Risk stratification for renal deterioration in the neurogenic bladder patient: Should it be a prerequisite for patient selection in video-urodynamic studies?

Objective: The aim of this retrospective review is to determine whether risk stratification for renal deterioration in neuro-urology patients is supported by urodynamic findings in terms of bladder safety and whether urodynamic findings affect bladder management in this patient group. The primary endpoints are to determine any statistically significant differences between the high and low risk for renal deterioration groups in terms of urodynamic findings regarding bladder safety, and the frequency of changes in bladder management following video-urodynamics (VUDs). Methods: VUDs, which were performed between March 2015 and March 2021 in view of neurogenic lower urinary tract dysfunction, were included in the study. These were divided into those performed in patients with high risk and those in patients with low risk for renal deterioration categories according to criteria specified in the National Institute of Clinical Excellence (NICE) Urinary Incontinence in Neurological Disease guidelines. The two groups were then statistically compared in terms of urodynamic parameters for bladder safety and changes in management thereafter. Results: In total, 69 VUDs were included, 49.3% were classified as having been performed in high risk for renal deterioration patients, and 50.7% as low risk. 50% of those in the former group were found to have an unsafe bladder versus 31.4% in the latter group ( p = 0.12). Meanwhile, 65.2% of VUDs resulted in a change in bladder management, with no difference in change in management frequency between the two risk stratification groups ( p = 0.36). Conclusion: The lack of statistically significant difference in urodynamic bladder safety findings and change in frequency of bladder management for the low and high risk for renal deterioration categories in this cohort bring into question the need for risk stratification in the clinical decision to perform VUDs in the neurogenic bladder patient. Level of evidence: 2c

Certificates and certification programmes for clinical excellence: A guide to international pharmacists

Pharmacy practice continues to evolve, and knowledge update is necessary to facilitate better and safer patient care. This article provides information about certificates and certification programmes hosted for international pharmacists to support their scope in advanced pharmacy practices. A pilot online survey to 59 pharmacists revealed preferences towards Board of Pharmacy Specialties (BPS), American Society of Health-system Pharmacists (ASHP) certificate, Society of Infectious Diseases Pharmacy (SIDP) Antimicrobial stewardship certificate programmes, University of Florida pharmacy certificate programmes, and Medication therapy management programme (MTM) for their certification programme. Grey literature and authentic websites of each programme were collected to provide information on each programme. This article serves as a guide for international pharmacists to know further information about certificates and certification programmes available to support them in advancing their practice.

PP219 Combining Healthcare Solutions For Cataract Surgery. An Incremental Benefit Analysis From The Perspective Of The Russian Healthcare System

IntroductionRising health expenditures lead to increasing budgetary pressures, which often manifest in budget managers seeking more for the same resources or trying to maintain the status quo with less. Consequently, enablers that drive efficiencies throughout the entire care pathway have come under increasing focus. This is particularly true in the operating room (OR) setting where considerations around operational efficiency, clinical excellence, and patient-centered care pose challenging questions. While a comprehensive solution set should be formulated, small parts of the solution can be applied now to prime systems for easy integration into future solutions. The objective of this analysis was to estimate the impact of combining custom healthcare solutions for cataract surgery from the perspective of a Russian hospital.MethodsA decision-analytic model was developed to assess the aggregated impact of combining the following products or services for cataract surgery: an intraocular lens delivery-system; process-redesign; a phacoemulsification machine; and a phaco tip. The model and underlying assumptions were validated by clinical experts. OR time-savings was chosen as the variable of efficiency underpinning the analysis. Inputs were estimated from the literature, expert opinion, and the local cost databases. Two scenarios were defined that reflected technologies commonly used in surgical practice. The model scenarios assumed that a hospital performs 2,000 cataract procedures per year, with 100 percent adoption and equal acquisition costs.ResultsChoosing a combination of healthcare solutions for cataract surgery was associated with an incremental benefit of RUB5,935,982 per year (EUR71,364) and generated an OR time saving of approximately 237 cataract procedures.ConclusionsThis analysis highlighted that, compared with treating technologies on an individual level, combining healthcare solutions commonly used for cataract surgery has the potential to drive efficiencies and cost savings for hospitals and to reduce surgical wait lists.

INNV-35. A MULTI-DISCIPLINARY REVIEW OF NEWLY DIAGNOSED HIGH GRADE GLIOMA REFERRALS TO THERAPIES, AND IMPLEMENTATION OF A SCREENING TOOL TO IMPROVE ACCESS TO THERAPIES AT THE ROYAL MARSDEN HOSPITAL (RMH)

Brain tumours make up 3% of all cancers. The disease and treatment have significant impact on function and quality of life (QoL). Early outpatient rehabilitation can improve function. National Institute of Clinical Excellence recommends patients have access to rehabilitation across the pathway, but unmet need is prevalent in this population. We recognised late referrals in our Trust and poor patient awareness of Therapies, resulting in reduced access to rehabilitation. METHOD: A retrospective notes review of new neuro-oncology patients (n=56) referred to RMH from July - December 2018 was undertaken to identify therapy needs and timeliness of referrals. A therapy screening tool was devised and piloted from July – December 2019. Additionally, an MDT questionnaire was circulated to gain feedback regarding this service. RESULTS: Retrospective review revealed that of those patients with identified therapy needs, 16% of physiotherapy (PT), 10% of Occupational Therapy (OT) and 9% of Speech and Language Therapy (SLT) were referred late. Additionally, referrals were not received for 40% of patients with OT needs, 32% for PT and 30% for SLT. Following implementation of the screening tool, referrals occurred earlier in the pathway, and rates increased by 60% in SLT, 59% in PT, and 25% in OT. An MDT questionnaire revealed 100% consensus that screening was beneficial to patients and the MDT with improved access to therapies. CONCLUSION: Brain tumour patients require prompt therapy intervention to improve and maintain function and QoL. We identified high levels of unmet need which was eliminated by a screening tool and subsequently increased referral rates. Patients and the MDT had improved awareness of the role of Therapies, as well as earlier access. The neuro-oncology MDT benefitted from the effects of therapy intervention improving patient tolerance to oncological treatment. Therapists were able to identify and manage impairments earlier, improving QoL.

Laboratory/Pathology Services and Blood Bank

Pathology and its laboratories are central in support of every facet of cancer care in a CCC center, from diagnosis, to patient support during treatment, research, therapeutic drug manufacture and development and bio-banking.We have approached this discussion from the perspective of the timeline of a patient’s journey through cancer care. We begin with screening programs, high quality diagnostics and then maintaining quality supportive cancer care. Specialised services such as cellular therapies and haematopoietic stem cell transplantation with their unique requirements are considered and lastly we discuss the vital role of clinical trials and research in comprehensive cancer care with a focus on biobanks.We also examine the role of the diagnostic laboratories and their clinical and scientific staff in shaping an integrated cancer diagnostic report, as an integral part of a cancer Multidisciplinary Team (MDT) or “Tumour Board”. Increasingly, integration of a large amount of clinical data, laboratory results and interpretation of complex molecular and genomic datasets is required to underpin the role of CCC’s as centres of clinical excellence and to collaborate with partners in local, national and international research protocols.

Should National Institute for Clinical Excellence (NICE) Guidelines Remove Urine Cytology as a Suggested Adjunct in Suspected Bladder Cancer (haematuria) Investigations?

BackgroundDespite National Institute for Clinical Excellence (NICE) guidelines suggesting the use of urine cytology (UC) for the diagnosis of bladder cancer, its use is variable. Reasons for this include sub-optimal sensitivity, financial cost, availability of alternative tests, and uncertainty over interpretation of results. Anecdotally, however, suspicious or malignant UC when other investigations are normal, occasionally leads to a cancer diagnosis. Therefore, we retrospectively assessed a cohort of our haematuria patients to determine the value of UC in cancer diagnosis and the clinical significance of atypical UC (graded as C3). Patients and methodsWe identified 3018 patients with haematuria referred on the suspected cancer pathway (“two-week wait”) in 2015. We retrospectively analysed clinical, demographic, and follow-up/outcome data in a random cohort of 500 cases. ResultsMedian follow up was 58 months. Urological malignancy was diagnosed in 61/500 patients; all were identified by cystoscopy or imaging, i.e., irrespective of UC result. No cases of atypical UC re-presented with a ‘missed’ cancer diagnosis within the five-year follow-up period. However, suspicious and malignant cytology was associated with high-grade/aggressive tumours and subsequent tumour recurrence. ConclusionUrine cytology did not identify any cancers that were not already found by imaging or cystoscopy. Atypical UC in the presence of negative haematuria investigations does not appear to be associated with malignancy, and therefore should not alter patient management nor prompt further investigation. Suspicious and malignant UC was associated with higher risk cancers and could therefore be used to prioritise waiting lists for transurethral resection of bladder tumour (TURBT), however, it is unclear whether this might benefit patient outcomes. We conclude therefore that UC has no role in haematuria investigations.

TP6.2.9 1224 Surgical Endoscopic Retrograde Cholangio-Pancreatography over three years. A single unit’s experience of service provision and delivery of clinical excellence

Aims Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is traditionally the domain of medical gastro-enterology. Our practice is exclusively surgeon delivered and therefore represents an alternative paradigm. The British society of Gastro-enterology (BSG) proposed key performance indicators in 2014 to evaluate standards of ERCP practice with focus on performance and safety against which we evaluated our practice. Methods The study period covers 3 years from September 2016 to August 2019. An analysis of prospectively collected data was performed. Performance of the individual surgeons and collective was collated and retrospectively analysed. Results The unit’s caseload for the 3 years period was 1224 procedures. Each surgeon’s share was similar, i.e. 454, 430 and 340 cases respectively (BCG 75 per annum). Most procedures were performed electively, some on emergency basis or within two weeks. Biliary duct stones were the most common indications for the procedure, followed by malignancy. Overall bile duct cannulation rate was 95.3%; and 91.8% for first ERCP (BSG > 85%). CBD clearance was achieved in 80.6% cases, and stone clearance at first ERCP was 78.6% (BSG > 75%). Successful stenting of extra-hepatic biliary stricture was achieved in 89.4% cases at first ERCP (BSG > 80%). Overall complications rate was 6.2% and for level 1 & 2 cases 5.3% (BSG less than 6% is accepted standard). Conclusions We performed a high volume of safe and effective ERCPs with low risk of complications in line with national standards. ERCP has become an exclusive therapeutic tool in surgical management of gall stones disease and biliary malignancy.

513 - Lithium monitoring in Old Age Psychiatry – a quality improvement project

INTRODUCTION:Lithium has a narrow therapeutic index with a risk of toxicity and potential to increase morbidity and mortality, particularly in the elderly with co-morbid illness and polypharmacy. Lithium therapy and monitoring of lithium levels require precision and several guidelines have been issued including recommendations for strict control of lithium levels in the elderly population.RESEARCH OBJECTIVE:We evaluated the effect of implementation of a multifaceted management programme on the compliance with international practice standards for lithium monitoring in patients under the care of Psychiatry of Old Age (POA), Sligo Leitrim Mental Health Services in the North West of Ireland.METHODS:Results from a prior audit performed in February 2020 involving a cohort of 18 patients prescribed lithium under the care of POA were analysed and compared to accepted standards. The guideline used as the benchmark for compliance was the National Institute for Clinical Excellence (NICE) guidelines on the use and monitoring of lithium therapy, as published in 2014. Several deficits were found and therefore a designated Lithium Management Programme was established. A subsequent audit, performed using a simplified audit tool incorporating the NICE guidelines, delivered results which were directly compared to the initial findings and analysed to evaluate the effect of the implemented management programme.PRELIMINARY RESULTS OF THE ONGOING STUDY:In comparison with findings from 2020, there had been a significant improvement in most facets of lithium management and compliance to practice standards. Of particular note was the improvement of biochemical monitoring, side effect screening, polypharmacy surveillance, patient education and interdisciplinary communication.CONCLUSION:The launch of a dedicated Lithium Management Programme with specific features aimed at identifying and addressing poor compliance with monitoring guidelines has led to improved adherence to accepted international practice standards. Our model provides a dynamic, multi-layered system which paves the way for better patient outcomes, timely access to care and furthering education for patients and staff members.

Adherence to NICE Guidelines on Colorectal Cancer Follow-Up: A Cross-Sectional Analysis

Purpose: Our aims were to determine adherence to National Institute of Clinical Excellence (NICE) guidelines on colorectal cancer (CRC) surveillance and to evaluate local practice patterns determine how it can be further improved. Patients and methods: Patients with colorectal cancer resection between January 1, 2017 and December 31, 2017 were identified, and their records retrospectively reviewed. Results: A total of 18 patients were eligible. Surveillance patterns, including blood tests and colonoscopies, were inconsistent with NICE recommendations in a significant proportion of patients. Follow up appointments and CT imaging occurred more frequently in line with the guidelines. For recurrences detected by surveillance, 66.6% were resectable whereas 0% of those detected by symptoms were resectable. Conclusions: The results prove that a moderately intensive follow-up strategy can positively identify resectable recurrence thus increasing overall survival. Our data highlights the need for local improvement to adherence to NICE guidelines regarding CRC follow-up. We have created a pro forma which is attached to the patient’s clinical notes. It will aid clinicians in reminding them when appropriates tests should be completed. A re-audit will be completed in December 2020 which will include looking at the effectiveness of the new pro forma.

From the margins to the NICE guidelines: British clinical psychology and the development of cognitive behaviour therapy for psychosis, 1982–2002

Although histories of cognitive behaviour therapy have begun to appear, their use with people with psychosis diagnoses has received relatively little attention. In this article, we elucidate the conditions of possibility for the emergence of cognitive behaviour therapy for psychosis (CBTp) in England between 1982 and 2002. We present an analysis of policy documents, research publications and books, participant observation, and interviews with a group of leading researchers and senior policy actors. Informed by Derksen and Beaulieu’s articulation of social technologies, we show how CBTp was developed and stabilised through the work of a variety of overlapping informal, academic, clinical, professional, and policy networks. The profession of clinical psychology played a key role in this development, successfully challenging the traditional ‘division of labour’ where psychologists focused on ‘neurosis’ and left ‘psychosis’ to psychiatry. Following Abbott's systems approach to professions, we identify a number of historical factors that created a jurisdictional vulnerability for psychiatry while strengthening the jurisdictional legitimacy of clinical psychology in providing psychological therapies to service users with psychosis diagnoses. The National Institute for Health and Clinical Excellence played a significant role in adjudicating jurisdictional legitimacy, and its 2002 schizophrenia guidelines, recommending the use of psychological therapies, marked a radical departure from the psychiatric consensus. Our analysis may be of wider interest in its focus on social technologies in a context of jurisdictional contestation. We discuss the implications of our study for the field of mental health and for the relationship between clinical psychology and psychiatry.