

Peter Williams and Gaurav Agarwal, Tunbridge Wells Hospital

The Management of Severe Sepsis at Tunbridge Wells Hospital, An audit and education programme

p12

Si Han Tan, Shin Yun Gooi, Dumfries and Galloway Royal Infirmary

Improving the standard of discharge summary with changes and innovation in computer software

p13

Muhammad Belal Soobadar, Arrowe Park Hospital

Venous Thromboembolism(VTE) assessment in Breast Cancer and Cancer patients in Queen’s Centre Castle Hill Hospital

p14

Dr Stephen D’Souza, Mrs Mary Donnelly, Lancashire Teaching Hospitals Foundation Trust

OPEN ACCESS, RADIOLOGY BASED, DAY-CASE PARACENTESIS SERVICE

p16

Eames, N, Kingston Hospital, Kingston

Audit assessing adherence to recommended standards for recording decisions about cardiopulmonary resuscitation

p17

Victor Ameh, Hamzah Nasir, Luke Harding, Roda Abdi, Sarah Ahmed, Ayaz Abbasi, The Royal Albert Edward InfirmaryDarren Aw, Queen’s Medical Centre

Quality care in The Royal Albert Edward Infirmary Emergency Department, Wigan, Greater Manchester

p18

Darren Aw, Queen’s Medical Centre

Improved patient flow through transformation of a general medical assessment ward into an acute elderly assessment ward? our local experience

p19

O’Flynn L, Eaden JA, Burch NE, Vinnamala S, Department of Gastroenterology. University Hospitals Coventry and Warwickshire NHS Trust

More for less - Gastroenterology Ward based Day Case Ring Fenced Bed Pilot

p20

Eva Patel, Dafydd Morgan, Kenneth Chan,, Ilnaz Akbarian, Amy Mallorie, Ambreen Muhammad, Cristina Psomadakis, Shamala Rajalingam and Ranjna Garg, Royal Free Hospital, London

Single versus recurrent hypoglycaemia episodes during hospital admissions:risk factors and patient outcome

p21

Dr Anthony Hall, Tauranga Hospital, New Zealand

Simple interventions improving sepsis treatment

p22

Mir Ahmad1; Michael Imana1; Akin Idowu2, Queen’s Hospital, Romford

The Post-take paradox: a point of view from the Emergency Department

p23

Fan H, Najim R, Karia M, Khwaja S, Norton B, Mukerji. Imperial College Health Care NHS Trust, London

Acute Bacterial Peritonitis Secondary to a Renal Abscess

p25

SK Thippeswamy; K Lakshimipathy; S Zachariah; J Clark; B Field

Hypercalcemia due to hypervitaminosis D

Yoon Ja, Sivakumar Pa, Ahmed La, O’Kane Ka aGuy’s and St Thomas’ NHS Foundation Trust, London Dr Hyne, S Dr Kodavali, K Dr Lakkappa, B Northamptonshire Healthcare NHS Foundation Trust (NHFT), Wellingborough

Okonkwo N, Selvam L.A.

Too Much for Too little? A Retrospective Audit on Temporal Artery Biopsies

Daniela Gradil, Chesterfield Royal Hospital

Should we be discussing DNAR wishes at the time of Hospital admission? The recommendations, what our patients think and what we are doing

Hicks D, Gupta S, Fletcher N, Seddon D, Department of Emergency Medicine, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK

Referral Line: A Quality Improvement Project for Managing Flow of Patients Referred by GPs to Specialties Through the Emergency Department

Dr. Jennifer Rossdale, Queen Elizabeth Hospital, Woolwich

Delays in chest x-rays in acute admission in elderly medicine

Mohd Faiz Mohd Fauzi, Scunthorpe General Hospital

A Bump On The Head – To Scan or Not To Scan?

Extended Glasgow Blatchford score to discharge patients early from acute admission? low risk or missed pathologies The impact of an automatic acceptance policy on the Emergency Access 4h standard and admission rates to specialties

p10

Chatten K, Banerjee A, Ang Y Salford Royal Foundation Trust, Stott Lane M68HD Edward Norris-Cervetto (Helen Witney and Francoise Ticehurst), Emergency Department, Wexham Park Hospital, Slough Ahmad Maatouk, Acute Medicine Registrar, Sheffield Teaching Hospitals, BEN KUMAR, Respiratory Consultant, Doncaster Royal Infirmary

p11

Dr Amy Kokkinos, Hinchingbrooke Hospital

The Fontan Challenge – A case of sepsis in a patient with a uni-ventricular heart and congenital asplenia

p12

Ashraf Kamour, North Manchester General Hospital

Multiple pulmonary emboli in low risk patient with negative D-dimer. A case report

p14

Gildeh N, Tayler-Gray J, Lohani S. Darent Valley Hospital, Dartford

An important complication of chest drain insertion

p15

Dr Nihal Abosaif, Dr Joseph Timothy, Dr Ilam Khan University hospital of Coventry and Warwickshire, Acute Medicine Department, and Stroke Department.

Encephalitis versus temporal lobe stroke, how to differentiate?

p16

Dr Gurdeep Dulay & Dr Jasbir Dulay, University Hospital Southampton

Caustic soda ingestion – a characteristic clinical sign

p17

Case report: The importance of fully analysing the ABG in a breathless patient – a case of methaemaglobinaemia Head Versus Heart: A Case Report

p19

Solway L, Disney BR, Bassford C, Abosaif N, Petterson T University Hospitals Coventry and Warwickshire NHS Trust Anwar, M. Jakupaj, A. Naziat, A. Luton and Dunstable University Hospital Dr Shyam Sundar Seshadri , Dr Rebecca Chapman, Dr Tay Naeem, Hinchingbrooke Hospital, Huntingdon

p20

Ravi Menon, Colchester Hospital

Rare presentation of Type A aortic dissection with painless paraplegia

p21

Richard Kirkdale, Queens Medical Centre

Case Report: Varicella Meningitis Causing an Unusual CSF Result

p22

Saira Batool, Blackpool Victoria Hospita

An unexpected cause of haematemesis

p23

Sarah Clarke, North Manchester General Hospital

Gout presenting as sepsis

p24

KOLOVOU V./BLOOMFIELD L./ FIKRI R, ST MARYS HOSPITAL

How we do feet in 2015

p25

Dr R Curtis, Foundation year 2, Heartlands Hospital, Heart of England Foundation Trust, Dr N Fergusson, Consultant Elderly care and General medicine

Case report: Voltage gated potassium channel (VGKC) antibody associated mesolimbic encephalitis with fronto-temporal behavioural changes

13th November, 15:00-16:30

Do age adjusted D-dimers work in an acute hospital setting?

p18

Comparison of international guidelines on primary spontaneous pneumothorax Effect of Electronic Medical Records on Compliance of Venous Thromboembolism Prophylaxisan Audit Cycle

A Panic Attack that turned out to be a deadly condition

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Doctors have a duty to provide leadership to the NHS Doctors have a unique leadership role to play in the NHS because they have enormous intellectual and professional capital and control the deployment of considerable financial resources. This is the view of Professor Tim Swanwick, Postgraduate Dean, Health Education Yorkshire and the Humber, who told Acute and General Medicine delegates that doctors should take responsibility for combatting the efforts of managers and politicians to impose change from the top down. “The purpose of clinical leadership is to sustain and improve the quality of patient care,” he said

Free clinical e-learning for all delegates

Delegates to Acute & General Medicine 2015 have free access to a comprehensive selection of clinical speaker presentations from the last three Acute & General Medicine Conferences. Plus complete access to the CloserStill Media Healthcare Learning Archive. The online learning archive is an invaluable information portal that can be accessed from home or work, designed to keep your medical knowledge updated allyear round. Receive instant access to the archive as soon as you become a delegate and start building on your cross-specialty knowledge through the multistream online programme of presentations.

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After 40 years of “managerialism” the current Health Secretary, Jeremy Hunt, was keen to engage clinicians in leadership. “Clinical leadership is vital for patients and vital for the future of the health service and the economy and therefore continues to be a high political priority,” he said.

development, be work and action orientated, develop practical skills, link theory to practice and build networks. Leadership programmes should be supportive of individual development through things like 360° feedback and often include learning about the self, usually done in a group setting.

He explained that healthcare is delivered by teams and complex systems of cross disciplinary organisational values not by clinicians working in isolation. Effective clinicians need to understand and work with those systems. “We have to come out of our rabbit holes and get real,” said Professor Swanwick.

Clinicians, and doctors in particular, need to develop a deep understanding of the service and systems in which they work and how to influence those around them effectively.

An effective leadership development programme should enable personal

Leaders learn to lead through courses, seminars workshops, action learning, multisource feedback, simulation, psychometric tests, structured workplace experiences, e-learning, coaching and

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January 2016

Professor Tim Swanwick, Postgraduate Dean, Health Education Yorkshire

mentoring and project work. “Leadership is everyone’s responsibility and opportunities for development are everywhere,” said Professor Swanwick.

Get up-to-date on acute and advanced internal medicine Doctors are experiencing unprecedented pressure at the hospital front door, and more are getting involved with the acute take and managing the wards. Acute & General Medicine offers a cost-effective, comprehensive training solution for doctors who need to get up to speed with the latest guidance and gain CPD points. You can tailor-make your clinical training from a comprehensive, cross-speciality speaker lineup and hands-on skills training programme.

Why clinicians need to attend:

Acute & General Medicine is the best way to get up-to-date on the latest clinical guidance in a cost- and time-effective way – get 100% of your acute and general medicine training needs covered. Get hands on training and update your skills on acute medical procedures including life-saving techniques, Ultrasound, NIV and Radiology. Delegates have rated the conference 4/4 on the Royal College of Physicians CPD log for the fourth year running. There are advanced clinical streams that cover every speciality. Update your clinical knowledge and gain 12 accredited CPD points

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January 2016

Issue 14

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POST SHOW EDITION / 11

@AGMConfUK 2015 Show Snapshot

@AGMConfUK #agmconfuk /AGMConference

Acute & General Medicine

Zoe Wyrko @geri_baby

Dr Amir Reyahi @amirreyahi

Just had my BP taken by a rather fancy gadget just before speaking at #agmconfuk. 109/65. Obviously not anxious!

@AGMConfUK really good lecture - thank you - CPR & Resus & outcomes & Pronostication.

“The talks at Acute and General Medicine are very useful, very relevant and are pitched at the right level. This conference is very good value for money.” Dr Palanichamy Chellamuthu, Consultant in Acute Medicine, Royal Cornwall Hospital

96% 94% met their learning objectives

of delegates agree AGM is the most affordable expert accredited clinical training event in the UK

91% 89% 81% 70% of delegates are likely to recommend AGM to a colleague

Sean KO @skokelly28

Mr T is a new fan of @AproDerm #AGMConfUK #quityojibbajabba “I’ve come to Acute and General Medicine for the last three years because it has always been very interesting and exciting. I’ve just taken on a new leadership role in my organisation so I’ve been going to a mixture of clinical updates and talks on other aspects of healthcare and healthcare management.” Dr Jo Thompson Consultant in Acute Medicine Imperial College Hospital, London.

Clare Worrall-Hill @CworrallHill

Dr Jasia Khan @JasiaKhan

Lots of entusiastic health professional are visiting the @ParkinsonsUK stand at the @AGMConfUK. We hope to welcome many more today!

Prostate alpha blockers cause of falls and fractures #elderlycare @AGMConfUK #agmconfuk

of delegates believe CPD training events like AGM are very important

rate the quality of content as high

believe it is better value for money than other events

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Issue 14

January 2016

22-23 NOVEMBER 2016 , EXCEL LONDON

TRAINING PASS

We know the pressure you’re under

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Thank you for visiting us at Acute & General Medicine to test your medico-legal knowledge in the MDU Pressure Zone. We’ll be back next year on Stand D30. There’s no pressure quite like the pressure you face as a consultant. The MDU is run by doctors for the purpose of supporting other doctors – something we’ve been doing for longer than any other medical defence organisation.

Call Martin Houlihan on 0207 348 1845 UPDATE YOUR CLINICAL KNOWLEDGE AND GAIN 12 ACCREDITED CPD POINTS TO SUPPORT YOUR REVALIDATION NEEDS

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Doctors feel the ‘pressure’ at The MDU Pressure Zone At the recent Acute & General Medicine, even the most seasoned doctors were put ‘under pressure’ at the MDU Pressure Zone. Testing delegates’ medico-legal knowledge through a series of timed multiple choice questions, The MDU Pressure Zone was well received and provided some interesting talking points on scenarios that doctors encounter daily. Medical ethics are not always black and white, and ethical dilemmas present in many ways. The MDU encourages its members to test their knowledge further with the online Medical Ethics and Law learning module. The module helps doctors to understand the principles and

apply that knowledge to a variety of scenarios that typically arise in day-today practice. The module is free for MDU members and is accredited by the Royal College of Physicians for 5 CPD points. For more information visit the MDU website – themdu.com The MDU is the UK market leader in providing professional medical indemnity. They are a not-for-profit organisation dedicated to their members’ interests. They provide expert guidance, personal support and robust defence in addressing medico-legal issues, complaints and claims. The MDU will be returning to Acute & General Medicine in 2016.