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Issue 1 • February 2014

Introduction to Translating an innovative or potentially transformative idea from inception to reality is hard but there can be no doubt that we need a strong dose of transformation in the NHS to help us in the current climate. This is the first edition of our in house e-zine, an innovation in itself, the aim of which is to both celebrate our very own success stories and to act as a sounding board for new ideas either from within or outside our organisation. As the newly instated Editior I am depending on you all for content - some might say a high risk strategy in itself but taking risks is a key part of what we need to do.

By: Deva Situnayake, Associate Medical Director for Innovation and Transformation. here for you to think about when you either encounter resistance to change or a flash of insight leads you to recognise you are part of it! They are all quite powerful thoughts and worthy of reflection. I hope you enjoy reading the first edition of our journal that is to be published initially twice each year. I congratulate the first contributors and their teams who have set the bar quite high for those that follow. The editorial team are looking forward to publishing more great examples of innovation from our midst as a catalyst for change. In the recent fifty year celebration episode on BBC, when asked about what he dreamed about, Dr Who replied: ‘I dream about where I am going’. Our horizon, illustrated in the quotes below and in no small part in the pages that follow should be food for thought. Enjoy!

Developing a culture of innovation that replicates the swiftness of foot of a small organisation in a large one is always going to be a challenge but to my mind is a necessary step. I know there is no shortage of ideas out there but equally I understand that in our trust getting new things done quickly at scale and pace requires persistence and sometimes, frankly, ‘insider knowledge’ - that’s got to change and it is our clinical and managerial community that should help us develop our thinking and change habits in this area. Innovation is not just doing new things. It can be doing old things in new, safer ways that create reliability under the intense pressures that test the ‘human factors’ that challenge us all in our everyday practice. It may be found in the way care may be transferred for our patients from one group of clinicians to another, from consultant to GP, nurse, pharmacist or optician and may exploit the technology that we take for granted in our normal personal lives. It can also be found in solutions to problems that were never on our radar in the first place.... but might be in the minds of our patients or their carers. Recalling our primary purpose to remain patient focused in all we do therefore keeps us centred and will, I am sure, deliver us to the goal for our hospitals as a solution shop for the communities we serve. Our aim in INNOV8 at SWBH is to celebrate, stimulate and in small part to act as a catalyst for change. A little while ago I went to a conference at the Kings Fund – always stimulating in itself - and I heard some words that emerged from international thinkers which have reverberated in my head ever since. Perhaps these thoughts should echo in your heads too as a constant reminder of what’s on the near horizon. So I have reproduced them

“We should think of ‘hospitals as solution shops’.”

“New entrants provide products that don’t make sense to established providers.”

“Scientific progress that makes expertise a commodity that can be transferred from experts to others will play a significant role in disruption.”

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Treating blood cancer through clinical trials Blood cancers form less than 10 percent of all diagnosed cancers, yet these are very aggressive and can kill within days if not diagnosed and treated in time. However the good thing about blood cancers, unlike other cancers, is that these are treatable and even curable and patients can live longer. The various types of blood cancers seen at our Trust are leukaemias (cancer of blood cells), lymphomas (cancer of lymph glands) and myelomas (cancer within the bone marrow leading to fractures and kidney failure) etc. Chemotherapy (combinations of intense drugs) was the mainstay of treatment till recently. This is associated with severe side effects, often needs hospital admission and is dreaded by all patients. The treatment of blood cancers has evolved through decades of research and sequential clinical trials which involves testing various combinations of medicines.

“Our aim

is to keep our patie nts at the forefront of modern research. ”

In recent decades we are now able to find the genetic origin of these cancers and we can now treat these cancers by targeting the genes and killing the bad genes responsible for cancer by using medicines which are often in simple tablet form and do not have many side effects unlike chemotherapy. Haematology has lead the way in both clinical and molecular research. Previously to the year 2000, chronic myeloid leukaemia (CML) was a killer disease and many patients would die within few years. The only cure at that time was bone marrow transplantation which was not available to all. Following the discovery of its gene, called Philadelphia chromosome, various laboratory and clinical trials of medicines were conducted which led to its cure. It is through these trials of medicines that this blood cancer is now curable, a breakthrough which has revolutionised the way cancer is targeted. We are proud to say many of our CML patients are cured of CML after stopping treatment. Similarly the treatment for other disease like multiple myeloma, has evolved over decades through clinical trials and many patients are now disease free and live longer. Many of these new anticancer drugs are expensive and are not easily available through NHS. Hence we conduct clinical trials in order to test and provide new cancer medicines which are now often less toxic with less side effects. So what exactly is a clinical trial? Clinical trials are research studies, involving patients that are carried out to find new and effective treatments. They can also look at screening for cancer and quality of life for cancer patients. Carrying out clinical trials is the only evidence-based method of deciding whether a new approach to treatment or care is better than the current standard.

The Haematology Clinical Research team at SWBH NHS Trust is made up of consultant haematologists, a trials manager, trained research nurses and data managers who actively promote and recruit into clinical trials. The Haematology Department participates in national and multi-national clinical trials involving patients with blood cancers like leukaemia, multiple myeloma, lymphomas and myeloproliferative disorders. In addition we are expanding our research initiatives in patients with sickle cell disease and blood clotting conditions.The Haematology Unit leads on some regional and national clinical trials. Our haematology research portfolio continues to grow and expand. We have a total of 15 national clinical trials open for recruitment. Our recruitment in 2012-13 makes up 21% of the cancer research at SWBH, which is a huge achievement. Our unit is now the second highest recruiter in clinical trials in the region as evidenced by the Pan Birmingham Cancer Unit report 2013. Many of our patients have praised our research staff for their support, accessibility, information and many are happy with the outcome. It is pleasing to know many of our patients are cured of their cancer with simple tablets. Our dedicated research staff adhere to high standards of care.The research unit is well received by the Trust’s management and won the prestigious Clinical Effectiveness Award at the 2013 Staff Awards. Our aim is to keep our patients at the forefront of modern research.

By Farooq A Wandroo Consultant Haematologist, Sandwell & West Birmingham NHS Trust, Honarary Senior Lecturer MDT Clinical Research Lead Haematology.

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OPAT Pathway paves the way to patient satisfaction Outpatient parenteral antibiotic therapy (OPAT) refers to the practice of treating patients who are medically stable with intravenous antibiotics in an ambulatory setting, either in their own home or on a day case unit. There is an increasing incidence of infections with antibiotic resistant organisms in the NHS. Patients who could be medically treated in the community are often admitted to the hospital for intravenous antibiotics due to the lack of an appropriate oral agent. OPAT reduce hospital inpatient days and allow care of patients in a more familiar and comfortable setting – usually their own home. SWBH has a high adult medical bed occupancy rate of 95%, which regularly leads to bed crisis and excess ward to ward movement of patients which has a deleterious effect on infection control and quality of care and may lead to cancellations of elective admissions. OPAT fulfils many of the essential criteria (e.g. choice, locally driven, high quality, patient centred and integrated) outlined in the NHS reforms that plan to improve patient care and access and also address the recent concerns about NHS waste and inefficiency A feasibility study, carried out at City Hospital over a 20 week period between July 2012 - November 2012, surveyed 55 patients admitted to medical and orthopaedics wards with a diagnosis of urinary tract infection, cellulitis enteric fever, septic arthritis and osteomyelitis were suitable to be treated as OPAT Pathway. This would save over 2973 bed days/year or 8.15 beds/year. 92% of the patients surveyed would have preferred to have their treatment as an outpatient. We have currently developed three OPAT pathways for the treatment of cellulitis, extended spectrum beta-lactamase (ESBL) urinary tract infection and Bronchiectasis pathway.

OPAT has a number of benefits which include improved patient choice and satisfaction, admission avoidance and reduced length of stay in hospital, with resulting increases in inpatient capacity, significant cost savings compared with inpatient care and reduction in risk of healthcare-associated infection such as MRSA and Clostridium difficile infection. All these benefits underpin the philosophy and direction of the UK healthcare-quality strategy, with the emphasis on patient-centred and ambulatory care. Each service has its advantages and disadvantages and there is not one model that suits all patients or healthcare settings. Most OPAT services have started on a small scale targeting a particular patient population and the services have then expanded over time to incorporate other patient groups and other delivery options so that the service offers the maximum amount of choice and ensures that efficiency and bed savings are optimised. OPAT is in line with the Trust’s Right Care, Right Here philosophy which promotes innovative ways of delivering patient-centred care where appropriate.

By Dr Tranprit Saluja, Consultant Microbiologist.

143 patients with cellulitis were managed successfully on Outpatient Parental Antibiotic Therapy (OPAT) pathway in the last year at EAU at Sandwell and there is considerable scope for further development and expansion for a range of infective ambulatory conditions Now we are aiming to improve the care for medically stable patients with infective conditions which require long courses of intravenous antibiotics. Examples include enteric fever, liver abscess, lung abscess, diabetic foot infection, MDR TB, and bone and joint infections, by offering them treatment at home instead of the existing lengthy spells in hospital, with an arrangement in place for follow up and monitoring of their treatment. By developing a multidisciplinary OPAT team comprising of a consultant microbiologist, ambulatory care advanced nurse practitioner with expertise in intravascular access and a clinical antimicrobial pharmacist, OPAT services encompass a range of different service models: • • • •

Delivery of IV therapy in the patient home by a district nurse. Delivery of IV therapy in a clinic Delivery of IV therapy in an intermediate care setting Delivery of IV therapy in the patient home by the patient or relative who has been trained in line care and drug delivery

“OPAT is in li Trust’s Rig ne with the ht Here phil Care, Right osophy w hich promotes in of deliveri novative ways ng patien t-ce care whe re approp ntred riate. ”

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A Joined-up approach to neonatal guidelines Like many other specialities, evidence based medicine and national guidelines are limited to very few conditions in neonates. Most neonatal units in the country therefore use their own local guidelines or individual consensus for most conditions. We are currently working on the amalgamation of neonatal guidelines in all neonatal units in West Midlands. This involved a vigorous process of updating the guidelines (by authors from different regions) and involving experts to get the latest and up to date scientific evidence for the specific condition. Our role was to facilitate the process via networking and engaging all the Neonatal guideline leads and authors in the region. This work is supported by an independent support body called the Bedside Clinical Guideline Partnership (BCGP). These amalgated regional neonatal guidelines were published as a booklet in January 2014. Amalagated regional guidelines reduce user variation between the units in the region, thereby reducing risk to the patients. With the possibility of babies getting transferred between different units, these provide good continuity of care and reduce confusion to health professionals and family. Common guidelines make regional audits easy to conduct and thus measuring outcomes becomes more comparable between units. The three yearly review process of the regional guidelines will be achieved by the regional guideline group taking the burden away from local teams.

Regional guidelines are usually generic; some of them could be used only after adding local additions or local contacts. Clinicians need to adopt these guidelines with an understanding that there maybe a slightly different way of managing certain conditions. The regional guideline may not follow local trust formats and local clinical governance should be flexible about this. These guidelines will be available as a booklet for most staff and also in an electronic format on our SWBH (Sandwell & West Birmingham NHS Trust) intranet (neonatal section with local additions). All duplicate or redundant local neonatal guidelines will be removed from the Trust website. Each neonatal unit will sign a form of implementation to indicate the details of adopting each guideline and this will be audited by the regional neonatal guideline group. Feedback from a user survey will be audited three months after implementation. We conclude that implementation of regional guidelines will achieve best neonatal care and strengthen clinical governance across all units in the West Midlands. In the future, it may be possible to amalgamate all neonatal guidelines from multiple regions and perhaps all regions in the UK. This process could be extended to other specialities and as such there is a guidelines group (BCGP) for obstetric, surgical and medical specialities.

By Shanmugasundaram Sivakumar, Consultant Neonatologist, Sandwell & West Birmingham NHS Trust, South West Midland Newborn Network Guideline Lead.

Vikranth Venugopalan,

Neonatal Guidelines 2013–15

The Bedside Clinical Guidelines Partnership in association with the Staffordshire, Shropshire & Black Country Newborn and Maternity Network Southern West Midlands NewbornNetwork

Hereford, Worcester, Birmingham, Sandwell & Solihull

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Consultant Neonatologist, Sandwell & West Birmingham NHS Trust, Guideline Lead for Neonates.

“In the fu tu possible to re, it may be amalgam ate all neonatal g multiple re uidelines from gions and perh all region s in the U aps K.�


Could your team be a Beacon Service of 2014?

Beacon Service of Sandwell and West Birmingham Hospitals

A Beacon Service is one that delivers a significantly higher quality service than its peers, and does so within budget, and at the same time as creating a reputation, influence and reach beyond that which would normally be expected. As a Trust it’s imperative that these services are highlighted, valued, rewarded and above all else supported to continue to grow and develop. Beacon Services will give the organisation an opportunity to bring attention to the Trust for the right reasons and promote the reputation of the organisation locally, regionally and nationally. The search for the next two Beacon Services within our Trust commences in April 2014, look out for the links in the Daily Bulletin and on the Innov8 website for more information.

2013 winner: Gastroenterology I have been asked to write about why we applied to become a Beacon service and how it has benefited us to be awarded this status. Looking back I actually think the first benefits came just by entering. It is a rare occasion for a team to come together to try and define its strengths. The majority of meetings and reports are usually about addressing risks, making savings and tackling problems. This was different. The Beacon service bid was a unique opportunity to invite the team to reflect on what we do well and what we have achieved over the last few years. Even within a team it is easy for members to be unaware of projects others are working on. It is also easy for early improvements to be lost and for old practices to drift back in. By highlighting all that we have done, and by telling the whole Trust about it; it served as a way of embedding those ideas into the team and committing us to their future. We chose to present a comprehensive overview of the team rather than select one particular disease pathway. Our work on ‘Think Alcohol’ and nutrition screening showed our public health and prevention role. Our research portfolio in cancer, liver disease and IBD outpaces some of our neighbouring trusts and we were able to highlight this. I don’t think we realised ourselves how much we were embracing new technology (including autofluoresence, liver fibroscanning and now endobarriers) until we wrote our bid. We organise national study days and in running bowel cancer screening programmes, Barrett’s oesophagus surveillance and comprehensive GI physiology services, we appreciated how we extend our influence beyond the traditional locality. It was rewarding to list our history of LiA events, patient feedback processes and continuous rolling audit programmes with data showing annual improvements over the past five years. I think that pulling all those initiatives into one document was a genuinely useful experience for the whole team. Everyone’s contribution was reflected in there, and there was a palpable sense of enthusiasm in our speciality meeting. I would strongly recommend entering because even doing that alone is a positive process. However, of course it was great to be one of the winners. The badges and logos are something we want to emblazon on our units and they remind us of our strengths but also of the ethos we have publicly committed to. The money has enabled us to purchase a new liver fibroscan probe so that our service can cover all sizes of patients. The possibility of bidding for the larger fund has got us thinking about what we could achieve with a significant cash injection. It is something every team always says they need, but when actually faced with describing what you would use it for, it is not so easy. I can think of no other item on our agenda over the last few years that has been purely positive or that has served as such a morale boost. I thoroughly recommend entering your team next time.

By Dr Mark Anderson, Clinical Director for Scheduled Care/Longterm Conditions.

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Beacon service winner 2013: The Breast Unit The SWBH Breast Unit has a reputation for innovation – whether it be for reducing lengths of stay, reducing duration of follow up or increased trial recruitment. After our achievement of a HSJ Award for Team Efficiency last year we felt we should enter for a Beacon Award to get more local recognition of our successes.

By working as a team with those principles in mind we are proud to offer a service where

Why did we think we had a chance of the award?

Team working. We work as an integrated team where all members feel valued and respected. Being a member of a strong and supportive team means members are willing to try new ways of working, even if not fully persuaded. Holistic approach. We believe that whilst it is essential that clinical care is of the highest standard it is equally important to provide quick and easy access, one stop investigations, high quality communications and predictable and reliable on going care from all members of the team to ensure first rate care throughout a patient’s pathway.

• •

• • •

Adaptability. Targets and change can be daunting challenges. We have always tried to be one step ahead by anticipating those challenges and seeing how we can meet them and in doing so provide a better service. We have very successfully achieved this with 2 week waits for all referrals, day case mastectomies and patient initiated follow up. Use the available tools. Health service IT cannot provide bespoke solutions for everyone’s needs. By utilising the functionality in iCM and CDA, particularly electronic results acknowledgement, we have patient communication and have introduced a Patient Initiated Follow-up reducing routine clinical follow up enormously within a safer and audited pathway. Never be satisfied with average. Breast services are amongst the most closely audited in the NHS, with detailed annual measures of workload published nationally. In many aspects of our service we exceed average, perhaps most notably in trials recruitment where we entered more patients into clinical trials than the rest of the Pan Birmingham network combined. The patient comes first. The innovations we have created have, in the main, been done to improve the patient’s experience. Whether it be ensuring that no-one waits more than two weeks before their clinic appointment, or utilising ERA to ensure patients get the results of their follow up mammograms within a few days, the question we should ask is, what kind of service would I expect for me or my family?

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All new referrals are seen within 14 days of receipt. All new referrals are seen in a multidisciplinary clinic where imaging and biopsies are done in a one stop visit. Pooling of workload, and a team focus on the importance of effective communications, means GPs and patients receive letters within a very few days of their visit. By annualising theatre lists we are able to offer all patients dates for surgery at the point of listing with minimal breaches of targets, and equal highest theatre utilisation in the Trust. Introduction of an integrated pre-operative assessment means we have the highest day surgery rate in the country. A research focussed MDT means very high levels of trial recruitment. Patients are discharged from routine follow up at an early stage with guaranteed rapid return to clinic using Patient Initiated Follow-Up.

We were very honoured to be one of the first SWBH teams to be awarded Beacon Status. While we were producing our application it was clear that the defining word is ‘Team’ and it quickly became clear that the team is much wider than the doctors and nurses in clinics and theatres. When it came to the award ceremony we felt proud that our table had representatives from imaging, out patients, pathology, nuclear medicine and secretarial staff, all of whom are indispensable to the quality service we always aspire to. It was also clear that all those attending did feel part of a team whose achievements had been awarded by the Trust. However well a team does, it is always possible to do better. Although we have been very proud of our rapid letter turnaround times, since the award we have started using digital dictation, with an increase in turnaround times for letters to a few hours, utilising the authorisation facility in CDA. We plan to use the Beacon Award money to improve IT support for our service, improving data capture and measurement, with the prospect of creating a fully electronic rapid access clinic, improved virtual follow up and outcome measurement for our cancer patients, and a better measured appreciation of capacity and demand in the service as a whole to assess where we can focus patient and GP education to reduce unnecessary referrals. What we have achieved has not been down to any individual but to genuine integrated team work, and we hope that our success will encourage other teams to consider what they might be able to learn from our success to improve their chances for their own Beacon Award. We have regularly hosted teams from around the UK to help them improve their day surgery rates, and we’d be more than happy to work with other SWBH teams to share our experience.

By Hamish Brown, Consultant Breast and General Surgeon.


Beacon service winner 2013: Gynae-Oncology In the eight years since its launch, the Pan-Birmingham Gynaecological Cancer Centre has earned an international reputation for clinical excellence supported by high quality research and medical education. We have, and continue to attract tertiary referrals from other UK regions and in terms of volume and complexity of work would rank as one of the top three centres in the UK. The centre is part of the division of Women and Child Health and is based at City Hospital, delivering complex surgical care to women with new and recurrent gynaecological cancers, providing over 700 surgical interventions to our catchment of over two million residents. The seven trained gynaecological oncologists, dedicated team of specialist nurses and a strong team ethos across all skills results in a strong morale and bespoke and high care delivering service. Our one-year survival for ovarian cancer is the highest in the UK and in addition the key performance indicators of length of stay, operative morbidity and mortality compare very favourably with other equivalent regional centres. Educational Excellence We are a recognised RCOG subspecialty training centre and are one of only two UK centres to have been formally recognised by the European Board and College of Obstetricians and Gynaecologists. The centre runs several postgraduate courses including the basic surgical skills module for MRCOG, surgical anatomy training; laparoscopic skills training; and vulval disorders. We have also hosted the West Midlands Gynaecological Oncology Group meeting and the British Society for Gynaecological Cancer. In 2011 we were awarded a £10,000 grant by the Pulse Trust to enhance our video teaching capacity and this project is now well advanced. Research and Development We are currently recruiting into over 10 clinical trials; are involved in the University’s tissue banking project and are responsible for the development and leadership of several other novel clinical trial initiatives. We have a full time clinical research fellow currently involved in studying the epigenetics of vulval carcinoma. Since the centre launched, there have been over 50 peer-reviewed publications, books or chapters published along with many national and international presentations.

Clinical Excellence Our team is multidisciplinary and we are proud of our nursing excellence as well. Our nurse specialists and ward-based team are truly patient focused and we were one of the first centres in the UK to develop a survivorship programme. In addition, our nurses have innovated through establishing nurse led paracentesis and outreach telephone contact services. We recognise that within the team we have differing areas of expertise and we feel that patients should access this expertise to maximize the quality of their care. It also allows us to be more imaginative in the use of our theatre time and waste as little as possible. Further integration of cancer unit and cancer centre activities is well advanced and will make the team more effective. We believe in our team and in each other. We have come a long way since our launch seven years ago, managing to secure a local uplift in tariff to ensure ongoing development of complex radical surgical techniques, but still retain the desire to develop further and improve our services to those women who put their trust in the Pan-Birmingham Gynaecological Cancer Centre. Beacon Service award The Beacon Service Award has encouraged our team to keep pushing forward, has confirmed we are doing exceptionally well in our Trust and the recognition has raised the team’s morale even higher. We are hoping to spend our winning £10,000 prize money on the redecoration of our wards, to greater still improve the patient experience. Naturally the whole team are very proud of having achieved Beacon status. Recognition of excellence by one’s peers is a very powerful motivator to go on and do more which is very much the case in the gynae oncology team.

By Professor David Luesley, Group Director, Women’s and Child Health.

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Endobarrier - a revolutionary new treatment in the management of diabesity? Type 2 diabetes (T2DM) and obesity are leading causes of morbidity and mortality worldwide. Type 2 diabetes is driven by obesity (diabesity). There is currently a worldwide pandemic of diabetes, the numbers growing relentlessly. It is expected that by 2030 there will be a global prevalence of 552 million - 186 million more people with diabetes globally by 2030 compared to 2011. Many patients with type 2 diabetes reach the end of the line using current therapies, remaining overweight and with poorly controlled diabetes. In this situation the only option is increasing the insulin dose, which may indeed in due course improve glucose control, but unfortunately at the expense of weight increase. The alternative of bariatric surgery is costly, invasive, permanent, and not widely available to the large number of patients with the problem. Relatively recently a new form of therapy has become available called endobarrier. Endobarrier is a 60cm tube-like liner made from a thin, flexible and durable impermeable polymer. It is inserted by an endoscopy procedure and does not involve any surgery. The endobarrier device is anchored in place, just beyond the stomach, by a basket of very thin wire made of Nitinol - an alloy of nickel and titanium. The endobarrier prevents food that passes through it (on its way along the intestine and out of the body in the stool) from contacting the first two feet of small bowel intestine. Studies have shown that after insertion of this device, patients lose a considerable amount of weight and their diabetes control improves. After a year the device is removed. Endobarrier, however, is not currently a treatment available in the NHS. In view of all this we have, at SWBH, set up a multicentre research study to assess the impact of this device, in an NHS setting, in these patients who remain obese and with poorly controlled diabetes, despite all current other therapies, including GLP-1 receptor agonist therapy (liraglutide). The two main clinical questions being asked in the study are: 1. 2.

Is the response to endobarrier enhanced by the continuation of liraglutide during the time it is in situ and the subsequent year? Is the response sustained during the year following removal of the device and does treatment with liraglutide during that year increase the sustainability, or not?

We are also taking the opportunity of doing a number of investigations to shed more light on exactly how the device works.

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The idea for the study was conceived whilst Dr Bob Ryder was at the EASD (European Association for the Study of Diabetes) in Lisbon in September 2011, sitting in a presentation about endobarrier and its impact in overweight people with diabetes. Since then, Dr Ryder has appointed a research fellow to lead the study, has applied for and obtained funding from the Association of British Clinical Diabetologists (ABCD), and with the help of the research fellow developed the protocol, obtained ethical approval, obtained MHRA (Medicines and Healthcare products Regulatory Agency ) approval and obtained NIHR (National Institute for Health Research) approval such that the study is accepted as an NHS supported study and, most importantly, has received the help and support of Jocelyn Bell and her R&D team. The study is multi-centred, with centres in Birmingham (City Hospital), London (Kings College Hospital; Guys and St Thomas’) and Glasgow (Royal Infirmary). The study aims to recruit 72 patients (24 from each centre) and will continue for two years after the last patient starts in the trial. Gastroenterologists, Dr Mark Anderson and Dr Ed Fogden have had special training with regard to insertion of the device, and the first patient to receive an endobarrier in the trial was a Birmingham patient on 25th July 2013 with the first London patient following closely behind on 5th August 2013. There was some press interest (www.diabetologists-abcd. org.uk/Research/Press). Dr Bob Ryder is chief investigator for the study and principal investigator for the Birmingham centre, supported by principle investigators at each of the other centres: Professor Stephanie Amiel (Kings), Dr Barbara McGowan (Guys and St Thomas’) and Dr Russell Drummond (Glasgow). The research fellow is Dr Piya Sen Gupta. Thus potentially endobarrier could provide great benefit to a large number of patients. It is readily inserted by the hospital’s endoscopy team. The icing on the cake is that after the patient has lost weight and the glucose control improved, the endobarrier is removed – in contrast to gastric bypass surgery which is permanent. Endobarrier is, potentially, a major breakthrough in our armamentarium against Type 2 diabetes. It is hoped that, if the study proves successful, the information gained will contribute to the endobarrier becoming standard NHS therapy for the types of patient concerned. Endobarrier and the REVISE-Diabesity study can be further understood by visiting: www.diabetologists-abcd.org.uk/Research/endobarrier_study

By Dr Bob Ryder Consultant Diabetologist, Chief Investigator for National Study Dr Piya Sen Gupta Research Fellow Fran Lloyd Research Nurse Lesley Sadler Endoscopy Nurse Dr Ed Fogden Consultant Gastroenterologist Dr Mark Anderson Consultant Gastroenterologist


Liver scanner brings instant benefits to patients An increasing number of people in the UK are suffering with liver disease and this can cause severe illness and death. Common causes of liver disease include alcohol excess, infection with viruses such as hepatitis B and hepatitis C, fatty liver (in patients with diabetes or cholesterol problems) and genetic conditions including iron overload. Traditionally, the method for assessing the degree of liver damage has been to take a sample of liver tissue under local anaesthetic (a liver biopsy); this is a very good test but can rarely cause internal bleeding which can require emergency surgery or even be fatal. Furthermore, a liver biopsy requires a day case or over night stay in hospital and it can take up to four weeks to get the result of the biopsy. A new type of device, the “FibroScan” (Transient Elastography), uses elastic waves to determine liver stiffness. The more stiff the liver is, the greater the damage, whereas the more elastic the liver is, the less the damage. This test takes about five minutes to do, does not require a prolonged stay in hospital, is not invasive so does not have any complications, and the result is available as soon as the procedure has been completed. At Sandwell and West Birmingham Hospitals we acquired a FibroScan machine in April 2012 through a combination of support from a number of local charities and from the former Sandwell Primary Care Trust. This has transformed the service that we are able to offer patients with a range of liver disease. We recently carried out a review of all the FibroScan procedures carried out at SWBH on liver disease patients since we have had this machine. We calculated that 135 FibroScan procedures had been carried out over this 18 month period. The majority of referrals to this service have come from colleagues within the Trust looking after patients with liver disease. However, a significant number of referrals (up to 10%) came from colleagues in neighbouring trusts who do not currently have access to this technique.

We reviewed the case notes of all these patients to assess the impact of the FibroScan. We concluded that in the majority of cases the use of the FibroScan significantly determined the management of the patient. Thus, a group of patients who underwent this procedure had normal results and were able to be safely discharged back to the care of their GP. Another group of patients were found to have significant liver damage that led to further investigation and specific drug treatment. Finally, we estimated that in a large number of patients (more than 50%) the use of the FibroScan technique meant that we did not have to perform a liver biopsy which has significant cost saving implications (each liver biopsy costs about £1,200). The one limitation of the FibroScan is that the standard probe that comes with the machine is unreliable in patients who are overweight (body mass index (BMI) >30). Since a significant proportion of liver disease patients are overweight these patients are not able to benefit from this new technique. We are pleased to report that we recently secured funding (again from a number of charitable sources) to purchase a special ‘XL’ probe that will allow the machine to be used in overweight patients thus expanding the number of liver disease patients that we can offer this technique to. We therefore conclude that the introduction of this innovative technique has had a significant positive benefit in the management of patients with liver disease at SWBH.

By Saket Singhal, Consultant Gastroenterologist and Postgraduate Clinical Tutor.

tion of this “...the introduc nique has innovative tech nt positive had a significa management benefit in the h liver disease of patients wit at SWBH.”

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Over to you...

Do you have an article you would like to see included in the next edition of INNOV8? Telephone: 0121 507 5446 Email: deva.stunayake@nhs.net


Innov8 - January 2014 Newsletter