Improving delirium screening and recognition in UK hospitals: results of a multi-centre quality improvement project.

BACKGROUND: delirium is an acute severe neuropsychiatric condition associated with adverse outcomes, particularly in older adults. However, it is frequently under-recognised.
METHODS: this multi-centre quality improvement project utilised a collaborative approach to implementation of changes at sites, with the aim to improve delirium screening, recognition and documentation on discharge summaries. Resources, including delirium guidelines and presentations, were shared between sites, and broad details of local interventions were collected. Three timepoints of data collection (14 March 2018, 14 September 2018 and 13 March 2019) were conducted to assess screening, recognition and documentation of delirium in unscheduled admissions of adults aged ≥65 years old. The impact of local interventions and site-specific factors was assessed using logistic regression analysis, adjusting for patient factors.
RESULTS: a total of 3,013 patients (mean age 80.2, 53.8% females) were recruited across the three timepoints. Screening for delirium was associated with increased odds of recognition (aOR 4.75, CI 2.98-7.56; P < 0.001); this was not affected by grade/profession of screener. Rates of screening, recognition and discharge documentation improved across the three timepoints of data collection. The presence of a local delirium specialist team was associated with increased rates of screening for delirium (aOR 1.75, CI 1.41-2.18; P < 0.001), and the presence of a geriatric medicine team embedded into the admissions unit was associated with increased recognition rates (aOR 1.78, CI 1.09-2.92; P = 0.022).
CONCLUSION: delirium screening is associated with improved recognition. Interventions that strive to improve screening within a culture of delirium awareness are encouraged.

A multi-centre ‘crowdsourcing’ approach to quality improvement is feasible.

Delirium screening, recognition and discharge documentation improved across each round of data collection.

Screening for delirium increases the odds of recognition, and drives to improve screening are recommended.

Background

Delirium is an acute neuropsychiatric state defined by cognitive change and altered consciousness that occurs secondary to physical precipitants, particularly in older adults during hospitalisation [1]. Delirium is associated with adverse outcomes, but is frequently under-recognised [2]. Our previous research demonstrated that delirium screening increases recognition [1]. However, delirium screening was inconsistent. Screening and recognition were particularly reduced in surgical specialties [1]. Although delirium is reversible, it is associated with increased risk of later life dementia diagnosis [3]. Follow-up of patients who have experienced delirium is, therefore, vital. Unfortunately, delirium documentation on discharge summaries is infrequently performed [4]. In the UK, National Institute for Health and Care Excellence guidelines recommend that all adults aged ≥65 years old are screened for delirium on admission to hospital [5], and that delirium diagnoses are communicated to General Practitioners (GPs) on hospital discharge [6].

To improve screening and recognition of delirium in older adults admitted to acute care hospitals as unscheduled admissions.

To improve documentation of delirium diagnoses on discharge summaries.

Methods

This study presents results of a multi-centre quality improvement project, utilising a collaborative approach. Resources and knowledge were shared between sites, and sites were able to implement interventions locally according to service needs. Three timepoints of data collection were utilised (14 March 2018, 14 September 2018 and 13 March 2019). All timepoints of data collection included newly admitted (unscheduled) patients aged ≥65 years old to acute care trusts (all specialties, excluding critical care). We assessed for statistical significance of differences in likelihood of screening, recognition and discharge documentation across timepoints using multivariable logistic regression analysis. Full methodology is Supplementary data (Figure S1, Figure S2) are available in Age and Ageing online.

Results

Timepoint 1 included 1,507 patients from 44 sites, Timepoint 2 included 656 patients from 26 sites and Timepoint 3 included 850 patients from 48 sites. Eighty-two sites contributed data to at least one timepoint (Table S1, Supplementary data are available in Age and Ageing online). Overall prevalence of delirium across all timepoints was 16.3% (491/2,522). Characteristics of patients at each timepoint are shown in Table 1. Interventions implemented at sites between timepoints are shown in Table S2, Supplementary data (Figure S1, Figure S2) are available in Age and Ageing online.

Table 1

Characteristics of study population across all timepoints

		Timepoint 1		Timepoint 2		Timepoint 3
		Delirium (N = 222)	No delirium (N = 1,285)	Delirium (N = 133)	No delirium (N = 523)	Delirium (N = 136)	No delirium (N = 714)
Age—mean (SD)		84.0 (7.4)	79.3 (8.3)	82.8 (8.1)	79.6 (8.2)	83.3 (7.9)	80.0 (8.5)
Gender—% females (N)		60.8 (135)	51.6 (663)	50.4 (67)	55.3 (289)	60.3 (82)	53.8 (384)
Dementia—% (N)		35.1 (78)	12.9 (166)	41.4 (55)	14.0 (73)	54.4 (74)	16.2 (116)
Clinical Frailty Scale	1	0.5 (1)	4.3 (55)	1.5 (2)	4.1 (21)	0	5.4 (39)
	2	2.7 (6)	11.3 (145)	1.5 (2)	10.9 (57)	2.2 (3)	9.7 (69)
	3	3.6 (8)	19.7 (253)	6.8 (9)	21.0 (110)	2.2 (3)	17.8 (127)
	4	10.8 (24)	18.1 (232)	15.0 (20)	19.5 (102)	8.1 (11)	16.0 (114)
	5	21.2 (47)	15.9 (204)	10.5 (14)	15.1 (79)	19.1 (26)	17.9 (128)
	6	28.4 (63)	17.6 (226)	30.8 (41)	15.9 (83)	29.4 (40)	17.4 (124)
	7	25.7 (57)	9.3 (119)	26.3 (35)	10.5 (55)	32.4 (44)	9.7 (69)
	8	4.5 (10)	0.9 (12)	6.0 (8)	1.5 (8)	5.1 (7)	1.3 (9)
	9	0 (0)	0.2 (3)	1.5 (2)	1.3 (7)	0 (0)	0.6 (4)
Specialty	Acute medicine	47.7 (106)	42.2 (542)	21.8 (29)	21.2 (111)	27.2 (37)	18.5 (132)
	Geriatric medicine	26.6 (59)	16.0 (206)	45.1 (60)	20.3 (106)	37.5 (51)	18.8 (134)
	Stroke	1.8 (4)	4.0 (52)	0.8 (1)	5.0 (26)	1.5 (2)	3.9 (28)
	Other medicine	14.0 (31)	22.1 (284)	21.1 (28)	27.9 (146)	19.1 (26)	35.9 (256)
	Orthopaedic surgery	6.8 (15)	6.2 (80)	6.0 (8)	9.0 (47)	8.1 (11)	9.0 (64)
	General surgery	3.2 (7)	6.5 (83)	4.5 (6)	8.0 (42)	4.4 (6)	9.1 (65)
	Other surgery	1.8 (4)	3.0 (38)	0.8 (1)	8.6 (45)	2.2 (3)	4.3 (31)

Delirium screening

Delirium screening increased across timepoints (27.3% versus 29.6% versus 37.1%; P < 0.001). Odds of screening increased between Timepoints 1 and 3 (aOR 1.33, CI 1.08–1.65; P = 0.001; Table 2). Delirium screening was associated with increasing age, mild–moderate (but not severe) frailty and dementia. Odds of delirium screening were increased with presence of specialist delirium teams (aOR 1.75, CI 1.41–2.18; P < 0.001; Table S3, Supplementary data are available in Age and Ageing online).

Table 2

Logistic regression analysis for odds of screening, recognition and discharge documentation between timepoints

	Timepoint 2 versus Timepoint 1		Timepoint 3 versus Timepoint 1
	OR (CI)	P value	OR (CI)	P value
Delirium screening
Unadjusted	1.18 (0.95–1.46)	0.142	1.45 (1.18–1.78)	<0.001
Adjusted¥	1.07 (0.85–1.34)	0.570	1.33 (1.08–1.65)	0.001
Delirium recognition
Unadjusted	2.60 (1.62–4.16)	<0.001	2.31 (1.41–3.77)	0.001
Adjustedǂ	1.93 (1.11–3.35)	0.019	2.33 (1.31–4.15)	0.004
Discharge documentation
Unadjusted	2.34 (1.23–4.46)	0.009	1.78 (1.02–3.11)	0.042
Adjusted¥	2.27 (1.10–4.68)	0.026	1.73 (0.93–3.24)	0.085

¥Adjusted for Clinical Frailty Scale, age, gender, dementia status, specialty and site-specific factors.

ǂAdjusted for screening, subtype, Clinical Frailty Scale, age, gender, dementia status, specialty and site-specific factors.

Delirium recognition

Delirium recognition increased across timepoints (34.2% versus 57.1% versus 63.2%; P < 0.001). Odds of recognition increased between Timepoints 1 and 2 (aOR 1.93, CI 1.11–3.35; P = 0.019), and 1 and 3 (aOR 2.33, CI 1.31–4.15; P = 0.004; Table 2). Screening for delirium was associated with delirium recognition (aOR 4.75, CI 2.98–7.56; P < 0.001); this was not affected by grade/profession of screener. Recognition odds were increased in patients with dementia (aOR 1.73, CI 1.06–2.84; P = 0.029), and presence of geriatric teams embedded into admissions units (aOR 1.78, CI 1.09–2.92; P = 0.022). Admissions under general (aOR 0.11, CI 0.02–0.58; P = 0.009) or orthopaedic (aOR 0.27, CI 0.09–0.79; P = 0.017) surgery were associated with reduced delirium recognition (Table S4, Supplementary data are available in Age and Ageing online).

Discharge documentation

Discharge documentation increased across timepoints (28.6% versus 48.4% versus 46.6%; P = 0.002) (Table 2). Odds of discharge documentation increased from Timepoint 1 to 2 (aOR 2.34, CI 1.23–4.46; P = 0.009). Odds of delirium documentation were increased in patients with dementia (aOR 2.01, CI 1.16–3.48; P = 0.012), but not affected by site-specific factors (Table S5, Supplementary data are available in Age and Ageing online).

Discussion

Delirium screening, recognition and discharge documentation all improved overall, demonstrating that rates of these are not fixed/inalterable. Importantly, screening is associated with increased odds of recognition; efforts to increase screening should be encouraged. Notably, grade and profession of screener did not affect recognition. Therefore, interventions to improve recognition may utilise trained multiprofessional screeners and junior staff. The 4AT has been validated for use by all healthcare professionals with minimal training [7, 8].

Discharge documentation was more likely in patients with pre-existing dementia. Reasons for this are unclear, but may relate to greater awareness of importance of delirium in dementia, in a similar manner to increased recognition rates. There may be a general misunderstanding as to why communication of delirium diagnoses to GPs is important, in terms of highlighting risk of future cognitive decline [3, 9]. Encouragingly, documentation improved across timepoints. Previous studies have shown that discharge documentation is often inadequate across many settings [10].

External validity

Overall delirium prevalence was 16.3%. This is lower than a previous single-site point prevalence study (19.6%) [11]. Differences are accounted for by inclusion of incident delirium in the latter study; only prevalent cases at admission were included at Timepoints 1 and 3. A higher prevalence rate (22.9%) was reported in a study considering positive screen with 4AT alone and not reference-standard delirium diagnosis [12]. Previous single centre quality improvement projects have demonstrated similar improvements in delirium screening and recognition with local interventions. A previous study involving implementation of a local delirium pathway and multidisciplinary teaching programme demonstrated improvement in delirium recognition rates from 5.7 to 35% over 11 weeks [13]. Similarly, implementation of dedicated teaching sessions within an acute medical unit, and management bundle with checklists, resulted in improved delirium screening rates from 40 to 61% [14].

Internal validity

Patient characteristics were similar across timepoints with regards to age, gender and specialties. Most patients were within acute and geriatric medicine specialties, which is consistent with recognised pathways of care within the UK [15]. However, at later timepoints higher dementia rates were recorded. Our results demonstrated that delirium was more likely to be recognised in patients with dementia. However, effects persisted in multivariable models adjusting for dementia.

We recognise that a significant limitation is that not all the same sites participated at each timepoint. Analyses and interpretation were performed for sites overall rather than at site level; site level analysis was not possible due to individually small numbers. Nevertheless, improvement in screening, recognition and documentation across timepoints demonstrates that such improvements are possible. We acknowledge that methodology differed between timepoints; data was collected prospectively at Timepoints 1 and 3 but retrospectively at Timepoint 2. We consider this variation unlikely to have significantly impacted upon results. Validated methodology for retrospective delirium ascertainment was used at Timepoint 2 [16, 17]. In addition, although this may have led to differences in recognition rates, this should not have affected screening rates. Documentation of screening was extracted from clinical records across all timepoints.

We cannot be certain specific interventions led to improvements, or if these relate to external factors. It is conceivable that improvements across timepoints related to improved culture of embedding delirium screening and assessment into clinical practice. This may have occurred due to leadership of collaborators at sites. However, many doctors rotated sites during this project, and collaborators at sites differed between timepoints. This suggests that changes can be sustained, even where leadership is rotated. Improved delirium screening and recognition rates may also be related to external factors. The International Federation of Delirium Studies (iDelirium) is an international collaboration of societies, which seeks to educate patients, caregivers, professionals and policy makers about delirium [18]. The society constantly aims to increase awareness of delirium, however, national campaigns peek around the time of WDAD (i.e. first and last timepoints) [18].

Recommendations

Our approach of sharing guidelines, resources and a central data collection point is feasible in involving multiple centres across multiple timepoints. Methodology was sufficiently simple to enable healthcare professionals of any grade or profession to be involved with screening and data collection. This is a model that may be replicated in future collaborative quality improvement projects.

Despite the focus on screening and recognition, it is important to recognise that assessment is only part of management. If delirium is present and recognised this should prompt healthcare professionals to take action by identifying and treating underlying causes [19]. Education should focus on rationale behind actions, such as the need to ensure delirium is communicated to primary care to enable appropriate follow-up of cognitive trajectories. Delirium may take some time to fully resolve [20], and communication to primary care is of utmost importance.

Although it was not possible to analyse site level data for effectiveness of individual interventions at site, we were able to identify site factors that were predictive of screening and recognition. Specialist delirium teams were associated with improved screening rates, and geriatric medicine teams embedded into admissions units were associated with improved recognition rates. Where sites are seeking to improve screening and recognition rates locally, we suggest that these findings are considered in service development. There was a very strong association (nearly fivefold) between delirium screening and likelihood of delirium recognition. Thus, drivers towards increased delirium screening are likely to prove beneficial.

Conclusions

A collaborative approach to multi-centre quality improvement is feasible; including multiple data collection timepoints, and sharing of guidelines/resources and knowledge across sites. Importantly, screening, recognition and delirium documentation rates are not fixed/unalterable; improved rates across timepoints suggest potential for responsiveness to interventions. Screening for delirium is associated with increased likelihood of delirium recognition. We encourage implementation of interventions to improve recognition through way of increased screening, alongside sustainable culture changes.

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Members of the Geriatric Medicine Research Collaborative

Manuscript preparation
First name	Middle initial	Last name	Affiliation
Julian		Lin	Torbay and South Devon NHS Foundation Trust
Sindhoora		Dama	South Warwickshire Foundation Trust
Carly		Welch	University of Birmingham
Steering group
Thomas	A.	Jackson	University of Birmingham
Laura		Magill
Lauren		McCluskey
Rita		Perry
Daisy		Wilson
Advisory group
Claire		Copeland	NHS Forth Valley
Emma		Cunningham	Queen’s University Belfast
Daniel		Davis	University College London
Jonathan		Treml	University Hospitals Birmingham NHS Foundation Trust
Thomas		Pinkney	University of Birmingham
Terrence		Quinn	University of Glasgow
Data analysis advisor
Peter		Nightingale	University Hospitals Birmingham NHS Foundation Trust
Regional leads
Benjamin		Jelley	Cardiff and Vale University Health Board
Victoria		Gaunt	Gloucestershire Hospitals NHS Foundation Trust
Mary		Ni Lochlainn	King’s College London
Kumudhini		Giridharan	Maidstone & Tunbridge Wells NHS Trust
Sarah		Richardson	Newcastle University
Mustafa		Alsahab	Oxford University Hospitals NHS Foundation Trust
Stephen		Makin	University of Aberdeen
Kelli		Torsney	University of Cambridge
Jane		Masoli	University of Exeter
Lindsay		Ronan	University of Exeter
Jenni	K.	Burton	University of Glasgow
Oliver		Todd	University of Leeds
Joanne		Taylor	University of Manchester
Ruth		Willott	University of Nottingham
Natalie		Cox	University of Southampton
Roisin		Healy	Western Health and Social Care Trust
Other collaborators
Nedaa		Haddad	Anuerin Bevan University Health Board
Sharan		Ramakrishna
Zahid		Subhan
Antonella		Mazzoleni	Barnet, Enfield and Haringey Mental Health Liaison Service
Olga		Nynaes
Jodie		Crofts	Barnsley District General Hospital
Emily		McNicholas
Hannah	J.	Robinson
Thyn		Thyn
Jonathan		Baillie	Belfast Health and Social Care Trust
William		McKeown
Caroline		Rice
Gerrard	W.	Sloan
Katherine		Williamson
Yasmeen		Hayat	Bolton NHS Foundation Trust
Vee Han		Lim
Katie		Millichamp
Amr		Bazaraa	Bradford Teaching Hospitals NHS Foundation Trust
Angharad		Chilton
Alexander		Harbinson
John		Headlam
Elisabeth		Hunter
Zainab		Hussain
Al Wakkass		Mahmood
Liji		Ng
Srividya		Sundara
Felicia		Tan
Alice		Wheeler
Sophie		Wright
Jack	B.G.	Baldwin	Brighton and Sussex University Hospitals NHS Trust
Kate		O'shea
Ghazal		Hodhody	Buckinghamshire Healthcare NHS Trust
Kara		Mayor
Riana		Patel
Shiv		Bhakta	Cambridge University Hospitals
Marie		Goujon
Adriana		Jakupaj
James		Dove	Camden & Islington NHS Foundation Trust
Matthew		Kearney	County Durham and Darlington NHS Foundation Trust
Vincent		McCormack
Kirsty		Moore
Leo		Pope
Hussun-Ara		Shah
Megan	E.	Shaw
Gemma	M.	Smith
Ryan		Love	East and North Hertfordshire NHS Trust
Maya		Mukundan
Muhammad		Shahid
Ahmad		Alareed
Clementine		Anderson
Karen		Beharry
Ganapathy		Bhat
Sanojan		Bremakumar
Laurence		Caines
Sandra		Darko
Nisha		Rai
David		Saliu
Pedro		Vila De Mucha
Phillipa		Adams	Gateshead Health NHS Foundation Trust
Helen		McDonald	Gloucestershire Hospitals NHS Foundation Trust
Sam		Mills
Frances		Parry
Frances		Rickard
Stuart		Winearls
Rinata		Farah	Great Western Hospitals NHS Trust
Robert		Grange
Fiona		Herbert
Elizabeth		Lonsdale-Eccles
Qurrat		Ul Ain
Hannah		Watson
Celine		Bultynck	Guy’s & St Thomas’ NHS Foundation Trust
Chiara		Cavaliere
Cal		Doherty
Sarah		Evans
Daniel		Furmedge
Annabel		Hentall MacCuish
Esther		Hindley
Caitlin		Meyer
Emma		Mullarkey
Rosamund		Pullen
Aidan		Ryan
Dhruv		Sarma
Elaine		Seymour
Katharine		Stambollouian
Darmiga		Thayabaran
Chenxian		Wu
George		Peck	Imperial College London Healthcare Trust
Mahrukh		Raza
Kapil		Sahnan
Amber		Dhillon	Keele University
Oluwatosin	O.	Abiola	King's College Hospital NHS Foundation Trust
Catherine		Bryant
Rachael		Bygate
John		Frewen
Isabel		Greaves
Olivia		Morrow
Simon		Tetlow
Guy		Tinson
Aayenah		Yunus
Simran		Bedi	King's College London
Olivia		Evans	Lewisham & Greenwich NHS Trust
Leeying		Giet
Taran		Nandra
Abolfazl		Behbahani	Liverpool University
Saurav		Bhattacharya	Maidstone and Tunbridge Wells NHS Trust
Clare		Hunt
Rajeev		Mishra
Louise		Connor	Newcastle University
Jack		Poynton
Elizabeth		Deacon	Newcastle Upon Tyne Hospitals NHS Foundation Trust
Rory		Durcan
Emma		Fisken
Susan	A.	Hall
Jane		Noble
Emma	L.	Prendergast
Ajay		Macharouthu	NHS Ayrshire and Arran
Victoria		Macrae
Emily		Murphy-Ackroyd
Emily	C.	Rose
Nicola		Watt
Mairi		Blair	NHS Forth Valley
Eilidh	R.	Mackenzie
Roisin		McCormack
Sophie	J.	Irwin	NHS Gateshead
Alice		Einarsson	NHS Grampian
Ming		Khor
Baraa		Alhadadi	NHS Greater Glasgow and Clyde
Ewen		Cameron
Angela		Campbell
Eileen		Capek
Lorna		Christie
Laura		Connell
Alan		Cook
Jordanna		Deosaran
Marianne		Elliott
Elizabeth		Evans
Sarah		Fancourt
Sarah		Henderson
Ambreen		Hussain
Karen		Jones
Dominic		Kelly
Catherine	Mary	McErlean
Hazel		Miller
Fariha		Naeem
Caroline		Ostrowski
Megan		Parkinson
Fadi		Sami
Alison		Shepherd
Lindsay		Whyte
Emily		Wright
Eilidh	E.C.	Ferguson	NHS Lanarkshire
Michael		Gallagher
Heather	J.	McCluskey
Louise		Beveridge	NHS Tayside
Hollie	A.	Clements
Jasmine		Hart
Neil		Henderson
Su Kwan		Lim
James	E.	Lucocq
Alison		McCulloch
Adam	A.	Murray
Esther	E.Y.	Ngan
Philippa	K.	Traill
Amy		Walter
Michael	S.J.	Wilson
Abigail		Wrathall
Zhi Jiun		Yap
Hashem		Abu-Arafeh	North Middlesex University Hospital NHS Trust
Ilan		Gluck
Oliver		Mitchell
Richard		Robson
Elizabeth	L.	Sampson
Arunkumar		Annamalai	North Tees and Hartlepool NHS Foundation Trust
Jamal		Bhatti
Laura		Briggs
Debbie		Fraser
Jonathan		Gui
Eleanor		Leah
Natasha		Matthews
Pryankaran		Mithrakumar
Mohammad		Moad
Michael		Sen
Jacqui		Straughan
Roxana		Taranu
Kasim		Usmani
Ayesha		Aamir	North West Anglia NHS Foundation Trust
Amaka		Achara
Olugbenro		Akintade
Elizabeth	J.	Ellis
Sneha		Gurung
Chioma		Iwu
Abdullah	B.	Khalid
Sejlo		Koshedo
Shonit		Nagumantry
Nader		Nashed
Philip		Nwabufor
Ijeoma	T.	Obi
Parrthiepan		Visvaratnam
Edward		Wu
Marc		Bertagne	Northern Devon Healthcare NHS Trust
Peter		Jackson
James		Allen	Oxford University Hospitals NHS Foundation Trust
Harriet		Brown
Jennifer		Champion
Natasha		Christodoulides
Olivia		Handley	Poole Hospital NHS Foundation Trust
Fiona	E.	Macdonald
Laura	J.	Beeley	Royal Cornwall Hospitals NHS Trust
Victoria		Clayton
Aaron		Kay
John		Marshall
Hannah		Morgan
George		Naish
Sarah	L.	Cleaver	Royal Devon & Exeter Hospital NHS Foundation Trust
Jenny		Evans
Abbie		Morrow
Raj		Amarnani	Royal Free London NHS Foundation Trust
Khai	L.	Cheah
Claire		Cushen
Amy		Enfield-Bance
Martin		Glasser
Suriti		Govindji
Shama		Mani
Jemma		Gregory	Sandwell and West Birmingham NHS Trust
Puja		Jatti
Asma		Khan
Helena		Lee
Helen		Millner
Huma		Naqvi
Emily		Williamson
Teresa		Harkin	Sherwood Forest Hospitals NHS Foundation Trust
Bushra		Khizar
Anna		Lewis
Hannah		Pendleton
Steve		Rutter
Rohan		Ahmed	Shrewsbury and Telford Hospital Trust
Farah		Coffey
Waleed		Faheem
Beth		Hackett
Elizabeth	A.M.	Holmes
Ali		Khan
Zeeshan		Mustafa
Mark	A.	Bowman	South Eastern Health and Social Care Trust
James		Irvine
Katherine		Patterson
Sarah		Horner	South Tees Hospitals NHS Foundation Trust
Ting	W.	Wong
Christopher		Cairns	South Tyneside and Sunderland NHS Foundation Trust
Kate		Foster
Alex		Hornsby
Robbie		Horton
Laura		Jones
Rachel		King
Emily		Lyon
Ani		Tencheva
Faye		Wilson
Lesley	J.	Young
Eleanor		Giblin	South Warwickshire Foundation Trust
Lleika		Kunaselan
Olivia		Lowes
Reema		Menezes
Abigail		Taylor
Alex		Timperley
Rachel		Batho
Charlotte		Bell
Sammy		Carter
Paul		Croft
Eliza		Griffiths
Giles		Hall
William		Hunt
Holly		Jacques
Felicity		Leishman
Seema		Murthy
Sinead		Quinn
James		Reid
Amy		Walker
Stephanie	A.	Matthews	Southend University Hospital Trust
Ayoub		Behbahani	Southport and Ormskirk Hospital NHS Trust
Martin		Glasser	St George's University Hospital NHS Trust
Ana		Silva Ferreira	Surrey and Sussex Healthcare NHS Trust
Caroline		Ashton	The Princess Alexandra Hospital NHS Trust
Swetha		Byravan	The Royal Wolverhampton NHS Trust
Laura		Cummings
Sana		Faruq
Sarah		Jagdeo
Philip		Thomas
Karen		Broadhurst	Torbay and South Devon NHS Foundation Trust
Joseph	B.	Wilson
Helen		Bowden	University College London
Katrin		Hoffman
Howell	T.	Jones
Charles		Katz-Summercorn
Ethan		Khambay
Lucy		Porter
James		Speed
Keziah		Austin	University College London Hospitals NHS Foundation Trust
Farrah		Bahsoon
Rose		Laud
Jawad		Ali	University Hospitals Birmingham NHS Trust (Birmingham Heartlands Hospital)
Niall		Fergusson
Claire		Wilkes
Laura		Babb	University Hospitals Birmingham NHS Trust (Good Hope Hospital) University Hospitals Birmingham NHS Trust (Good Hope Hospital)
James		Gaywood
Jessica		Green
Ada		Kantczak
Katy	F.	Madden
Sasha		Porter-Bent
Moe		Su Su San
Laxmi		Babar	University Hospitals Birmingham NHS Trust (Queen Elizabeth Hospital Birmingham)
Helen		Chamberlain
Tamsin		Cricklow
Alexis		Giles
Abhishek		Gupta
Clare		Hughes
Tammy		Lee
Anum		Cheema	University Hospitals Birmingham NHS Trust (Solihull Hospital)
Yathu		Matheswaran
Asiodu		Nneamaka
Anekea		Ross
Tarunya		Vedutla
Theresa	J.	Allain	University Hospitals Bristol NHS Trust
Emily		Bowen
Julie		Dovey
Natalie		Gaskell
Deborah		Scott
Emma		Stratton
Miriam		Thake
Stuart		Bullock	University Hospitals Coventry and Warwickshire NHS Trust
Siobhan		McKay
Stephanie		Radoja
Sherif		Abdelbadiee	University Hospitals of Leicester NHS Trust
Samuel		Cohen
Jane		Giddings
Christopher	J.	Miller
Emma		Mumtaz
Minal	D.	Patel
Vishnu		Prasad
Lahiru		Satharasinghe
Mark		Studley
Marylin		Browne	University Hospitals of North Midlands NHS Trust
Sabrina	K.	Durrant
Emma		Jay
Alex		McQuillan
Megan		Offer
Jessel		Varghese
Alexander		Baron	University Hospitals Plymouth NHS Trust
Christian		Chourot
Peter		Jackson
Kimberley		Kirrane
Helen		Rayner
Kate		Tantam
Ebrahiem		Tumi
Shabnam		Venkat
Nisha		Aggarwal	University of Birmingham
Emma		Astaire
Karthik		Basker
L		Berwick
Edward		Bilton
Aimee-Louise		Chamboult
George		Chapman
Jasmine		Chevolleau
Grace		Fenneley
Shannelle		House
Nathan		Ingamells
Emilia		Jewell
Vickneswaran		Kalyaani
Mahum		Kiani
Nagarjun		Konda
Anusha		Kumar
Jo		Lai
Jamie		Large
Joanna		Livesey
Zeinab		Majid
Jack		McCready
Hannah		Moorey
Bethan		Morgan
Kirty		Morrison
Alice		Mosley
Adam		Pailing
Sophie		Pettler
Shayan		Rashid
Lucy		Rimmer
Danielle		Scarlett
Gurpreet		Sehmi
Abigail		Smith
Nina		Smith
Charles		Sprosen
Emily		Taylor
Jemima		Taylor
Connie		Tse
Sophie		Turton
Henry		Vardon
Jasmine		Virk
Sarah		Warwicker
Hannah		Woodman
Beth	L.	Woodward
Luke		Wynne
Leah		Yule
Asim		Ahmad	University of Bristol
Paapa		Appiah-Odame
Ciaran		Barlow
Dorothy		Kuek
Isabelle		Nicholls
Emma		Norman
Wioletta		Pyc
Ashish		Vasudev
Lawrence	A.T.	Adams	University of Dundee
Emma		Box
Chung Sien		Chai
Darcy	S.	Wilson
Bogna		Drozdowska	University of Glasgow
Emma		Elliott
Adam		Stirling
Martin		Taylor-Rowan
Hannah		Webb
Li		Wong
Ahmed		Abras	Walsall Healthcare NHS Trust
Muhammad		Adam
Zarah		Amin
Olivia		Cooper
Rhianna		Davies
Wan Idoracaera	C.	Ikhwan
Georgia	R.	Layton
Awolkhier		Mohammedseid-Nurhussien
Sohail		Shakeel
Hana		Waraich
Jabed		Ahmed	West Hertfordshire Hospitals NHS Trust
Katie		Ball
Kwasi		Debrah
Valerie		Page
Zhao		Xiao Bei
Hannah		McCauley	Western Health and Social Care Trust
David		McShane
Freya		Cooper	Weston Area Health NHS Trust
Natalie		Grundmann
Michael		Haley
Andre		Le Poideven
Sarah	B.	McClelland
Emily		Moore
Norman		Pang
Hannah		Currie	Wye Valley NHS Trust
Jayne		Davies-Morris
Sarah		Edwards
Sureena		Janagal
Rodric		Jenkin
Polly		Jones
Gary		Kumbun
Sarah		Parry
Bhav		Tyagi
Janine		Valentine	Yeovil District Hospital NHS Foundation Trust
Saad		Abdullah	York Teaching Hospital NHS Foundation Trust
Emmy		Abu
Sarah		Ahmad
Bilquis		Ahmed
Hamza		Ahmed
Ana		Andrusca
Matthew		Ansell
Thomas		Arkle
Imola		Bargaoanu
Charlotte		Chuter
Katie		Houldershaw
Jacqueline		Ibanichuka
Shoaib		Iqbal
Angela		Kabia
Ismail		Kadir
Anjli		Krishan
Adam		McClean
Gerry		McGonigal
Pranav		Mishra
Gladys		Ofoche
Anna		Reay
Simon	M.	Stapley
Adam		Swietoslawski
Nihaad		Syed
Karthika		Velusamy
Afnan		Wahballa
James		Wilcockson