Abstract
Aims
Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance.
Methods
This national cross-sectional study was carried out at 87 NHS centres in the UK involving 122 EDs and 184 minor injuries units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for suspected scaphoid fractures in EDs, MIUs, and orthopaedic services. Overall, 62 of 87 centres (71%) had a guideline for the management of suspected scaphoid fractures.
Results
A total of 11 of 87 centres (13%) had MRI directly available from the ED. Overall, 14 centres (17%) used cross-sectional imaging direct from the ED: MRI in 11 (13%), CT in three (3%), and a mixture of MRI/CT in one (1%). Four centres (6%) used cross-sectional imaging direct from the MIU: MRI in three (4%) and CT in two (2%). Of 87 centres’ orthopaedic specialist services, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in three (3%), and radiographs in 11 (13%).
Conclusion
Only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance.
Cite this article: Bone Jt Open 2021;2(11):997–1003.
Take home message
Only a small minority of centres in the UK offer MRI directly from the emergency department for patients with suspected scaphoid fractures.
Further research is needed to investigate the facilitators and barriers to the implementation of National Institute for Health and Clinical Excellence (NICE) guidance.
Introduction
Wrist trauma represents a large clinical and economic burden for both patients and healthcare services.1 A significant proportion of patients with wrist trauma have clinical signs consistent with a potential scaphoid fracture but normal radiographs,2 the so-called ‘suspected scaphoid fracture’. Only a minority of these patients will have a scaphoid injury that necessitates immobilization, but given the high chance of developing post-traumatic arthritis in an untreated acute scaphoid fracture,3 and the notable difficulty and expense of treating a scaphoid nonunion and any associated arthritis, the accurate identification of fractures at the time of acute presentation is imperative to enable prompt appropriate treatment.
In the UK, National Institute for Health and Clinical Excellence (NICE) guidance currently advises that MRI is considered the first line imaging for people with suspected scaphoid fractures following a thorough clinical examination;4 the guidance is based upon some detailed health economic modelling which compared three clinical pathways (radiographs alone vs radiographs + CT vs radiographs + MRI), which indicated that MRI was the most cost-effective option.5 There are also other potential advantages of early MRI, including achieving a prompt diagnosis in order to enable safe early mobilization and a return to activities.6 The COVID-19 pandemic is likely to have had a significant impact upon practice, with an emphasis on reducing the number of face-to-face contacts with patients.
Our primary objective was to assess the availability of MRI imaging direct from the emergency department (ED). Our secondary objectives were to assess the availability of MRI imaging direct from minor injuries units (MIUs), the specifics of patient management pathways for suspected scaphoid fracture in EDs, MIUs, and orthopaedic services (OSs), and the estimated incidence of scaphoid fractures at each centre.
Methods
We carried out a multicentre, survey-based cross-sectional study in 87 UK centres over six months from November 2020 to April 2021. REC approval was not required, as per National Research Ethics Service (NRES) guidance, as it involved clinician surveys only.
Participating centres and clinicians
The SUSPECT working group, involving collaborators from multiple stakeholder groups, including EDs, orthopaedics, and radiology, was assembled. Participating centres were recruited using clinician contacts from previous collaborative projects and advertising on social media.7 Any centre which regularly treated patients with acute wrist trauma was eligible to participate. Each centre had to serve at least one ED and involve a distinct specialist surgical department. The set of surveys will consist of a surgeon-lead survey, an ED-lead survey, and an MIU-lead survey, when an MIU was present. These surveys had been created by the study group and previously piloted at four centres. The clinician surveys were completed remotely in electronic format by the representatives from surgical services, as well as the ED and MIU where applicable, for each centre for each centre. If any questions were unclear, then these were addressed by email or telephone communication. Local clinical guidance was gathered when possible, and responses cross-referenced with local guidance to ensure accuracy of responses.
Outcomes
The primary outcome measure was availability of MRI direct from the ED. The secondary outcomes included the availability of MRI imaging direct from MIUs, the specifics of patient management pathways for scaphoid fractures in EDs, MIUs, and OSs, and the estimated incidence of scaphoid fractures at each centre.
Statistical analysis
The study was done according to a previous template for survey-based studies.8 Statistical analysis was carried out using IBM SPSS Statistics for Windows (version 27.0; IBM, USA). Unless otherwise stated in the characteristics description, numbers represent n (percent) for categorical variables, and median (interquartile range (IQR)) for continuous variables.
Results
Centres
In total, 87 UK centres participated (see Table I for characteristics), of which 17 (23%) were designated major trauma centres, and a majority of 75 (86%) were from England. The sum of the centres’ catchment populations was 49 million (approximately 65% of the UK’s population). Using the frequency of suspected scaphoid fractures estimated by EDs and MIUs, as shown in Table II and Table III, a conservative estimate for the number of the suspected scaphoid fractures in the UK per annum is 70,000, assuming each centre sees ten scaphoid fractures per week. In all, 62 of 87 EDs (71%) had a guideline for the management of suspected scaphoid fractures, while 59 of 82 centres (72%) with an MIU had a guideline.
Table I.
Centre characteristics.
| Variable | Data, n = 87, n (%) |
|---|---|
| Major trauma centre | 20 (23) |
| Catchment population, median (IQR) | 500 (350 to 612) |
| Country | |
| England | 75 (86) |
| Scotland | 7 (8) |
| Wales | 4 (5) |
| Northern Ireland | 1 (1) |
| Number of emergency departments | |
| 1 | 60 (69) |
| 2 | 22 (25) |
| > 2 | 5 (6) |
| Local clinical guideline for the management of suspected scaphoid injuries? | |
| Yes | 62 (71) |
| No | 25 (2) |
| Number of minor injuries units | |
| 0 | 6 (7) |
| 1 | 36 (41) |
| 2 | 22 (25) |
| > 2 | 23 (26) |
| Management of suspected scaphoid injuries in minor injuries unit? | |
| Yes | 59 (72) |
| No | 23 (28) |
-
IQR, interquartile range.
Table II.
Emergency department survey results.
| Variable | Data, n = 87, n (%) |
|---|---|
| What is your role? | |
| Consultant ED | 65 (75) |
| Specialist trainee ED | 4 (5) |
| Advanced nurse practitioner | 5 (6) |
| Advanced physiotherapist | 4 (5) |
| Staff grade or GP | 9 (10) |
| < 5 | 16 (18) |
| 5 to < 10 | 30 (34) |
| 10 to < 20 | 30 (34) |
| 20 to < 30 | 8 (9) |
| 30 or > | 3 (4) |
| Which type of radiographs do you routinely obtain? | |
| Posteroanterior/lateral wrist | 4 (5) |
| PA/lateral wrist and scaphoid views | 40 (46) |
| Scaphoid views | 44 (51) |
| How are patients typically immobilized? | |
| Splint without thumb | 35 (40) |
| Splint with thumb | 45 (52) |
| Backslab/temporary cast | 7 (8) |
| What are the clinical signs for further investigation? | |
| All with history, irrespective of signs | 33 (38) |
| ASB tenderness | 6 (7) |
| ASB and/or tubercle tenderness | 39 (45) |
| ASB or tubercle tenderness or axial loading | 5 (6) |
| Other | 4 (4) |
| Do you provide further investigation direct from ED? | |
| No | 72 (83) |
| Yes, MRI | 11 (13) |
| Yes, CT | 3 (3) |
| Yes, other (MRI and CT mix) | 1 (1) |
| Subgroups | |
| For those centres with imaging direct from ED, how are patients followed-up? (n = 15) | |
| ED | 5 (33) |
| Specialist | 6 (40) |
| Mixture of ED and specialist | 4 (27) |
| For those centres without direct imaging, where are patients followed-up? (n = 72) | |
| ED for radiographs and then onward specialist referral | 1 (1) |
| ED for CT | 2 (3) |
| ED for MRI | 3 (4) |
| Specialist services | 66 (92) |
-
ASB, anatomical snuffbox; ED, emergency department; GP, general practioner.
Table III.
Minor injuries unit survey results.
| Variable | Data, n = 82, n (%) |
|---|---|
| What is your role? | |
| Consultant ED | 8 (10) |
| Specialist trainee ED | 1 (1) |
| Advanced nurse practitioner | 60 (73) |
| Advanced physiotherapist | 6 (7) |
| Other | 7 (9) |
| How many patients are seen in your unit per week? | |
| < 5 | 16 (20) |
| 5 to < 10 | 35 (43) |
| 10 to < 20 | 25 (30) |
| 20 to < 30 | 6 (7) |
| 30 or > | 0 (0) |
| Which type of radiographs do you routinely obtain? | |
| Posteroanterior/lateral wrist | 36 (44) |
| Posteroanterior/lateral wrist + scaphoid views | 0 (0) |
| Scaphoid views | 46 (56) |
| How are patients typically immobilized? | |
| Splint without thumb | 28 (34) |
| Splint with thumb | 48 (59) |
| Backslab/temporary cast | 6 (7) |
| What are the clinical criteria for further investigation? | |
| All with history, irrespective of signs | 37 (45) |
| ASB tenderness | 1 (1) |
| ASB and/or tubercle tenderness | 38 (46) |
| ASB or tubercle tenderness or axial loading | 2 (2) |
| Other | 4 (5) |
| Do you provide further investigation direct from MIU? | |
| No | 77 (94) |
| Yes, MRI | 3 (4) |
| Yes, CT | 2 (2) |
| Subgroups | |
| For those centres with imaging direct from MIU, how are patients followed-up? (n = 5) | |
| MIU/ED | 1 (20) |
| Specialist | 3 (60) |
| Mixture of MIU/ED and specialist | 1 (20) |
| For those centres without direct imaging, where are patients followed-up? (n = 77) | |
| MIU/ED | 10 (13) |
| ED/specialist mixture | 3 (4) |
| Specialist | 64 (83) |
| For those centres with MIU/ED follow-up, how are patients next managed? (n = 10) | |
| Repeat scaphoid view radiographs and specialist referral | 3 (30) |
| Repeat scaphoid view radiographs and MRI | 4 (40) |
| Repeat scaphoid view radiographs and CT | 1 (1) |
| MRI | 2 (2) |
-
ASB, anatomical snuffbox; ED, emergency department; MIU, minor injuries unit.
Primary outcome: NICE guidance adherence
In total, 11 of 87 centres (13%) had MRI directly available from ED in adherence with NICE guidance. This is demonstrated in Table II and Figure 1.
Fig. 1
A summary of pathways from the emergency department.
Secondary outcomes
ED based pathways
These pathways are summarized in Table II and Figure 1. The most common frequency of scaphoid fracture patients per week were five to < ten (30 centres; 34%) and ten to < 20 (30 centres; 34%). All centres routinely used radiographs which were variable in nature, while most used splint immobilization initially (82 centres; 92%). The most common clinical criteria for further investigation were anatomical snuffbox (ASB) or scaphoid tubercle tenderness (39 centres; 45%), and a suspicious history irrelevant of clinical examination (33 centres; 38%). In all, 72 centres (83%) did not offer cross-sectional imaging direct from ED, and in these centres follow-up was by OSs in 66 (76%) and ED in six (7%). Of these 72 centres (83%), 44 (51%) used MRI directly, 13 (15%) used CT, two (2%) used a CT/MRI mix, and 13 (15%) used radiographs alone. Follow-up after direct ED imaging was mixed in terms of ED and specialist input.
MIU based pathways
These pathways are summarized in Table III and Figure 2. The most common frequency of scaphoid fracture patients per week were five to < ten (35 centres; 43%) and ten to < 20 (25 centres, 30%). All centres routinely used radiographs which were variable in nature, while most centres used splint immobilization initially (76 centres; 93%). The most common clinical criteria for further investigation were anatomical snuffbox (ASB) or scaphoid tubercle tenderness (38 centres; 46%), and a suspicious history irrelevant of clinical examination (37 centres; 45%).
Fig. 2
A summary of pathways from minor injury units.
Four centres (6%) used cross-sectional imaging direct from the MIU: this was MRI in three (4%) and CT in two (2%). Overall, 77 centres (94%) did not offer cross-sectional imaging direct from MIU, and of these, follow-up was in OSs in 64 (78%), an ED/MIU clinic in ten (12%), and a mixture of ED/OSs in three (4%).
Specialist surgery pathways
These pathways are summarized in Table IV. All respondents were Orthopaedic surgeons. Of 87 centres OSs, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI (55; 63%), then CT (16; 19%), a mixture of MRI/CT (three; 3%), and radiographs (11; 13%). The most common clinical criteria for further investigation were anatomical snuffbox (ASB) or scaphoid tubercle tenderness (49 centres; 56%), and a suspicious history irrelevant of clinical examination (28 centres; 32%). Overall, 74 centres routinely obtained scaphoid series radiographs (74 centres; 85%) while the remainder did not do any radiographs (13 centres; 15%).
Table IV.
Surgeon survey results.
| Variable | Data, n (%) |
|---|---|
| What is your role? | |
| Consultant orthopaedic surgeon | 87 (100) |
| What are the clinical signs for further investigation? | |
| All with history, irrespective of signs | 28 (32) |
| ASB tenderness and axial loading | 3 (3) |
| ASB and/or tubercle tenderness | 49 (56) |
| Other | 7 (8) |
| Which type of radiographs do you routinely obtain? | |
| None | 13 (15) |
| Scaphoid views | 74 (85) |
| How are patients typically next managed? | |
| Splint/cast and MRI | 55 (63) |
| Splint/cast and CT | 16 (19) |
| Mixture of MRI and CT | 3 (3) |
| Splint and return for x-rays | 7 (8) |
| Cast and return for x-rays | 4 (5) |
| Other | 2 (2) |
| For those who use MRI, do you routinely use CT to assess for fracture displacement? (n = 58) | |
| Yes | 8 (14) |
| For radiograph positive scaphoid fractures, do you routinely use further imaging to assess for displacement? | |
| No | 55 (63) |
| Yes, CT | 29 (33) |
| Yes, MRI | 3 (3) |
| How do you manage scaphoid fractures non-surgically? | |
| Below elbow cast with thumb | 8 (9) |
| Below elbow cast without thumb | 79 (91) |
| How long do you immobilize scaphoid fractures (weeks)? | |
| 4 to 5 | 3 (3) |
| 6 | 59 (68) |
| 7 | 1 (1) |
| 8 | 24 (28) |
| How do you assess for union routinely? | |
| CT routinely | 22 (25) |
| Radiographs initially ± CT if judged necessary | 64 (74) |
| No imaging | 1(1) |
-
ASB, anatomical snuffbox.
A small minority of centres (eight; 14%) routinely obtained a CT scan to assess for displacement in patients with an MRI detected scaphoid fracture. Over half of centres (55; 63%) did not routinely use further imaging to assess for displacement in radiograph detected scaphoid fractures, while 29 (33%) used CT for this purpose. All centres used a below elbow cast for the non-surgical management of scaphoid fractures; this did not involve the thumb in 79 centres (91%) and did involve the thumb in the remainder (eight centres; 9%). The most common period of cast immobilization was six weeks (59 centres; 68%), followed by eight weeks (24 centres; 28%). CT was used a routine first line imaging for scaphoid union in 24 centres (28%).
Discussion
The results of this study demonstrate that only a small minority (11 centres; 13%) of centres are adherent with NICE guidance in terms of being able to offer MRI direct from the ED for scaphoid fractures, while only 4% (three centres) were able to offer MRI directly from the MIU. Given the evidence demonstrating both the economic and clinical gains of early MRI, there remains a case for better implementing the NICE guidance and for future work to support the bridging of this implementation gap.
The great strength of our study is that by spanning specialist services, EDs, and MIUs, we have been able to unpick the overall pathways with greater clarity than previous studies. A limitation to our study is the sample size of 87 centres, although this is larger than previous studies, and sampling bias may have influenced our results. While a further limitation is that our study relies on the assumption that the results of surveys accurately represent what is happening to real patients on the clinical frontline, this may not always be the case.
The most recent study on UK pathways for scaphoid fractures was carried out over two years ago in January 2019, with responses from 66 EDs demonstrating only 3% of centres offered imaging beyond radiographs directly from the first ED attendance.9 Our findings have shown that this has improved to 17%; however, it cannot be ruled out that this change may be due to sampling bias. The study by Snaith et al9 was limited by its smaller sample size of 66 EDs and its reliance on data solely from EDs; no data was gathered from OSs or MIUs. Chunara et al10 carried out a survey-based study in 2017, and reported that 38 of 74 responding NHS trusts offered MRI as a ‘first-line investigation’. Notably, the question posed to entirely radiologists, ‘Do you offer MRI as a first line investigation for scaphoid fracture where plain radiographs are normal?’, would likely have resulted in MRI used after repeat radiographs in an orthopaedic clinic being deceptively counted as MRI being used as a ‘first-line investigation’.
The costs associated with repeated clinical attendances and repeat radiographs have been well described previously, with a short sequence wrist MRI costing around £72 and an initial fracture clinic appointment, without radiographs, costing £165 alone.5,11 The Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was a single-centre, randomized controlled trial involving 132 patients, which compared a novel pathway involving early MRI direct from the ED with a conventional pathway involving clinic attendance with radiographs, followed by a CT scan if clinically indicated, and then further radiographs after four to eight weeks.6 It was shown that early MRI resulted in cost savings of £174 per patient at three months, and £266 per patient at six months.6 Not only did early MRI have this clear cost advantage, it also benefits diagnostic accuracy and patient satisfaction.6 The accurate early diagnosis also enables the immobilization of scaphoid fractures, which will arguably minimize the costs of litigation and early mobilization, without the need for further clinic attendances in a large proportion of patients.12
The reasons underlying the failure to implement the NICE guidance are likely complex and multifactorial. The capacity for MRI may be a factor; however, Chunara et al10 found no strong relationship between the MRI usage and the number of MRI scanners available. One key issue is potentially a lack of awareness of the NICE guidance and the evidence, which supports the use of early MRI; it may be that the better communication and dissemination of information is influential. The care for patients with scaphoid fractures involves many staff from multiple departments, including the ED, MIUs, radiology, orthopaedic surgery, and, perhaps most importantly, management. Improving cross-departmental communication and breaking down artificial clinical silos may also be necessary to implement change. Certainly, there is a strong justification for future research to explore the barriers and facilitators to change.
In conclusion, only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance.
References
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Funding statement
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
ICMJE COI statement
B. J. F. Dean reports a grant from AO UK, which is related to this work; M. L. Costa declares that his employer, University of Oxford, receives research grants from NIHR, Wellcome, EU, industry, and charities for research into musculoskeletal trauma, which is unrelated to this article; N. Riley reports consultancy for Acumed, which is also unrelated.
Acknowledgements
*The SUSPECT study and writing group consists of:
Benjamin J F Dean (first author), PhD FRCS, Consultant Hand Surgeon and Senior Research Fellow. Contributions to study: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing.
Nicholas Riley, FRCS, Consultant Hand Surgeon. Contributions to study: Conceptualization, Formal Analysis, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing – original draft, Writing – review & editing.
Christopher Little, FRCS, Consultant Hand Surgeon. Contributions to study: Conceptualization, Formal Analysis, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing – original draft, Writing – review & editing.
Alasdair Bott, FRCS, Consultant Hand Surgeon. Contributions to study:
Conceptualization, Formal Analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.
Edward Sellon, FRCR, Consultant Radiologist. Contributions to study: Conceptualization, Formal Analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.
Will Mason, FRCS, Consultant Hand Surgeon. Contributions to study: Conceptualization, Formal Analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.
David Metcalfe, PhD, Clinical Lecturer in Emergency Medicine. Contributions to study: Conceptualization, Formal Analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.
Emma Phelps, PhD, Postdoctoral Research Associate. Contributions to study: Conceptualization, Formal Analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.
Elizabeth Tutton, PhD, Senior Research Fellow. Contributions to study: Conceptualization, Formal Analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.
Matt L. Costa (senior author), PhD, Professor of Orthopaedic Surgery. Contributions to study: Conceptualization, Formal Analysis, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing – original draft, Writing – review & editing.
The following are UK collaborators to the SUSPECT study group:
Phil Hormbrey, Warren Sheehan, Angela O’Neill: Oxford University Hospitals NHS Trust.
Sunil Garg, Nitin Modi, James Crawford: James Paget University Teaching Hospital, NHS Foundation Trust.
Raveen Jayasuriya, Phil Storey, Ben Cooper, Sheffield Teaching Hospitals NHS Foundation Trust.
David Bodansky, Stephen Lipscombe, Caroline Laundy, Graeme Inkster: St Helens and Knowsley Teaching Hospitals NHS Trust.
Thomas Bochmann, Chrishnan Mariathas, Jonathan Scrimshaw, Emma Watson: Leeds Teaching Hospitals NHS Trust.
Abhay Sood, Neeraj Ahuja, David Snow, Victoria Jeffrey: Southport & Ormskirk Hospital NHS Trust.
Clare Wildin, Nicky Allen-Ventola: University Hospitals of Leicester.
Richard Dimock, Gavin Brigstocke, Rebecca Owens, Glyn Barnett, Janet Thompson: Frimley Health NHS Foundation Trust.
Suresh Srinivasan, Hannah Lennox-Warburton, Vijay Garg, Sarah Tye: Kettering General Hospital NHS Trust.
Maxim D Horwitz, Anna Loch-Wilkinson, Samim Ghorbanian: Chelsea and Westminster Hospitals NHS Trust.
Rob Poulter, Ciaran Brennan, Tamsin Fussell, Neil Davidson: Royal Cornwall Hospitals NHS Trust.
Abdus Burahee, Dominic Power, Nasir Ali, Darren Reid: University Hospitals Birmingham NHS Trust team 1.
David Murray, Albert Tang, James Stuart, Emma Kenyon: Fairfield General Hospital, Pennine NHS Trust.
Prithee Jettoo, Dave Cloke, Jo Hughes, Julian Coffey: Northumbria Healthcare NHS Foundation Trust.
Jonathan D’Souza, Saurabh Odak, Andrew Starkey, Claire Woolfitt: University Hospital of Morecambe Bay NHS Foundation Trust.
Suddhajit Sen, Marius Sainiuc, David Frazer, Jamie Hawkins: Noble’s Hospital, Isle of Man.
Raveen Jayasuriya, Phil Storey, Ben Cooper, Kirsten Clinton: Sheffield Teaching Hospitals NHS Foundation Trust.
Aziz Haque, Sami Hassan, Mike Pearce, Pamela Charters: Northampton General Hospital NHS Trust.
Rakan Kabariti, Robert Turner, Mohamed Ali, Julie Littlehales: Shrewsbury and Telford NHS Trust.
Anish Koneru, Richard Gadd: Barnsley Hospital NHS Foundation Trust.
Martin Sharrock, Mohammed Shoaib Arshad, John Durrell, Shelagh Scott: Royal Oldham Hospital, Pennine NHS Trust.
Sarah Henning, Clare Langley, Romany Daniel, Ruth Jackson: University Hospitals Coventry and Warwickshire.
Anshul Sobti, Mohamed Imam, Sriram Thillainayagam, Patricia Miles: Ashford and St Peter’s Hospital’s NHS Foundation Trust.
Aaron Rooney, Adrian Chojnowski, Dhananjay Kumar, Paul Welander: Norfolk and Norwich University Hospital NHS Foundation Trust.
Stephen Boyce, Paul Jenkins, Pauline Kerray, Pauline Rush, Tina Ha: Greater Glasgow & Clyde Health Board.
Alasdair Bott, Sam Haines, Elizabeth Hooper, Richard Donovan, Emilie Lostis: North Bristol NHS Trust.
Andrew Clarke, Samuel Haines, John Bowditch, Peter Foley: Taunton and Somerset NHS Foundation Trust.
Will Mason, Dan Yeomans, Cristina Soare, Lee Iddles: Gloucester NHS Foundation Trust.
Moritz Lebe, Shahrier Sarker, Alexander Hieatt, Richard Horton: Mid Essex NHS Hospital Trust.
William Fletcher, Fizan Younis, Sanjoy Battacharrya, Jo Dunstan: East Lancashire Hospitals NHS Trust.
Jemma Rooker, Adam Smith, Elizabeth Barneby, Satinder Mann: Great Western Hospitals NHS Foundation Trust.
Joshua Luck, James Logan, Mirza Marican, Sue Carl: Royal Surrey County Hospital.
David Lawrie, Jillian Reid, James Ferguson, Jun Wei Lim: NHS Grampian.
Beatrice Ho, Charles Gozzard, Sally Pearson, Annette Rickard: University Hospitals Plymouth NHS Trust.
Owen Richards, Preetham Kodumuri, Robin Roop, Natalie Hayward: Wrexham Maelor Hospital.
Zaf Naqui, Andrew McDonough: Salford Royal NHS Foundation Trust.
Kriti Singhania, Andrew McKee, Ben Fletcher, Ieuan Metcalfe: North West Anglia NHS Foundation Trust.
Ruben Thumbadoo, Andrew Hacker, Divyansh Gulati: Milton Keynes University Hospital NHS Trust.
Thomas Walton, Oliver Stone, Andy Appelboam, Adam Reuben: Royal Devon and Exeter NHS Foundation Trust.
Kalpesh R. Vaghela, Dafydd Edwards, Samira Akberali, Jane Walledge: Royal London Hospital, Barts Health NHS Trust.
Simon Bellringer, Riem Johnson, Duncan Bootland, Cordelia Smith, Penny Stuart: Brighton and Sussex University Hospitals NHS Trust.
Medhat Zekry, Nicholas Garlick: Royal Free NHS Foundation Trust.
Sandeep Deshmukh, Alexia Karantana, Jamier Johnson, Jim Quinn: Nottingham University Hospitals NHS Trust:
Feiran Wu, Rangaraju Raganathan, Daisy Taylor: University of Hospitals Birmingham NHS Trust team 2.
Chu-Hao Chiang, Andrew Smith, Georgiana Scarlat, Jenny Taylor: East Kent NHS Foundation Hospitals.
Aaron Ng, Donald Buchanan, Luke Chirayil, G Shuttleworth, B Ketzer: The Mid Yorkshire Hospitals NHS Trust.
Olivia McCabe-Robinson, Alistair Konarski, Stephen Hodgson, Jennifer Scott, Usman Arif, Hannah Reeve: Royal Bolton Hospital.
Rebecca Martin, Emma Reay, Ian Blain, Andrew Hebron: South Tees Hospital NHS Foundation Trust.
Adeline Clement, Ahmed Elhalawany, Michael Rennie: Raigmore Hospital, NHS Highland.
Motunlayo Falade, Nikolas Jagodzinski, Liam Kevern, Robert Edwards: Northern Devon Healthcare NHS Trust.
Baseem Choudhry, James Nicholl, Jim McDonald, John Clulow: Maidstone and Tunbridge Wells NHS Trust.
Gavin Schaller, Onur Berber, Lucy Parker: Whittington Health NHS Trust.
Matthew Weston, Karanjit Mangat, Paul Shore, Susan Marlow: South Warwickshire NHS Foundation Trust.
Ann McCormack, Miranda Champion, Anandkumar Ganesan, Lucy Maling: East Sussex NHS Trust.
Lugman Elgayar, Angus Maclean, Ryan Hawkins, Sarah Blandford: Cwm Taf Morgannwg University Health Board.
Ryan Trickett: Cardiff and Vale University Health Board.
Micheal Feeney, Alison Billings, Angela Valentine, Hassan Rameez: United Lincolnshire Hospitals NHS Trust.
Madeline Warren, Fred Schreuder, Kevin Zammit, Kevin Cooper: East and North Hertfordshire NHS Trust.
Michael Elvey, John Hardman, Amy Farmiloe, Daniel Osikomino: University College London Hospitals NHS Trust.
Matthew Torkington, Omer Alanie: Greater Glasgow and Clyde Queen Elizabeth University Hospital.
Edwin Jesudason, Rajiv Doshi, Nicky Somers: Ysbyty Gwynedd Hospital, Ysbyty Glan Clwyd.
Alan Armstrong, Andrew James, Tuk Goh, Lynda Olone: South Eastern Health and Social Care Trust.
Nastaran Sargazi, Simon Robinson, Amir Norouzi, Susan Rowhan: Wirral University Teaching Hospital NHS Foundation Trust.
Ethan Caruana, Mayank Vashishtha, Nandini Sen, Julie Kay: Manchester University Hospitals Foundation Trust.
Sudhi Ankarath, Paramjit Singh: Calderdale & Huddersfield NHS Trust.
Duncan Coffey, Nick Aresti, Krasimira Tchobanov, Tony Sebastian: Whipps Cross Hospital.
Roshana Mehdian, Shami Umaji, Rhys Beynon, Lucy Sandles: St George’s NHS Trust.
Thomas Holme, Nashat Siddiqui, Deepika Pyda, Thomas Milliner: Kingston Hospital NHS Foundation Trust.
Clare Middleton, Avadhut Kulkarni, Manish Thakker, Kath O’Hagan: Royal Berkshire Hospital NHS Foundation Trust.
Zoe Lin, Simon Richards, Karim Hassan, Daniel Elliott: University Hospitals Dorset NHS Foundation Trust.
Antonia Hoyle, Gill Eastwood, Sean McEwan, Kenneth Anderson, Iain McLaughlin-Symon: Stockport NHS Foundation Trust.
Greg Pickering, Aex Cowey, Saif Al-Nahhas, Rachel Vincent: Royal United Hospitals Bath NHS Foundation Trust.
Thomas Harding, Simon Johnson, Peter Croll, Julie Ronald: NHS Tayside.
Barbara Frank, David Warwick, Kenneth Reid, Andrew Rudge: University Hospital Southampton NHS Trust.
Paul Stirling, Jane McEachan, Nilesh Champaneria: NHS Fife.
Kanthan Theivendran, Asif Naveed, Martin Holmes: Sandwell & West Birmingham Hospitals NHS Trust.
Arvind D Vijapur, Ramesh Chennagiri, Ravi Kumar Kakanur, Alan Gibson: Buckinghamshire Hospitals NHS Trust.
Vasudev Zaver, Sumedh Talwalkar, Rajendra Ghosh, Marwan Hassan: Wrightington, Wigan & Leigh NHS Foundation Trust.
Sarah Rehman, Darren Roberts: Portsmouth Hospitals NHS Trust.
Shireen Ibish, Raymond Anakwe, George Bailey, Layla Hassan: Imperial College NHS Trust.
Paul Paterson-Byrne, Amir Afshari, Soham Gangopadhyay, Dhananjay Singh, Jackie McLoughlin: South Tyneside and Sunderland NHS Foundation Trust.
Andrew Duckworth, Caitlin Brennan, Anne Grant, Krishna Murthy: NHS Lothian.
David Ferguson, Claire Fitzgerald, Sarah Perkins, Bhartiya Malay: Newham University Hospital, Barts Health NHS Trust.
Sam Gidwani, Tim Yorston, Oliver Grant: Guy’s and St Thomas’ NHS Foundation Trust.
Mahbub Chowdhury, Robert Halstead, David Dickson, Jacob Mushlin: Bradford Teaching Hospitals NHS Trust.
Ethical review statement
Ethical approval was not required according to HRA guidance.
Open access funding
The authors report that this work has been supported by a pump priming grant from AO UK.
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