Imperial College London

Emeritus ProfessorDerekBell

Faculty of MedicineSchool of Public Health

Emeritus Professor in Acute Medicine



+44 (0)7886 725 212d.bell




Miss Heather Barnes +44 (0)20 3315 8144




Chelsea and Westminster HospitalChelsea and Westminster Campus





Publication Type

246 results found

Cafferkey J, Ferguson A, Grahamslaw J, Oatey K, Norrie J, Lone N, Walsh T, Horner D, Appelboam A, Hall P, Skipworth R, Bell D, Rooney K, Shankar-Hari M, Corfield A, Gray Aet al., 2023, Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis"., J Intensive Care Soc, Vol: 24, Pages: 78-84, ISSN: 1751-1437

BACKGROUND: Patients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window. METHODS: ABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours. OBJECTIVES: Primary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs. DISCUSSION: This trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.

Journal article

Sakonidou S, Kotzamanis S, Tallett A, Poots AJ, Modi N, Bell D, Gale Cet al., 2023, Parents’ Experiences of Communication in neonatal care (PEC): a neonatal survey refined for real-time parent feedback, Archives of Disease in Childhood: Fetal and Neonatal Edition, Pages: 1-5, ISSN: 1359-2998

Objective Assessing parent experiences of neonatal services can help improve quality of care; however, there is no formally evaluated UK instrument available to assess this prospectively. Our objective was to refine an existing retrospective survey for ‘real-time’ feedback.Methods Co-led by a parent representative, we recruited a convenience sample of parents of infants in a London tertiary neonatal unit. Our steering group selected questions from the existing retrospective 61-question Picker survey (2014), added and revised questions assessing communication and parent involvement. We established face validity, ensuring questions adequately captured the topic, conducted parent cognitive interviews to evaluate parental understanding of questions,and adapted the survey in three revision cycles. We evaluated survey performance.Results The revised Parents’ Experiences of Communication in Neonatal Care (PEC) survey contains 28 questions (10 new) focusing on communication and parent involvement. We cognitively interviewed six parents, and 67 parents completed 197 PEC surveys in the survey performance evaluation. Missing entries exceeded 5% for nine questions; we removed one and format-adjusted the rest as they had performed well during cognitive testing. There was strong inter-item correlation between two question pairs; however, all were retained as they individually assessed important concepts.Conclusion Revised from the original 61-question Picker survey, the 28-question PEC survey is the first UK instrument formally evaluated to assess parent experience while infants are still receiving neonatal care. Developed with parents, it focuses on communication and parent involvement, enabling continuous assessment and iterative improvement of family-centred interventions in neonatal care.

Journal article

Sunkersing D, Martin FC, Sullivan P, Bell Det al., 2022, Care and support networks of community-dwelling frail individuals in North West London: a comparison of patient and healthcare workers’ perceptions, BMC Geriatrics, Vol: 22, ISSN: 1471-2318

Background:Evidence suggests that successful assessment and care for frail individuals requires integrated and collaborative care and support across and within settings. Understanding the care and support networks of a frail individual could therefore prove useful in understanding need and designing support. This study explored the care and support networks of community-dwelling older people accessing a falls prevention service as a marker of likely frailty, by describing and comparing the individuals’ networks as perceived by themselves and as perceived by healthcare providers involved in their care.Methods:A convenience sample of 16 patients and 16 associated healthcare professionals were recruited from a community-based NHS ‘Falls Group’ programme within North-West London. Individual (i.e., one on one) semi-structured interviews were conducted to establish an individual’s perceived network. Principles of quantitative social network analysis (SNA) helped identify the structural characteristics of the networks; qualitative SNA and a thematic analysis aided data interpretation.Results:All reported care and support networks showed a high contribution level from family and friends and healthcare professionals. In patient-reported networks, ‘contribution level’ was often related to the ‘frequency’ and ‘helpfulness’ of interaction. In healthcare professional reported networks, the reported frequency of interaction as detailed in patient records was used to ascertain ‘contribution level’.Conclusion:This study emphasises the importance of the role of informal carers and friends along with healthcare professionals in the care of individuals living with frailty. There was congruence in the makeup of ‘patient’ and ‘provider’ reported networks, but more prominence of helper/carers in patients’ reports. These findings also highlight the multidisciplinary makeup of a care and s

Journal article

Soong JTY, Bell D, Ong MEH, 2022, Meeting today's healthcare needs: Medicine at the interface., Annals of the Academy of Medicine, Singapore, Vol: 51, Pages: 787-792, ISSN: 0304-4602

The demographic of Singapore has undergone dramatic change. Historically, younger patients with communicable diseases predominated, whereas patients are now older with chronic multimorbidity and functional impairment. This shift challenges existing health and social care systems in Singapore, which must pivot to meet the changing need. The consequences of mismatched health and social care to patient needs are the fragmentation of care, dysfunctional acute care utilisation and increasing care costs. In Singapore and internationally, there is an inexorable rise in acute care utilisation, with patients facing the greatest point of vulnerability at transitions between acute and chronic care. Recently, innovative care models have developed to work across the boundaries of traditional care interfaces. These "Interface Medicine" models aim to provide a comprehensive and integrated approach to meet the healthcare needs of today and optimise value with our finite resources. These models include Acute Medical Units, Ambulatory Emergency Care, Extensivist-Comprehensivist Care, Virtual Wards, Hospital-at-Home and Acute Frailty Units. We describe these models of care across the acute care chain and explore how they may apply to the Singapore setting. We discuss how these models have evolved, appraise the evidence for clinical effectiveness, point out gaps in knowledge for further study and make recommendations for future progress.

Journal article

Blackwell N, Durham L, Binks R, Bell D, Williams Bet al., 2022, The development and introduction of a national e-learning programme to support the dissemination of NEWS2., Clinical medicine (London, England), Vol: 22, Pages: 530-533, ISSN: 1470-2118

Early detection, timeliness and competence of clinical response are a triad of determinants of clinical outcome in people with acute illness. In 2012, the Royal College of Physicians published the National Early Warning Score (NEWS) with the aim of standardising the response to, assessment of and monitoring of acutely ill patients. This was subsequently updated in December 2017 to become NEWS2. Alongside the development of NEWS/NEWS2, it was clear that a supportive educational package was going to be essential for dissemination, learning and national adoption of NEWS/NEWS2 across all healthcare settings. Another driver for the early development of an e-learning package to accompany the launch of NEWS in 2012 was the opportunity that it provided not only to standardise the early warning system across the NHS but also to use that standardised process to facilitate better and more consistent education and training across the entire healthcare system; building on the concept of NEWS providing a common language.

Journal article

Nakubulwa MA, Greenfield G, Pizzo E, Magusin A, Maconochie I, Blair M, Bell D, Majeed A, Sathyamoorthy G, Woodcock Tet al., 2022, To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study, PLoS One, Vol: 17, ISSN: 1932-6203

National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote heal

Journal article

Marinova M, Sathyamoorthyr G, Singhal P, Bullivant J, Bell Det al., 2021, Equality and diversity in health governance systems: are we getting it right and are there lessons from COVID-19?, Journal of the Royal College of Physicians of Edinburgh, Vol: 51, Pages: 407-413, ISSN: 1478-2715

The COVID-19 pandemic highlighted major challenges in governance and inequalities particularly among those from Black, Asian and minority ethnic (BAME) groups. This paper focuses on the BAME community and explores this through a governance lens, with particular reference to the representation and functioning of boards involved in healthcare and building a transparent culture. To illustrate this, the paper utilises a series of structured reflective questions with model answers termed Right Question, Right Answer and links to the Centre for Quality in Governance (CQG) Maturity Matrix. This article highlights the need to improve diversity and accountability of health and care organisations to their staff and local population. For governance to be effective, it must be aligned and comply with healthcare system regulations to ensure improvement of legislative acts and standards. The paper aims to inform government policy by moving from rhetoric, or merely describing challenges, to action and change by increasing accountability.

Journal article

Soong JTY, La Wong A, O'Connor I, Marinova M, Fisher D, Bell Det al., 2021, Acute medical units during the first wave of the COVID-19 pandemic: a cross-national exploratory study of impact and responses, Clinical Medicine, Vol: 21, Pages: E462-E469, ISSN: 1470-2118

Background The COVID-19 pandemic represents one of the greatest ever challenges for healthcare. In the UK and beyond, acute medical units (AMUs) are the first point of assessment and care for the majority of medical inpatients. By their design and systems, they inevitably played an important role in the COVID-19 response but to date little has been published on how the COVID-19 pandemic has affected how AMUs have reorganised their resources, processes and structure.Methods This retrospective study in August 2020 of 10 AMUs across Europe and Australasia used a standardised questionnaire to investigate existing practice and structure of AMUs, the national context of local hospital experience, changes to practice during the COVID-19 pandemic and views regarding future practice.Results Changes to AMU structure, process and organisation are described in two contexts: preventing and controlling the spread of COVID-19 and adding value to the patient's acute care journey in the local context. We describe novel practices that have arisen and highlight areas of concern.Conclusions The AMUs were able to adapt to meet the demands of acute care delivery during the first wave of the COVID-19 pandemic. Operational planning and prioritisation of resources must be optimised to ensure sustainability of these services for future waves.

Journal article

Barker RE, Kon SS, Clarke SF, Wenneberg J, Nolan CM, Patel S, Walsh JA, Polgar O, Maddocks M, Farquhar M, Hopkinson NS, Bell D, Wedzicha JA, Man WD-Cet al., 2021, COPD discharge bundle and pulmonary rehabilitation referral and uptake following hospitalisation for acute exacerbation of COPD, Thorax, Vol: 76, Pages: 829-831, ISSN: 0040-6376

Pulmonary rehabilitation (PR) following hospitalisations for acute exacerbation of COPD (AECOPD) is associated with improved exercise capacity and quality of life, and reduced readmissions. However, referral for, and uptake of, post-hospitalisation PR are low. In this prospective cohort study of 291 consecutive hospitalisations for AECOPD, COPD discharge bundles delivered by PR practitioners compared with non-PR practitioners were associated with increased PR referral (60% vs 12%, p<0.001; adjusted OR: 14.46, 95% CI: 5.28 to 39.57) and uptake (40% vs 32%, p=0.001; adjusted OR: 8.60, 95% CI: 2.51 to 29.50). Closer integration between hospital and PR services may increase post-hospitalisation PR referral and uptake.

Journal article

Bell D, 2021, Our NHS our concern – written evidence PSR0035, Publisher: Our NHS Our Concern


Wong KY, Davies B, Adeleke Y, Woodcock T, Matthew D, Sekelj S, Orlowski A, Porter B, Hashmy S, Mathew A, Grant R, Kaba A, Unger-Graeber B, Petrungaro B, Wallace J, Bell D, Cowie MR, Khan Set al., 2021, Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative, Open Heart, Vol: 8, ISSN: 2053-3624

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

Journal article

Vaughan L, Bardsley M, Bell D, Davies M, Goddard A, Imison C, Melnychuk M, Morris S, Rafferty AMet al., 2021, Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study, Health Services and Delivery Research, Vol: 9, Pages: 1-158, ISSN: 2050-4349

BackgroundThe increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.ObjectiveTo investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.MethodsThe design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.ResultsIn total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that mod

Journal article

Marinova M, Bell LM, Watkin S, Bell Det al., 2020, A prospective audit of bed utilisation and delays in care across London, Journal of the Royal College of Physicians of Edinburgh, Vol: 50, Pages: 365-371, ISSN: 1478-2715

Background A prospective bed utilisation census of acute London hospitals using an established Day of Care Survey (DoCS), which quantified adult patients not meeting criteria for in-hospital care.Methods Twenty-three hospitals were surveyed over two weeks in October/November 2017 using supervised trained hospital staff. Pairs of staff visited wards, reviewed all patients and identified those not meeting inpatient care criteria, recording reasons for delay. Patient demographics, length of stay (LOS), ward specialty and delay reasons were collected.Results Overall – In total, 8,656 in-patients were studied (overall occupancy 96%, range 82-117%): 800 definite discharges were excluded, leaving 7,856 patients for analysis; seven hospitals had ≥100% occupancy; 1,919/7,856 patients (24%, range 12–43%) did not meet criteria; 56% of patients were over 70 years; five hospitals had higher number of patients <70yo. 56% patients had LOS 0≤7days. Delayed patients – Number of delayed patients increased with age, but three hospitals had more patients <70yo; 53% had LOS≤14 days and 47% LOS>14 days; 13 hospitals had greater/equal number of patients in ≤14 days LOS. For delayed patients in ≤14 days group, most were within seven days of admission (627 ≤7days, 393 8-14 days). In total 34% (range 11-54%) of delays were related to acute hospital reasons (AHR) and 61% (range 46-83%) to wider system reasons (WSR). Eight common themes accounted for 67% of recorded reasons and were equally split between AHR and WSR.Conclusion Data showed high occupancy levels with insufficient discharges. This study suggests policies selecting age and/or LOS alone as cut offs to tackle delays in care may miss a large proportion of patients requiring more timely interventions. Adopting a proactive thematic approach to improvement using the top eight delay reasons provides an obvious opportunity to reduce delays while noting the inter site variation. All metrics anal

Journal article

Barker RE, Jones SE, Banya W, Fleming S, Kon SSC, Clarke SF, Nolan CM, Patel S, Walsh JA, Maddocks M, Farquhar M, Bell D, Wedzicha JA, Man WD-Cet al., 2020, Reply to: one step at a time: a phased approach to behavioral treatment development in pulmonary rehabilitation, American Journal of Respiratory and Critical Care Medicine, Vol: 202, Pages: 775-777, ISSN: 1073-449X

Journal article

Barker RE, Jones SE, Banya W, Fleming S, Kon SSC, Clarke SF, Nolan CM, Patel S, Walsh JA, Maddocks M, Farquhar M, Bell D, Wedzicha JA, Man WD-Cet al., 2020, The effects of a video intervention on post-hospitalization pulmonary rehabilitation uptake: a randomized controlled trial., American Journal of Respiratory and Critical Care Medicine, Vol: 201, Pages: 1517-1524, ISSN: 1073-449X

RATIONALE: Pulmonary rehabilitation following hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life, and reduces readmissions. However, post-hospitalization pulmonary rehabilitation uptake is low. To date, no trials of interventions to increase uptake have been conducted. OBJECTIVE: Effect of a co-designed education video as an adjunct to usual care on post-hospitalization pulmonary rehabilitation uptake. METHODS: An assessor- and statistician-blinded randomized controlled trial with nested qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including pulmonary rehabilitation information leaflet) or usual care plus the co-designed education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, forced expiratory volume in 1 second (FEV1) % predicted, frailty, transport availability and previous pulmonary rehabilitation experience. MEASUREMENTS AND MAIN RESULTS: The primary outcome was pulmonary rehabilitation uptake within 28 days of hospital discharge. 200 patients were recruited with 196 randomized (51% female, median (interquartile range) FEV1 % predicted 36(27, 48)). Pulmonary rehabilitation uptake was 41% and 34% in the usual care and intervention groups respectively (p=0.37), with no differences in secondary (pulmonary rehabilitation referral and completion) or safety (readmissions and death) endpoints. Six of the fifteen participants interviewed could not recall receiving the video. CONCLUSION: A co-designed education video delivered at hospital discharge did not improve post-hospitalization pulmonary rehabilitation uptake, referral or completion. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0

Journal article

Sakonidou S, Andrzejewska I, Webbe J, Modi N, Bell D, Gale Cet al., 2020, Interventions to improve quantitative measures of parent satisfaction in neonatal care: a systematic review, BMJ Paediatrics Open, Vol: 4, ISSN: 2399-9772

Objective: Interventions improving parent satisfaction can reduce parent stress, may improve parent-infant bonding and infant outcomes. Our objective was to systematically review neonatal interventions relating to parents of infants of all gestations where an outcome was parent satisfaction. Methods: We searched the databases MEDLINE, EMBASE, PsychINFO, Cochrane Central Register of Controlled Trials, CINAHL, HMIC, Maternity and Infant Care between 1 January 1946 and 1 October 2017. Inclusion criteria were randomised controlled trials (RCT), cohort studies and other non-randomised studies if participants were parents of infants receiving neonatal care, interventions were implemented in neonatal units (of any care level) and ≥1 quantitative outcome of parent satisfaction was measured. Included studies were limited to the English language only. We extracted study characteristics, interventions, outcomes and parent involvement in intervention design. Included studies were not sufficiently homogenous to enable quantitative synthesis. We assessed quality with the Cochrane Collaboration risk of bias tool (randomised) and the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) (non-randomised studies). Results: We identified 32 studies with satisfaction measures from over 2800 parents and grouped interventions into 5 themes. Most studies were non-randomised involving preterm infants. Parent satisfaction was measured by 334 different questions in 29 questionnaires (only 6/29 fully validated). 18/32 studies reported higher parent satisfaction in the intervention group. The intervention theme with most studies reporting higher satisfaction was parent involvement (10/14). Five (5/32) studies reported involving parents in intervention design. All studies had high risk of bias. Conclusions: Many interventions, commonly relating to parent involvement, are reported to improve parent satisfaction. Inconsistency in satisfaction measurements and high risk of b

Journal article

Soong JT, Rolph G, Poots AJ, Bell Det al., 2020, Validating a methodology to measure frailty syndromes at hospital level utilising administrative data., Clinical medicine (London, England), Vol: 20, Pages: 183-188, ISSN: 1470-2118

BACKGROUND: Identifying older people with clinical frailty, reliably and at scale, is a research priority. We measured frailty in older people using a novel methodology coding frailty syndromes on routinely collected administrative data, developed on a national English secondary care population, and explored its performance of predicting inpatient mortality and long length of stay at a single acute hospital. METHODOLOGY: We included patient spells from Secondary User Service (SUS) data for those ≥65 years with attendance to the emergency department or admission to West Middlesex University Hospital between 01 July 2016 to 01 July 2017. We created eight groups of frailty syndromes using diagnostic coding groups. We used descriptive statistics and logistic regression to explore performance of diagnostic coding groups for the above outcomes. RESULTS: We included 17,199 patient episodes in the analysis. There was at least one frailty syndrome present in 7,004 (40.7%) patient episodes. The resultant model had moderate discrimination for inpatient mortality (area under the receiver operating characteristic curve (AUC) 0.74; 95% confidence interval (CI) 0.72-0.76) and upper quartile length of stay (AUC 0.731; 95% CI 0.722-0.741). There was good negative predictive value for inpatient mortality (98.1%). CONCLUSIONS: Coded frailty syndromes significantly predict outcomes. Model diagnostics suggest the model could be used for screening of elderly patients to optimise their care.

Journal article

Adeleke Y, Matthew D, Porter B, Woodcock T, Yap J, Hashmy S, Mathew A, Grant R, Kaba A, Unger-Graeber B, Khan S, Bell D, Cowie MRet al., 2019, Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices, Open Heart, Vol: 6, ISSN: 2053-3624

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

Journal article

Kremers MNT, Nanayakkara PWB, Levi M, Bell D, Haak HRet al., 2019, Strengths and weaknesses of the acute care systems in the United Kingdom and the Netherlands: what can we learn from each other?, BMC Emergency Medicine, Vol: 19, Pages: 1-7, ISSN: 1471-227X

BackgroundThe demand on Emergency Departments and acute medical services is increasing internationally, creating pressure on health systems and negatively influencing the quality of delivered care. Visible consequences of the increased demand on acute services is crowding and queuing. This manifests as delays in the Emergency Departments, adverse clinical outcomes and poor patient experience.OverviewDespite the similarities in the UK’s and Dutch health care systems, such as universal health coverage, there are differences in the number of patients presenting at the Emergency Departments and the burden of crowding between these countries. Given the similarities in funding, this paper explores the similarities and differences in the organisational structure of acute care in the UK and the Netherlands. In the Netherlands, less patients are seen at the ED than in England and the admission rate is higher. GPs and so-called GP-posts serve 24/7 as gatekeepers in acute care, but EDs are heterogeneously organised. In the UK, the acute care system has a number of different access points and the accessibility of GPs seems to be suboptimal. Acute ambulatory care may relieve the pressure from EDs and Acute Medical Units. In both countries the ageing population leads to a changing case mix at the ED with an increased amount of multimorbid patients with polypharmacy, requiring generalistic and multidisciplinary care.ConclusionThe acute and emergency care in the Netherlands and the UK face similar challenges. We believe that each system has strengths that the other can learn from. The Netherlands may benefit from an acute ambulatory care system and the UK by optimizing the accessibility of GPs 24/7 and improving signposting for urgent care services. In both countries the changing case mix at the ED needs doctors who are superspecialists instead of subspecialists. Finally, to improve the organisation of health care, doctors need to be visible medical leaders and participate in

Journal article

Sakonidou S, Andrzejewska I, Kotzamanis S, Carnegie W, Nakubulwa M, Woodcock T, Modi N, Bell D, Gale Cet al., 2019, Better use of data to improve parent satisfaction (BUDS): protocol for a prospective before-and-after pilot study employing mixed methods to improve parent experience of neonatal care, BMJ Paediatrics Open, Vol: 3, ISSN: 2399-9772

Introduction Having a baby that requires neonatal care is stressful and traumatic. Parents often report dissatisfaction with communication of clinical information. In the UK neonatal care data are recorded daily using electronic patient record systems (EPR), from which deidentified data form the National Neonatal Research Database (NNRD). We aim to evaluate the impact of sharing neonatal EPR data with parents, on parent-reported satisfaction, parent–staff interactions, staff workload and data completeness.Methods A prospective, before-and-after, mixed-method study. Participants are parents of inpatient babies (maximum 90) and staff in a tertiary neonatal intensive care unit, London, UK. The intervention was developed by former neonatal parents, neonatologists and neonatal nurses: a communication tool for parents comprising individualised, written, daily infant updates for parents, derived from EPR data. The intervention will be provided to parents over 6 weeks. Plan-Do-Study-Act cycles will inform the tool’s iterative development and improvement. The tool’s impact will be measured using a validated parent survey, staff survey, data completeness measures and interviews.Analysis Primary outcome: parent satisfaction ‘with communication of clinical information and involvement in care’. Secondary outcomes: parent–staff interactions, staff workload, data completeness. Baseline survey data will be obtained from clinical service evaluation preceding the intervention. Baseline data completeness will be derived from the NNRD. During the intervention, surveys will be administered biweekly and data completeness assessed daily. We will analyse outcomes using run charts and partially paired statistical tests. Parent and staff interviews will explore information exchange and the communication tool’s impact.Discussion This study will evaluate the impact of a parent co-designed intervention on communication with parents in neonatal care and

Journal article

Soong JTY, Kaubryte J, Liew D, Peden CJ, Bottle A, Bell D, Cooper C, Hopper Aet al., 2019, Dr Foster global frailty score: an international retrospective observational study developing and validating a risk prediction model for hospitalised older persons from administrative data sets, BMJ Open, Vol: 9, ISSN: 2044-6055

OBJECTIVES: This study aimed to examine the prevalence of frailty coding within the Dr Foster Global Comparators (GC) international database. We then aimed to develop and validate a risk prediction model, based on frailty syndromes, for key outcomes using the GC data set. DESIGN: A retrospective cohort analysis of data from patients over 75 years of age from the GC international administrative data. A risk prediction model was developed from the initial analysis based on seven frailty syndrome groups and their relationship to outcome metrics. A weighting was then created for each syndrome group and summated to create the Dr Foster Global Frailty Score. Performance of the score for predictive capacity was compared with an established prognostic comorbidity model (Elixhauser) and tested on another administrative database Hospital Episode Statistics (2011-2015), for external validation. SETTING: 34 hospitals from nine countries across Europe, Australia, the UK and USA. RESULTS: Of 6.7 million patient records in the GC database, 1.4 million (20%) were from patients aged 75 years or more. There was marked variation in coding of frailty syndromes between countries and hospitals. Frailty syndromes were coded in 2% to 24% of patient spells. Falls and fractures was the most common syndrome coded (24%). The Dr Foster Global Frailty Score was significantly associated with in-hospital mortality, 30-day non-elective readmission and long length of hospital stay. The score had significant predictive capacity beyond that of other known predictors of poor outcome in older persons, such as comorbidity and chronological age. The score's predictive capacity was higher in the elective group compared with non-elective, and may reflect improved performance in lower acuity states. CONCLUSIONS: Frailty syndromes can be coded in international secondary care administrative data sets. The Dr Foster Global Frailty Score significantly predicts key outcomes. This methodology may be feasibly utili

Journal article

Honeyford K, Bell D, Chowdhury F, Quint J, Aylin P, Bottle Aet al., 2019, Unscheduled hospital contacts after inpatient discharge: A national observational study of COPD and heart failure patients in England, PLoS ONE, Vol: 14, ISSN: 1932-6203

IntroductionReadmissions are a recognised challenge for providers of healthcare and incur financial penalties in a growing number of countries. However, the scale of unscheduled hospital contacts including attendances at emergency departments that do not result in admission is not well known. In addition, little is known about the route to readmission for patients recently discharged from an emergency hospital stay.MethodsThis is an observational study of national hospital administration data for England. In this retrospective cohort study, we tracked patients for 30 days after discharge from an emergency admission for heart failure (HF) or chronic obstructive pulmonary disorder (COPD).ResultsThe majority of patients (COPD:79%; HF:75%) had no unscheduled contact with secondary health care within 30 days of discharge. Of those who did have unscheduled contact, the most common first unscheduled contact was emergency department (ED) attendance (COPD:16%; HF:18%). A further 5% of COPD patients and 4% of HF patients were admitted for an emergency inpatient stay, but not through the ED. A small percentage of patients (COPD:<1%, HF:2%) died without any known contact with secondary care. ED conversion rates at first attendance for both COPD and HF were high: 75% and 79% respectively. A quarter of patients who were not admitted during this first ED attendance attended the ED again within the 30-day follow-up period, and around half (COPD:56%; HF:63%) of these were admitted at this point.Patients who live alone, had an index admission which included an overnight stay and were comorbid had higher odds of being admitted through the ED than via other routes.ConclusionWhile the majority of patients did not have unscheduled contact with secondary care in the 30 days after index discharge, many patients attended the ED, often multiple times, and many were admitted to hospital, not always via the ED. More frail patients were more likely to be admitted through the ED, suggesting a

Journal article

McNicholas C, Lennox L, Woodcock T, Bell D, Reed Jet al., 2019, Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed methods study, BMJ Quality and Safety, Vol: 28, Pages: 356-365, ISSN: 2044-5415

BackgroundThough widely recommended as an effective approach to quality improvement (QI), the Plan-Do-Study-Act (PDSA) cycle method can be challenging to use and low fidelity of published accounts of the method has been reported. There is little evidence of the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use. Data collected from 39 frontline improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this overtime.MethodsThe fidelity of 421 PDSA cycles was reviewed using a pre-defined framework, and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews.ResultsAlthough modest, statistically significant improvements in PDSA fidelity occurred, however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use, and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.ConclusionsThis study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.

Journal article

Reed JE, Howe C, Doyle C, Bell Det al., 2019, Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence): simple rules to guide practice and research., Int J Qual Health Care, Vol: 31, Pages: 238-244

BACKGROUND: Evidence translation and improvement research indicate that healthcare contexts are complex systems, characterized by uncertainty and surprise, which often defy orchestrated intervention attempts. This article reflects on the implications of complexity on attempts to translate evidence, and on a newly published framework for Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence). DISCUSSION: SHIFT-Evidence positions the challenge of evidence translation within the complex and evolving context of healthcare, and recognizes the wider issues practitioners routinely face. It is empirically grounded, and designed to be comprehensive, practically relevant and actionable. SHIFT-evidence is summarized by three principles designed to be intuitive and memorable: 'act scientifically and pragmatically'; 'embrace complexity'; and 'engage and empower'. Common challenges and strategies to overcome them are summarized in 12 'simple rules' that provide actionable guidance. CONCLUSION: SHIFT-Evidence provides a practical tool to guide practice and research of evidence translation and improvement within complex dynamic healthcare settings. Implications are that improvement initiatives and research study designs need to take into account the unique initial conditions in each local setting; conduct needs to respond to unpredictable effects and address dependent problems; and evaluation needs to be sensitive to evolving priorities and the emergent range of activities required to achieve improvement.

Journal article

Sunkersing D, Martin F, Reed J, Woringer M, Bell Det al., 2019, What do care home managers believe constitutes an ‘assessment for frailty’ of care home residents in North-West London? A survey, BMC Geriatrics, Vol: 19, ISSN: 1471-2318

BackgroundFrail individuals are at risk of significant clinical deterioration if their frailty is not identified and managed appropriately. Research suggests that any interaction between an older person and a health or social care professional should include an assessment for frailty. Many older care home residents are frail when admitted, but we have little knowledge of whether or how this is assessed. The aim of this paper is to understand and establish the characteristics of the reported ‘assessments for frailty’ used in care homes with nursing (nursing homes) across North-West London. This will help understand what an ‘assessment for frailty’ of care home residents mean in practice in North-West London.MethodsTelephone contact was made with every Care Quality Commission (CQC) (independent regulator of health and adult social care in England) regulated nursing home across North-West London [n = 87]. An online survey was sent to all that expressed interest [n = 73]. The survey was developed through conversations with healthcare professionals, based on literature and tested with academics and clinicians. Survey responses were analysed using descriptive statistics. The Mann-Whitney U test was used for statistical analyses.Results24/73 nursing homes completed the survey (33%). Differences in the characteristics of reported ‘assessments for frailty’ across nursing homes were evident. Variation in high level domains assessed (physical, social, mental and environmental) was observed. Nurses were the most common professional group completing assessments for frailty, with documentation and storage being predominantly paper based. A statistically significant difference between the number of assessments used in corporate chain owned nursing homes (3.9) versus independently owned nursing homes (2.1) was observed (U = 21, p = .005).ConclusionsGreat variation existed in the characterist

Journal article

Soong J, Bell D, Poots AJ, 2018, The challenges of using the hospital frailty risk score, The Lancet, Vol: 392, Pages: 2692-2692, ISSN: 0140-6736

Journal article

Bell D, Deighan M, Gillen P, Rooke L, Small Ket al., 2018, Quality governance – a call to arms, Journal of the Royal College of Physicians of Edinburgh, Vol: 48, Pages: 195-197, ISSN: 1478-2715

Journal article

Bottle A, Honeyford K, Chowdhury F, Bell D, Aylin Pet al., 2018, Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study, Health and Social Care Delivery Research, Vol: 6, Pages: 1-84, ISSN: 2755-0060

Background: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplannedhospital activity, but our understanding of what drives this is incomplete.Objectives: To model patient, primary care and hospital factors associated with readmission and mortalityfor patients with HF and COPD, to assess the statistical performance of post-discharge emergencydepartment (ED) attendance compared with readmission metrics and to compare all the results for thetwo conditions.Design: Observational study.Setting: English NHS.Participants: All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.Interventions: None.Main outcome measures: One-year mortality and 30-day emergency readmission following the patient’sfirst unplanned admission (‘index admission’) for HF or COPD.Data sources: Patient-level data from Hospital Episodes Statistics were combined with publicly availablepractice- and hospital-level data on performance, patient and staff experience and rehabilitationprogramme website information.Results: One-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factorspredicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long)index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS andcomorbidities also predicted readmission. Of the practice and hospital factors we considered, only moredoctors per 10 beds [odds ratio (OR) 0.95 per doctor; p < 0.001] was significant for both cohorts for mortality,with staff recommending to friends and family (OR 0.80 per unit increase; p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP; p = 0.004) important for COPD. For readmission,only hospital size [OR per 100 beds = 2.16, 95% confidence interval (

Journal article

Reed JE, Howe C, Doyle C, Bell Det al., 2018, Simple rules for evidence translation in complex systems: a qualitative study, BMC Medicine, Vol: 16, ISSN: 1741-7015

BackgroundEnsuring patients benefit from the latest medical and technical advances remains a major challenge, with rational-linear and reductionist approaches to translating evidence into practice proving inefficient and ineffective. Complexity thinking, which emphasises interconnectedness and unpredictability, offers insights to inform evidence translation theories and strategies. Drawing on detailed insights into complex micro-systems, this research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems.MethodsUsing analytical auto-ethnography, including documentary analysis and literature review, we assimilated learning from 5 years of observation of 22 evidence translation projects (UK). We used a grounded theory approach to develop substantive theory and a conceptual framework. Results were interpreted using complexity theory and ‘simple rules’ were identified reflecting the practical strategies that enhanced project progress.ResultsThe framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) positions the challenge of evidence translation within the dynamic context of the health system. SHIFT-Evidence is summarised by three strategic principles, namely (1) ‘act scientifically and pragmatically’ – knowledge of existing evidence needs to be combined with knowledge of the unique initial conditions of a system, and interventions need to adapt as the complex system responds and learning emerges about unpredictable effects; (2) ‘embrace complexity’ – evidence-based interventions only work if related practices and processes of care within the complex system are functional, and evidence-translation efforts need to identify and address any problems with usual care, recognising that this typically includes a range of interdependent parts of the system; and (3) ‘engage and empower&r

Journal article

Soong JTY, Poots AJ, Rolph G, Bell Det al., 2017, Frailty Syndromes Coded within Secondary User Service(SUS) Data Predict Inpatient Mortality and Long Length of Stay, Society for Acute Medicine Autumn Conference, Publisher: Rila Publications Ltd, Pages: 131-132, ISSN: 1747-4884

Conference paper

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