Browse site A to Z

Search results

Go To Advanced Search

Vestibular rehabilitation - patient information

Description: This factsheet explains what vestibular rehabilitation is, what it involves and how it can help with your recovery.
Url: /Media/UHS-website-2019/Patientinformation/Audiology/Vestibular-rehabilitation-2565-PIL.pdf

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

UHS AR 22-23-6

Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2023 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 33 Directors’ report 34 Remuneration report 57 Staff report 71 Annual governance statement 91 Quality account 106 Statement on quality from the chief executive 107 Priorities for improvement and statements of assurance from the board 110 Other information 188 Annual accounts 222 Statement from the chief financial officer 223 Auditor’s report 224 Foreword to the accounts 230 Statement of Comprehensive Income 231 Statement of Financial Position 232 Statement of Changes in Taxpayers’ Equity 233 Statement of Cash Flows 234 Notes to the accounts 235 5 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) experienced another challenging year during 2022/23. Nonetheless, the Trust and its staff have continued to deliver for patients and the wider system in which it operates. Trust highlights from 2022/23 include: • Delivering an 8% increase in activity (compared to 2019/20) under the elective recovery programme, which places us as one of the top performing trusts in England. • Being recognised in the NHS staff survey as the seventh highest trust for recommendation as a place to work nationally and the best performing trust in opportunities for career development. • Celebrating 50 years as a medical school with the University of Southampton and continuing to pioneer UK and world-first research studies. • Enhancing the reputation of our specialist care – for example our bone marrow transplant team at UHS have the best patient outcomes in Europe. However, as was the picture across the country, UHS had an extremely challenging winter with attendances at our emergency department often in excess of 400 a day. This was driven in part by high prevalence of streptococcus A (strep A) in the community along with other seasonal illnesses such as influenza and high incidences of COVID-19 at times. Moreover, the lack of availability of care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore we have been operating at or near to capacity throughout the year. At the time of writing, there continues to be operational pressures due to industrial action by the Royal College of Nursing and British Medical Association. Throughout the disputes, we have attempted to balance the right of our staff to strike with the need to minimise the impact on the Trust’s operations and patients and ensure that safety was not compromised. Our leadership team has engaged proactively with the unions to agree, where possible, derogations (i.e. services that will continue to be staffed during strikes) to ensure that the running of our hospitals can continue and that patients remain safe. We would like to express our thanks to all staff who have gone over and above during these periods of industrial action by being willing to do different work to usual, often at anti-social times of the day. While we cannot influence national negotiations, we are focusing on what we can control within UHS. Our people strategy published last year sets out how we will grow and deploy our workforce of today and the future as part of a thriving community to deliver world-class patient care. Building on this, we have recently launched our inclusion and belonging strategy so that as a leadership team we can deliver what is required for all our workforce to feel they can belong and thrive at UHS. The Trust achieved its Cost Improvement Plan (CIP) target of £45.6m for 2022/23, the highest in our history but despite this, ended the year with a deficit of £11m. The deficit was driven by a combination of factors including a substantial increase in energy prices, higher costs of medicines and equipment and temporary staffing costs as well as changes in recent years in respect of the NHS funding infrastructure, which adversely impacted the Trust relative to others during the year. In terms of the broader context, the Hampshire and Isle of Wight Integrated Care System, in which the Trust operates, reported an overall deficit for 2022/23 driven in part by a significant increase in staffing numbers when compared to 2019/20 as well as structural factors. 6 We have continued to make progress on our estates strategy, building new theatres and carrying out improvements to existing facilities, as well as opening a new park and ride for staff at Adanac Park and progressing plans for a new innovation campus there. During 2022/23 we invested over £88m of capital expenditure to meet our ambition of increasing capacity and improving services in order to manage the increasing demand. All development is underpinned by our green plan, which sets out areas of focus for decarbonising UHS and achieving the net zero target set by the NHS. The Trust has continued to support the Hampshire and Isle of Wight Integrated Care System, which was formed on 1 July 2022 to facilitate integration and collaboration across health and social care partners in the region. In particular, UHS has worked closely with the Integrated Care Board and other providers in the development of the operating plan for 2023/24. We have also continued to work with other partners in the region, including local authorities and the University of Southampton. The 13,000 staff of UHS are our greatest asset and we would like to express our gratitude to them for continuing to go above and beyond to put patients first under very challenging circumstances. Without our staff, we would be unable to fulfil our ambition to be a world-class organisation with world-class people delivering world-class care. Jenni Douglas-Todd Chair 26 June 2023 David French Chief Executive Officer 26 June 2023 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer The Trust experienced another challenging year with the need to balance the delivery of quality patient care with a significant increase in demand for the Trust’s resources and the need to do so whilst maintaining a sustainable financial position. The Trust saw the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. Despite this, however, the Trust was successful in reducing the number of patients waiting more than 104 weeks to nil and in reducing the number of patients waiting more than 78 weeks to 14 by the end of the year. In addition, the Trust’s performance under the elective recovery programme placed it as one of the topperforming trusts in the country. Demand for non-elective care also significantly increased during the year with the emergency department seeing more than 400 attendances per day at some points, especially during the winter months. The industrial action seen in the latter part of 2022/23 placed further pressure on the Trust and resulted in a need to cancel elective procedures and outpatients appointments. However, on balance, the Trust was able to manage these events through effective planning and the engagement and support of its staff. Although the Trust was successful in recruiting to substantive roles, especially in terms of reducing the number of Health Care Assistant vacancies, the anticipated reduction in use of bank and agency staff was not seen. This, among other factors, such as the substantial increase in energy costs and the rate of inflation, posed a significant challenge in terms of the Trust’s financial position. Despite achieving savings of £45.6m, the Trust reported a deficit of £11m for 2022/23. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2022/23. It is based on the coast in southeast England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 160,000 inpatients and day patients, including about 75,000 emergency admissions sees over 650,000 people at outpatient appointments deals with around 150,000 cases in our emergency department delivers more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 55% is paid for by NHS England and 43% by the Hampshire and Isle of Wight Integrated Care Board. These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System (ICS) when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board (ICB). The ICP is a statutory committee jointly formed between the NHS integrated care board and all uppertier local authorities that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2022/23 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Recovery, restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Always Improving strategy • Delivering a high-quality experience of care for all • Delivery of year two of the research and innovation investment plan • Strategy and partnership working • Growing, developing and innovating our workforce • A great place to work, develop and achieve • Compassionate and inclusive workplace for all • We Work in partnership with Integrated Care System and Primary Care Networks • Integrated Networks and Collaborations • Establishing Southern Counties Pathology Network • Establishing the Wessex Imaging Network • Develop Collaborations strategy • Creating a sustainable financial infrastructure • Making our corporate infrastructure fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS Performance against these objectives will be monitored and reported to the Trust’s Board on a quarterly basis. 14 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2022/23 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (capital departmental expenditure limit (CDEL)). • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2022/23, the Trust continued to experience the impact of the COVID-19 pandemic. The need to ensure a safe environment for patients through stringent infection control processes impacted the Trust’s capacity due to the need to isolate patients with COVID-19 in separate areas of the hospital. In addition, outbreaks of norovirus during the winter months placed further pressure on hospital capacity. The impact of the pandemic continued to be felt in terms of staff absence due to becoming infected with COVID-19 as well as the significant impact on staff mental health. The higher than normal (i.e. pre-COVID) levels of staff absence placed additional strain on the Trust’s operations and led to increased expenditure due to the requirement to enlist bank and/or agency staff to maintain safe staffing levels. 15 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The pressures of the COVID-19 pandemic led to increases in the waiting times for patients and the number of patients waiting for more than a year increased significantly. During the year, the Trust achieved its goal of no patients waiting more than 104 weeks by July 2022 and finished the year with only 14 patients waiting for more than 78 weeks. However, the length of time patients are waiting for treatment remains one of the key risks for the Trust. This situation was compounded by the sustained demand for non-elective activity, which saw attendances at the emergency department rise to over 400 patients per day during some periods of 2022/23 and was consistently higher than previously was the case. The significant increase in referrals, often requiring more complex treatment, has seen the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. In addition, the industrial action during the year placed further strain on the Trust’s ability to both provide urgent care and manage its elective recovery programme. Quality and compliance Furthermore, difficulties in obtaining care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore the Trust has been operating at or near to capacity throughout the year. The Trust continued to monitor the quality of care delivered throughout 2022/23. The Trust continued its focus on infection prevention and control, which had proven successful during the COVID-19 pandemic. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of 84 quality improvement projects. In addition, the Trust continued to implement the patient safety incident response framework as well as taking other steps to drive a safety culture within the organisation. Furthermore, the Trust conducted further trials of shared decision making between clinicians and patients and is a leading site nationally for shared decision-making principles. Further information can be found in the Quality Account. 16 Partnerships The new arrangements for integrated care systems were implemented in July 2022 with the Trust becoming part of the Hampshire and Isle of Wight Integrated Care System. As such, the Trust’s senior management frequently meets with peers from across the system to consider and agree matters of wider concern across the system. In addition, the Trust worked with the Integrated Care Board in order to develop its financial and capital plans for 2023/24 and beyond. The Trust also attends the Southampton Health and Wellbeing Board at Southampton City Council and in the Hampshire and Isle of Wight Acute Provider Partnership Board. During 2022/23, the Trust continued to progress research activities and opportunities with the University of Southampton and Wessex Health Partners. Workforce In addition, work continued in the development of an elective hub at Winchester with Hampshire Hospitals NHS Foundation Trust, which will provide the Trust with additional capacity to carry out its elective programme. The Trust’s key areas of focus during 2022/23 were in respect of increasing the substantive workforce and reducing staff turnover. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 1,068 whole-time equivalents above its plan for 2022/23. Included in this figure is the TUPE transfer of genomics staff from Salisbury. A particular area of focus was the recruitment of Health Care Assistants where the Trust was successful in reducing the number of vacancies from 27% to 18%. Whilst the Trust was successful in reducing staff turnover from 14.9% in 2021/22 to 13.5%, it remained above the 12% target. However, the Trust did experience a reduction in staff absence from 4.7% in April 2022 to 4.3% in March 2023, and initiatives to improve staff wellbeing were an area of focus during the year. Estate Innovation and technology The industrial action in late 2022 and early 2023 posed significant challenges for the Trust, including in terms of the need to engage additional temporary staff to ensure patient safety. The Trust continued to invest in and develop its estate during 2022/23 including successful completion of the Paediatric Intensive Care Unit project, which delivered single rooms and specialist accent lighting alongside delivery of a ‘twin care’ room. There were a number of other significant projects during the year, including refurbishments of wards and work on creating new theatres as well as projects to improve staff wellbeing. These were part of over £88m of capital expenditure in 2022/23 that also included equipment, digital and the backlog maintenance programme. The Trust continued to promote research and development during 2022/23, including through partnerships with the University of Southampton and Wessex Health Partners. Furthermore, the Trust continued to examine ways to make use of technology to improve its service delivery. In particular, the Trust has promoted the use of MyMedicalRecord, which gives patients the ability to co-manage their healthcare online and through an app. 17 Sustainable financial model The Trust did not achieve breakeven status at the end of 2022/23 and reported a deficit of £11.037m at year-end. This was due to a number of factors, including the Trust’s underlying deficit as well as the increase in energy prices. The Trust was more exposed than most to fluctuations in the wholesale price of gas due to its reliance on a gas-powered energy supply. In addition, the Trust’s 8% uplift in elective activity when compared to 2019/20 was not fullyfunded, which placed further pressure on the Trust’s existing financial resources, which had been used to ensure a breakeven position in 2021/22. The continued use of bank and agency staff as well as the costs of industrial action in late 2022 and early 2023 further eroded the Trust’s financial position. Notwithstanding the above, the Trust did succeed in obtaining a number of sources of nonrecurrent funding during the year, including a successful bid for £29.4m of funding through the Public Sector De-Carbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. The financial outlook across the NHS continues to appear very challenging during 2023/24 and the Hampshire and Isle of Wight Integrated Care System is forecasting one of the highest deficits in England. 18 Performance analysis COVID-19 Impacts Although the pandemic has ended and serious cases of COVID-19 have reduced significantly, the Trust continued to be impacted by COVID-19 during 2022/23. Heightened infection prevention control measures in respect of patients with COVID-19 placed additional stress on the Trust’s capacity due to the need to isolate those patients and there was a consequential reduction in the Trust’s ability to make most efficient use of its available spaces. Furthermore, the ongoing impact on the Trust’s staff has led to higher staff absence than was the case prior to the pandemic, particularly due anxiety, infectious diseases and colds and flu. • The Trust experienced an average number of 98.7 patients per day who tested positive for COVID-19. During the winter months, this number increased substantially to nearly 200. • During the year, an average of 3.6 intensive care/high-dependency beds per day were occupied by COVID-19 patients. However, at times this increased to as much as ten. • Although staff sickness rates remained higher than pre-pandemic, the Trust saw a decrease in the absence rate from 4.7% at the beginning of 2022/23 to 4.3% by the end of the period. COVID-19 Cases UHS average number of confirmed COVID-19 patients in bed (08:00 census) 250 200 150 100 50 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 Intensive care/higher care beds UHS average number of confirmed COVID-19 patients in an ICU/HDU bed (08:00 census) 12 10 8 6 4 2 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 19 Number of patients Emergency access through the emergency department The Trust continued to experience high demand from patients presenting to receive care in the emergency department throughout the year above that seen prior to the COVID-19 pandemic. In particular, during the period between January and March 2023, the Trust averaged 352 attendances per day compared to 301 during the same period in 2019/20, an increase of 17%. The Trust also saw a significant increase in attendances during December due to both seasonal illnesses, but also due to the prevalence of streptococcus A in the community with attendances sometimes over 400 per day. Furthermore, the industrial action during the latter part of 2022 and early 2023 placed further pressure on the Trust’s ability to deliver services. In addition, the difficulties in discharging patients in need of care either at home or in another setting resulted in reduced flow from the emergency department to the relevant ward(s), which placed further strain on the Trust’s performance. During the year, in order to reduce emergency department attendances, the Trust trialled using General Practitioners to triage and see more straightforward patients who would otherwise have presented to the emergency department. Although this trial did result in a slight reduction in terms of number of patients and waiting times in ambulatory majors and majors, the affordability and value for money of this scheme is under review. Number of patients presenting to the emergency department 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 As a result of the increase in demand upon the emergency department, there continued to be a significant adverse impact on timeliness of care. The Trust failed to meet the national target of 95% of main emergency department/type 1 attendances seen within four hours, achieving 64.5% in March 2023, although this performance was above average in England. 20 % standard met Emergency access 4hr standard UHS vs NHSE average Type 1 performance 70% 0 10 60% 20 50% 30 40 40% 50 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Ambulance handovers are an area of focus for NHS England, with a target of all handovers having to take place within 15 minutes and none waiting more than 30 minutes. The Trust performed well in this area with an average handover time of 17 minutes, having made the conscious decision to ensure that patients did not queue in ambulances at the expense of patients being queued within emergency department majors – thus impacting the Trust’s four-hour target, but meaning that ambulances were not queued outside the hospital as was seen in other areas of the country. Elective Waiting times Demand The year saw a continuation of the trend of increasing elective referrals experienced in 2021/22 following the pandemic, and referral rates continued to be above those seen prior to the pandemic. UHS Accepted Referrals 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Number of accepted referrals 21 Activity The Trust experienced significant increases in terms of the number of hospital appointments, diagnostic tests and elective admissions during the year, exceeding levels in previous years. The Trust was one of the top performing trusts in terms of its elective recovery programme, achieving an 8% increase in its elective activity during the year when compared to 2019/20. However, performance in this area and in terms of outpatients appointments was negatively affected by the industrial action by nurses, junior doctors and other members of staff, which took place in late 2022 and early 2023 due to the need to cancel non-urgent procedures and appointments in favour of maintaining safe staffing levels in areas such as the emergency department. In addition, the continued presence of COVID-19 as well as other illnesses such as influenza and norovirus placed significant pressure at times on the Trust’s capacity due to the need to implement appropriate infection prevention control measures. Furthermore, difficulties in discharging patients fit to be discharged, but in need of a care package, placed additional strain on the Trust’s capacity. Elective admissions (including day case) Post-COVID-19 pandemic Elective (including day case) recovery (% of same month compared between March 2019 – February 2020) 105% 100% 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 % recovery Outpatient attendances Post-COVID-19 pandemic outpatient seen recovery (% of same month compared between March 2019 – February 2020) 140% 0 90% 10 20 40% 30 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 UH S UHS rank amongst NHSE trusts % recovery Rank 22 Diagnostics The Trust measures performance on a total of 15 frequently used diagnostic tests. In March 2023, 22% of patients were waiting more than six weeks for diagnostics compared with the national target of less than 1%. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) UHS diagnostic waiting list volume 12,000 11,500 11,000 10,500 10,000 9,500 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Diagnostic waiting list volume Percentage of patients waiting over 6 weeks for a diagnostic test to be performed Diagnostic 6 week wait performance UHS vs. NHSE average 35% 30% 25% 20% 15% 10% 5% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 23 Referral to Treatment The Trust continued to see an increase in the number of patients being referred for treatment during 2022/23 with just over 55,000 patients on a waiting list under the 18-week referral to treatment pathway at the end of the year. Averaged across the year, the volume of referrals exceeded the Trust’s theoretical capacity by around 3.5%. Due to this significant demand, the Trust only achieved 63.2% of patients being treated within 18 weeks of referral in March 2023 compared with the monthly target of more than 92%. However, despite this, the Trust remained in the top quartile when compared to other teaching hospitals, reflecting that this growth in demand continues to be a national challenge. During 2022/23, the national target was to ensure that there were no patients waiting over two years for treatment by July 2022, and that there were no patients waiting more than 78 weeks by the end of March 2023. Long-waiting patients were an area of particular focus for the Trust during the year with no reported two-year waits since November 2022 and only two between the period June-November due to patients choosing to delay their treatment. This was a significant improvement compared to the peak of 171 patients reported in December 2021. Similarly, the Trust made progress in reducing the number of patients waiting over 78 weeks for treatment. In February 2023, the Trust reported 84 patients in this category compared to the peak of over 900 patients in September 2021. By the end of March 2023, the Trust had managed to further reduce this number of patients to 14, with those in breach of the target all due to the complexity of the cases. UHS referral to treatment waiting list 56,000 54,000 52,000 50,000 48,000 46,000 44,000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 24 Number on waiting list % standard met Percentage of patients waiting up to 18 weeks between referral and treatment RTT 18 week performance UHS vs. NHSE average 70% 65% 60% 55% 50% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Percentage of patients waiting more than 52 weeks between referral and commencement of a treatment for their condition Number of patients Rank UHS Referral to treatment patients waiting more than 52 weeks 3,000 0 2,500 10 2,000 20 1,500 30 1,000 40 500 50 0 60 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts % of RTT patients RTT % of patients waiting more than 52 weeks UHS vs. NHSE average 5.0% 0 4.5% 20 40 4.0% 60 3.5% 80 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts Rank 25 % standard met Cancer Waiting Times The Trust is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as cancer in children and brain cancer. The Trust has historically been in the upper quartile, relative to teaching hospital peers. Due to loss of key members of staff and industrial action, the Trust’s performance has slipped over the year with 72.5% of patients seen within two weeks in March 2023 following referral by a General Practitioner for suspected cancer (national target: > 93% per month). Cancer waiting times - 2 week wait performance UHS vs NHSE average 100% 0 80% 50 60% 100 40% 150 Apr-22May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Referrals for January to March 2023 were at the highest for that month for the past five years and overall referral volumes in 2022/23 averaged 2,049 patients per month, 8% higher than in 2021/22 and 28% higher than in 2019/20. The national target was for 96% of patients to commence treatment within 31 days of diagnosis. However, in March 2023, the Trust only achieved 87.9%, but this figure hides considerable variation dependent on the tumour site and type of cancer with a range of 100% for haematology and children’s cancers to 71% for skin. The high rate of referrals led to a significant backlog in terms of patients waiting longer than 62 days for treatment. However, the Trust took steps to reduce this backlog by more than 50% through a dedicated recovery programme. In March 2023, the Trust treated 54.8% of patients within 62 days of referral compared to the target of more than 85%. Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer waiting times 62 day RTT performance UHS vs. NHSE average 80% 60% 40% 20% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 26 First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performance UHS vs. NHSE average 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Quality priorities The Trust set eight quality priorities in 2022/23, which were aimed at ensuring it continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. The Trust recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the previous two years of the COVID-19 pandemic. The challenge was to deliver the best quality care in the context of these operational pressures, and the Trust set its quality priorities accordingly. Out of the eight priories set, the Trust achieved five and partially achieved three. Priority One: Enhancing capability in Quality Improvement (QI) through our Always Improving strategy The transformation team has grown to over thirty team members including project support officers, project managers, benefit realisation managers. This has allowed the Trust to develop that systematic organisational approach to guide and support its staff in their QI projects. The Trust originally set a target of delivering fifty quality improvement projects but have successfully supported a total of 84 (55 local and 29 flow improvements). These are local change projects which were identified, proposed, led, and delivered by the people who do the work. To date over 1500 people have been trained in the Trust’s improvement approach, which exceeds the original target of 500. The Trust also developed a QI project register and held an Always Improving conference. Priority Two: Developing a culture of kindness and compassion to drive a safety culture The Trust only partially achieved this priority as plans to fully deliver training were affected by operational pressures. However, during the year a variety of communication platforms were used to make sure staff understood the Trust’s vision and were kept up to date with plans and progress. The Trust worked to develop and embed a ‘just culture’ allowing staff to speak up and ask, “what happened and how do we learn?” and developed ‘stop for safety’ staff huddles. Priority Three: We will improve mental health care across the Trust including support for staff delivering care The Trust only partially achieved this priority as several key quality improvement projects have not yet been delivered, and the mental health strategy not yet been finalised. However, a training needs analysis was completed and significant staff training and an education scheme were introduced in response to the findings of the analysis. Mental health champion training has been delivered to 153 staff and IT systems have been improved to help capture vital data to help shape the Trust’s service. 27 Priority Four: Recognising and responding to deterioration in patients During 2021/22 the Trust successfully introduced national Paediatric Early Warning System (nPEWS) into its Southampton Children’s Hospital and UHS is now part of the national test and trial of nPEWS which is assessing the usability of the scoring system. The Trust has also explored how nPEWS can be adapted for children with complex medical conditions requiring interventions (including non-invasive ventilation) as part of their normal care. A daily heat map of escalation times over a 24-hour period was piloted in 2022 and will be rolled out across all adult’s inpatient areas during 2023. The Trust has also performed well with its cardiac arrest audits, and training and education programmes have consistently been delivered. September 2022 saw the implementation of a 24-hour paediatric outreach service. There is a deteriorating patient group and several successful QI projects have been introduced. Priority Five: Improving how the organisation learns from deaths The Trust only partially achieved this priority as it has been unable to establish a learning from deaths steering group. The Trust has introduced a mortality governance coordinator/analyst and grown its bereavement care service. Priority Six: Shared Decision Making (SDM) The shared decision models started at UHS in 2021/22 and have continued to grow with investment in pilot roles to expand these models, which include several advanced nurse practitioner roles, models in paediatrics bringing Shared Decision Making to patients who are transitioning from paediatric to adult services, while in maternity we have introduced SDM in birth planning. When assessing delivery of SDM against NICE guidelines, UHS performs well, especially in targets related to Trust buy-in, governance and practices of pilot areas. This year the Trust has implemented training through key platforms and expanded patient involvement in the project. As a leading site nationally for SDM principles, UHS have worked with NHS England on creating materials for others to learn from. Priority Seven: Working with our local community to expose and address health inequalities During the year the Trust refocused its efforts on making sure that its involvement and participation activities support the health inequalities agenda, while also working to deliver responsive information and advice to patients, carers, and families. Priority Eight: Ensure patients are involved, supported, and appropriately communicated with on discharge During the year the Trust has focused on improved patient, carer and family involvement, and improved communication during the discharge process as well as prompting a more collaborative working between social and health care staff. Strong partnership working with external agencies has been developed to support a system approach to hospital discharge, develop digital solutions, develop the patient hub to support discharge and delivered education to UHS staff. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2023/24, in the Trust’s Quality Account for 2022/23. 28 Financial performance The Trust delivered a deficit of £11 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England, such as the financial position of the Southampton Hospitals Charity, were removed. The Trust was unable to deliver the planned breakeven position. Several material cost pressures were incurred, including unfunded high-cost drugs costs and energy prices. These were unable to be off set in full by a savings programme, despite delivery of £45.6m of efficiencies (2021/22: £15m). Trust operating income rose by £64m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Income reduced from the prior year in relation to ending a nationally funded project regarding testing for COVID-19. The Trust has however been successful in increasing funding for research and development. Trust operating expenditure rose by £78m, incorporating funded inflationary costs as well as the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investmen
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-22-23-6.pdf

Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2021 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 29 Directors’ report 30 Remuneration report 53 Staff report 65 NHS Foundation Trust Code of Governance 81 NHS Oversight Framework 81 Annual governance statement 84 Quality report 95 Statement on quality from the chief executive 96 Priorities for improvement and statements of assurance from the board 99 Other information 153 Annual accounts 180 Statement from the chief financial officer 181 Auditor’s report 182 Foreword to the accounts 188 Statement of Comprehensive Income 189 Statement of Financial Position 190 Statement of Changes in Taxpayers’ Equity 191 Statement of Cash Flows 192 Notes to the accounts 193 5 Welcome from our chair and chief executive 2020/21 was undoubtedly the most challenging year in the history of the NHS, and we have felt the impact of the COVID-19 pandemic here at University Hospital Southampton NHS Foundation Trust (UHS) in full. Responding to this has meant there isn’t a single part of our organisation that hasn’t changed in some way over the last year and we have all had to adapt to a rapidly changing environment. Our staff have been unwavering in their dedication, hard work and commitment to keeping our hospitals running, our patients cared for, and their colleagues supported. Every single member of the UHS family has played their part. The loss of life from COVID-19 has been devastating, and at UHS we stand shoulder-to-shoulder with everyone affected by this tragedy, including the families of staff members whom we lost. We must recognise the incredible work of Southampton Hospital Charity, which has funded boost boxes, wellness rooms, a helpline and so much more to support staff at a time when their wellbeing is more important than ever. As the nationwide vaccination programme continues to offer hope of life more like pre-pandemic times, we are proud to have been at the forefront of these efforts - from being part of early research for the Oxford-AstraZeneca vaccine, to the opening of one of the largest vaccination hubs in the region on our site in December 2020. We will continue to play a key role in vaccination development by leading the world’s first clinical trial into the effectiveness of COVID-19 booster vaccines, as well as taking part in a study involving pregnant people. Our response to COVID-19 has prompted innovation and new ways of working across the Trust, to the benefit of patient experience. At the start of the pandemic we faced real challenges of capacity and increases in waiting times, which led to us working with Spire Southampton so cancer treatment and surgery could continue for patients at highest risk. We also increased the number of outpatient attendances which took place by telephone or video call, and our patient support hub was set up to provide a single point of support for patients who had been advised to shield. We are immensely proud of the record of the Trust during the pandemic, exemplified by the number of patients we were able to take into our care from well outside the local area. The Trust is in a strong financial position as a result of careful spending and efficiencies, which has allowed us to invest significantly in upgrading our estate. These improvements have seen the opening of the general intensive care unit, and the new cancer ward, which was built in just six months. These formed part of overall capital expenditure of £80 million during the year. The last year has seen us say goodbye to two members of our executive leadership team. Paula Head left the chief executive officer role in November to join the national response to COVID-19, before becoming a senior fellow at The King’s Fund. Derek Sandeman moved on from being our chief medical officer to take the same position at the Hampshire and Isle of Wight Integrated Care System. We are grateful to both for their efforts on the Trust leadership team during the most challenging of years. One of our non-executive directors, Jenni Douglas-Todd, also left the Trust to take on the important role of director of equality and inclusion with NHS England and NHS Improvement. 6 Looking ahead to the future, UHS will play a key role in the Hampshire and Isle of Wight Integrated Care System. Our commitment is to deliver services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries for seamless patient care. We as a Trust board are looking forward to implementing our own five year strategy, which sets out ambitions for what we want the hospital to be in 2025, for both patients and staff. Our focus will always be on enabling world class people to deliver world class care. Peter Hollins David French Chair Chief Executive Officer 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive Over the last year, the way in which the Trust has worked and performance it has achieved, has been transformed by the COVID-19 pandemic. • UHS saw a number of large surges in demand for inpatient care, and for intensive respiratory support in particular, due to COVID-19 infection rates. Our capacity to deliver intensive care had to be increased, and many of our staff moved from other services such as our elective theatres in order to meet this need for care. • We have introduced and continue to maintain a number of changes to reduce the risk of COVID-19 being transmitted, or adversely affecting patient outcomes, within the Trust. Changes have included the wearing of additional personal protective equipment by our staff (especially when caring for patients who might have COVID-19 or undertaking higher risk procedures), reducing the number of patients coming to our outpatient departments and increasing the number of telephone and video consultations, separating elective and emergency patients within our departments and regular testing of our staff and all patients on or prior to their admission to hospital for treatment. • Public concerns about safety, government restrictions and the efforts of community services actually contributed to reductions in the total number of patients who sought hospital care this year. • Treatment plans have been modified by a number of services, in partnership with patients, to reduce the risk posed by COVID-19 to those patients. This was often appropriate in those circumstances in which the normal treatment would significantly reduce the patient’s own resistance to infections. Our performance has, in many cases, been strongly influenced by these profound changes. We have responded well to the need to provide the most urgent care, and the adverse impacts on elective care have been slightly less than the average across the NHS. However, we remain very concerned by the significant increase in the numbers of patients waiting longer than they should for elective care. It will take concerted and sustained action within both the Trust and the wider NHS in order to return elective performance to levels achieved before the pandemic whilst also continuing to meet urgent care needs as the restrictions that have been implemented within our society are progressively relaxed. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2020/21. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health Research (NIHR), Wellcome Trust and Cancer Research UK. UHS is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volume as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Over 50% of UHS services are paid for by CCGs and approximately 48% by NHS England. We provide these under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Division B Division C Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Division D Trust Headquarters Division Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Corporate Affairs Communications Estates, Facilities and Capital Development Finance Human Resources Informatics Patient Support Services Procurement and Supply Transformation and Improvement (‘Always Improving’) Research and Development Strategy and Business Development 11 The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/2021 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these describes a number ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research and innovation in Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the tax payer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust will set out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2020/21 these objectives included: • Recovery, restoration and improvement of clinical services • Implementing the ‘Always Improving’ strategy • Restoring a full research portfolio • Continuing our focus on staff wellbeing including the long-term effects of coronavirus (long COVID) • Working in partnership with the newly established integrated care system • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century, including an estates masterplan. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2020/21 were that: • it would be unable to form effective partnerships that achieve networked care for patients; • it could not develop the estate in line with the ambitions set out in the strategy; • it would fail to restore and increase capacity following the COVID-19 pandemic to meet waiting times for elective care and cancer care needs; • it would fail to introduce and implement new technology for the transformation of care; • it would be unable to retain, recruit, develop and train a diverse and inclusive workforce necessary to meet the strategic goals; • it could not develop a sustainable model within the new financial regime that preserves quality care; • it would fail to provide vulnerable service users with timely and high quality and appropriate care; • it would not reach the ambition of outstanding compliance and quality standards; • it could not sufficiently engage with key stakeholders and system partners to support effective interventions and maintain the health of the local population; • it would be unable to respond to the needs of the NHS in order to deliver our strategy; • it would fail to capitalise on its relationship with the universities in Southampton and other health education providers in line with our strategy; • it would not develop innovative education and training approaches. 14 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, added to the risks facing the Trust. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52 and 78 weeks has increased significantly. While the Trust was able to recover capacity quickly between waves of the pandemic, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by the reduction in the number of referrals from GPs during the pandemic, leading to a potential future increase in the number of patients being referred as people visit their GPs for the first time with more advanced disease. During the pandemic the Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2020/21 (described in the Estates section below), the Trust also committed expenditure and commenced construction works in 2020/21 in order to be in a position to open an additional endoscopy room and four further operating theatres during 2021/22 and prepared plans for a significant expansion in ophthalmology outpatient capacity. These initiatives will contribute to improvements in elective waiting times that needed following the pandemic. Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2020/21. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of a successful COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). The Trust also achieved its annual target for reduction in Clostridium Difficile infections, however, there was one MRSA Bacteraemia during March 2021, the only such event in 2020/21. The Trust continued to develop its proactive patient safety culture during 2020/21 with changes to the way in which patient safety incidents are investigated and the approval of its Always Improving strategy, which will be launched in 2021. Reporting and investigation of incidents continued during 2020/21. Partnerships – During 2020/21, the Trust and its partners worked together very effectively to discharge patients safely and provide ongoing support to patients who had tested positive for COVID-19, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop a COVID-19 saliva testing pilot with the University of Southampton and local authorities. Work to respond to the COVID-19 pandemic, however, meant that as a system we were unable to progress the Hampshire and Isle of Wight strategic plan delivery at the pace we would have wanted or had set out to achieve, particularly the development of networks. Nonetheless the application for Hampshire and Isle of Wight to become an integrated care system was approved with effect from 1 April 2021. 15 Existing networks continued to develop and improve. The Trust also became the Wessex Cancer Surgical Hub during 2020 as a result of a national initiative with the aim of maximising the number of patients receiving curative surgery. Both the Wessex Cancer Alliance and the Trust ended the year as the second highest performing among their respective peers for cancer treatment. Workforce – While additional staff were recruited to specifically assist the Trust during the pandemic, the Trust continued to recruit nurses from overseas during 2020/21 meaning that the number of vacancies has reduced compared to the position prior to the pandemic. Changes to recruitment processes were approved in 2020/21 to improve the fairness, transparency and quality of these. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2020/21 our main focus has been on supporting our staff to respond to the COVID-19 pandemic and providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2020/21 including the opening a new general intensive care unit (GICU), a new operating theatre and a new cancer care ward, built in just six months. These were part of £80 million of capital expenditure in 2020/21. The Trust has also established a programme to reduce backlog maintenance in addition to continuing to add to and improve the environment in which services are provided to patients and the working environment for staff. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these from page 167 of the quality report. The board of directors also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. Sustainable financial model – The Trust achieved its forecast breakeven position in 2020/21. Income was more predictable in 2020/21 as block contract arrangements were put in place in response to the COVID-19 pandemic and ensured that costs were covered. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. 16 Summary of performance COVID-19 bed occupancy UHS has experienced two distinct peaks in inpatient care for patients with COVID-19 infection, with smaller numbers of patients continuing to receive care outside these peak times. Bed occupancy reached a maximum of 173 in the first peak in April 2020, and 322 in the second peak in January 2021. All bed types Intensive care/higher care beds 17 Emergency access through our emergency and eye casualty departments Public concerns about safety, government restrictions on the activities people were able to do, and the efforts of community services contributed to significant reductions in the total number of patients who presented to our departments. All patients presenting to the emergency department Many changes were introduced within our departments in the course of the year to ensure that emergency assessment and treatment could be provided safely, including wearing of protective equipment by staff and patients, providing care in separate areas for patients suspected or known to have COVID-19, and using rapid laboratory tests to identify infection and confirm/exclude COVID-19 as a cause. Emergency access performance (measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department) improved significantly in 2020/21 compared to previous years. The national target of 95% was not achieved, however, the performance of our departments compared favourably with the average for acute trusts in England. 18 Emergency access four hour performance 19 Elective Waiting times Demand We saw a significant reduction in the number of elective referrals to hospital in the early part 2020/21, though they had returned close to pre-pandemic levels by the end of the year. It is likely that this pattern relates to a range of factors including reluctance from members of the public to attend healthcare facilities at that time, changes to the ways in which primary care was accessed, and efforts made within primary and community to avoid hospital referrals needing to be made. Accepted referrals The number of patients referred to hospital with suspected cancer also reduced during 2020/21; 7% fewer patients were seen across the year as a whole, though referrals returned to pre-pandemic levels or higher from July 2020 onwards. Patients seen following ‘Two week wait’ urgent referral for suspected cancer 20 Activity UHS hospital appointments, diagnostic tests and elective admissions were all significantly reduced during 2020/21 due to the impact of COVID-19. • During periods of higher bed occupancy with COVID-19 it was necessary to significantly reduce the number of elective admissions undertaken in order that additional staff could work in intensive care. Less clinically urgent and therefore longer waiting patients were primarily those affected. • Throughout the year, additional infection prevention measures have reduced the number of patients that can be seen in each session, particularly when higher risk ‘aerosol generating’ procedures are planned, but also as a result of additional PPE being worn or to enable greater distancing of patients attending outpatient departments. UHS was offered additional capacity at local independent sector hospitals and used this effectively to minimise these adverse impacts. Approximately 30% of outpatient appointments are now undertaken by telephone or video, helping to maintain the capacity for patient care whilst reducing the infection risk for those patients and helping to maintain distancing measures for those patients still attending our outpatient departments. The graphs below show 2020/21 activity levels as a percentage of those achieved in the previous year. Elective admissions (including daycase) 21 Outpatient attendances Performance The average waiting time for first outpatient appointments has remained close to nine weeks for the majority of the year. UHS has however experienced very significant deteriorations in the waiting times our patients experience for diagnostic tests to be undertaken and elective treatment to be provided. The reduced number of new patients referred to hospital early in 2020/21 has moderated the extent of the growth in the total numbers of patients waiting, and the greatest rate of growth has unfortunately been amongst those groups of patients already waiting longest. 22 Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. The waiting list is approximately 50% bigger than it was before the pandemic and stable through the second half of the year. At the end of the year 28% of patients were waiting more than six weeks to receive their investigation compared to the national target of 1%. The tests with the largest numbers of longer waiting patients include non-obstetric ultrasound, MRI and endoscopies, and further recovery will be driven through a combination of recruitment, independent sector capacity and an additional endoscopy room which opened at the start of April 2021. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 23 Referral to Treatment Our waiting list from referral to treatment increased in size by 6% (2,220 patients) during 2020/21, rising when the recovery in referral numbers exceeded the recovery in clinical activity, the total increase in waiting list size would have been significantly higher had it not been for the significant reduction in the referrals received by the hospital especially during the early months of the pandemic. Looking forward, we anticipate referrals numbers returning to pre-pandemic levels, and being able to maintain the total size of our waiting list by delivering an equivalent number of treatments each month. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance against this measure is now 12% worse than one year ago, at 66%. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 24 Unfortunately, the number of patients waiting significantly longer than the 18 week target has increased at a faster rate than the size of the waiting list as a whole. The graph below shows how the percentage of patients who have waited more 52 weeks increased. The number of patients who have waited more 52 weeks increased from 40 in March 2020 to 3,419 by March 2021 (of these 445 patients had waited more than 78 weeks). Such patients often require surgical treatment, particularly in the orthopaedic, ear nose and throat and oral surgery specialities. The impact on surgical care has been greater than that in outpatients during the pandemic, and it is also more challenging to increase capacity due to the need for additional operating theatres and a combination of different healthcare professionals to work within them. UHS opened an additional operating theatre in 2020/21, and has a further four theatres scheduled to open during 2021/22, which will make a significant contribution to our capacity to treat more patients. Unfortunately, the number of patients waiting significantly longer than the 18 week target is likely to continue to grow further in the short term, due to diagnostic investigations having been progressed less quickly than usual during the pandemic, the need to prioritise our increased treatment capacity according to the clinical urgency of conditions and because our scheduled capacity increases will not be completed before the autumn of 2021. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 25 Cancer Waiting Times UHS has been mostly successful in maintaining the timeliness of urgent services for patients with suspected cancer through the pandemic, and our performance has been amongst the best in both the south-east and nationally. UHS prioritised the theatre and intensive care capacity we were able to provide during the pandemic in order to meet the needs of those patients with the greatest clinical urgency, used capacity offered by independent sector hospitals to supplement that available within NHS, and operated a hub through which hospitals in Wessex were able to collaborate to continue critical cancer surgery during periods of peak COVID-19 demand. The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. Whilst UHS performance remained below this level in the majority of months, our performance has been significantly better than the national average, and has improved relative to other trusts. Treatment for Cancer within 62 days of an urgent GP referral to hospital 26 The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients; both for the first and any subsequent treatments for cancer. UHS achieved this level on average across the year, and in the majority of months. The treatments provided are typically by means of surgery, chemotherapy/immunotherapy or radiotherapy. The most significant performance challenge this year has been in radiotherapy, where more sophisticated treatment plans improve patient outcomes but take longer to prepare, and there was also reduced treatment capacity whilst we replaced one of our ‘Linear Accelerator’ treatment machines with a new model. First definitive treatment for cancer within 31 days of a decision to treat Equality in service delivery Identifying and addressing health inequalities have been the central part of the Trust’s approach to improving the experience of care for our patients, families and carers. Over the past year, new initiatives have augmented progress on existing work to ensure there is appropriate support, due regard and recognition of those patients and their families and carers who are most at risk of poor experiences, outcomes and access to services. In 2020 we added two questions to our patient surveys, asking first if patients felt themselves to have a disability or require a reasonable adjustment, and, if yes, whether the Trust met this need. In 2020/21, the results were: TOTAL Had a disability / required a reasonable adjustment 27% Had this need met by the Trust (positive response) 95% This question was added to our major Friends and Family Test surveys as well as our local service-specific patient surveys. In June 2020 the Trust launched the sunflower lanyard scheme for hidden disabilities, participating in the national initiative to ensure that people whose disabilities are not visible are able to access further support and reasonable adjustments by means of a nationally recognised indicator (the sunflower). In 2020/21, 618 lanyards were issued with those needs recorded to ensure future reasonable adjustments are made for those individuals. 27 Carers have always been essential partners in the care that we provide, and having introduced a new post at the end of 2019 to focus solely on carer experience, this work has culminated in a Trust strategy for improving the involvement, support and experience carers have of our services. We have, over the past year, introduced carers cards, virtual peer support and carer-specific information about services while actively participating in local and regional work on carers. In January 2021 we realised our ambition of becoming an accredited ‘Veterans Aware’ hospital, with our submission of evidence being recognised as ‘strong’ and indicative of an organisation that has made great progress in helping to provide enhanced support for the armed forces community. Towards the end of 2019 we worked with the disability organisation AccessAble to produce accessibility guides for all of our services and estate. These online guides allow patients and visitors with disabilities to plan their journey and identify potential challenges to the environment. In 2020/21 our guides had 5,000 unique visits per month. One of our COVID-19 initiatives, a patient support hub, was set up in May 2020 to provide a single point of support for our patients who had been advised to shield. The service has grown and now offers support to patients and carers who are vulnerable, disabled or with additional needs. This includes coordinating community transport, arranging companions to assist with attending appointments, hosting a technology library to support those who are digitally excluded in accessing virtual appointments and information, and most recently receiving funding to pilot volunteer-led support for diabetes patients. Across the Trust, we continue to actively promote the importance of asking patients and carers about disabilities and reasonable adjustments, flagging needs on our patient administrative system to prompt our services to take proactive steps to ensure that any needs or adjustments are met on each and every visit. This has been of vital importance for meeting accessible information and communication needs. We are currently one of first trusts to pilot a new translation app that provides immediate interpretation into different languages, and we have worked closely with our communication support partners to ensure that where virtual appointments are needed, people with communication needs (BSL, foreign language) are supported to access care virtually. Our specialist nursing liaison teams continued to support access to services throughout the pandemic, ensuring that patients with dementia, with learning disabilities and autism, were supported to attend hospital where necessary. Further information about the Trust’s work in relation to equality, diversity and inclusion can be found on page 69 and pages 106 and 160 in the quality report. Going concern After making enquiries, the directors have a reasonable expectation that the services provided by the Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual. David French Chief Executive Officer 28 June 2021 28 Accountability report Directors’ report Board of directors The board of directors is usually made up of six executive directors and seven non-executive directors, including the chair. Since 1 January 2021 the number of non-executive directors has been reduced by one as Jane Bailey’s reappointment as a non-executive director was deferred to allow her to lead the Hampshire and Isle of Wight saliva mass testing programme. Jane is expected to return to the board of directors in her non-executive director role by 1 July 2021. Paragraph B.1.2 of the NHS foundation trust code of governance provides that at least half the board of directors, excluding the chair, should comprise non-executive directors determined by the board to be independent. Pending the reappointment of Jane Bailey as a non-executive director, the Trust has been operating with one fewer non-executive directors than is required by the Trust’s constitution and the Trust has been non-compliant with this paragraph of the code. During this period the provisions of the Trust’s constitution that a quorum for meetings of the board of directors requires at least one non-executive director and one executive director to be present and for the chair to have a second and casting vote in the case of an equal vote continued to apply. The board of directors has given careful consideration to the range of skills and experience it requires to run the Trust. Together the members of the board of directors bring a wide range of skills and experience to the Trust, such that the Board achieves balance and completeness at the highest level. The chair was determined to be independent on his appointment and the other non-executive directors have been determined to be independent in both character and judgement. This included specific consideration of Jane Bailey’s continued independence following her role leading the Hampshire and Isle of Wight saliva mass testing programme. The chair, executive directors and non-executive directors have declared any business interests that they have. Each director has declared their interests at public meetings of the board of directors. The register of interests is available on the Trust’s website. 30 The current members of the board of directors are: Non-executive directors Peter Hollins Chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, in 1992 he was appointed as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, before returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non-executive director in 2010, became senior independent director and deputy chairman of UHS in 2014 and was appointed chair in April 2016. Trust roles: • Chair of remuneration and appointment committee • Chair of governors’ nomination committee Jane Bailey Non-executive director In 1985, Jane joined the pharmaceutical company Glaxo as a management trainee, having graduated from London University with a degree in environmental science and pharmacology. Here she rose to senior commercial vice-president, gaining experience of a broad range of disease areas across different regions of the world. She specialised in leading global research and development teams in the formation of strategies to bring new medicines to patients. She also worked to ensure that the medicines developed were supported by robust evidence demonstrating their clinical and cost-effectiveness. In delivering this she gained extensive experience of leading large diverse teams across a complex global organisation. For five years, Jane ran her own strategy development consultancy, working across a breadth of healthcare organisations. In 2017 Jane gained an MSc in public health, with distinction, at King’s College, London University. Her studies focused on how to ensure the public are engaged in development of healthcare services and how social theories can help inform effective disease prevention and management. Jane is a director of Wessex NHS Procurement Limited, a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust and a director of Healthwatch Portsmouth. Trust roles: • Deputy chair and senior independent director • Chair of finance and investment committee • Audit and risk committee member • Charitable funds committee member • People and organisational development committee member • Remuneration and appointment committee member • Wellbeing Guardian 31 Non-executive directors Dave Bennett Non-executive director Dave graduated in chemistry from the University of Southampton before entering management consulting, becoming a partner in Accenture’s strategy practice. In 2003 he joined Exel Logistics (later acquired by DHL), managing the company’s healthcare business across Europe and the Middle East. During this time, he established NHS Supply Chain, a UK organisation responsible for procuring and delivering medical consumables for the NHS in England, as well as sourcing capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016, where he chaired the Trust’s quality committee. Dave is a non-executive director at the Faculty of Leadership and Medical Management and a director of Royal College of General Practitioners (RCGP) Enterprises Ltd and RCGP Conferences Ltd. Trust roles: • Chair of charitable funds committee • Chair of finance and investment committee (from 1 January 2021) • Audit and risk committee member (from 9 February 2021) • Quality committee member • Remuneration and appointment committee member • Chair of Trust’s organ donation committee 32 Non-executive directors Cyrus Cooper Non-executive director Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He is also vice-dean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. He is president of the International Osteoporosis Foundation, chair of the BHF Project Grants Committee, an emeritus NIHR senior investigator, a director of The Rank Prize Funds and associate editor of Osteoporosis International. He has previously served as chairman of the Scientific Advisors Committee (International Osteoporosis Foundation), the MRC Population Health Sciences Research Network and the National Osteoporosis Society of Great Britain. He has also been president of the Bone Research Society of Great Britain and has worked on numerous Department of Health, European Community and World Health Organisation committees and working groups. Cyrus has published extensively on osteoporosis and rheumatic disorders and pioneered clinical studies on the developmental origins of peak bone mass. In 2015, he was awarded an OBE for services to medical research. Trust roles: • Quality committee member • Remunerati
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-20-21.pdf

STHW841-V1-Biomerieux-Blood-culture-guidance

Description: BLOOD CULTURE A key investigation for diagnosis of bloodstream infections OUR SPECIAL THANKS GO TO Dr Susan M. Novak-Weekley Ph.D. D(ABMM), S(M)ASCP Vice-President, Medical Affairs, Qvella, Carlsbad, CA, USA Wm. Michael Dunne, Jr. Ph.D. D(ABMM), F(AAM, CCM, IDSA, PIDJ) Senior Fellow, Clinical Microbiology, Data Analytics Group, bioMérieux, Inc., Durham, NC, USA Adjunct Professor of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA Adjunct Professor of Pediatrics, Duke University School of Medicine, Durham, NC, USA for their helpful advice and comprehensive review of this booklet. INTRODUCTION “…the laboratory detection of bacteremia and fungemia remains one of the most important functions of clinical microbiology laboratories... A positive blood culture establishes or confirms that there is an infectious etiology of the patient’s illness. Moreover, it provides the etiologic agent and allows antibiotic susceptibility testing for optimization of therapy.”1 The laboratory detection of bacteremia and fungemia using blood cultures is one of the most simple and commonly used investigations to establish the etiology of bloodstream infections. Rapid, accurate identification of the bacteria or fungi causing bloodstream infections provides vital clinical information required to diagnose and treat sepsis. Sepsis is a complex inflammatory process that is largely underrecognized as a major cause of morbidity and mortality worldwide. There are an estimated 19 million cases worldwide each year,2 meaning that sepsis causes 1 death every 3-4 seconds.3 Early diagnosis and appropriate treatment make a critical difference when it comes to improving sepsis patient outcomes. Chances of survival go down drastically the longer initiation of treatment is delayed. If a patient receives antimicrobial therapy within the first hour of diagnosis, chances of survival are close to 80%; this is reduced by 7.6% for every hour after. Yet, if a patient initially receives inappropriate antimicrobial treatment, they are five times less likely to survive.4 This booklet aims to: a nswer key questions commonly asked in relation to blood culture p rovide practical recommendations for routine blood culture procedures o ffer an illustrated step-by-step guide to best blood culture collection practices. This booklet is intended to be a useful reference tool for physicians, nurses, phlebotomists, laboratory personnel and all other healthcare professionals involved in the blood culture process. DEFINITIONS Bacteremia: the presence of bacteria in the blood. It may be transient, intermittent or continuous. Blood culture: blood specimen submitted for culture of microorganisms. It enables the recovery of potential pathogens from patients suspected of having bacteremia or fungemia. Blood culture series: a group of temporally related blood cultures that are collected to determine whether a patient has bacteremia or fungemia. Blood culture set: the combination of blood culture bottles (one aerobic and one anaerobic) into which a single blood collection is inoculated. Bloodstream Infection (BSI): an infection associated with bacteremia or fungemia. Contaminant: a microorganism isolated from a blood culture that was introduced during specimen collection or processing and is not considered responsible for BSI (i.e., the isolates were not present in the patient’s blood when the blood was sampled for culture). Contamination: presence of microorganisms in the bottle that entered during sampling but were not actually circulating in the patient’s bloodstream. Fungemia: the presence of fungi in the blood. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection.5 Septicemia: clinical syndrome characterized by fever, chills, malaise, tachycardia, etc. when circulating bacteria multiply at a rate that exceeds removal by phagocytosis.6 Septic episode: an episode of sepsis or septic shock for which a blood culture or blood culture series is drawn. Septic shock: a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.5 Source: Wayne, P.A. Principles and procedures for Blood Cultures; Approved Guideline, CLSI document M47-A. Clinical and Laboratory Standards Institute (CLSI); 2007 unless otherwise specified. 2 TABLE OF CONTENTS 1 BLOOD CULTURE ESSENTIALS p. 2 1 What is a blood culture? p. 4 2 Why are blood cultures important? p. 4 3 When should a blood culture be performed? p. 5 4 What volume of blood should be collected? p. 6 5 How many blood culture sets should be collected? p. 8 6 Which media to use? p. 10 7 Timing of blood cultures p. 11 8 How to collect blood cultures p. 12 9 How many days of incubation are recommended? p. 14 10 Is it a contaminant or a true pathogen? p. 15 2 SPECIAL TOPIC : INFECTIVE ENDOCARDITIS p. 18 3 PROCESSING POSITIVE BLOOD CULTURES p. 20 4 INTERPRETATION OF RESULTS p. 22 5 BLOOD CULTURE/ SEPSIS GUIDELINES p. 24 REFERENCES p. 26 RECOMMENDATIONS FOR BLOOD CULTURE COLLECTION p. 30 3 1 BLOOD CULTURE ESSENTIALS 1 What is a blood culture? A blood culture is a laboratory test in which blood, taken from the patient, is inoculated into bottles containing culture media to determine whether infection-causing microorganisms (bacteria or fungi) are present in the patient’s bloodstream. v B lood cultures are intended to: Confirm the presence of microorganisms in the bloodstream Identify the microbial etiology of the bloodstream infection 3 MAIN AIMS OF BLOOD CULTURE*: Help determine the source of • Confirm infectious etiology infection (e.g., endocarditis) • Identify the etiological agent P rovide an organism for • Guide antimicrobial susceptibility testing and optimization therapy of antimicrobial therapy * Adapted from ESCMID (European Society of Clinical Microbiology and Infectious Diseases) guidelines, 2012.7 2 Why are blood cultures important? Blood culture is the most widely used diagnostic tool for the detection of bacteremia and fungemia. It is the most important way to diagnose the etiology of bloodstream infections and sepsis and has major implications for the treatment of those patients. A positive blood culture either establishes or confirms that there is an infectious etiology for the patient’s illness.3 A positive blood culture also provides the etiologic agent for antimicrobial susceptibility testing, enabling optimization of antibiotic therapy.3 Sepsis is one of the most significant challenges in critical care, and early diagnosis is one of the most decisive factors in determining patient outcome. Early identification of pathogens in the blood can be a crucial step in assuring appropriate therapy, and beginning 4 BLOOD CULTURE ESSENTIALS effective antibiotic therapy as early as possible can have a significant impact on the outcome of the disease.8, 9 v P roviding adequate antibiotic therapy within the first 24-48 hours leads to:10-14 Decreased infection-related mortality (20-30%) Earlier recovery and shorter length of hospital stay Less risk of adverse effects Reduced risk of antimicrobial resistance Cost reduction (length of stay, therapy, diagnostic testing) Figure 1: Fast effective antimicrobial therapy increases survival chances Adapted from Kumar A, et al. Crit Care Med. 2006;34(6):1589-96.15 Total patients (%) Patient survival rate (%) 100 Patients with e ective antibiotic therapy 80 60 40 20 0 0 hours 1 2 3 4 5 6 9 12 24 36 Time to antibiotics 3 When should a blood culture be performed? Blood cultures should always be requested when a bloodstream infection or sepsis is suspected. v C linical symptoms in a patient which may lead to a suspicion of a bloodstream infection are: undetermined fever (≥38°C) or hypothermia (≤36°C) shock, chills, rigors s evere local infections (meningitis, endocarditis, pneumonia, pyelonephritis, intra-abdominal suppuration…). abnormally raised heart rate low or raised blood pressure raised respiratory rate 5 BLOOD CULTURE ESSENTIALS v B lood cultures should be collected: as soon as possible after the onset of clinical symptoms; ideally, prior to the administration of antimicrobial therapy.16 If the patient is already on antimicrobial therapy, recovery of microorganisms may be increased by collecting the blood sample immediately before administering the next dose and by inoculating the blood into bottles containing specialized antimicrobial neutralization media. 4 W hat volume of blood should be collected? The optimal recovery of bacteria and fungi from blood depends on culturing an adequate volume of blood. The collection of a sufficient quantity of blood improves the detection of pathogenic bacteria or fungi present in low quantities. This is essential when an endovascular infection (such as endocarditis) is suspected. The volume of blood that is obtained for each blood culture set is the most significant variable in recovering microorganisms from patients with bloodstream infections.17, 18 Blood culture bottles are designed to accommodate the recommended bloodto-broth ratio (1:5 to 1:10) with optimal blood volume. Commercial continuously monitoring blood culture systems may use a smaller blood-to-broth ratio ( 200 4 2 6 12.8-36.3 28-80 > 800 10 10 20 > 36.3 > 80 > 2,200 20-30 20-30 40-60 % of patient’s total blood volume 4 4 3 2.5 1.8-2.7 7 BLOOD CULTURE ESSENTIALS 5 H ow many blood culture sets should be collected? Since bacteria and fungi may not be constantly present in the bloodstream, the sensitivity of a single blood culture set is limited. Using continuous-monitoring blood culture systems, a study investigated the cumulative sensitivity of blood cultures obtained sequentially over a 24-hour time period. It was observed that the cumulative yield of pathogens from three blood culture sets (2 bottles per set), with a blood volume of 20 ml in each set (10 ml per bottle), was 73.1% with the first set, 89.7% with the first two sets and 98.3% with the first three sets. However, to achieve a detection rate of > 99% of bloodstream infections, as many as four blood culture sets may be needed.22 Figure 2: Cumulative sensitivity of blood culture sets22 Adapted from Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed? J Clin Microbiol 2007;45:3546-3548. Detection sensitivity 100% 90% 89.7% 98.3% 80% 73.1% 70% 20 ml 40 ml 60 ml A single blood culture bottle or set should never be drawn from adult patients, since this practice will result in an inadequate volume of blood cultured and a substantial number of bacteremias may be missed.3, 22 8 BLOOD CULTURE ESSENTIALS A contaminant will usually be present in only one bottle of a set of blood culture bottles, in contrast to a true bloodstream infection, in which multiple blood culture bottles/sets will be positive. Therefore, guidelines recommend to collect 2, or preferably 3, blood culture sets for each septic episode.3, 7, 16 If 2 to 3 sets are taken and cultures are still negative after 24-48 hours incubation, and the patient is still potentially septic, 2 to 3 additional cultures may be collected, as indicated in the following diagram.16 Figure 3: Recommended number of blood culture sets Adapted from Baron EJ, Cumitech 1C, Blood Cultures IV. Coordinating ed., E.J. Baron. ASM Press, Washington, D.C. 2005 Collect 2 to 3 sets of bottles (aerobic + anaerobic) for each septic episode If culture is negative after 24-48 h incubation and patient is still potentially septic without an identified source Collect 2 to 3 additional sets of bottles (aerobic + anaerobic) If culture is negative after 24 h incubation Repeat protocol Prolong if necessary incubation Investigate non-microbial etiology 9 BLOOD CULTURE ESSENTIALS 6 W hich media to use? Microorganisms causing bloodstream infections are highly varied (aerobes, anaerobes, fungi, fastidious microorganisms…) and, in addition to nutrient elements, may require specific growth factors and/or a special atmosphere. In cases where the patient is receiving antimicrobial therapy, specialized media with antibiotic neutralization capabilities should be used. Antibiotic neutralization media have been shown to increase recovery and provide faster time to detection versus standard media.23-26 It is recommended that each adult routine blood culture set include paired aerobic and anaerobic blood culture bottles. The blood drawn should be divided equally between the aerobic and anaerobic bottles. If an anaerobic bottle is not used, it should always be replaced by an additional aerobic bottle to ensure that a sufficient volume of blood is cultured.27 v A blood culture medium must be: sensitive enough to recover: - a broad range of clinically relevant microorganisms, even the most fastidious (Neisseria, Haemophilus…) - microorganisms releasing small amounts of CO2 (Brucella, Acinetobacter…) versatile: able to provide a result for all types of sample collection (adults, infants, patients receiving antibiotic therapy, sterile body fluids…) v Which bottle should be inoculated first? If using a winged blood collection set, then the aerobic bottle should be filled first to prevent transfer of air in the device into the anaerobic bottle. If using a needle and syringe, inoculate the anaerobic bottle first to avoid entry of air. If the amount of blood drawn is less than the recommended volume*, then approximately 10 ml of blood should be inoculated into the aerobic bottle first, since most cases of bacteremia are caused by aerobic and facultative bacteria. In addition, pathogenic yeasts and strict aerobes (e.g., Pseudomonas) are recovered almost exclusively from aerobic bottles. Any remaining blood should then be inoculated into the anaerobic bottle.8 * For recommended volumes, see page 6 “What volume of blood should be collected? 10 BLOOD CULTURE ESSENTIALS 7 T iming of blood cultures Studies have shown that the time interval between collecting two blood culture samples is not considered to be a critical factor as the diagnostic yield remains the same.7 Guidelines recommend that the first two/three sets (2 bottles/set) of blood culture be obtained either at one time or over a brief time period (e.g., within 1 hour) from multiple venipuncture sites.1,16 Drawing blood at spaced intervals, such as 1 to 2 hours apart, is only recommended to monitor continuous bacteremia/fungemia in patients with suspected infective endocarditis or other endovascular (i.e., catheterrelated) infections.16 Two to three additional blood culture sets can be performed if the first 2-3 blood cultures are negative after 24-48 hours incubation in cases of severe infection or in order to increase detection sensitivity (in cases of pyelonephritis for example). This also depends on the microorganisms involved: while sensitivity is relatively good for organisms like Escherichia coli or Staphylococcus aureus, it is lower for Pseudomonas aeruginosa, streptococci or fungi.28 8 H ow to collect blood cultures Sample collection is a crucial step in the blood culture process. Standard precautions must be taken, and strict aseptic conditions observed throughout the procedure. Compliance with blood culture collection recommendations can significantly improve the quality and clinical value of blood culture investigations and reduce the incidence of sample contamination and “false-positive” readings. A properly collected sample, that is free of contaminants, is key to providing accurate and reliable blood culture results. It is recommended that blood cultures should be collected only by members of staff (medical, nursing, phlebotomist or technician) who have been fully trained and whose competence in blood culture collection has been assessed.29 11 BLOOD CULTURE ESSENTIALS 10 Key Steps to Good Sample Collection: For an illustrated step-by-step, see page 30. 1 Prior to use, examine the bottles for evidence of damage, deterioration or contamination. Do not use a bottle containing media which exhibits turbidity or excess gas pressure, as these are signs of possible contamination. 2 Check the expiry date printed on each bottle. Discard bottles that have expired. 3 S trictly follow the collection protocol in use in the healthcare setting, including standard precautions for handling blood at the bedside. 4 Blood culture bottles should be clearly and correctly labelled, including patient identification, date and collection time, puncture site (venipuncture or intravascular device). 5 E ach blood culture set should include an aerobic and an anaerobic bottle. 6 Blood for culture should be drawn from veins, not arteries.30 7 It is recommended to avoid drawing blood from a venous or arterial catheter, since these devices are often associated with higher contamination rates.31 12 BLOOD CULTURE ESSENTIALS 8 Carefully disinfect the skin prior to collection of the sample using an appropriate disinfectant, such as chlorhexidine in 70% isopropyl alcohol or tincture of iodine in swab or applicator form.1 9 Transport the inoculated bottles and the completed blood culture request to the clinical microbiology laboratory as quickly as possible, preferably within 2 hours per CLSI.1 Any delay in testing the inoculated bottles may potentially lead to an increased risk of false negative results. If delays are expected, it is important to refer to the manufacturer’s Instructions for Use (IFU) for guidance. As an example for guidance regarding delays, the ESCMID guidelines recommend that blood culture bottles for testing in continuous monitoring systems should be stored temporarily at room temperature, whereas bottles for manual testing should be incubated as soon as possible.32Again, refer to the manufacturer’s IFU for guidance. The use of vacuum tube transport systems can facilitate the rapid transmission of bottles to the microbiology laboratory. However these systems should be used with caution if using glass bottles.33 10 All blood cultures should be documented in the patient’s notes, including date, time, collection site and indications. 13 BLOOD CULTURE ESSENTIALS 9 H ow many days of incubation are recommended? The current recommendation, and standard incubation period, for routine blood cultures performed by continuous-monitoring blood systems is five days.34 However, published data suggest that three days may be adequate to recover over 97% of clinically significant microorganisms. A study by Bourbeau, et al. (JCM, 2005) showed the number of significant microorganisms isolated per day for 35,500 consecutive blood cultures collected over 30 months, of which 2,609 were clinically significant isolates and 1,097 were contaminants.35 Figure 4: Clinically significant isolates per day35 Adapted from Bourbeau PP, Foltzer M. Routine incubation of BACT/ALERT* FA and FN blood culture bottles for mo10re0t%han 3 days may not be necessary. J Clin Microbiol. 2005;43:2506-2509. 80% 74.1% 60% 40% 19.7% 20% 3.6% 1.7% 0.9% 0% Day 1 Day 2 Day 3 Day 4 Day 5 These results demonstrate that 97.4% of clinically significant isolates were recovered within the first 3 days of incubation and 93.8% within 2 days of incubation. v Incubation of Fastidious Microorganisms Another study by Cockerill, et al. (CID, 2004) demonstrated that, when using a continuous-monitoring blood culture system, 99.5% of non-endocarditis bloodstream infections and 100% of endocarditis episodes were detected within 5 days of incubation.19 This data suggests that extended incubation periods previously recommended for detection of the fastidious microorganisms* that sometimes cause endocarditis, are no longer necessary when using continuous-monitoring blood culture systems.16 * including Brucella, Capnocytophaga and Campylobacter spp., and the HACEK group (Haemophilus (except H. influenzae) species, Aggregatibacter (previously Actinobacillus) species, Cardiobacterium hominis, Eikenella corrodens and Kingella species)36 14 BLOOD CULTURE ESSENTIALS 10 I s it a contaminant or a true pathogen? Contamination of blood cultures during the collection process can produce a significant level of false-positive results, which can have a negative impact on patient outcome. A false positive is defined as growth of bacteria in the blood culture bottle that were not present in the patient’s bloodstream, and were most likely introduced during sample collection. Contamination can come from a number of sources: the patient’s skin, the equipment used to take the sample, the hands of the person taking the blood sample, or the environment. Collecting a contaminant-free blood sample is critical to providing a blood culture result that has clinical value. Certain microorganisms such as coagulase-negative staphylococci, viridansgroup streptococci, Bacillus spp, Propionibacterium spp., diphtheroids, Micrococcus spp. rarely cause severe bacterial infections or bloodstream infections. These are common skin contaminants, and a though they are capable of causing serious infection in the appropriate setting, their detection in a single blood culture set can reasonably be identified as a possible contaminant without clinical significance. However, it is important to consider that coagulase-negative staphylococci are the primary cause of both catheterand prosthetic device-associated infections and may be clinically significant in up to 20% of cases.37 The most difficult interpretation problem for the physician is whether the organism recovered from a blood culture is a true pathogen causing bloodstream infection, or a contaminant. If it is a contaminant, the patient may be treated unnecessarily with antibiotics, leading to additional patient risks. Interpretation of true pathogen versus contaminant should be based on whether the blood has been collected with a venipuncture or an intra-vascular device, and multiplicity of isolation of the same species. This illustrates the crucial nature of having collection site information included with the blood culture request sent to the laboratory. 15 BLOOD CULTURE ESSENTIALS In contrast to patients with infective endocarditis or other true positive bloodstream infections, patients whose blood cultures grow contaminants usually have only a single blood culture that is positive. This information is of great practical value for physicians, and underlines the importance of taking two to three blood culture sets from different anatomical sites.16 Contamination rates can be most effectively reduced by strict compliance with hand hygiene rules and best practices for blood collection, particularly during the stages of skin antisepsis, venipuncture and sample transfer to blood culture bottles. However, even when the best blood collection protocols are used, it may not be possible to reduce the contamination rate below 2%.38 The American Society for Microbiology and CLSI recommend targeting contamination rates not exceeding 3% of the total of collected sets.1, 16 v Impact of contamination rates A contaminated blood culture can result in unnecessary antibiotic therapy, increased length of hospitalization and higher costs. It has been found that each false positive result can lead to: Increased length of stay - on average 1 day.39 39% increase in intravenous antibiotic charges.39 $5,000 to $8,720 additional charges.40, 41 20% increase in laboratory charges.39 3 days longer on antibiotics.39 16 BLOOD CULTURE ESSENTIALS Figure 5: E xample of a laboratory-based algorithm to determine blood culture contamination42 Adapted from Richter SS, Beekman SE, Croco JL, Diekema DJ, et al. Minimizing the workup of blood culture contaminants: implementation and evaluation of a laboratory-based algorithm. J Clin Microbiol. 2002;40:2437-2444. Potential contaminant* isolated from blood culture Additional draws +/48 hours? NO YES Positive with same organism? NO YES Evaluation by qualified personnel Probable contaminant; AST** not performed unless requested Viridans group streptococci? NO YES Evaluation by qualified personnel Pathogen; set up AST† * Microorganisms such as coagulase-negative staphylococci, Streptococcus viridans, Bacillus spp, Propionibacterium spp., diphtheroids, Micrococcus spp. † AST: Antimicrobial Susceptibility Testing 17 2 SPECIAL TOPIC: INFECTIVE ENDOCARDITIS Blood culture is essential in the diagnosis of infective endocarditis (infection of the heart valves). In this elusive disease, blood cultures may need to be taken repeatedly during febrile episodes, when bacteria are shed from the heart valves into the bloodstream. For patients with infective endocarditis, positive blood cultures will be obtained in greater than 90% of cases, if optimal culture conditions are respected.43 v Acute Infective Endocarditis This is a fulminant illness progressing rapidly over days to weeks, which may be caused by highly virulent pathogens, such as Staphylococcus aureus. When suspected, the severity of this disease requires blood cultures to be drawn immediately to avoid unnecessary delays in treatment. Multiple blood culture sets should be drawn during a 30-minute period prior to administration of empiric antimicrobial therapy.44 v Subacute Infective Endocarditis If sub-acute infection is suspected, there is usually not an urgent need to initiate empiric therapy. It is more important to attempt to establish the microbiological diagnosis. Multiple blood culture sets should be obtained prior to initiation of antimicrobial therapy, with sets spaced 30 minutes to one hour apart. This may help document a continuous bacteremia, and could be of additional clinical value.3 v Fungal Infective Endocarditis Once a rare occurrence, the incidence of fungal endocarditis is increasing considerably.45 Candida species are the most common fungal pathogens involved in infective endocarditis.46 If optimum collection conditions are observed, the yield for positive blood cultures in fungal endocarditis for Candida spp. is 83 to 95%.47 18 SPECIAL TOPIC: INFECTIVE ENDOCARDITIS v How many cultures? In order to distinguish between contamination and true bacteremia, a total of three to five blood culture sets should be sufficient. Initially, two to three blood culture sets should be obtained from patients with suspected infective endocarditis. If the first 2-3 sets are negative after 24-48 hours, collect two to three more sets of cultures.3 Often patients with suspected infective endocarditis have been put on antibiotics prior to blood collection. This is the most common reason for “culture-negative” infective endocarditis. It is therefore important to use a blood culture medium that has antimicrobial neutralization capacity in order to sustain microbial growth in the presence of antibiotics (see page 10 “Which media to use?”).48,49 However, “culture-negative” endocarditis may also be due to fastidious microorganisms, such as Aspergillus spp., Brucella spp., Coxiella burnetii, Chlamydia spp. and HACEK* microorganisms. S ince current continuous-monitoring blood culture systems can recover all HACEK and other fastidious organisms within a 5-day period, extending incubation beyond this period is no longer considered to be necessary. However, if all blood culture bottles are negative after 5 days, and infectious endocarditis is still suspected, all bottles should be subcultured to chocolate agar.50 19 3 PROCESSING POSITIVE BLOOD CULTURES Today, continuously-monitored blood culture systems provide the optimum solution for blood sample processing. Generally accepted incubation periods can vary from 5-7 days, with 5 days being most popular.27 The study discussed in Figure 4 shows that 98% of all positive specimens were detected within the first 3 days (see page 14).35 Patients who progress to septic shock have a 7.6% increase in mortality every hour while not on appropriate therapy.15 Following an instrument-flagged positive event, the bottle is removed from the system and a Gram stain and subculture is performed. If the sample is Gram stain positive, the morphology of the organism should be reported immediately to the physician. Subcultures or rapid techniques (e.g., molecular diagnostics) should be initiated immediately in order to provide further organism identification and antibiotic susceptibility testing should be performed as soon as possible. If a sample is Gram stain negative, no report is made to the clinician unless there is growth on subculture. A positive blood culture is a critical result and must be reported as soon as available, due to the immediate impact on patient care decisions. When reports are delivered rapidly, studies have shown broadly improved outcomes and efficiencies in patient management.51, 52 A study by Barenfanger, et al. (Am J Clin Pathol. 2008) validated that Gram stains of positive blood cultures are a very important factor influencing appropriate therapy and patient outcomes. The study documented a statistically significant increase in the mortality rate for patients who had blood cultures processed after a delay (i.e., Gram stain performed ≥1 hour after being detected as positive; P= 0.0389). The timely removal and reporting of Gram stain results have a positive impact on patient care and this study supports the need for 24/7 coverage of blood culture instruments.53 20 PROCESSING POSITIVE BLOOD CULTURES Recent technological advances such as MALDI-TOF (Matrix-Assisted Laser Desorption Ionization Time of Flight) provide the ability to rapidly deliver definitive organism identification. Molecular diagnostics can identify the most common pathogens in positive blood cultures as well as specific antibiotic resistance genes associated with bloodstream infections. Rapid identification allows physicians to prescribe more targeted and effective antimicrobial therapy earlier to positively influence outcomes.54-56 Additionally, antibiotic susceptibility testing techniques should be performed on positive blood cultures to provide the clinician with a complete result. Appropriate use of antibiotics is crucial in cases of bloodstream infections and sepsis. Accurately determining the antimicrobial resistance profile of the causative pathogen in order to select the most effective antibiotic therapy can have a significant impact on patient outcomes. When processed correctly, blood cultures provide clinically relevant information that can help improve patient outcomes, decrease length of hospital stay and reduce use of antibiotics. 21 4 INTERPRETATION OF RESULTS The microbiology laboratory can provide useful information to clinicians to help them determine whether a blood culture sample is a true positive or a false positive (contaminant). For example, the identity of the micro- organism isolated can help determine if the culture is contaminated, and the number of Figure 6: Example of interpretation algorithm for blood culture results 1 More than one positive bottle monomicrobial culture + clinical symptoms (e.g., endocarditis, meningitis, pneumonia…) polymicrobial culture (from the appropriate clinical setting (e.g., transplants, intraabdominal infection, immunocompromized patient…) bloodstream infection probable bloodstream infection 3 Negative blood cultures but clinical symptoms 22 INTERPRETATION OF RESULTS cultures positive with the same organism can help predict true infections.57 Time to positivity is also a factor used to determine potential contamination as contaminants usually have a delayed (longer) time-to-detection due to a lower overall bio-load. Laboratories should consult with their medical director to create an algorithm which helps determine whether or not an isolated organism is a contaminant vs. an infective agent. Models, such as the algorithm below, can give guidance only on the interpretation of blood culture results.42, 57, 58 These guidelines should be used in conjunction with clinical guidelines e.g., patient’s full blood count, presence of catheters, radiological findings, etc. 2 Only one positive bottle if pathogenic organism: Listeria, S. aureus, Brucella, Haemophilus, Enterobacteriaceae, … if normal skin flora: Propionibacterium, corynebacterium, Bacillus, coagulase-negative staphylococci if viridans streptococci or coagulase-negative staphylococci and consistent with clinical setting (e.g., indwelling catheter, prosthetic heart valve, immunocompromized patient) probable bloodstream infection probable contamination probable bloodstream infection Repeat blood samples Consider non-infectious etiology Investigate viral etiology or non-culturable microorganism 23 5 BLOOD CULTURE/SEPSIS GUIDELINES v International Guidelines WHO guidelines on drawing blood: best practices in Phlebotomy. World Health Organization 2010. http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Dellinger RP., et al. Crit Care Med. 2013;41:580-637. http://www.survivingsepsis.org/guidelines/Pages/default.aspx The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M., et al. JAMA. 2016;315(8):801-810. http://jama.jamanetwork.com/article.aspx?articleid=2492881 v National Guidelines COUNTRY/ REGION GUIDELINES Australia Clinical Excellence Commission. SEPSIS KILLS Adult Blood Culture Guideline Updated September 2016. SHPN (CEC) 160406. http://www.cec.health.nsw.gov.au/__data/assets/pdf_ file/0005/259412/adult-blood-culture-guideline-updated-sept2016.pdf Brazil Elmor de Araujo MR, Hemocultura: recomendações de coleta, processamento e interpretação dos resultados, J Infect Control 2012; 1: 08-19 http://www.iqg.com.br/pbsp/img_up/01355393320.pdf Europe European Society for Clinical Microbiology and Infectious Diseases, European Manual for Clinical Microbiology, 1st Edition, 2012. https://www.escmid.org/escmid_publications/manual_of_microbiology/ 24 BLOOD CULTURE/SEPSIS GUIDELINES COUNTRY/ REGION France GUIDELINES REMIC 2015. Automatisation des cultures microbiennes : quel cahier des charges ? Chapitre 11 http://www.sfm-microbiologie.org/ Germany Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, et al., Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI). German Medical Science, 2010, Vol. 8: 1-86 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899863/pdf/ GMS-08-14.pdf South Africa Guideline for the optimal use of blood cultures. SAMJ 2010; Vol. 100, No. 12: 839-843 SAMJ https://www.fidssa.co.za/Content/Documents/Guideline_for_the_optimal_use_of_blood_cultures.pdf UK UK Standards for Microbiology Investigations. Investigation of Blood Cultures (for Organisms other than Mycobacte- rium species). Bacteriology | B 37 | Issue no: 8 | Issue date: 04.11.14 | Page: 1 of 51. Issued by the Standards Unit, Health Protection Agency, PHE. https://assets.publishing.service.gov.uk/government/uploads/sys- tem/uploads/attachment_data/file/372070/B_37i8.pdf Taking blood cultures - a summary of best practice: Saving lives reducing infection, delivering clean and safe care. London: Department of Health; 2007. http://webarchive.nationalarchives.gov.uk/20120118171812/http://hcai. dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf USA American Society for Microbiology: Cumitech 1C, 2005 (EJ Baron et al.) ASM Press Clinical and Laboratory Standards Institute (CLSI®), document M47-A, Vol 27, 2007 (ML Wilson et al.) E mergency Nurses Association (ENA). Clinical Practice Guideline: Prevention of Blood Culture Contamination https://www.ena.org/docs/default-source/resource-library/practice-resources/cpg/bcccpg2c37f1815b664d2fa8d7e9fd0f475a41.pdf E .Septimus.CDCClinicianGuideforCollectingCultures.2015 https://www.cdc.gov/antibiotic-use/healthcare/implementation/clinicianguide.html 25 REFERENCES 1. P rinciples and procedures for Blood Cultures; Approved Guideline, CLSI document M47-A. Clinical and Laboratory Standards Institute (CLSI); Wayne, P.A. 2007 2. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010;376(9749):1339–1346. 3. WSD fact sheet 2013. www.world-sepsis-day.org 4. Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009;136(5):1237-1248. 5. Singer M, Deutschmann CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. 6. Koneman EW. Color Atlas and Textbook of Diagnostic Microbiology. Third Edition. 7. European Society for Clinical Microbiology and Infectious Diseases, European Manual for Clinical Microbiology, 1st Edition, 2012 8. Garey KW, Rege M, Pai MP, Mingo DE, et al. Time to Initiation of Fluconazole Therapy Impacts Mortality in Patients with Candidemia: A Multi-Institutional Study. Clin Infect Dis. 2006;43(1):25-31. 9. Khatib R, Saeed S, Sharma M, Riederer K, Fakih MG, Johnson LB. Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia. Eur J Clin Microbial Infect Dis. 2006; 25(3):181185. 10. K ollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115(2):462-474. 11. H arbarth S, Garbino J, Pugin J, Romand JA, Lew D, Pittet D. Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med. 2003;115(7):529-535. 12. Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of Delayed Antibiotic Treatment for Hospital-Acquired Staphylococcus aureus Bacteremia. CID 2003;36:1419-1423. 13. Kang CL, Kim SH, Kim HB, et al. Pseudomonas aeruginosa bacteremia: risk factors for mortality and influence of delayed receipt of effective antimicrobial therapy on clinical outcome. Clin Infect Dis. 2003; 37(6): 745-51 14. Forrest GN, Mankes K, Jabra-Rizk MA, et al. Peptide Nucleic Acid Fluorescence In Situ Hybridization Based Identification of Candida albicans and Its Impact on Mortality and Antifungal Therapy Costs. J Clin Microbiol. 2006;44(9):3381-3383. 26 15. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596. 16. B aron EJ, Weinstein MP, Dunne Jr. WM, Yagupsky P, Welch DF, Wilson DM. Cumitech 1C, Blood Cultures IV. Coordinating ed., E.J. Baron. ASM Press, Washington D.C. 2005. 17. M ermel LA, Maki DG. Detection of bacteremia in adults: consequences of culturing an inadequate volume of blood. Ann Intern Med. 1993;119:270-272. 18. Bouza E, Sousa D, Rodriguez-Creixems M, Lechuz JG, Munoz P. Is the volume of blood cultured still a significant factor in the diagnosis of bloodstream infections? J Clin Microbiol. 2007 45:2765-2769. 19. Cockerill FR 3rd, Wilson JW, Vetter EA, et al. Optimal testing parameters for blood cultures. Clin Infect Dis. 2004;38:1724-1730. 20. K ellog JA, Manzella JP, Bankert DA. Frequency of low-level bacteremia in children from birth to fifteen years of age. J Clin Microbiol. 2000;38:2181-2185. 21. Freedman SB, Roosevelt GE. Utility of anaerobic blood cultures in a pediatric emergency department. Pediatr Emerg Care. 2004;20(7):433-436. 22. Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed? J Clin Microbiol. 2007;45:3546-3548. 23. Lee DH, Kim SC, Bae IG, Koh EH, Kim S. Clinical Evaluation of BACT/ALERT FA Plus and FN Plus Bottles Compared with Standard Bottles. J Clin Microbiol. 2013;51(12):4150-4155. 24. Amarsy-Guerle R, Mougari F, Jacquier H, et al. High medical impact of implementing the new polymeric bead-based BACT/ALERT FA Plus and FN Plus blood culture bottles in standard care. Eur J Clin Microbiol Dis. 2015:34(5):1031-1037. 25. Kirn TJ, Mirrett S, Reller LB, Weinstein MP. Controlled Clinical Comparison of BACT/ ALERT FA Plus and FN Plus Blood Culture Media with BACT/ALERT FA and FN Blood Culture Media. J Clin Microbiol. 2014;52(3):839-843. 26. Doern CD, Mirrett S, Halstead D, Abid J, Okada P, Reller LB. Controlled Clinical Comparison of New Pediatric Medium with Adsorbent Polymeric Beads (PF Plus) versus Charcoal-Containing PF Medium in the BACT/ALERT Blood Culture System. J Clin Microbiol. 2014;52(6):1898-1900. 27. R iley JA, Heiter BJ, Bourbeau PP. Comparison of recovery of blood culture isolates from two BACT/ALERT FAN aerobic blood culture bottles with recovery from one FAN aerobic bottle and one FAN anaerobic bottle. J Clin Microbiol. 2003;41:213-217. 27 REFERENCES 28. W einstein MP,Towns ML, Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s; a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24:584-602. 29. U K Department of Health: Taking Blood Cultures – A summary of best practice. 2007 30. W einstein MP. Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. Clin Infect Dis. 1996;23:40-46. 31. E verts RJ, Vinson EN, Aholla PO, Reller LB. Contamination of catheter-drawn blood cultures. J Clin Microbiol. 2001;39:3393-3394. 32. Cornaglia G, Courcol R, Hermann JL, Kahlmeter G. European Manual of Microbiology. ESCMID-SFM 2012. 33. K irm TJ, Weinstein MP. Update on blood cultures: how to obtain, process, report, and interpret. Clin Microbiol Infect. 2013;19(6):513-520. 34. W ilson ML, Mirrett S, Reller LB, Weinstein MP, Reimer LG. Recovery of clinically important microorganisms from the BACT/ALERT blood culture system does not require testing for 7 days. Diagn Microbiol Infect Dis. 1993;16:31-34. 35. Bourbeau PP, Foltzer M. Routine Incubation of BACT/ALERT FA and FN blood culture for more than 3 days may not be necessary. J Clin Microbiol. 2005;43:2506-2509. 36. S chlossberg D, ed. Clinical Infectious Disease. Cambridge University Press, 2015. 37. Hall KK, Lyman JA. Updated Review of Blood Culture Contamination. Clin Microbiol Rev. 2006,19(4):788. 38. D unne Jr. WM, Nolte FS, Wilson ML. Cumitech 1B, Blood Cultures III. coordinating ed. Hindler JA. ASM Press. Washington, D.C. 1997. 39. Hall KK, Lyman JA. Updated review of blood culture contamination. Clinical Microbiology Reviews. 2006;19:788-802. 40. Bamber AI, Cunniffe JG, Nayar D, Ganguly R, Falconer E. The effectiveness of introducing blood culture collection packs to reduce contamination. Br J Biomed Sci. 2009;66(1):1-9. 41. Gander RM, Byrd L, DeCrescenzo, Hirany S, Bowen M, Baughman J. Impact of Blood Cultures Drawn by Phlebotomy on Contamination Rates and Health Care Costs in a Hospital Emergency Department. J Clin Microbiol. 2009;47:1021-1024. 42. Richter SS, Beekman SE, Croco DJ, et al. Minimizing the workup of blood culture contaminants: implementation and evaluation of a laboratory-based algorithm. J Clin Microbiol. 2002;40:2437-2444. 43.T owns ML, Reller LB. Diagnostic methods: current best practices and guidelines for isolation of bacteria and fungi in infective endocarditis. Infect Dis Clin N Am. 2002;16:363-376. 44. Osborn TM, Nguyen HB, Rivers EP. Emergency medicine and the surviving sepsis campaign: an international approach to managing severe sepsis and septic shock. Ann Emerg Med. 2005;46:228-231. 45. R ubenstein E, Lang R. Fungal endocarditis. Eur Heart J. 1995:16(Suppl B):84-89. 46. E llis ME,Al-Abdely H, Sandridge A, Greer W,Ventura W. Fungal endocarditis: evidence in the world literature, 1965-1995. Clin Infect Dis. 2001; 32:50-62. 28 REFERENCES 47. M cLeod R., Remington JS. Fungal endocarditis. In: Rahimtoola SH et al., eds. Infective Endocarditis. New York, NY: Gune & Stratton.1978:211-290 48. Z iegler R, Johnscher I, Martus P, Lenhardt D, Just HM. Controlled Clinical Laboratory Comparison of Two Supplemented Aerobic and Anaerobic Media Used in Automated Blood Culture Systems to Detect Bloodstream Infections. J Clin Microbiol. 1998;36:657-661. 49. Pohlman JK, Kirkley BA, Easley KA, Basille BA, Washington JA. Controlled Clinical Evaluation of BACTEC Plus Aerobic/F and BACT/ALERT Aerobic FAN Bottles for Detection of Bloodstream Infections. J Clin Microbiol. 1995;33:2856-2858. 50. B aron EJ, Scott JD,Tompkins LS. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis. 2005;41:1677-1680. 51. Beekmann SE, Diekema DJ, Chapin KC, Doern GV. Effects of rapid detection of bloodstream infections on length of hospitalization and hospital charges. J Clin Microbiol. 2003;41:3119-3125. 52. Munson EL, Diekema DJ, Beekmann SE, Chapin KC, Doern GV. Detection and treatment of bloodstream infection: laboratory reporting and antimicrobial management. J Clin Microbiol. 2003;41:495-497. 53. B arenfanger J, Graham DR, Kolluri L, et al. Decreased Mortality Associated With Prompt Gram Staining of Blood Cultures. Am J Clin Pathol. 2008;130:870-876. 54. Timbrook T, Boger MS, Steed LL, Hurst JM. Unanticipated Multiplex PCR Identification of Polymicrobial Blood Culture Resulting in Earlier Isolation, Susceptibilities, and Optimization of Clinical Care. J Clin Microbiol. 2015;53(7):2371-2373. 55. Bauer KA, West JE, Balada-Llasat JM, Pancholi P, Stevenson KB, Goff DA. An Antimicrobial Stewardship Program’s Impact with Rapid Polymerase Chain Reaction Methicillin-Resistant Staphylococcus aureus/S. aureus Blood Culture Test in Patients with S. aureus Bacteremia. Clin Infect Dis. 2010;51(9):1074-1080. 56. Dierkes C, Ehrenstein B, Siebig S, Linde HJ, Reischl U, Salzberger B. Clinical impact of a commercially available multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis. BMC Infect Dis. 2009; 9(1):126 57. Weinstein MP. Blood Culture Contamination: Persisting Problems and Partial Progress. J Clin Microbiol. 2003;41:2275-2278. 58. Weinstein MP, Towns ML Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24:584-602. 59. Ernst DJ. Applied Phlebotomy. Dennis J. Ernst (MT(ASCP)). Lippincott Williams & Wilkins, 2005. 60. Lieseke CL, Zeibig EA. Essentials of Medical Laboratory Practice. F.A. Davis, 2012. 61. Q amruddin A, Khanna N, Orr D. Peripheral blood culture contamination in adults and venipuncture technique: prospective cohort study. J Clin Pathol. 2008;61:509513. 29 RECOMMENDATIONS FOR BLOOD CULTURE COLLECTION A) USING WINGED BLOOD COLLECTION SET (preferred method of collection)59-61 1 PREPARE BLOOD COLLECTION KIT Confirm the patient’s identity and gather all required materials before beginning the collection process. Do not use blood culture bottles beyond their expiration date, or bottles which show signs of damage, deterioration or contamination. It is recommended to identify the Fill-to Mark or mark the target fill level on the blood culture bottle label about 10 ml above the media level. 2 PREPARE BOTTLES FOR INOCULATION Wash hands with soap and water then dry, or apply an alcohol hand rub or another recognized effective hand rub solution. Remove the plastic “flip-cap” from the blood culture bottles and disinfect the septum using an appropriate and recognized effective disinfectant, such as chlorhexidine in 70% isopropyl alcohol, 70% isopropyl alcohol, or tincture of iodine in swab or applicator form. Use a fresh swab/applicator for each bottle. Allow bottle tops to dry in order to fully disinfect. 30 3 PREPARE VENIPUNCTURE SITE If skin is visibly soiled, clean with soap and water. Apply a disposable tourniquet and palpate for a vein. Apply clean examination gloves (sterile gloves are not necessary). Cleanse the skin using an appropriate disinfectant, such as chlorhexidine in 70% isopropyl alcohol or tincture of iodine in swab or applicator form. The venipuncture site is not fully clean until the disinfectant has fully evaporated. 6 OTHER BLOOD TESTS If blood is being collected for other tests, an insert placed into the adapter cap may be required. The insert is used to guide blood collection tubes onto the needle. If other blood tests are requested, always collect the blood culture first. 4 VENIPUNCTURE Attach a winged blood collection set to a collection adapter cap.* To prevent contaminating the puncture site, do not re-palpate the prepared vein before inserting the needle. Insert the needle into the prepared vein. 5 CULTURE BOTTLE INOCULATION Place the adapter cap over the aerobic bottle and press straight down to pierce the septum. Hold the bottle upright, below the level of the draw site, and add up to 10 ml of blood per adult bottle and up to 4 ml per pediatric bottle.† Ensure the bottle is correctly filled to the Fill-to Mark or target fill level. Once the aerobic bottle has been inoculated, repeat the procedure for the anaerobic bottle. 7 FINISH THE PROCEDURE Discard the winged collection set into a sharps container and cover the puncture site with an appropriate dressing. Remove gloves and wash hands before recording the procedure, including indication for culture, date, time, site of venipuncture, and any complications. Ensure additional labels are placed in the space provided on the bottle label and do not cover the bottle barcodes, and that the tear-off barcode labels are not removed. If additional labels contain a barcode, they should be positioned in the same manner as the bottle barcode. Inoculated bottl
Url: /Media/SUHTExtranet/DepartmentOfInfection/STHW841-V1-Biomerieux-Blood-culture-guidance.pdf

UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

BRC Science Forum

Description: Auto Generated Title During the current pandemic, NIHR Southampton Biomedical Research Centre hold a weekly forum to discuss the latest COVID-
Url: /ClinicalResearchinSouthampton/For-researchers/BRC-Science-Forum.aspx

Annual-report-24-25-final

Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-24-25-final.pdf

Wessex leaflet - why does my GP want to reduce my painkillers

Description: Why does my GP want to reduce my pain killers? If you are in pain, you may feel that the idea of reducing and stopping pain killers doesn’t make sense. This leaflet will help to explain why it may be beneficial. We are referring to opioid painkillers used for long-term, non-cancer pain. What are opioids? Opioid drugs include: • Buprenorphine patches (e.g., Butrans®, Butec®, Reletrans®, Sevodyne®) • Codeine (e.g., co-codamol, Zapain®, Solpadol®) • Dihydrocodeine (e.g., co-dydramol®, DHC Continus®) • Fentanyl patches (e.g. Mezolar®, Fencino®, Matrifen®, Durogesic®) • Morphine (e.g. Zomorph®, MST®, Sevredol®, Oramorph®) • Oxycodone (e.g. Longtec®, Shortec®, Oxycontin®, Oxynorm®) • Tramadol (e.g. Zydol®, Tramulief®, Zamadol®) 10 reasons why reducing opioids might be beneficial for me. • Recent evidence shows little benefit of opioids when used long term for pain. They are not actually very effective when taken for more than a few months. • Patients taking opioids for pain have been compared with patients with pain who are not taking opioids. The patients taking opioids tend to have more pain, a worse quality of life and more problems due to side effects. • Everyone who takes opioids long term will become tolerant to them. This means that higher doses are required for the same effect. If you think your opioid must be working because your pain increases when you miss a dose, you may in fact be experiencing withdrawal symptoms. Often pain is no worse after a slow reduction and eventually stopping opioids – sometimes it is improved. Lowering the dose is likely to make you feel better in yourself too. • Reducing opioids may reduce pain! This is more common when very high doses of opioids have been taken as they can damage the pain nerves, making them too sensitive. • Opioids can cause constipation, abdominal pain, weight gain, itchy skin and difficulty breathing at night. It may be more difficult to think clearly when taking opioids. • Opioids can affect your hormones which can result in you feeling miserable and tired or can lead to reduced sexual drive and infertility. • Opioids increase the risk of falls and fractures by over a third. • Taking opioids for many years can affect your ability to fight infection. • Opioids can affect your ability to drive. It is against the law to drive if your ability is impaired, even if this is due to prescribed medication. If in doubt, you should not drive. See https://www.gov.uk/drugdriving-law • Opioids are linked with an increased risk of death, particularly at high doses and when combined with some other medications such as benzodiazepines (e.g. diazepam, temazepam), zopiclone and / or alcohol. This resource has been adapted from NHS Great Yarmouth and Waverney CCG and Southampton City CCG with kind permission. This document has been reviewed by the Wessex Opioid working group in April 2023. How can I reduce my opioids? Discuss a tapering programme with your healthcare professional. Slow, gradual reductions are needed to reduce withdrawal symptoms from the opioids. Your dose may be reduced by 10% every 1-2 weeks. A slower reduction may be more suitable for some people, especially if you have been taking opioids for several years. Do not stop your opioids suddenly as this will result in more severe withdrawal symptoms. Ask for support from your family and friends. Self-management. Ideas to help you to look after your own health and wellbeing are available on the internet. These can help with understanding and managing your pain: • The Retrain Pain Foundation: 8 lessons on understanding pain (one minute each) • Understanding Pain: Brainman Stops His Opioids YouTube video. • My Live Well With Pain: Ten Footsteps (other useful videos and resources about pain self- management also available on this website) What should I expect? You may experience increased pain to start with. This might be the same pain you are being treated for or might be general joint and muscle aches. This is a withdrawal symptom and should settle within a few days. Make a plan to deal with this, for example distraction, activity, stretching, mindfulness, heat. Other withdrawal symptoms can be flu-like, for example, sweats, chills and headache. Diarrhoea, fatigue, anxiety and sleep disturbance can also occur. Withdrawal symptoms can be reduced by slowing the tapering rate or holding the dose. Ensure you discuss this with your GP or healthcare professional and agree a plan to pause or reduce the taper rate. Do not take a higher dose of opioid once tapering has started. This may be dangerous as your tolerance of the opioid will be reduced making you at risk of overdose. Make sure you are reviewed by the same GP or healthcare professional each time (either by telephone or by attending the surgery) so they can provide you with continued support with your dose reductions. It is ok to take a break in the tapering but try to continue to move forward after the pause. Remember that the long term goal is improved pain control and better quality of life while reducing potential harms of treatment. This resource has been adapted from NHS Great Yarmouth and Waverney CCG and Southampton City CCG with kind permission. This document has been reviewed by the Wessex Opioid working group in April 2023.
Url: /Media/UHS-website-2019/Docs/Services/Pain/Wessex-leaflet-why-does-my-GP-want-to-reduce-my-painkillers.pdf

Ready Steady Go: Ask 3 questions

Description: Ask 3 Questions There may be choices to make about your healthcare. Make sure you get the answers to these three questions:* What are my choices? How do I get support to help me make a decision that is right for me? What is good and bad about each choice? Your healthcare team needs you to tell them what is important to you. It’s about shared decision making. AdvAandcvianngciQnugaQlituyaAlitlyliaAnlclieance Right Care Shared Decision Making Programme *Ask 3 Questions has been adapted with kind permission from the MAGIC programme, supported by the Health Foundation. Ask 3 Questions is based on Shepherd HL, et al. Three questions that parents can ask to improve the quality of information physicians give about treatment options: A cross-over trial. Patient education and Counselling, 2011;84: 379-85 StperRoagerdaamydmyGe o Hteosealrvdliucoelts Other questions I would like to ask during my appointment: 1 2 3 4 5 Remember, you can bring someone else with you to your appointment, such as a relative, carer or friend.
Url: /Media/UHS-website-2019/Patientinformation/Visitinghospital/Ready-Steady-Go-Ask-3-questions.pdf

1 to 10 of 132

Previous 1 2 3 4 5 … Next

Browse site A to Z

Search results

Vestibular rehabilitation - patient information

Annual report 2021-2022

UHS AR 22-23-6

Annual report 20-21

STHW841-V1-Biomerieux-Blood-culture-guidance

UHS AR 23-24 Final

BRC Science Forum

Annual-report-24-25-final

Wessex leaflet - why does my GP want to reduce my painkillers

Ready Steady Go: Ask 3 questions

Site policies

Contact details

Useful links