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Take a look at a selection of our recent media coverage:

Best practice and the collaborative power of the multidisciplinary team in cardiology

16th April 2024

From his base in Leeds, Dr Rani Khatib champions holistic, person-centred approaches and the collaborative power of the multidisciplinary team in cardiac care. Here, the newly appointed fellow of the European Society of Cardiology speaks to Allie Anderson about his innovative services that have enjoyed local, national and international acclaim, and how his own recent experiences as a patient have bolstered his professional work.

Dr Rani Khatib is a trailblazer in cardiology and cardiovascular pharmacy, achieving success locally and nationally through clinical work and research. As well as a consultant pharmacist in cardiology and cardiovascular research at Leeds Teaching Hospitals NHS Trust, he is visiting associate professor at the Leeds Institute for Cardiometabolic Medicine at the University of Leeds.

He has enjoyed acclaimed in Europe, too, sitting on cardiology allied professional groups for the European Society of Cardiology (ESC), and last year Dr Khatib was elected Fellow of the ESC in honour of his distinguished career.

‘It’s a huge recognition and becoming a Fellow of the ESC as a pharmacist rather than a cardiologist is an added bonus,’ Dr Khatib says. ‘The Society includes non-physicians as part of its structure because, simply, the care of patients with cardiology conditions requires input from multiple healthcare professionals.’

Dr Khatib embodies this multidisciplinary approach, not only contributing to but spearheading a number of pharmacy-led services at his Trust – and beyond. At their core are medicines optimisation and managing patient risk. ‘Cardiovascular disease is one of the biggest killers worldwide,’ he explains, ‘so there is a huge opportunity to ensure patients are on the right therapies and to optimise those therapies.’

Optimising medicines and adherence post-MI

Having noted suboptimal secondary prevention medicine (SPM) regimes and low adherence among myocardial infarction (MI) patients, Dr Khatib embarked on a project to ‘re-engineer’ post-MI care. Together with a consultant cardiologist, he established a post-MI multidisciplinary medicines optimisation clinic. Patients who had been hospitalised following an MI could see Dr Khatib, who is an independent prescriber, for a 30-minute consultation post-discharge to discuss any questions or problems they had with their medication.

He could manage patients autonomously but also escalate cases to the consultant cardiologist where necessary. ‘That was important because we worked together to identify the best set-up, so that we have access to each other, we work collaboratively, and we deliver what is best for the patients,’ Dr Khatib says.

Ahead of the clinic, patients were asked to complete a ‘My Experience of Taking Medicines’ questionnaire, known as MYMEDS. This self-reporting tool was designed to assess use of SMPs and to identify modifiable barriers – actual or perceived – to adherence. The completed questionnaire is a starting point for Dr Khatib to dig deeper.

‘It enabled patients to raise concerns about their medicines, whether that’s side effects or fitting medicines into their daily routine,’ he says. ‘Patients will often say “yes”, they remember to take their medicines, but if you have a further conversation using the MYMEDS tool, you might identify that they’re having problems swallowing the tablets so actually, they found taking them challenging.’ After identifying a barrier, Dr Khatib adds, he can work with the patient to overcome them.

The service was piloted between October 2015 and December 2016 among 270 patients. Optimisation of drugs improved significantly, with numbers of patients taking the recommended doses of ACE-inhibitors or ARBs increasing from 16.3% to 73.9%.

Patients reported significantly fewer concerns with their medications, non-adherence rates fell by up to 70.8% and readmission rates decreased.

Building on success to drive holistic cardiac care

In recent years, there has been a sharpened focus on holistic patient care and, with it, more emphasis on tackling multimorbidity. Patients with cardiovascular disease and type 2 diabetes have historically been managed by two distinct teams, but in Leeds, Dr Khatib spotted an opportunity to drive improvements in both specialties.

‘We identified that cardiology patients with type 2 diabetes were not necessarily receiving the best care,’ he says. ‘Newer diabetes medicines like SGLT2 inhibitors and GLP1 agonists also confer significant cardiovascular and renal benefits, so looking at the interplay between cardio-renal-metabolic seemed obvious.’

Dr Khatib established the CaReMe service, which streamlined cardio-renal-metabolic services into a ‘one-stop clinic’ for these comorbid patients. The consultant pharmacist-led clinic, supported by wider multidisciplinary teams, assesses patients six to eight weeks after an MI event.

It uses an adapted version of the MYMEDS tool – MYMEDS-Cardiometabolic – so as well as optimising medicines use and adherence, the consultant pharmacist provides a comprehensive review of the patient’s cardiovascular, diabetes and renal management needs. Such needs include key cardio-renal-metabolic biomarkers; analysis of risk factors; post-MI SPMs; and dietary, weight management and other lifestyle advice.

National adoption of best practice in cardiology

As well as improving patient outcomes, services like these highlight the crucial role of consultant pharmacists in multidisciplinary teams. They also create opportunities to expand input from appropriately trained senior pharmacists. Such initiatives free consultants to deliver other specialist services, thereby increasing capacity.

Moreover, Dr Khatib’s work has been taken further to not only reach patients in Leeds but nationally as well, notably with PCSK9 inhibitors. Designed to treat high cholesterol in patients who are not suitable for or poorly controlled on other lipid-lowering therapies, PCSK9 inhibitors are underused in optimising lipid management according to Dr Khatib.

‘We are always trying to improve access to innovative medicines, and bring what pharmacy can offer into the patient pathway to forward the cardiovascular agenda,’ he comments. ‘So, to improve access to these drugs, we set up another pharmacist-led, multidisciplinary clinic.’

Established in 2017, the clinic – the only service that was prescribing PCSK9 inhibitors in the Leeds area – also provides patient support, education and monitoring to promote adherence, as well as tackling statin intolerance.

The service proved successful and has yielded significant improvements in patients’ total and LDL cholesterol levels that are maintained at 12-month follow-up. It was deemed cost-effective and patient feedback was positive.

Furthermore, the project caught the attention of stakeholders at the Accelerated Access Collaborative (AAC), a UK-wide initiative aimed at extending access to high-quality healthcare, through improving uptake of the best treatments, for example. Harnessing his experience delivering the pharmacy-led service, Dr Khatib worked with NHS England and the AAC to develop a NICE-endorsed national lipid management pathway and the statin intolerance pathway.

‘Our model, uniquely, established a centralised service run by a consultant cardiology pharmacist and advanced cardiology pharmacists. We offered a vehicle for these medicines to be prescribed and demonstrated that lipid optimisation doesn’t have to be managed only by lipidologists,’ Dr Khatib explains. ‘We need to tap into the pharmacy profession more, and through collaboration with cardiology and lipidology colleagues the patient receives the best care, and the pharmacist is well-supported to deliver it.’

Patient-centricity as a priority

Dr Khatib believes that person-centred care must underpin every aspect of pharmacy. ‘As much as we talk about it, it’s often missed because it’s not as easy to apply as we think,’ he comments. However, being on the other side of the patient-clinician partnership has given Dr Khatib a broader understanding of the dynamics.

Having contracted Covid-19 in November 2020, he spent seven months in hospital in what he describes as ‘a terrible ordeal’ that caused multiple organ failures and cardiac arrests. This left him with extensive deconditioning and multiple morbidities – all of which he has documented in a Journal of Cardiac Failure editorial. His book with full reflections and lessons about this experience will soon be published.

‘I continue to live the patient experience and it has opened my eyes to a lot of things you only see as a patient, and not as a healthcare professional,’ he says, adding that it gives him a fresh perspective on patient need when it comes to multidisciplinary working.

‘Often patients said they preferred to see a cardiologist because they felt they’re more likely to get a rounded view, rather than just a medicines-focused discussion, which triggered something in my mind: we need to change the way we do pharmacy-led clinics to a more patient-centred approach,’ he explains.

This requires what Dr Khatib calls a ‘zoom out’ mindset, aided by tools like MYMEDS to support a holistic view. ‘So, when patients tell me about their experiences, I am ready to hear about their anxiety, their challenges going back to work, or how they’re getting on with lifestyle modifications,’ he comments. ‘I may not be able to solve those problems, but I can be considerate of them.’

In that way, Dr Khatib believes, pharmacy-led services can tick patient-centricity boxes while also helping to improve adherence and outcomes. He concludes: ‘I believe this is a better way of delivering the medicines optimisation concept.’

Explore the latest innovations in respiratory care at HHE’s latest Clinical Excellence event

11th April 2024

Kicking off on 1 May 2024, Clinical Excellence in Respiratory Care is a one-day event for the multidisciplinary team exploring the latest advances in respiratory – and registration is now open.

Back for a second year, the Clinical Excellence events series brings together renowned experts from recognised Centres of Excellence and other UK and European hospitals to share their experiences of clinical innovations, examples of best practice and how they are improving patient care.

This year’s spring respiratory care offering has been developed by the team at Hospital Healthcare Europe and Hospital Pharmacy Europe with guidance from industry experts, including event chairs John Dickinson, professor in sport and exercise sciences, head of exercise respiratory clinic at the University of Kent, England, and Garry McDonald, respiratory pharmacist at University Hospital Crosshouse, Scotland.

Topics include diagnostic imaging innovations, what healthcare professionals need to know about occupational lung disease, recognising and managing tuberculosis and respiratory infections, critical care in respiratory medicine and the move towards personalised medicine and updates on targeted therapies.

The work of the multidisciplinary team is a theme running throughout the event, focusing on how respiratory physicians, surgeons, pharmacists, nurses and members of the wider clinical team can effectively and efficiently work together to provide better outcomes for patients.

The event is free to attend and comprises individual presentations, panel discussions and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.

Pick and choose sessions most relevant to your clinical practice, specifically tailoring the day to your needs, and gain CPD hours from the comfort of your computer.

With a whole host of fascinating insights and inspiration for improving patient care, it’s not to be missed. Register now to join us on 1 May and on demand.

Don’t forget to check out Hospital Healthcare Europe’s respiratory Clinical Excellence section, brimming with content including interviews with prominent physicians to complement the event’s offering.

More Clinical Excellence events are in development for respiratory care and other specialities, which will be launching throughout 2024 – watch this space.

Position statement on integrated respiratory care published by BTS and PCRS

9th February 2024

The importance of integrated respiratory healthcare models that put patients at their centre has been outlined in a new joint position statement from the British Thoracic Society (BTS) and the Primary Care Respiratory Society (PCRS).

Aimed at all respiratory healthcare professionals across primary and secondary care, the position statement aims to improve health outcomes, tackle complex challenges and inequalities in the provision of healthcare, and prevent avoidable hospital admissions.

It highlights the common priorities shared by the BTS and PCRS and sets out a series of common goals to support the coordination of the multi-professional team and deliver high-quality, accessible care that considers physical and mental health, housing and social care.

The common goals focus on maintaining pathways of care that help to avoid unnecessary admission to hospital, advocating a whole-person approach to planning and delivering respiratory care, supporting improved outcomes and addressing health inequalities, and facilitating workforce recruitment, retention and capacity models.

These goals sit alongside each organisation’s own range of existing initiatives to support the provision of integrated care, they said.

The position statement also includes a five-part high level model for use by respiratory teams, detailing practical steps to help ensure the success of integrated respiratory healthcare: build relationships; identify funds; establish clear, identified goals; build the right team; and actively deliver the pathway.

Dr Paul Walker, chair of the BTS, said: ‘Integration of respiratory care is vital to optimally deliver health and social care in a system that is often disjointed and challenging for patients and carers to navigate. Not only is integrated respiratory care more efficient and productive it encourages sharing of skills, knowledge and insight.

‘This position statement encourages respiratory professionals and teams, across the healthcare landscape, to work better together to improve outcomes for patients.’

Daryl Freeman, chair of the PCRS’ Service Development Committee, associate clinical director primary care and GP in older people’s medicine in Norfolk, said: ‘It’s been an inspiration to be part of the BTS/PCRS joint working group delivering this statement.

‘I know that it will inspire clinicians, trusts and integrated care boards to design and deliver integrated care in their own regions and enable new implementers; giving them access to a document to which they can not only refer, but the support and experience of clinicians from BTS and PCRS who are either actively working in or developing integrated services.’

The BTS and PCRS represent and support all respiratory healthcare professionals working in the NHS across the UK.

The organisations hope that their collaboration on the position statement will help to ensure that tools, resources and education materials are shared widely across all members of the multi-professional respiratory team to the benefit of patients.

Explore the latest innovations in cardiovascular care at HHE’s new Clinical Excellence event

1st February 2024

Kicking off on 19 March 2024, Clinical Excellence in Cardiovascular Care is a one-day cardiology event for the multidisciplinary team exploring the latest advances in cardiology – and registration is now open.

Back for a second year, the Clinical Excellence events series brings together renowned experts from recognised Centres of Excellence and other UK and European hospitals to share their experiences of clinical innovations, examples of best practice and how they are improving patient care.

This year’s spring cardiovascular care offering has been developed by the team at Hospital Healthcare Europe and Hospital Pharmacy Europe with guidance from industry experts, including event chair Rebecca Dobson, consultant cardiologist (imaging & cardio-oncology) at Liverpool Heart and Chest Hospital, UK.

Topics include the multidisciplinary team in cardiac care, cardiorenal syndrome, stroke care and cardiovascular diseases, and new advances in cardiac imaging.

The work of the multidisciplinary team is a theme running throughout the event, focusing on how cardiologists, surgeons, pharmacists, nurses and members of the wider clinical team can effectively and efficiently work together to provide better outcomes for patients.

The event is free to attend and comprises individual presentations, panel discussions and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.

Pick and choose sessions most relevant to your clinical practice, specifically tailoring the day to your needs, and gain CPD hours from the comfort of your computer.

With a whole host of fascinating insights and inspiration for improving patient care, it’s not to be missed. Register now to join us on 19 March and on demand.

Don’t forget to check out Hospital Healthcare Europe’s cardiology Clinical Excellence section, brimming with content including interviews with prominent physicians to complement the event’s offering.

More Clinical Excellence events are in development for cardiovascular care and other specialities, which will be launching throughout 2024.

Best practice strategies for improving institutional fluid stewardship

11th January 2024

A recent multidisciplinary report concluded that significant gaps currently exist in consistent education and training on fluid management, and innovative solutions are needed to drive change and transformation.1 Healthcare institutions should therefore implement programmes on fluid stewardship to achieve their quality improvement and patient safety goals.

The fundamental concept of intravenous (IV) fluid therapy is to ‘restore and maintain tissue oxygen, fluid and electrolyte homeostasis, and central euvolaemia’.2 This should be combined with an understanding of proper fluid management goals in resuscitation, replacement, nutrition, dilution (for other medications) and maintenance settings – see Figure 1.

Figure 1. The 7 Rs framework with the five indications for fluid administration (resuscitation, routine maintenance, replacement, dilution or nutrition)

Figure 1. The 7 Rs framework with the five indications for fluid administration (resuscitation, routine maintenance, replacement, dilution or nutrition)

Cl: chloride; GI: gastrointestinal; Gluc: glucose; H2O: water; IV: intravenous; K: potassium; Na: sodium; PO: per os; SSCG: Surviving Sepsis Campaign Guidelines.

The National Institute for Health and Care Excellence fluid guidelines provide a good starting point3 for fluid stewardship interventions, and these should include:

  1. An understanding of the physiology of water and electrolyte homeostasis
  2. Knowledge of the risks, benefits and harms of IV fluids
  3. Assessment of fluid and electrolyte needs
  4. Assessment of fluid and volume status and fluid (un)responsiveness
  5. Prescribing IV fluids properly to each patient
  6. Evaluating and documenting changes
  7. Monitoring the response to IV fluids
  8. Taking further action as required
  9. Reporting complications of fluid management or administration as incidents that require investigation, to provide a basis for learning and improvement.

Improving education and training for fluid management

When implementing effective fluid stewardship, it is essential to provide a platform that meets the needs of all healthcare practitioners at all stages of their careers.

In previous questionnaire-based analyses of clinicians responsible for fluid management – and with experience levels ranging from trainees to experienced clinicians – fluid management knowledge scores were low, and most participants reported having experienced unreported fluid-related serious adverse events.4,5

To reach all clinicians involved in fluid management with education and training based on evidence-based medicine and guidelines, educators should abandon old ideas that are often based in silo thinking and understand the value of a systems approach to education that improves patient care.

A systems approach recognises the roles that all specialties play in patient care and encourages open communication that avoids practices that unnecessarily separate different aspects of the fluid management team into independent parts.1

To achieve this systems approach goal, and to maximise staff involvement from all relevant specialties involved in fluid management, effective training should take advantage of a variety of innovative educational resources.

Better education and training require a transformation in mindset and behaviour among both junior and established clinicians. It is important to identify fluid stewards and institutional ambassadors who support not only staff education but also change, and who can obtain the necessary buy-in from hospital administrators, such as medical and nursing directors.

Innovative virtual learning platforms should be considered for staff convenience and flexibility. Targeted education should be provided to all staff responsible for fluid management decisions.

Guidelines, KPIs and data

Guidelines are valuable tools to ensure consistent fluid delivery practices after regular staff education is established. Any proposed local guideline should include assessment, prescription, monitoring, fluid balance charting and regular review of clinical status.

To facilitate the implementation of fluid stewardship programmes, it is important to analyse the local hospital situation regarding fluid delivery and consumption and the calculation of some common key performance indicators (KPIs) such as the total amount of fluids per patient and occupied bed days.

For isotonic resuscitation fluids, the ratio between balanced and unbalanced (abnormal saline) fluids could be prospectively monitored. For maintenance, the ratio between hypotonic balanced maintenance versus other glucose-containing solutions could be monitored.

Poor fluid management might not directly result in mortality but can impact clinically relevant outcomes such as acid-base and electrolyte disturbances, fluid accumulation (syndrome) and acute kidney injury, which, in turn, might contribute to morbidity and mortality.6

Studies have shown that about one patient in five will suffer from deleterious consequences of inappropriate fluid management; this can be related to too little or too much fluid.

Considering the risk of poor outcomes, institutions need to analyse the potential cost benefits of good fluid stewardship. To achieve this, institutions will need to rely on big data strategies derived from available data sources as opposed to snapshots of local data.

These data sources already exist and include prescription data, laboratory records, imaging results and patient admission and discharge information.

Real-world data and machine learning

In the meantime, without robust data on complication rates, a real cost-effectiveness analysis might be extremely challenging, and the best approach that can be applied is to monitor fluid (mis)use and outcomes in specific hospitals.

One such example of real-world data is the European Health Data & Evidence Network (EHDEN) project, which aimed to collect Observational Medical Outcomes Partnership-Common Data Model (OMOP-CDM) compatible data from 100 million patient records and has now collected data on 236 million patient records.

Developing machine learning models that consider costs, outcomes and long-term implications of different fluid management approaches can assist in decision-making and resource allocation and could result in potential cost savings associated with implementing evidence-based fluid management practices.

Figure 2 illustrates how OMOP-CDM can help to analyse annual fluid consumption and associated costs. In this case, the annual cost savings could mount up to approximately €38,000 and €42,000 depending on a reduction in total fluid consumption to 4 L and 3 L per stay, respectively.

Figure 2. Annual total consumption and cost of intravenous fluids and drugs in a medium-sized hospital (250 beds)

Figure 2. Annual total consumption and cost of intravenous fluids and drugs in a medium-sized hospital (250 beds)

Resuscitation = isotonic fluids; maintenance = glucose-containing fluids; drug dilution = small 50- or 100-ml fluid bags.

Data analysis undertaken with hospi-intelligence, which was developed by Medaman, via OMOP-CDM showed that fluid overuse was present in 20% of cases. This is defined as more than 6 L per patient stay and more than 0.6 L per bed occupying day.

Assuming that drugs and nutrition cannot be omitted, a potential cost reduction can come from stopping maintenance and reducing isotonic fluids as well as further concentration of drug dilution.

Effective institutional fluid stewardship

The practice scope of healthcare providers involved in fluid management varies widely, from the complicated and risky administration and monitoring of fluids in the critical care setting to procurement, quality improvement and evidence-based research projects.

Monitoring daily and cumulative fluid balance is an integral component of fluid therapy and good patient care; it can identify potential problems and allow for earlier escalation when required.

A trigger point on a fluid balance chart that supports fluid delivery decision-making is important for the identification of suboptimal or increased fluid intake or output.

These trigger points should be highlighted in an institution-specific educational programme that emphasises the importance of early warning scores and strategies for an appropriate response.

Patient information leaflets encourage patients and their relatives to be aware of their fluid needs and explain IV therapy. Self-monitoring of intake is possible for some patients.

A consistent approach to teaching fluid therapy based on established guidelines, as well as implementation of fluid stewardship, should help reduce prescriber confusion when faced with the need to prescribe fluids in different patient scenarios.

All institutions should consider a commitment to effective fluid stewardship at the local level. Institutions that have yet to implement standardised fluid stewardship can follow some key steps for success, as seen in Figure 3.

Figure 3. Strategies to achieve institutional best practices in fluid stewardship*

Figure 3. Strategies to achieve institutional best practices in fluid stewardship

*Figure 3 adapted with permission from Malbrain MLNG et al. according to the Open Access CC BY licence 4.0.1

Once fluid stewardship is implemented, metrics for recording staff education should include the number of learners taught and accessing e-learning modules, assessment results, and ultimately whether prescribers are following guidelines, as determined by information from snapshot audits and fluid usage data. Strategies are discussed in Table 1.

Table 1. Strategies to engage clinical leads with the implementation of a fluid stewardship programme**

Table 1. Strategies to engage clinical leads with the implementation of a fluid stewardship programme

**Table 1 adapted with permission from Malbrain MLNG et al. according to the Open Access CC BY licence 4.0.1

Best practices for fluid stewardship

For the attending clinician, the process of fluid prescription can be condensed to four questions:

  1. Does my patient need fluid, and is there a potential benefit of fluid administration?
    Remember that the best fluid may be the one that has not been administered unnecessarily.
  2. If so, why?
    This question considers whether it is for maintenance, replacement of losses, or resuscitation, or if the patient requires fluid restriction? Is there body compartment fluid redistribution?
  3. Which fluid should be used in these differing scenarios?
  4. How much should I give to the patient, when and for how long?
    This question considers the dosing, rate, speed, timing, duration and route of administration.

After starting an IV fluid, the next four questions that should be addressed are:6

  1. When to stop IV fluids? When shock has been resolved
    This question addresses the risks of ongoing fluid administration
  2. When to start fluid de-escalation?
    (E.g. when to stop maintenance fluids or when to start hypercaloric enteral feeding to reduce fluid intake and the risk of fluid accumulation)
  3. When to start active fluid removal or deresuscitation?
    When the presence of fluid accumulation or global increased permeability syndrome negatively impacts end-organ function.
    This question addresses the benefits of fluid removal (e.g. improvement of pulmonary oedema)
  4. When to stop fluid removal?
    This question addresses the risks of fluid removal (e.g. causing hypoperfusion).

To expand on these questions, the ‘Five Ps’ of effective fluid prescriptions should be considered:

  • Physician: All starts with the physician’s participation in making decisions related to fluid management
  • Prescription: The physician should engage in writing a prescription that accounts for drug, dose, duration and, whenever possible, de-escalation
  • Pharmacy: The prescription is sent to the pharmacy and is checked for inconsistencies by the pharmacist to get a more holistic view
  • Preparation: The process by which the prescription is prepared and additions (e.g. electrolytes) made
  • Patient: The filled prescription goes back to the patient and fluid stewards should observe administration, response and debrief.

Finally, all staff responsible for fluid management should regularly monitor patients for the appropriateness of fluid prescriptions, including initial patient assessment, decisions on fluid indication, fluid prescription and regular fluid management. The stages for checking on the appropriateness of IV fluid therapy are summarised in Table 2.7

Table 2. Four stages of monitoring the appropriateness of fluid prescription at the bedside***

Table 2: Four stages of monitoring the appropriateness of fluid prescription at the bedside

***Table 2 adapted with permission from Malbrain et al.7

Conclusion

The implementation of effective fluid stewardship programmes in healthcare is of paramount importance, and these should involve coordinated interventions to optimise fluid therapy for the best clinical outcomes, cost-effectiveness and prevention of adverse events.8

Guidelines exist to standardise fluid management, and it is essential to identify effective fluid stewards in every hospital ward to ensure consistency.9 Data can be used for support and training and clinical outcomes can demonstrate the value of proper fluid prescription.

The message urges immediate implementation of fluid stewardship in hospitals and stresses the need for education and training to bridge practice gaps and improve patient outcomes.

Authors

Manu Malbrain
First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Poland; Medical Data Management, Medaman, Geel, Belgium; International Fluid Academy, Lovenjoel, Belgium

Dries Tant
Medical Data Management, Medaman, Geel, Belgium

Geert Byttebier
Medical Data Management, Medaman, Geel, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium

Marc Lamont
Medical Data Management, Medaman, Geel, Belgium

Luc Belmans
Medical Data Management, Medaman, Geel, Belgium

References

  1. Malbrain MLNG et al. Multidisciplinary expert panel report on fluid stewardship: perspectives and practice. Ann Intensive Care 2023 Sep 25;13(1):89
  2. Miller TE, Myles PS. Perioperative fluid therapy for major surgery. Anesthesiology 2019;130(5):825–32
  3. National Institute for Health and Care Excellence (NICE). Intravenous fluid therapy in adults in hospital: clinical guideline CG174. [Last accessed January 2024]
  4. Leach R et al. Fluid management knowledge in hospital physicians: “Greenshoots” of improvement but still a cause for concern. Clin Med (Lond) 2020;20(3):e26–31
  5. Nasa P et al. Intravenous fluid therapy in perioperative and critical care setting-Knowledge test and practice: An international cross-sectional survey. J Crit Care 2022 Oct;71:154122
  6. Malbrain MLNG et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann Intensive Care 2018;8(1):66
  7. Malbrain MLNG et al. It is time for improved fluid stewardship. ICU Manag Pract 2018;18(3):158–62
  8. Malbrain ML et al (eds). Rational Use of Intravenous Fluids in Critically Ill Patients. Springer, Cham
  9. Malbrain MLNG et al. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA). Ann Intensive Care 2020;10(1):64.

Transitional care interventions on hospital discharge reduce readmissions by more than half

18th December 2023

Patients given transitional care before and during discharge from hospital are less likely to be readmitted, according to new research from the University of Manchester.

The systematic review and network meta-analysis was published in the journal JAMA Network Open considered data from 126 trials with 97,408 participants.

It showed that interventions were associated with significant reductions in readmissions at 180 days post-discharge.

While the types of changes implemented differed across the studies, common changes included improved discharge planning, medication review, case management, multi-agency team meetings, psychological support, home visits and peer support.

Low complexity interventions comprised of one to three changes to usual care applied together and were associated with a 55% reduction in readmissions at 180 days post-discharge.

The medium complexity interventions, with four to seven changes to usual care, were associated with a 42% reduction during the same time period.

Even at 30 days, the low complexity interventions were associated with a 22% decrease in the odds of readmission and the medium complexity interventions were associated with a 18% decrease.

For high complexity interventions, which included eight or more changes to usual practice applied together, were associated with a 24% reduction in readmissions at 180 days post-discharge.

Principle investigator Maria Panagioti, senior lecturer from The University of Manchester, said: ‘This study shows that more changes to usual practice are not always better to reduce health care needs and prevent emergency department visits for patients transitioning from hospital to the community.

‘We need to think about what changes to the usual care are truly meaningful for patients, whether professionals can implement those changes and how those changes can work together as a coherent bundle of care.

‘We strongly recommend that the NHS develops of a set of patient and staff-reported outcomes to better capture the full range of benefits and impacts of transitional care interventions especially those of high complexity.’

Natasha Tyler, research fellow from the University of Manchester and lead author of the study, added: ‘This study shows that transitional care arrangements are a powerful way to avoid readmission to hospital because patients feel more involved in decisions and supported during a particularly vulnerable stage in the care pathway.

‘It is well known that an increased demand for urgent hospital care has created pressure to discharge patients to the community. We know some of those patients are discharged too early or without necessary support to recover in the community.

‘There is also evidence that one in five patients may experience suboptimal or unsafe care around the time of discharge from hospital mainly because of the prompt reduction in continuity of care and co-ordination challenges of multiple independent professionals and agencies.

‘This is why it is important to understand the value of intermediate care and how best that is delivered.’

Working with primary care to optimise severe asthma management

11th May 2023

Professor Adel Mansur specialises in asthma, leading one of the largest severe asthma clinics in the UK. Here, he discusses the centre’s involvement in primary care diagnostic hubs and his most recent practice-altering research.

Adel Mansur is a consultant physician at University Hospitals Birmingham NHS Foundation Trust and honorary professor in respiratory medicine at the University of Birmingham. Originally from Libya, where he attended medical school, Professor Mansur completed a research PhD in asthma genetics at the University of Leeds and joined Heartlands Hospital as a consultant in 2002.

Asthma is where Professor Mansur’s specialist interest lies, and he leads the trust’s severe asthma service – one of the largest and busiest centres of its kind in the UK, serving a local population of over 1.5 million and a regional population of 7.3 million.

Please tell us about your institution and the work it is doing in respiratory medicine

We are a regional hub centre for severe asthma, so we receive referrals from across the region, from the West Midlands and beyond. Because of that, it’s a busy centre. There are currently just over 1,000 patients with severe asthma seen at the hub, and on a weekly basis we see 50 to 60 patients. We have a multidisciplinary team looking after our patients, comprised of doctors, specialist asthma nurses, physiotherapists, psychologists and speech therapists.

Our service is geared to deal with the complex and multifactorial disease of difficult to treat asthma, which forms a minority group of all asthma. However, most patients with asthma in primary care have mild or moderate disease but still many remain uncontrolled due to inadequate access to good quality diagnostics and treatment optimisation rather than because of disease severity. On this basis, we piloted with our primary care colleagues in Birmingham a respiratory community diagnostic hub. This provided a service of high-quality diagnostic and specialist input to optimise treatment and triage patients when necessary to our severe asthma network. We were pleased with the pilot outcomes, which led to its adoption by NHS locally and was also quoted by NHS England as an exemplar model.

We believe that we have now a good integrated pathway model in our locality to build on. The University Hospitals Birmingham NHS Foundation Trust still, however, receives 2,000 admissions every year due to asthma – the majority of which would be preventable with proper management in the community, thus arguing for increased capacity of this service model. 

What are the wider benefits of this approach for patients and clinicians?

In many respects what we’re trying to do is to filter out those who are sub-optimally managed before they come to us. However, poorly controlled asthma can become severe, and that’s the danger that people will end up with sub-optimally managed disease that deteriorates to become more severe. It’s about being able to find those patients first, and that’s what the diagnostic hubs are doing.

Uncontrolled asthma is serious on its own because patients are exposed to potentially fatal attacks. A study looking at fatality in asthma found almost 60% of patients who sadly died from asthma attacks did not have severe asthma, but instead had uncontrolled asthma and weren’t on appropriate medication. This is a major current issue for which there are guidelines aimed at improving asthma management and outcomes. However, the implementation of such guidelines has been a challenge across the board, although I believe that progress has been made in terms of recognition of this issue and provision of clearer asthma management pathways for patients.

When you’ve optimised patients with uncontrolled asthma, you are left with around 10-20% who have severe asthma and will need, for example, a biologic treatment. For the majority of the others, regular preventer inhalers are usually adequate to control their asthma.  

I would say up to 90% of asthma is a primary care issue that, with the right treatment and support, should be controlled. Those patients’ management would be best served in the community and wouldn’t require referral to come to severe asthma centres.

Does your institution have any preceptorship or training programmes for clinicians?

Yes, for example we have a research fellowship where junior doctors could do research with us as well as getting clinical experience. That could be for year, or two or three. We have visitors from different disciplines who come to sit in our clinics and shadow our multidisciplinary team members for experience. They’re not just doctors, we have visitors from various disciplines including pharmacists, physiotherapists, speech therapists and nurses who come from primary or secondary care, or even tertiary severe asthma centres, looking for exchange of expertise. We currently have a pharmacist from Saudi Arabia spending three years with us doing his PhD on treatment adherence in severe asthma.

What are the main active areas of clinical research your centre?

At Heartlands, we have a respiratory research clinical trials unit, where we take part in various clinical trials that include cystic fibrosis, COPD, interstitial lung disease, occupational lung disease, asthma and some other acute presentation conditions such as pneumonia. It’s an active and large R&D department, so there are many other disciplines. Sometimes there is some overlap with other departments, for example, research into infectious diseases, Covid and viruses. 

Primarily, I do clinical work, but I take part in research as an academic as well. With clinical work you have more direct interaction with patients, and more insight into patients’ needs. We can use that to explore the main research questions, and that will lead to conducting trials or taking part in studies locally. That could be through collaborations with other centres, either in the UK or internationally. 

We then apply that in the clinic because clinical trials allow us to adopt cutting-edge treatments for our patients. They allow us to take the lead in providing our patients with access to cutting-edge and novel treatments, which, in many ways, transform the lives of many of our patients.

Can you tell us about a key clinical paper that your organisation has published recently, and what was the rationale and outcome?

We developed in-house an assay for measuring prednisolone and cortisol simultaneously in the blood using high-performance liquid chromatography and spectrometry methodology. There are currently about four centres in the UK who provide this test clinically.  

One of the issues in severe asthma is that 40% of patients are on oral maintenance steroids, and we assume that if a patient is prescribed 30mg prednisolone daily, for example, that is what they take. But with the assay we developed, we could actually look for adherence to prednisolone. We’ve done a case-controlled study using this assay among patients who are on steroids and patients who aren’t. We found that 40% of patients who are meant to be on maintenance steroids are not taking it. The assay results from non-adherent patients were similar to those who were not on maintenance prednisolone.  

Now, we use the assay in practice and around our network, and it has been advocated by NHS England as well. We don’t really want our patients to be on maintenance steroids because there are newer treatments available now, and steroids are a legacy treatment that should be a last resort.  

But we still have a substantial number of patients who are prescribed maintenance steroids, and knowing if they are taking the treatment or not is crucial – if they’re not we’ll stop the prescription of prednisolone and look for other treatments. The assay has also proved useful in managing adherent patients by allowing us to taper the prednisolone dose in a more controlled way. So, this is an example of something we developed here that has been quite crucial for the way we manage our severe asthma patients.

Tell us about your research on the severe asthma registry

We have a registry for all of our severe asthma patients. There’s a local one and a national one, and the registry nationally produced more than 20 papers in good-impact journals in the last 10 years or so. One of the recent publications, of which I was the primary author, was on the UK practice of biologics in asthma. It looked at variation in practice between different centres, using registry data. We also looked at the outcomes of various biologics and observed that seven to eight in 10 patients do get a worthwhile benefit from biologic treatments. 

The aim of having the registry for severe asthma is to promote standardisation of care across the country as well as cross-learning between different centres and adding to debate. We complemented the severe asthma registry analysis with a survey of specialists across the UK. We asked specialists why they choose a certain biologic over others, and which one they would start with and why, and we found variation in practice. It largely stems from the fact that there wasn’t a head-to-head trial to say one biologic is better than another one.

Looking forward, what are the current unmet needs in severe asthma and how will these challenges be tackled?

There is always going to be unmet need. We are not going to run out of jobs here, that’s for sure! One thing is the adherence issue, either to a biologic or to other preventer treatments. As humans we don’t like to adhere to things consistently. Some people can master it, but a lot of us can’t. So how can we really help people to have a treatment regime that works for them, and which they can maintain?

There are things like the interconnected digital inhaler, with sensors connected to the inhaler itself, which we are working on. I feel future practice in severe asthma will mean that the majority of patients will have smartphone apps with sensors connected to their inhalers. They’ll have their management plan and their treatment records on their app, which the physician can see on a separate platform, so we know when there are gaps in treatment.

The cost of severe asthma management to health services is high. Ensuring basic treatment in the form of regular use of preventer inhaler therapy may prove effective in controlling asthma without the need to escalate to expensive biologic treatment, as well as reducing burden to the NHS through a reduction in emergency room visits and hospital admissions. The adoption of digital inhalers as routine in severe asthma services is likely to be a much cheaper way of making sure patients’ disease remains under control. I think most severe asthma patients should be, at least in part, on this type of electronically monitored treatment.

Another unmet need is biologics – we still don’t have long-term data on those. I have seen patients whom, after two or three years, will have a viral illness or other trigger and then they feel the treatment is not working as it used to be. Or they suddenly start to flare up, so we look at switching biologics. Sometimes that works, but why does it happen in asthma? Why do some people have a super response, like remission, while others have had some response but still get exacerbations, and they still have residual disease of significance?

We have patients who have not been lucky enough to get a biologic treatment because of their disease type. They are not what we call T2-high, which is a type-2 inflammation that responds well to currently available biologic agents. About 20-30% of patients within the service are in this T2-low class, and these are the ones for whom there is unmet treatment need. Unfortunately, the asthma-related clinical outcomes of this group of patients remain significantly worse than those who could have, and respond well to, biologic treatments.

What other treatments do you see becoming available in the coming years for severe asthma?

Things have moved on hugely in terms of the availability of good treatment for patients with severe asthma since I started practising 20 years ago. Our main treatment was lots of steroids, which, as lifesaving as they are, have short- and long-term serious side effects. We then had other things of questionable efficacy such as continuous terbutaline infusion. Nowadays, treatment for severe asthma has been transformed by a precision medicine era with the development of effective yet safe treatment options in the form of biologic treatments. There are currently six NICE-approved biologics and these cover around 60-70% of patients with severe asthma.

Tremendous progress has been made in dissecting the immunological cascades and mechanistics of inflammation in asthma. This provided plethora of therapeutic targets with many currently being trialled for asthma in general and severe asthma in particular. For example, there is a drug called masitinib, which is a tyrosine-kinase inhibitor that is being trialled as a possible treatment for asthma. Another example is the ongoing trialling of JAK-family inhibitors as a treatment option in asthma.

How is your organisation adapting to the demand and developments in this area of medicine?

In addition to us being the hub here at Heartlands, we created a severe asthma network that included various centres – or spokes – within the West Midlands, Derbyshire and Gloucestershire, which covers a total population of 7.3 million people. Currently, the network is comprised of about 10 spokes. The spokes can initiate biologics in their respective hospital following approval from a monthly conducted regional multidisciplinary meeting with the hub. This model increased our region service capacity so patients can get the treatment in a quicker time and could have it initiated closer to home than if all patients have to travel to the hub in Birmingham.

This model provided resilience to service delivery due to the high number of asthma specialists included in the running of the service. We have 10 physicians, for example, and more than 10 nurses, who serve the network, contrasted to a small group in any single centre. So, that has been one of the strong points for our service – having a good, strong network. We are maintaining the quality through the performance and standardisation of patients being presented. That’s led to a successful network. It’s still a work in progress, as always, but we think we have good infrastructure.

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