Case Studies

Background: Repetitive Transcranial Magnetic Stimulation (rTMS) is a type of technology that can be used in treatment for psychiatric conditions. rTMS involves contact between the device and the patient’s head and uses electromagnetic induction to stimulate parts of the brain. This has been shown in clinical studies to be effective. This technology is non-invasive, stimulation of the brain happens through the skull so there is no need for the patient to be under anaesthetic. Following treatment, a patient can drive themselves home.

Magstim® a Welsh company that produce rTMS technology, loaned one of their devices to Hywel Dda University Health Board (HDUHB), for an evaluation at the adult mental health service within Glangwili hospital (GGH). This evaluation was carried out over a three-month period and finished at the end of April 2022. The reasoning behind this evaluation was that published research show that rTMS is safe and effective, but more work is required regarding cost effectiveness and and scalability within the NHS. This technology is currently not used clinically within any NHS Wales health board.

This evaluation was aimed at understanding the factors that might be important to organisations considering whether to adopt rTMS or not and also to explore the potential for a national roll out of rTMS technology in Wales. As part of the evaluation 10 patients with drug resistant depression were invited to receive 30 treatments of rTMS, each lasting 37 minutes each over a course of 6 weeks.

As part of the evaluation two questions were asked:

• Can rTMS be safely and quickly implemented as a service within NHS Wales? Is it acceptable to patients and staff?

Outcomes: All 10 patients that were involved in the evaluation completed all treatments. Positive changes were seen in most of the patients and these changes were noted in the clinical scores and from the patients themselves or family members. More data is needed regarding long term clinical effectiveness and to assess if costs are saved in other areas. An economic analysis and research projects into additional applications of rTMS would help to support justify costs of the device and the running of such a service.

Those who had gone through electroconvulsive therapy (ECT) treatments before, which is an invasive form of therapy that requires anaesthesia, expressed that rTMS was much more favourable. Most patients remained hopeful of treatments throughout the evaluation and stayed hopeful and positive towards the end of treatments even if they were not noticing these improvements in themselves. The great attention and care they got from the clinical team likely played a large role in the positive feedback from patients.

The majority of patients experienced fatigue from the treatments, and several experienced some level of pain or involuntary movements. Only a few patients had issues regularly attending the appointments, and those most affected by the frequency/total number of treatments were in full time employment. However, despite any discomfort or inconvenience caused, all patients completed their treatment and only a small number of individual treatments were missed.

The staff who were directly in contact with the patients during treatments had positive attitudes towards the device and its clinical potential. There was interest from staff in using the technology for further research to determine the effectiveness of other protocols to reduce the treatment lengths and to test it on other conditions or symptoms.

Currently the next steps following this evaluation is a robust economic analysis and business case development which is currently being developed by the Life Sciences Hub Wales (LSHW). If the business case shows a potential cost benefit to the health board, then this will support further research with rTMS devices within HDUHB. Exploration of clinical awareness and need for this technology and research into additional clinical applications are important next steps.

Background: Building upon our already established track record of innovation, The TriTech Institute was established by Hywel Dda UHB, mindful of the national and local policy and strategic context, to support the development and evaluation of innovative healthcare technologies, which contribute to improved patient outcomes. Previous work supported by Hywel Dda includes the following.

Bite-sized’ diabetes training for healthcare staff…

• Improving knowledge,
• Boosting confidence and
• Promoting safer patient care.

About the Cambridge Diabetes Education Programme (CDEP)

The Cambridge Diabetes Education Programme was designed and tested by a multi-disciplinary, diabetes specialist team, consisting of nurses, dietitians, podiatrists, health care assistants, general practitioners and hospital consultants including Dr Sam Rice in Hywel Dda and Chris Cotterell in Swansea Bay. It is based on the UK, nationally recognised, diabetes framework of competencies for healthcare practitioners, to ensure that they have the right diabetes skills and knowledge to support patients living with diabetes.

The various UK diabetes competency frameworks CDEP utilises are:

• TREND-UK: An integrated career and competency framework for adult diabetes nursing
• Diabetes UK: An integrated career and competency framework for dietitians and frontline staff
• Diabetes UK: Podiatry competency framework for integrated diabetes foot care
• Diabetes UK: An integrated career and competency framework for pharmacists in diabetes

CDEP’s content is continually reviewed and further developed to ensure the learning opportunities offered are evidence-based, up-to-date and relevant to the target audience. CDEP’s outcomes are routinely audited to ensure that we are meeting healthcare practitioners’ needs.

CDEP audit outcomes: In the last audit (Nov 2020 n= 41,137), an impressive 99.98% of users reported that undertaking a CDEP topic, either confirms their high level of diabetes knowledge (15%) or alternatively, supports an improvement in their diabetes knowledge (85%). To date 3,844 HCPs from Wales have been trained using the system and as a follow on from the collaboration, Dr Sam Rice was able to negotiate free access for all Healthcare Professionals across Wales.

Background: The project investigates biomarkers (chemicals in people’s blood, urine, saliva and sputum) that may be detectable before patients develop symptoms or changes are seen on hospital scans and chest X-rays. The project then further explores how biomarkers are affected by changes in a person’s condition or treatment. Information from participants’ medical records are gathered together with samples that undergo i-omics analysis. This research programme, which is contributing to educational studies, may help to diagnose these types of diseases earlier so that future care can be improved.

Outcomes: This is an ongoing project in collaboration with Aberystwyth University. The project began with Hywel Dda University Health Board in 2016 and was extended to include Betsi Cadwaladr University Health Board in 2017. More than 1200 participants with a respiratory condition have been recruited to date.

A number of publications and conference abstracts have already resulted from this work, including:

Publications:

• da Costa, R.; Love, K.; Beckmann, M.; Morley, A.; Bhatnagar, R.; Maskel, N.; Mur, L.A.; Lewis, K. Metabolomics differentiate cancer from non-cancer pleural effusions based on steroid lipids and acyl carnitines. medRxiv 2020, 10.1101/2020.07.27.20162958, 2020.2007.2027.20162958, doi:10.1101/2020.07.27.20162958.
• Paes de Araujo, R.; Bertoni, N.; Seneda, A.L.; Felix, T.F.; Carvalho, M.; Lewis, K.E.; Hasimoto, E.N.; Beckmann, M.; Drigo, S.A.; Reis, P.P., et al. Defining Metabolic Rewiring in Lung Squamous Cell Carcinoma. Metabolites 2019, 9, doi:10.3390/metabo9030047.
• Mironas, A.; Cameron, S.; O’Shea, K.; Lu, C.; Lewis, P.; Mur, L.; Lewis, K. Exploiting metabolomic approaches to aid in the diagnosis of lung cancer. European Respiratory Society: 2016. (Conference)
• Non-targeted integrative multi-omics approaches on sputum reveal potential diagnostic and monitoring biomarkers for respiratory diseases (2017) Luis Mur, Adrian Mironas, Rachel Paes de Araujo, Keiron O’Shea, Keir Lewis

Conference abstracts:​

• Early exploratory use of omic approaches to assess metabolite changes in COPD (2020) Tina Kramaric, Sarah Thomas, Katie Love, Ian Bond, David Rooke, Luis Mur, Keir Lewis​
• Rapid diagnostic approaches for thoracic disease based on pleural effusions (2018) Katie Love, Rachel Paes de Araujo, Ricardo da Costa, Manfred Beckmann, Keir Lewis, Nick Maskell, Luis Mur​

Background: The project proposes to digitalise our existing, effective 12-module pain management programme, creating a linear programme in a digital format – LMS. Each module will include education around pain, relaxation, goal setting, pacing and exercises as well as additional resources that users could access. When the user has selected their chosen language for the app (Welsh or English) each module will require completion before progressing to the next module. As the user progresses through each module, they will be able to access all previously completed content to explore further and review; this can ultimately be used as an ongoing resource for the user. The LMS will be interactive and will include video, voice, illustration, and text. Simple knowledge checks will allow patients to track progress, incorporating resources such as relaxation techniques and sound files to assist at each stage of recovery. The easy-to-use, pixel perfect design works across a range of platforms including desktop, tablet and mobile.

Outcomes: This is an ongoing project, but it has been successful in winning almost £14,000 from the Welsh Health Hack. Dr Ffion John has teamed up with OSP Healthcare, who are developing the digital platform for their E-Learning programme.

Additional funding has also been secured to complete the project. Hywel Dda University Health Board have supported the development and evaluation moving forward – in partnership with Accelerate, Swansea University.

IP: Contract acknowledges significant Health Board input and secures a share of any income associated with the company’s future commercialisation.

Background: PocketMedic is a digital platform that allows clinicians in primary, secondary or community care, to send film-based prescriptions to patients to help manage chronic diseases. These can be watched on mobile phones, tablets, or PCs. Over 30 films are now available for type 2, type 1, gestational and pre-diabetes – covering all aspects of diabetes care. They were recently incorporated into the National Direct Enhanced Service (DES) for Diabetes in Wales and are viewed by approximately 1,000 patients each month. Initial evaluation of the system demonstrated improvement in disease control as measured by HbA1c.

Outcomes: Further evaluations looking at pre-diabetes in partnership with Aberystwyth University are ongoing. eDigital Health are working with our team on a variety of projects around diabetes, COPD, long-COVID and staff wellbeing in partnership with The Bevan Commission, Swansea University and Aberystwyth University.

PocketMedic (eDigital Health), in collaboration with Dr Sam Rice of Prince Philip Hospital, was given a commendation in the ‘Quality in Care Diabetes Awards 2018’. Dr. Sam Rice is the DRU Cymru Work Package Lead for the ‘Self-management of Diabetes’ theme. A Quality in Care award means an initiative has been recognised by the NHS, patients and industry as improving the quality of life for people living with diabetes.

The judges said: “A very innovative idea to have films available on prescription. An excellent concept, well thought through from the patients’ perspective and well presented. These videos help educate and inform patients more effectively than traditional methods.”

Background: To support self-management, in partnership with Bond Digital Health (BDH), Bevan Commission, Swansea University and patient representatives, a digital mobile phone app was developed that allowed patients to take control of their Chronic Obstructive Pulmonary Disease (COPD). A tailored prototype of the app, through funding from Welsh Government (ETTP – £115,720), was developed and tested within 2 REC approved studies – Phase 1 (IRAS ID: 270736, REC ref:19/LO/1649) and Phase 2 (IRAS ID: 235302, REC ref: 19/WA/0347).

Outcomes: Studies found it was acceptable and led to improved control of symptoms. Bond Digital Health and Hywel Dda University Health Board are now working together to further refine the app to maximise impact on patient wellbeing.

Publications:

• Knox, L., Gemine, R., Rees, S., Bowen, S., Groom, P., Taylor, D., Bond, I., Rosser, W., & Lewis, K. (2020). Using the Technology Acceptance Model to conceptualise experiences of the usability and acceptability of a self-management app (COPD.Pal®) for Chronic Obstructive Pulmonary Disease. Health and Technology, 1 – 7.
• Knox, L., Gemine, R., Rees, S., Bowen, S., Groom, P., Taylor, D., Bond, I., Rosser, W., & Lewis, K. (2021). Assessing the uptake, engagement, and safety of a self-management app, COPD.Pal®, for Chronic Obstructive Pulmonary Disease: a pilot study. Health and Technology (in press).

Background: Pulmonary rehabilitation is a programme of exercise and education for patients with Chronic Obstructive Pulmonary Disease (COPD), which traditionally takes place twice a week over a seven-week period. For individuals with a chronic lung condition, Pulmonary Rehabilitation should be an integral part of their care, and the Welsh Government outlined an expectation that all eligible patients are offered such services. This project aimed to provide a more efficient and equal pulmonary rehabilitation service across rural areas in Wales by delivering rehabilitation interventions using video conferencing technology.

Outcomes: VIPAR has saved driving time and miles travelled for all patients, as well as providing improved health outcomes. The project was able to clearly demonstrate (via 3 programmes) that virtual pulmonary rehabilitation:

• is both feasible and safe
• is popular with staff and patients
• appears at least as effective as standard pulmonary rehabilitation in the short-term.
• saves money and reduces environmental impact

The future ambitions of the project are to secure funding to continue running virtual rehabilitation services in rural areas using a hub and spoke model, creating a virtual pulmonary rehabilitation (VIPAR) network pan-Wales.

Publications & Awards:

• Mediwales 2018 Winner
• Knox L, Dunning M, Davies CA, Mills-Bennet R, Sion TW, Phipps K, Stevenson V, Hurlin C, Lewis K. Safety, feasibility, and effectiveness of virtual pulmonary rehabilitation in the real world. Int J Chron Obstruct Pulmon Dis. 2019 Apr 8;14:775-780. doi: 10.2147/COPD.S193827. PMID: 31040656; PMCID: PMC6459142.

Background: There are more than 30,000 out-of-hospital cardiac arrests (OHCAs) in the UK each year and the overall survival rate in the UK is just 1 in 10. Every minute without cardiopulmonary resuscitation (CPR) and defibrillation reduces the chance of survival by up to 10%, while performing CPR can more than double the chances of survival in some cases (ventricular fibrillation). The Resuscitation Council made a number of changes to the guidance during the COVID-19 pandemic in order to help protect healthcare workers in hospital settings. The principle of “shock first” was introduced in an attempt to restore circulation as early as possible. The guidance recommended the wearing of Level 2 Personal Protective Equipment (surgical mask, gloves, apron, and eye protection) when a defibrillator is available and defibrillate shockable rhythms rapidly prior to starting chest compressions. Early restoration of circulation may prevent the need for further resuscitation measures.

The change in the resuscitation guidance resulted in the clinical engineering team having to reconfigure over 269 defibrillators (a mix of manual and automated external defibrillators, AED’s) across four acute hospitals and a number of community settings. This prompted us to consider alternative strategies to reconfigure devices in future through a cloud-based system.

Outcomes: All defibrillators reside within the acute and community hospitals, but update to the Cloud and Health Board Code STAT server on a daily basis. Automated device self-tests are undertaken at 3am every day and the results are uploaded to the cloud. Notifications are forwarded to the Clinical Engineering departments should any errors appear to allow immediate corrective actions to be undertaken. We now have the availability to:

• wirelessly transmit device and patient data to a central location.
• examine an easy-to-read dashboard that delivers information in a timely manner
• measure compression ratio
• measure compression rate
• measure compression depth
• end-Tidal Carbon Dioxide EtCO2 trend data
• interrogate chronological cardiac event logging
• remotely configure changes through Wi-Fi that supports UK Resuscitation Council guideline changes
• provide feedback to clinical teams.

Learning points:

The guidelines call for compression fractions above 80% with compressions at 100-120/min. Hywel Dda University Health Board can now measure how we compare in terms of compression, ventilation rates and compression fraction to see our performance compared to Resuscitation Council standards across the UK. We can gather quantitative data from each event to show hands-on clinical teams how they performed and to show clinical leadership teams how the whole system is performing.

Our Clinical Engineers are now performing modifications and changes to the cloud-based system in order to improve functionality and availability of data. We will use the data gathered from the new cloud-based system to develop strategies that allow our clinical teams to streamline protocols and treatments, to help further improve practice in line with the Resuscitation Council guidelines.

Introduction: During the second wave of the SARS-CoV-2 pandemic, the numbers of patients admitted into hospital rose steadily across the UK from a weekly average of 122 (September 1st 2020) up to 2,037 (17th December) eventually reaching a peak of 4,232 cases per week on 9th January 2021. During this time, the NHS continued to deliver with other non-COVID admissions and elective surgery.

The increase in hospital admissions led our ITU teams to consider expanding to ward areas to manage SARS-CoV-2 critically ill patients. They requested an urgent review of the feasibility, efficacy and safety of UVC air sterilisation devices to reduce the length of the fallow period between patient procedures required for the room ventilation system to clear air potentially contaminated by viral-loaded aerosol generated particles (AGPs).

Computational Fluid Dynamics (CFD) offers insights into ventilation efficiency and contamination spread not previously available in the original design of the existing treatment spaces.

Objective: to review existing data on UVC air sterilisation

Main Questions

• What effect does UVC radiation (250 nm) have on bacteria and viruses particularly SARS-CoV-2
• How could we predict UVC efficacy in a real world setting through the use of computational modelling and/or environmental air sampling?

Assessment: Quantifying the rate of far-UVC viral inactivation within a general room is complex and multi-physics in nature. The judicious application of CFD modelling to the understanding of the complex anisotropic air flows associated with fixed and moving objects (including humans) can suggest effective optimisations of ACH strategies achieved by combining air scrubbing with pre-existing HVAC’s [7].

Our Computational Fluid Dynamics (CFD) models provide information on the dispersion of airborne particles in healthcare environments where AGPs present a significant risk. CFD is a useful tool to understand the dynamics of infectious particles through the air. It has been used successfully to study the effect of different ventilation regimes, and layouts within clinical areas [8,9].

A CFD expert group was established to model the flow dynamics within a dental treatment room in Birmingham Women’s and Children NHS Foundation Trust. (Prof Tony Fisher, Royal Liverpool University Hospital, Prof Paul A White, Cambridge University Hospitals NHS Foundation Trust, Fred Mendonça and Pawan Ghildiyal, Open CFD Ltd, Peter Bill, Birmingham Women’s and Children NHS Foundation Trust, Claire Greaves, Nottingham University Hospitals and Prof Chris Hopkins, Hywel Dda). This high-risk AGP environment was taken as a surrogate of the endoscopy suite which is the focus of this study (vide supra).

Computational Fluid Dynamics (CFD) modelling: CFD in the Engineering Sciences of buildings is well-established [10]. Solving the Navier-Stokes equations governing continuum air movement, combined with the discrete particulate transport, gives us a compete view of complex ensemble of turbulence, buoyancy, aerosol dispersion, evaporation and wall interaction across the full range of particle sizes of interest, notionally [0.1 .. 100µm3].

In this study of indoor ventilation, sponsored by UK Research and Innovation [11], using fully ISO9001:2015 QA’ed open-source CFD [12], the efficacy of several ventilation strategies was assessed. The strategies include mechanical (controlled by the building air-management system), natural (opening window), augmented ventilation (from UV air-cleaning devices) and several roof-diffuser vent designs.

CFD tracks the age of the air (AoA) from a fresh source to anywhere within the room volume, therefore identifying which parts are well ventilated, and conversely, locations of dead air or recirculating bubbles. Mean-AoA then becomes a meaningful measure of clean air circulation in the enclosure.

A CFD model of Birmingham Children’s Hospital’s 44.7m3 fully equipped dental treatment room comprises three occupants; dentist, patient and nurse. Roof ventilation slightly offset from directly above the treatment chair was supplied in the centre of the room at 5 ACH with balanced extraction to one side.

This was carried out by installing a mobile UVC unit into the room which provided 7 ACH of recirculated air leading to a total ‘equivalent’ of 12 ACH, i.e. 5 ACH of outdoor air supplied by the mechanical HVAC system and 7 ACH of recirculated and clean/sterilised air supplied by the UV mobile unit.

When the UVC steriliser was introduced into the room, there was a reduction in fallow time by up to 75%. On standard settings (180m3.h-1), the age of air within the room reduced to 6 minutes and on the purge or boost (360m3.h-1) setting, this was further reduced to 4 minutes.

Similar studies in well ventilated rooms of different sizes and ventilation strategies suggests a close link between the ventilation rate (ACH) and mean-AoA as an absolute measure in minutes. Positioning of UVCs or direction of airflow gives only +/-15% variation in the clean air mixing.

Conclusion: CFD modelling suggests a significant improvement in ‘clean air’ after introduction of the UVC sterilisers and early work with the PCR detection method for SARS-CoV-2 seems to confirm this. The improvement is seen in both age of air and ‘air mixing’ when placed in an optimum position, with no significant issues raised from real-world testing. There is ongoing work to develop guidelines for using portable air cleaning devices in a range of clinical settings.