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Byline: Amar. Shah, Anirudh. Shah Micturating cystourethrography (MCUG) is a very commonly performed diagnostic procedure in pediatric urology. Although considered to be simple, safe, and cost-effective, it can incur some [...]

The healthcare industry is a major contributor to climate change globally. There is growing interest in using quality improvement methods to improve the sustainability of healthcare. East London NHS Foundation Trust uses quality improvement as its approach to solving complex problems. This article uses a case study methodology to describe how the trust's programme of sustainability used quality improvement at both systemic and local levels to support the organisation to reduce direct greenhouse gas emissions by 40% by 2025 and indirect emissions by 40% by 2036. Using quality improvement in a structured way enabled staff and service users to consider their contribution to sustainability and develop, test and measure ideas that were within their control. This led to an organisational reduction in gas emissions of 37% and CO2emissions by 14% in winter months. At a local level, three case studies showcase the accomplishments of teams who successfully reduced medication waste by 66.2kg CO2e per year, reduced spending on single-use plastics by 54% and lowered CO2emissions by 10798kg per year through the return of walking aids. Supporting structures for the programme included active and visible participation from senior stakeholders, with service users and carers involved at both strategic and operational levels, and tracking data over time. Future work should focus on creating a change package of ideas to serve as a blueprint to scale up these initiatives across the organisation.

Against a backdrop of stalling life expectancy, the COVID-19 pandemic highlighted the need to tackle inequities in healthcare. Quality improvement has become an increasingly recognised way of tackling complex problems in healthcare. This article presents a step-by-step approach for the use of quality improvement to pursue equity at an NHS provider in England. The Model for Improvement was used to set an aim, develop a theory of change and measures, and test change ideas through plan-do-study-act cycles. A five-step sequence of improvement was used to provide a structured approach to identifying and tackling problems. Projects were designed to use a time series testing strategy in which baseline data were collected, a change was introduced and data continued to be collected over time to assess improvement. The results of three teams that have demonstrated sustained improvements were analysed using statistical process control charts. The teams' achievements included a 27% increase in access to early intervention mental health services for ethnic minority groups; a 92% reduction in racist incidents on inpatient wards; and a reduction in the gap between cervical screening rates for different age groups from 8% to 3%. Quality improvement offers those closest to the delivery of care a way of systematically making improvements in equity. Further opportunities for the field include the use of experimental designs to test combinations of interventions and potential scalability of quality improvement methods across systems with multiple partners.

Byline: Mitul. Jasani, Alpa. Jasani, Anirudh. Shah, Amar. Shah Context: Postoperative fever is known to occur after all surgical procedures irrespective of the type of anesthesia. Thermometry devices that work [...]

Byline: Amar. Shah Dr. Nikhilesh Bhattacharjee was born on April 1, 1945. He completed his MBBS from Gauhati Medical College in 1966. He did his MS General Surgery in 1971 [...]

Background/AimsAsthma in children and young people represents a substantial burden to the healthcare system, with these patients requiring frequent emergency care and having poorer health outcomes, leading to high system costs and poor patient experiences. This study used quality improvement methodology to achieve the triple aim of improved outcomes, better experience and reduced costs for those aged 0–16 years with asthma in north east London.MethodsA multidisciplinary project team used quality improvement methods to implement and assess two interventions: a community high-risk asthma clinic and educational asthma-friendly school groups, both of which were delivered by a specialist asthma nurse. Population-level outcomes included asthma control test scores, accident and emergency department admissions and costs. Intervention-specific outcomes included number of clinic consultations delivered, did-not-attend rates and participant confidence ratings following the school sessions.ResultsAccident and emergency admissions for asthma reduced by 52%, with a 50% reduction in average monthly acute care costs. Asthma control test scores improved significantly, from an average of 18.56 to 22.34 out of a maximum score of 25 (P=0.000) following the interventions. Participants in the asthma-friendly school groups reported increased confidence in both day-to-day and emergency asthma management at the end of their sessions.ConclusionsHaving dedicated specialist asthma nurse input in the community and using school-based interventions can help to improve asthma care for children and young people, reducing the burden of frequent accident and emergency department admissions. Using quality improvement methods in pursuit of triple aim outcomes can help teams to work towards a shared goal.

Byline: Amar. Shah, Khalid. Mahmud, Anirudh. Shah Generalized lymphangioma of tongue is a rare cause of macroglossia in children. It causes mechanical discomfort and functional and psychological disturbances. We report [...]

Byline: Amar. Shah, Anirudh. Shah Segmental dilatation of the intestine is a rare disease and mostly involves the ileal segment. It commonly presents in the neonatal period and early infancy [...]

There has been an increase in the adoption of quality improvement methods to tackle complex problems in healthcare. One of the key requisites for sustainable quality improvement is ensuring that organisations have the capacity and capability to make these changes effectively. This article uses a case study methodology to describe the learning from 9 years of developing, delivering and evaluating quality improvement learning programmes at East London NHS Foundation Trust. The key quality improvement learning progammes are evaluated using a Kirkpatrick framework across four levels: reaction, learning, behaviour and outcomes. Five key principles were identified: using a dosing approach; standardising development, delivery and evaluation; developing a community to support learners; making training relevant; and the importance of leadership. However, the authors believe that more research is needed to develop standardised approaches to evaluating quality improvement capability building and to understand why some quality improvement projects are less successful than others.

In 2021, 38 healthcare teams across England and Wales took part in the national enjoying work quality improvement collaborative, which aimed to enhance staff wellbeing and create joy in work. Participating teams were supported to use quality improvement methodology and tools as part of a national learning network. At the end of the programme, 16 teams saw an improvement in at least one outcome measure, while 17 teams saw a sustained deterioration in at least one outcome measure. Aggregate data from all teams demonstrated improvements from baseline in all three outcome measures, with a 51% average improvement in the percentage of people who frequently enjoyed being at work, a 41% average improvement in the percentage of people experiencing no symptoms of burnout and a 42% average improvement in the percentage of people who were extremely likely to recommend their team as a place to work. As the first programme on this topic at a national scale, these findings provide ideas for change that can be adapted or replicated by clinical and non-clinical teams to improve their joy and wellbeing at work, and build their understanding of the barriers they may face and what is needed to overcome them. From the ideas tested and the learning from across the collaborative, a theory of change for enhancing staff wellbeing and joy in work has been created to inform future work in this area.

Staff wellbeing is increasingly linked to good outcomes for service users in healthcare. Therefore, it is important for organisations to find ways to focus on wellbeing and staff experience at work. This article shares learning from 5 years of using the Institute for Healthcare Improvement's joy in work framework, coupled with quality improvement methods to enhance staff experience and wellbeing. This demonstrates how teams were brought together in a collaborative learning system to apply quality improvement to enhance joy in work. Key steps are shared for other organisations wanting to undertake this work, including the application of improvement methods to empower teams locally to develop, design and test change ideas, and measure their impact. The design of systems and structures required to meaningfully bring teams together and the type of leadership that enhances this work are also considered. Key learning points for other organisations include the need for improvement principles to iterate the organisational approach, make measurement simple, encourage a bias to action and make the work fun.

Byline: Mitul. Jasani, Anirudh. Shah, Amar. Shah Littoral cell angioma is a rare primary splenic vascular tumor, originating from the littoral cells lining the red pulp sinuses of the spleen, [...]

Byline: Mitul. Jasani, Amar. Shah, Anirudh. Shah Primary chylopericardium is a rare entity in the pediatric population, which is characterized by chyle accumulation in the pericardial sac. Treatment of this [...]

In 2018, 38 mental health inpatient wards belonging to NHS trusts across England took part in the national reducing restrictive practice collaborative project, which aimed to reduce the use of rapid tranquillisation, restraint and seclusion of patients by 33%. Teams were supported to use quality improvement tools by skilled coaches as part of a national collaborative learning system. At the end of the programme, the overall use of restrictive practice had reduced by 15%. Of the teams that achieved improvements, the average reduction in restrictive practice was 61%. Across the collaborative there were improvements in the mean monthly use of restraints and rapid tranquillisation, and in the total use of all three measures of restrictive practice combined. Support from quality improvement coaches allowed ideas to be tested across the collaborative, enabling the creation of a theory of change for reducing restrictive practice based on areas with a high degree of belief to inform future improvement work in this area.

Lurbinectedin is FDA approved for treatment of metastatic small cell lung cancer (SCLC) following progression on or after platinum-based chemotherapy. Prostatic small cell or neuroendocrine carcinoma (SC/NEPC) behaves like SCLC; however, no safety or efficacy data for lurbinectedin in SC/NEPC exists.

Serial anterior chamber paracentesis for sustained intraocular pressure elevation after intravitreal injections may be complicated by hypotony, choroidal detachment, intraocular lens dislocation, vitreous prolapse, and trauma to the penetrated ocular tissues. Complications may be limited by preventing hypotony and alternating wound location.

The triple aim is defined as the simultaneous pursuit of improvement across three areas: population health outcomes, quality of care and value for the system. Since the triple aim framework was first introduced in 2008, it has been applied in various contexts across several countries. The triple aim has been proposed as a core purpose of the integrated health and care systems in England. However, little has been written about how the systematic application of quality improvement can support the process of achieving the triple aim, despite the increasingly widespread use of quality improvement methods and tools in the quality of care element of the triple aim. This article, the third in a three-part series about applying quality improvement to practice, puts forward a step-by-step guide for healthcare systems to use their existing quality improvement capabilities to help them achieve the triple aim, with examples and learning from the authors' experience at East London NHS Foundation Trust.

Acute hypercapnic respiratory failure accounts for 50 000 hospital admissions each year in the UK. This article discusses the pathophysiology and common causes of acute hypercapnic respiratory failure, and provides practical considerations for patient management in acute medical settings. Non-invasive ventilation for persistent acute hypercapnic respiratory failure is widely recognised to improve patient outcomes and reduce mortality. National audits highlight a need to improve patients' overall care and outcomes through appropriate patient selection and treatment initiation. Multidisciplinary involvement is essential, as this underpins inpatient care and follow up after hospital discharge. New non-invasive ventilation modalities may offer better patient comfort and compensate better for sleep-related changes in respiratory mechanics. Emerging therapies, such as nasal high flow, may offer an alternative treatment approach in those who cannot tolerate non-invasive ventilation, but more research is required to completely understand its effectiveness in treating acute hypercapnic respiratory failure.

As healthcare systems emerge from the COVID-19 pandemic and begin the process of recovery and rebuilding, it is more important than ever to find systematic ways to ensure that all healthcare staff are focusing on their wellbeing, are able to reflect on new ways of working and find methods to improve their experience at work. This article, the second in a three-part series on the practical application of quality improvement in healthcare, presents four case studies that demonstrate the learning from four healthcare systems that have been applying both quality improvement and the Institute for Healthcare Improvement's ‘joy in work’ framework to enhance staff wellbeing and experience. These case studies demonstrate the benefits of involving staff deeply in the process of understanding factors that impact on experience at work, developing and testing creative ideas that can make a difference. The ideas that emerged were diverse and highly contextualised to the local service. Ideas related most strongly to four areas: wellness and resilience, daily improvement, camaraderie and teamwork, and recognition and reward. The systematic approach that quality improvement brings is potentially replicable across all healthcare settings, and can provide a way for all teams to have greater ownership and control over their wellbeing and experience at work.

Applying quality improvement methods to solve complex quality issues involves people deeply. People discover solutions, test and adapt ideas, thereby giving them autonomy and control over the system in which they work. Focusing quality improvement on what matters most for staff and service users creates the opportunity to bring a deeper sense of meaning and connection to purpose, both of which are integral to joy in work. When applying quality improvement at scale within large organisations or systems, bringing teams together in learning systems can provide a critical structure to build skills, collaborate and learn from one another. This article describes the core elements of learning systems designed to support quality improvement and joy in work, illustrated through two examples. The framework can be applied at different levels of a system, including the individual, the team and the organisation, or even to a large improvement effort across organisational boundaries. The next article in this series will discuss the application of the joy in work framework to healthcare settings.

Many processes in nature such as conformal changes in biomolecules and clusters of interacting particles, genetic switches, mechanical or electromechanical oscillators with added noise, and many others are modeled using stochastic differential equations with small white noise. The study of rare transitions between metastable states in such systems is of great interest and importance. The direct simulation of rare transitions is difficult due to long waiting times. Transition path theory is a mathematical framework for the quantitative description of rare events. Its crucial component is the committor function, the solution to a boundary value problem for the backward Kolmogorov equation. The key fact exploited in this work is that the optimal controller constructed from the committor leads to the generation of transition trajectories exclusively. We prove this fact for a broad class of stochastic differential equations. Moreover, we demonstrate that the committor computed for a dimensionally reduced system and then lifted to the original phase space still allows us to construct an effective controller and estimate the transition rate with reasonable accuracy. Furthermore, we propose an all-the-way-through scheme for computing the committor via neural networks, sampling the transition trajectories, and estimating the transition rate without meshing the space. We apply the proposed methodology to four test problems: the overdamped Langevin dynamics with Mueller's potential and the rugged Mueller potential in 10D, the noisy bistable Duffing oscillator, and Lennard-Jones-7 in 2D. • Methodology for sampling transition path processes using optimal stochastic control. • Theorems on the connection between the optimal control and the committor function. • A method for estimating transition rates using the controlled dynamics. • Inexact committors still give very good controllers. • Test cases include 10D and 14D benchmark problems. [ABSTRACT FROM AUTHOR]

Objectives:This study aims to showcase the complementary nature of utilizing both histopathology and magnetic resonance imaging (MRI) in understanding the otologic pathophysiology of Meniere disease. In addition, it seeks to raise awareness of the value of preserving and curating historical temporal bone collections which continue to inform our understanding of otologic diseases. Methods:The essential anatomical feature of Meniere disease—the distended membranous labyrinth—is explored through a comparison of early temporal bone studies with contemporary MRI techniques. The histopathologic photomicrographs are of inner ear specimens from deceased patients with symptoms consistent with Meniere disease. The MRI sequences from living patients exhibiting classic Meniere disease symptoms during life are captured 4 hours post-administration of gadolinium. Results:Both histopathologic examination and MRI imaging reveal consistent distention of the saccule, utricle, and scala media in patients with Meniere disease. The study shows the histologic photomicrographs of actual Meniere patients compared to the MRIs and successfully demonstrates the correlation between postmortem histological findings and MRI evidence of distension in living patients. Conclusions:A corresponding distension of the membranous labyrinth is seen in both the histologic specimens and the Meniere MRIs. This correlation suggests the potential utility of utilizing MRI to aid in diagnosing atypical Meniere disease and distinguishing it from other disease processes, such as migraine equivalent vertigo. The integration of historical temporal bone studies with modern MRI techniques offers valuable insights into the pathophysiology of otologic diseases. In addition, it emphasizes the importance of preserving and curating historical temporal bone collections for continued research and medical education purposes. Previous studies of delayed MRIs did not use Meniere disease temporal bone histopathology images.

The presence of Descemet membrane scrolls is an uncommon finding reported in syphilitic interstitial keratitis. We herein describe a novel surgical strategy for this entity; this report demonstrates that Descemet membrane endothelial keratoplasty surgery can be performed with excellent visual outcomes in the event of corneal edema as a late sequela of syphilitic keratitis.

Quality improvement is increasingly being used within healthcare as an operating model to empower and enable teams of staff and service users at the point of care to find solutions to complex quality and safety issues. Adopting quality improvement methods in healthcare poses several challenges, and many healthcare providers have faced barriers in embedding a culture that nurtures and supports a systematic approach to problem-solving at the point of care. This article proposes a simple framework with three components to help healthcare systems avoid the common barriers to introducing quality improvement interventions. First, simplify the language and accentuate the similarities between methods. Second, support those applying quality improvement with skilled, accessible improvement expertise and applying evidence-based adult education theories. Third, design quality improvement interventions so that they strengthen a shared purpose by allowing teams to decide what to prioritise and involving patients and family members as equal partners in quality improvement work.

Graphical Abstract

Preoperative assessment with computed tomography (CT) is critical before transcatheter interventions for structural heart disease. CT provides information for device selection, device sizing, and vascular access approach. The interpreting radiologist must have knowledge of appropriate CT protocols, how and where to obtain the important measurements, and know additional imaging characteristics that are important to describe for optimal support of the interventionalist. CT is the modality of choice for pre-operative evaluation in patients undergoing transcatheter aortic valve replacement and left atrial appendage occlusion, and is also useful before transcatheter mitral valve replacement, which is an ongoing area of research.

BackgroundUse of the radial artery as an access site for neurointerventional procedures is gaining popularity after several studies in interventional cardiology have demonstrated superior patient safety, decreased length of stay, and patient preference compared with femoral artery access. The transradial approach has yet to be characterized for intraoperative cerebral angiography.ObjectiveTo report a multicenter experience on the use of radial artery access in intraoperative cerebral angiography, including case series and discussion of technical nuances.Methods27 patients underwent attempted transradial cerebral angiography betweenMay 2017 and May 2019. Data were collected regarding technique, patient positioning, vessels selected, technical success rate, and access site complications.Results24 of the 27 patients (88.8%) underwent successful transradial intraoperative cerebral angiography. 18 patients (66.7%) were positioned supine, 6 patients (22.2%) were positioned prone, 1 patient (3.7%) was positioned lateral, and 2 patients (7.4%) were positioned three-quarters prone. A total of 31 vessels were selected including 13 right carotid arteries (8 common, 1 external, 4 internal), 11 left carotid arteries (9 common and 2 internal), and 6 vertebral arteries (5 right and 1 left). Two patients (7.4%) required conversion to femoral access in order to complete the intraoperative angiogram (1 due to arterial vasospasm and 1 due to inadvertent venous catheterization). One procedure (3.7%) was aborted because of inability to obtain the appropriate fluoroscopic views due to patient positioning. No patient experienced stroke, arterial dissection, or access site complication.ConclusionsTransradial intraoperative cerebral angiography is safe and feasible with potential for improved operating room workflow ergonomics, faster patient mobility in the postoperative period, and reduced costs.

ABSTRACTBackgroundIndia has been implementing active case-finding (ACF) for TB among marginalised and vulnerable (high-risk) populations since 2017. The effectiveness of ACF cycle(s) is dependent on the use of appropriate screening and diagnostic tools and meeting quality indicators.ObjectivesTo determine the number of ACF cycles implemented in 2021 at national, state (n = 36) and district (n = 768) level and quality indicators for the first ACF cycle.MethodsIn this descriptive study, aggregate TB program data for each ACF activity that was extracted was further aggregated against each ACF cycle at the district level in 2021. One ACF cycle was the period identified to cover all the high-risk populations in the district. Three TB ACF quality indicators were calculated: percentage population screened (≥10%), percentage tested among screened (≥4.8%) and percentage diagnosed among tested (≥5%). We also calculated the number needed to screen (NNS) for diagnosing one person with TB (≤1538).ResultsOf 768 TB districts, ACF data for 111 were not available. Of the remaining 657 districts, 642 (98%) implemented one, and 15 implemented two to three ACF cycles. None of the districts or states met all three TB ACF quality indicators’ cut-offs. At the national level, for the first ACF cycle, 9.3% of the population were screened, 1% of the screened were tested and 3.7% of the tested were diagnosed. The NNS was 2824: acceptable (≤1538) in institutional facilities and poor for population-based groups. Data were not consistently available to calculate the percentage of i) high-risk population covered, ii) presumptive TB among screened and iii) tested among presumptive.ConclusionIn 2021, India implemented one ACF cycle with sub-optimal ACF quality indicators. Reducing the losses between screening and testing, improving data quality and sensitising stakeholders regarding the importance of meeting all ACF quality indicators are recommended.

Background : Sex cord and stromal tumors are a heterogeneous group of tumors that arise from gonadal sex cord cells, gonadal stromal cells, or both. They are divided into pure stromal tumors, pure sex cord tumors, and mixed tumors. Some of these tumors are hormonally active, producing androgens and estrogens, and may therefore exhibit virilization or excess estrogen. Sertoli-Leydig cell tumors are rare tumors belonging to mixed tumors representing less than 0.5% of ovarian tumors. Few cases have been reported in the medical literature. Case presentation: We report the case of a 1-year-old girl who was admitted for breast lumps and pubic hair with intermittent painless vaginal bleeding in the past 2 weeks. The abdominal examination objectified the presence of an intraperitoneal mass to which an abdominal ultrasound and computerized tomography (CT) scan had confirmed the presence of a right ovarian mass. A laparoscopy was performed which showed an encapsulated mass arriving from the right ovary replacing the normal ovarian tissue. Laparoscopic-assisted removal of the entire mass was done. The postoperative course was uneventful. The histopathological study demonstrated an intermediately differentiated Sertoli cell tumor with an intact capsule, no lymphovascular invasion, or heterologous elements (TNM stage 1). Conclusions: Although Sertoli-Leydig tumors are commonly seen after the second decade of life in young women, their discovery before puberty is not uncommon. Mass syndrome and signs of virilization are two frequently reported signs that should prompt the clinician to mention this entity among the differential diagnoses. The first-line radiological examination is pelvic ultrasound. The treatment is mainly based on surgery. The prognosis is excellent especially if the tumor is well differentiated.

ABSTRACT The definition and management of borderline resectability for periampullary pancreatic adenocarcinoma are evolving. In this case report, we discuss the presentation, workup, and therapeutic management of a 40-year-old man [...]

Byline: Amar, Shah; Girish, Jawaheer Laparoscopic repair of Morgagni hernia has been described in adults and children. In the published reports, the crux of the repair consists of suturing the [...]

Byline: Amar. Shah, Rakesh. Thakur, Karan. Parashar Juvenile dermatomyositis classically manifests as necrotising vasculitis in multiple organs. It mainly involves the vessels of skin and muscle and is associated with [...]

There is increasing interest and belief in applying quality improvement (QI) to help solve our most complex challenges in healthcare, yet little published literature to help leaders develop a business case and evaluate return on investment from QI. This is even more pronounced in fields such as mental health and community health services. This paper presents a framework to help identify, understand and evaluate return on investment from large-scale application of QI in healthcare providers. The framework has been developed at East London NHS Foundation Trust (ELFT), a provider of predominantly mental health and community health services to a population of 1.5 million people, which has been undertaking QI at scale since 2014. This paper presents case studies and examples from ELFT to illustrate return on investment from QI at multiple levels: improving outcomes for patients and service users, improving the experience of staff, improving productivity and efficiency, avoiding costs, reducing costs and increasing revenue.

This article reviews the diagnostic criteria for coronary artery aneurysms, their histologic features, current theories of pathophysiology, and the spectrum of conditions in which they occur, as well as their characteristic imaging appearances, associated findings, and potential complications.

SummaryQuality improvement (QI) offers a route to transforming care delivery at the scale and pace needed to ensure sustainability in the National Health Service. However, it is a complex endeavour with numerous challenges to consider, and it takes time. There are many ways of understanding quality and QI in healthcare, and it is important for doctors to develop knowledge of the core principles of QI, which increasingly feature in clinical settings and in training curricula for healthcare professionals.Learning Objectives• Describe what QI means in healthcare contexts and explain how it is different from clinical audit• Identify when QI methodology can add value to efforts to improve quality in clinical settings• Describe contextual factors that influence the effectiveness with which QI can be applied

Violence is the biggest cause of reported safety incidents at East London NHS Foundation Trust. Evidence suggests the utility of structured risk assessment, discussion of violence in ward community meetings and the use of restraint and seclusion in psychiatric wards. The Tower Hamlets Violence Reduction Collaborative brought together six wards with the aim of reducing violence by 40% by the end of 2015. A collaborative learning system was used to test a bundle of four interventions on the four acute admissions wards and two psychiatric intensive care units. A 40% reduction in physical violence was seen across the six wards. Physical violence reduced from 12.1 incidents per 1000 occupied bed days in 2014 to 7.2 in 2015. Across the four general acute admissions wards there was a 57% reduction in physical violence. Key elements of the system that have been addressed through this work have been developing a more predictive approach, and developing a more open and shared experience of violence and aggression on the wards.