The clinically led worforcE and activity redesign (CLEAR) programme: a novel data-driven healthcare improvement methodology.

BACKGROUND: The NHS is facing substantial pressures to recover from the COVID-19 pandemic. Optimising workforce modelling is a fundamental component of the recovery plan. The Clinically Lead workforcE and Activity Redesign (CLEAR) programme is a unique methodology that trains clinicians to redesign services, building intrinsic capacity and capability, optimising patient care and minimising the need for costly external consultancy. This paper describes the CLEAR methodology and the evaluation of previous CLEAR projects, including the return on investment. METHODS: CLEAR is a work-based learning programme that combines qualitative techniques with data analytics to build innovations and new models of care. It has four unique stages: (1) Clinical engagement- used to gather rich insights from stakeholders and clinicians. (2) Data interrogation- utilising clinical and workforce data for cohort analysis. (3) Innovation- using structured innovation methods to develop new models of care. (4) Recommendations- report writing, impact assessment and presentation of key findings to executive boards. A mixed-methods formative evaluation was carried out on completed projects, which included semi-structured interviews and surveys with CLEAR associates and stakeholders, and a health economic logic model that was developed to link the inputs, processes, outputs and the outcome of CLEAR as well as the potential impacts of the changes identified from the projects. RESULTS: CLEAR provides a more cost-effective delivery of complex change programmes than the alternatives - resulting in a cost saving of £1.90 for every £1 spent independent of implementation success. Results suggest that CLEAR recommendations are more likely to be implemented compared to other complex healthcare interventions because of the levels of clinical engagement and have a potential return on investment of up to £14 over 5 years for every £1 invested. CLEAR appears to have a positive impact on staff retention and wellbeing, the cost of a CLEAR project is covered if one medical consultant remains in post for a year. CONCLUSIONS: The unique CLEAR methodology is a clinically effective and cost-effective complex healthcare innovation that optimises workforce and activity design, as well as improving staff retention. Embedding CLEAR methodology in the NHS could have substantial impact on patient care, staff well-being and service provision.

Training and redeployment of healthcare workers to intensive care units (ICUs) during the COVID-19 pandemic: a systematic review.

OBJECTIVES: The rapid influx of patients with COVID-19 to intensive care at a rate that exceeds pre-existing staff capacity has required the rapid development of innovative redeployment and training strategies, which considered patient care and infection control. The aim of this study was to provide a detailed understanding of redeployment and training during the first year of the COVID-19 pandemic by capturing and considering the merit of the strategies enlisted and the experiences and needs of redeployed healthcare workers (HCWs). DESIGN: The review involved a systematic search of key terms related to intensive care AND training AND redeployment AND healthcare workers within nine databases (Medline, CINAHL, PsychINFO, MedRxiv, Web of Science, The Health Management Consortium database, Social Science Research Network, OpenGrey and TRIP), which took place on 16 July 2021. Analysis consisted of a synthesis of quantitative study outputs and framework-based thematic analysis of qualitative study outputs and grey literature. These results were then combined applying an interpretative synthesis. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and the review protocol was available online. RESULTS: Forty papers were analysed. These took place primarily in the UK (n=15, 37.5%) and USA (n=17, 42.5%). Themes presented in the results are redeployment: implementation strategies and learning; redeployed HCWs' experience and strategies to address their needs; redeployed HCWs' learning needs; training formats offered and training evaluations; and future redeployment and training delivery. Based on this, key principles for successful redeployment and training were proposed. CONCLUSIONS: The COVID-19 pandemic presents unique challenges to develop flexible redeployment strategies and deliver training promptly while following infection control recommendations. This review synthesises original approaches to tackle these challenges, which are relevant to inform the development of targeted and adaptative training and redeployment plans considering the needs of HCWs.

PROCESS AND SYSTEMS: The WRaPT process - a novel and patient-centred approach to workforce planning by a clinically active workforce.

The concept of supply and demand is well established within the health economy of the UK. However, complex health and social care needs, associated with an ageing population, pose a novel challenge to NHS resources and, in particular, its workforce. Although existing strategies adopt a more linear approach to clinical activity and workforce demands, the Workforce Repository and Planning Tool process draws upon the principles of 'realist' data evaluation to combine -empirical evidence, practical experience and clinical theory to offer transformation strategies for an NHS workforce that is fit for purpose and its patients.

The use of high-dose intrathecal diamorphine in laparoscopic bariatric surgery: a single-centre retrospective cohort study.

INTRODUCTION: The use of intrathecal diamorphine is not commonplace in laparoscopic bariatric surgery. At our institution, a major UK bariatric centre, high-dose intrathecal diamorphine is routinely utilised. METHODS: Data were analysed retrospectively. Fifty-three patients who had a spinal anaesthetic were matched against age, sex, body mass index and surgical procedure type to generate controls. Pain scores were recorded in the post-anaesthetic care unit on arrival, after 1 hour and on discharge to the ward. Post-operative nausea and vomiting; post-operative hypertension; pruritus; 24-hour morphine consumption and length of stay were measured. RESULTS: Pain scores were better in the spinal anaesthetic group in all measured categories (p = 0.033, p < 0.01, p < 0.01); post-operative nausea and vomiting was less common in the spinal anaesthetic group (p < 0.01); post-operative hypertension was less common in the spinal anaesthetic group (p = 0.25); pruritus was more common in the spinal anaesthetic group (p < 0.01); morphine consumption was less common in the spinal anaesthetic group (p = 0.037). Length of hospital stay was reduced by 12.4 hours (p = 0.025). CONCLUSION: We propose that this is a practical and safe technique to adopt. A randomised-control trial will need to be conducted in order to find the most efficacious volume of local anaesthetic and dose of diamorphine.

The association of noise and surgical-site infection in day-case hernia repairs.

INTRODUCTION: Surgical-site infections (SSIs) are associated with an increased duration of hospital stay, poorer quality of life, and an marked increase in cost to the hospital. Lapses in compliance with aseptic principles are a substantial risk factor for SSI, which may be attributable to distractions such as noise during the operation. The aims of this study were to assess whether noise levels in the operating room are associated with the development of SSI and to elucidate the extent to which these levels affect the financial burden of surgery. METHODS: Prospective data collection from elective, day-case male patients undergoing elective hernia repairs was undertaken. Patients were included if they were fit and at low risk for SSI. Sound levels during procedures was measured via a decibel meter and correlated with the incidence of SSI. Data analysis was performed with IBM SPSS (IBM, Armonk, NY). RESULTS: Noise levels were substantially greater in patients with SSI from time point of 50 minutes onwards, which correlated to when wound closure was occurring. Additional hospital costs for these patients were £243 per patient based on the National Health Service 2013 reference costing. CONCLUSION: Decreasing ambient noise levels in the operating room may aid in reducing the incidence of SSIs, particularly during closure, and decrease the associated financial costs of this complication.

Pubic lice: an endangered species?

UNLABELLED: The incidence of pubic lice infestations is estimated to be between 1.3% and 4.6%, with an average incidence of 2% worldwide. It is also estimated that 70% to 80% of adults now remove pubic hair in part or entirety, using a variety of methods. It is hypothesized that the destruction of this pubic hair habitat may account for the falling incidence of pubic lice and may possibly lead to its eradication or atypical presentation. AIM: To report the changing incidence of pubic lice infestation from our unit over the last 10 years and assess its association, if any, with pubic hair removal of any kind. METHODS: Assessment of medical records and questionnaires were used to identify the incidence of hair removal and pubic lice infestation over a 10-year period. Data were anonymized and analyzed to identify any correlation. RESULTS: A significant and strong correlation between the falling incidence of pubic lice infections and increase in pubic hair removal was observed, with a Pearson correlation r value of 0.9686 (95% confidence intervals, 0.88-0.992). The P value is less than 0.0001. CONCLUSIONS: The increased incidence of hair removal may lead to atypical patterns of pubic lice infestations or its complete eradication as the natural habitat of this parasite is destroyed.