Supporting integration: the creation of a framework to support the design and delivery of clinical academic integration across a complex system.

Transforming outcomes for patients by aligning and integrating care requires complex systems change and management across multiple organisational boundaries. This case study outlines one part of the integration journey across a partnership between three independent NHS foundation trusts with strong affiliations to two universities, the combined expertise of which places them at the forefront of being able to deliver the best heart and lung outcomes for patients. It specifically describes the process of designing, testing and implementing a bespoke tool called the Clinical Academic Integration Framework (CAIF) to support clinical and academic teams in owning, planning and delivering their paths to full integration, defined as 'one team, across multiple sites' in this context.

Identifying value in healthcare transformation initiatives: an evaluation of an approach to benefits realisation.

Benefits realisation management (BRM) aims to facilitate the process of identifying, measuring and tracking desired benefits derived from a project. Improvement methodology frameworks often describe BRM as integral to identifying and measuring value derived from transformation initiatives within the National Health Service and beyond. Despite this, reporting of benefits realisation plans and methodological approaches to identifying and measuring benefits remains surprisingly scarce.This project aimed to pilot and evaluate the application of a purpose-designed benefits mapping template with seven newly funded transformation projects across three hospitals in the UK. The scope of the template was to identify key project benefits and metrics associated with the project initiatives. Plan-do-study-act (PDSA) cycles were used to capture the approach and utilisation of the template by project teams. These methods also enabled critical review of the template as an enabler to identifying relevant benefits and project metrics.Stakeholder engagement with the templates was variable. This was attributed to clinical pressures induced by the second wave of COVID-19 in the UK. Despite this, teams were able to produce completed templates outlining a number of wide-ranging benefits. Themes of benefits drawn from the maps include patient experience, patient outcomes, staff experience, access to care and efficiency. Qualitative feedback from teams included the reported value of a structured template to help recognise all the potential benefits associated with each project initiative. The PDSA cycles highlighted the template as an early step in BRM. Further components to this process are recommended to include consensus of the key metrics to be measured, a tool that summarises the reporting details of those metrics, and an effective means to collate reported metrics overtime.

Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study.

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.

What risks to sustainability are identified throughout care bundle implementation and how can they be addressed? A mixed methods case study.

OBJECTIVES: Despite national guidance on how to identify and treat heart failure (HF), variation in HF care persists across UK hospitals. Care bundles have been proposed as a mechanism to deliver reliable optimal care for patients; however, specific challenges to sustain care bundles in practice have been highlighted. With few studies providing insight into how to design or implement care bundles to optimise sustainability, there is little direction for practitioners seeking to ensure long-term impact of their initiatives. This study explores the sustainability risks encountered throughout the implementation of a HF care bundle (HFCB) and describes how these challenges were addressed by a multidisciplinary team (MDT) to enhance sustainability over time. DESIGN: A longitudinal mixed method case study examined the HFCB improvement initiative from September 2015 to August 2018. A standardised sustainability tool was used to collect perceptions of sustainability risks and actions throughout the initiative. Observations, key-informant interviews and documentary analysis were conducted to gain in-depth understanding of how the MDT influenced sustainability through specific actions. A qualitative database was developed using a consolidated sustainability framework to conduct thematic analysis. Sustainability outcomes were explored 1-year post funding to ascertain progress towards sustainment. RESULTS: The MDT identified six sustainability challenges for the HFCB: infrastructure limitations, coding reliability, delivery consistency, organisational fit, resource stability and demonstrating impact. The MDT undertook multiple actions to enhance sustainability, including: (1) developing a business case to address infrastructure limitations; (2) incorporating staff feedback to increase bundle usability; (3) establishing consistent training; (4) increasing reliability of baseline data; (5) embedding monitoring and communication; and (6) integrating the bundle into current practices. CONCLUSION: Through the description of challenges, actions and learning from the MDT, this study provides practical lessons for practitioners and researchers seeking to embed and sustain care bundles in practice.

Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative.

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia. Undiagnosed and poorly managed AF increases risk of stroke. The Hounslow AF quality improvement (QI) initiative was associated with improved quality of care for patients with AF through increased detection of AF and appropriate anticoagulation. This study aimed to evaluate whether there has been a change in stroke and bleeding rates in the Hounslow population following the QI initiative. METHODS: Using hospital admissions data from January 2011 to August 2018, interrupted time series analysis was performed to investigate the changes in standardised rates of admission with stroke and bleeding, following the start of the QI initiative in October 2014. RESULTS: There was a 17% decrease in the rate of admission with stroke as primary diagnosis (incidence rate ratio (IRR) 0.83; 95% CI 0.712 to 0.963; p<0.014). There was an even larger yet not statistically significant decrease in admission with stroke as primary diagnosis and AF as secondary diagnosis (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071). No significant changes were observed in bleeding admissions. For each outcome, an additional regression model including both the level change and an interaction term for slope change was created. In all cases, the slope change was small and not statistically significant. CONCLUSION: Reduction in stroke admissions may be associated with the AF QI initiative. However, the immediate level change and non-significant slope change suggests a lack of effect of the intervention over time and that the decrease observed may be attributable to other events.

Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices.

Objective: Atrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative. Methods: Using the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018. Results: When comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change. Conclusion: Implementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.

Exercise training modifies walking kinematics and energy cost in obese adolescents: A pilot controlled trial.

The aim of this study was to investigate the effects of a weight loss intervention based on physical exercise on the relationship between energy cost and stride frequency during walking in obese teenagers. Participants aged 13-16 years old were assigned to a training (n = 14) and control (n = 10) groups. During eight weeks, the training group performed three 60-min weekly sessions of high-intensity intermittent activities coupled with aerobic training. Body composition, gait parameters and energy cost during 4-min walking bouts at participants' most comfortable speed and preferred stride frequency (PSF), PSF-10%, PSF + 10%, PSF-20% and PSF + 20% were measured before and after intervention. The effects of training and stride frequencies on the energy cost of walking were analysed by an ANOVA with repeated measures. The main results showed that the exercise intervention induced a significant increase in walking speed (+23.2%), and significant decreases in body mass (-1.4%), body fat percentage (-2.1%) and energy cost of walking at various frequencies (decreases ranging from -10.5% to -20.4%, p < .05). In addition, significantly greater decreases were shown at high frequencies (p < .05). No significant differences were shown in the control group (p > .05). These results suggest that this type of training is beneficial to reduce walking energy cost of obese teenagers, in particular at high frequencies. This should improve their well-being during daily activities.

Effect of stride frequency on the energy cost of walking in obese teenagers.

The aim of this study was to compare the energy cost of obese and non-obese teenagers while walking at their preferred speed and different stride frequencies. Twelve obese and twelve non-obese teenagers walked continuously on the treadmill at their most comfortable speed for 6 periods of 4 min each. Each period corresponded to a specific stride frequency: preferred (PSF), force-driven harmonic oscillator (FDHO), PSF+10%, PSF+20%, PSF-10% and PSF-20%. Cardiorespiratory parameters were collected between the 3rd and 4th minute of each stage, and used to calculate the energy cost of walking (EC). The main results showed a significantly higher cost of walking expressed relative to lean body mass. In addition, a U-shaped relationship between EC and stride frequency was shown in both groups, with PSF and FDHO leading to a significantly lower value compared to all other frequencies. This showed first, that FDHO is a good predictor of PSF and minimal energy cost of walking in both groups, and second, that excess body fat does not affect the relationship between energy expenditure and stride frequency. Walking at lower or higher than preferred frequencies could be used as an exercise mode to promote weight loss in obese teenagers.

Heart rate, blood lactate concentration, and time-motion analysis of female basketball players during competition.

The aim of this study was to examine the physiological demands and movement patterns of female basketball players after changes in the rules of the game. Nine varsity players were studied during nine official games. Each game was videotaped to identify the frequencies of the main movements performed, heart rate was recorded continuously, and blood samples were collected to determine blood lactate concentration when the competition rules allowed. The main results showed that the players performed on average 652 +/- 128 movements per game, which corresponded to a change in activity every 2.82 s. Mean heart rate was 165 +/- 9 beats . min(-1) (89.1% of maximum heart rate) for total time and 170 +/- 8 beats . min(-1) (92.5% of maximum) for live time. Mean blood lactate concentration was 5.2 +/- 2.7 mmol . l(-1) (55.9% of maximum blood lactate concentration). In addition, heart rates were significantly higher in the first half than the second half of games. These results indicate: (1) a greater physiological load compared with previous studies on female players tested before the rules modification (Beam & Merrill, 1994; McArdle et al., 1971) and (2) lower movement frequencies compared with male players competing under modern rules (Ben Abdelkrim et al., 2007). These observations must be taken into account by coaches and conditioning specialists working with female players.