Adrian Hopper

Improving care for patients whose recovery is uncertain. The AMBER care bundle

Introduction Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1–2 months. This paper suggests an approach to improve this care. Intervention A care bundle (the AMBER care bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The care bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. Clinical impact This paper describes the development and implementation of a care bundle. From August 2011 to July 2012, 638 patients received care supported by the AMBER care bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. Conclusions It has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated.

Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service

AIMS To explore the experience of senior staff on acute medical wards using an established inpatient liaison psychiatry service and obtain their views on clinically relevant performance measures. METHODS Semistructured face-to-face interviews with consultants and senior nurses were taped, transcribed and analyzed manually using the framework method of analysis. RESULTS Twenty-five referrers were interviewed. Four key themes were identified - benefits of the liaison service, potential areas of improvement, indices of service performance such as speed and quality of response and expanded substance misuse service. Respondents felt the liaison service benefited patients, staff and service delivery in the general hospital. Medical consultants wanted stepped management plans devised by consultant liaison psychiatrists. Senior nurses, who perceived themselves as frontline crisis managers, valued on-the-spot input on patient management. CONCLUSIONS Consultants and senior nurses differed in their expectations of liaison psychiatry. Referrers valued speed of response and regarded time from referral to definitive management plan as a key performance indicator for benchmarking services.

Patient and carer experiences of clinical uncertainty and deterioration, in the face of limited reversibility: A comparative observational study of the AMBER care bundle

Background: Clinical uncertainty is emotionally challenging for patients and carers and creates additional pressures for those clinicians in acute hospitals. The AMBER care bundle was designed to improve care for patients identified as clinically unstable, deteriorating, with limited reversibility and at risk of dying in the next 1–2 months. Aim: To examine the experience of care supported by the AMBER care bundle compared to standard care in the context of clinical uncertainty, deterioration and limited reversibility. Design: A comparative observational mixed-methods study using semi-structured qualitative interviews and a followback survey. Setting/participants: Three large London acute tertiary National Health Service hospitals. Nineteen interviews with 23 patients and carers (10 supported by AMBER care bundle and 9 standard care). Surveys completed by next of kin of 95 deceased patients (59 AMBER care bundle and 36 standard care). Results: The AMBER care bundle was associated with increased frequency of discussions about prognosis between clinicians and patients (χ2 = 4.09, p = 0.04), higher awareness of their prognosis by patients (χ2 = 4.29, p = 0.04) and lower clarity in the information received about their condition (χ2 = 6.26, p = 0.04). Although the consistency and quality of communication were not different between the two groups, those supported by the AMBER care bundle described more unresolved concerns about caring for someone at home. Conclusion: Awareness of prognosis appears to be higher among patients supported by the AMBER care bundle, but in this small study this was not translated into higher quality communication, and information was judged less easy to understand. Adequately powered comparative evaluation is urgently needed.

Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation

Introduction Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1–2 months. This paper suggests an approach to improve this care. Intervention A care bundle (the AMBER care bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The care bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. Clinical impact This paper describes the development and implementation of a care bundle. From August 2011 to July 2012, 638 patients received care supported by the AMBER care bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. Conclusions It has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated.

Feasibility and effect of supplementing a modified OTAGO intervention with multisensory balance exercises in older people who fall: a pilot randomized controlled trial:

Objective: To investigate the feasibility and comparative effect of supplementing a modified OTAGO falls rehabilitation programme with multisensory balance exercises and informed sample size calculation for a definitive trial. Design: Single-blinded randomized controlled trial with pre/postcomparisons using a per-protocol analysis. Setting: Secondary care-based falls clinic, London, UK. Subjects: Community-dwelling older people (n = 21) experiencing ≥2 non-syncopal falls during previous 12 months. Intervention: Modified OTAGO exercise classes supplemented with supervised home-based rehabilitation consisting of multisensory balance or stretching exercises. Group classes and home sessions each occurred twice-weekly for eight weeks. Measurements: A computerised randomization was used for group allocation. A rater, blinded to intervention, performed the assessment including the Functional Gait Assessment (primary outcome), Physiological Profile Assessment, and questionnaires relating to symptoms, balance confidence, and psychological state (secondary outcomes). Results: Significant within-group improvements were noted for the Functional Gait (p < 0.01, r = −0.63) and Physiological Profile Assessments (p < 0.05, r = −0.63) in the OTAGO+multisensory rehabilitation group only and for balance confidence scores in the OTAGO+stretching group (p < 0.01, r = −0.63). Between-group differences were noted for the Functional Gait (p < 0.01, r = −0.71) and Physiological Profile (p < 0.05, r = −0.54) assessments with the OTAGO+multisensory group showing significantly greater improvement. The drop-out rate was similar for both groups (~30%). No serious adverse events were reported. Conclusions: Supplementing the OTAGO programme with multisensory balance exercises is feasible in older people who fall and may have a beneficial effect on falls risk as measured using the Functional Gait and Short-form Physiological Profile Assessments. An adequately powered randomized controlled trial would require 36 participants to detect an effect size of 1.35 on the Functional Gait Assessment.

Seeing is believing – healthcare professionals’ perceptions of a complex intervention to improve care towards the end of life: A qualitative interview study:

Background: Methods to improve care, trust and communication are important in acute hospitals. Complex interventions aimed at improving care of patients approaching the end of life are increasingly common. While evaluating outcomes of complex interventions is essential, exploring healthcare professionals’ perceptions is also required to understand how they are interpreted; this can inform training, education and implementation strategies to ensure fidelity and consistency in use. Aim: To explore healthcare professionals’ perceptions of using a complex intervention (AMBER care bundle) to improve care for people approaching the end of life and their understandings of its purpose within clinical practice. Design: Qualitative study of healthcare professionals. Analysis informed by Medical Research Council guidance for process evaluations. Setting/participants: A total of 20 healthcare professionals (12 nursing and 8 medical) interviewed from three London tertiary National Health Service hospitals. Healthcare professionals recruited from palliative care, oncology, stroke, health and ageing, medicine, neurology and renal/endocrine services. Results: Three views emerged regarding the purpose of a complex intervention towards the end of life: labelling/categorising patients, tool to change care delivery and serving symbolic purpose indirectly affecting behaviours of individuals and teams. All impact upon potential utility of the intervention. Participants described the importance of training and education alongside implementation of the intervention. However, adequate exposure to the intervention was essential to witness its potential added value or embed it into practice. Conclusion: Understanding differing interpretations of complex interventions is essential. Consideration of ward composition, casemix and potential exposure to the intervention is critical for their successful implementation.

Pentazocine-induced cutaneous scarring.

A 34-year-old Nigerian woman presented with skin lesions 4 days after her arrival in the UK. She reported having had an 18-month illness in Nigeria, where she had been treated for malaria and typhoid. She also gave a history of leg pain during her illness, which had required an injectable analgesic for control. Her family members mentioned her having a labile mood since the injections had begun. On physical examination, the patient was found to have bilaterally distributed, indurated and hyperpigmented nodules and plaques on her legs and buttocks, sparing the face and trunk completely. Some were centrally ulcerated, and others resembled hypertrophic scars with central hypopigmentation. She also had several depressed and atrophic scars on her buttocks, as well as ulcers and leaking sinuses (Fig. 1). Communication with the patient was difficult because of her deafnes and general condition, but her patient’s family reported that she had been receiving, and subsequently self-administering, pentazocine injections for pain control while in Nigeria. This treatment was dispensed in batches, and subsequently self-administered intramuscularly by the patient. The initial differential diagnoses included Kaposi sarcoma and atypical mycobacterial infection. A deep skin biopsy was taken from the patient’s right thigh. On histological examination, a superficial and deep perivascular lymphocytic infiltrate was seen containing common plasma cells and occasional eosinophils. There was also prominent pan-dermal fibrosis and focal haemosiderin deposition. Focal subcutaneous fibrosis and fat necrosis were also identified (Fig. 2). Immunostaining for human herpes virus-8 was negative. Laboratory investigations showed the patient to have a macrocytic, normochromic anaemia, normal white cell count, mild thrombocytosis, and normal urea and electrolyte levels. She had raised levels of creatinine (132 lmol/L; normal range 60–110 lmol/L) and C-reactive protein (82 mg/dL; normal < 10 mg/dL). Tests for myeloma, sickle-cell anaemia, human immunodeficiency virus and autoimmune disease were normal, and a chest radiograph was unremarkable. Based on the clinical history, examination and histological findings, a diagnosis of pentazocine-induced dermal necrosis and scarring was made. Pentazocine, introduced in 1967 as a ‘non-narcotic, nonaddicting’ analgesic, is a synthetically prepared mixed agonist–antagonist opioid analgesic drug of the Correspondence: Prof Jonathan Barker, St John’s Institute of Dermatology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK E-mail: jonathan.barker@kcl.ac.uk

Non-steroidal anti-inflammatory drugs in elderly people. Treat mild chronic pain with paracetamol initially.

EDITOR,--In their editorial on the use of anti-inflammatory drugs in elderly patients D N Bateman …

OPTIMISING FALLS RISK ASSESSMENT IN MEMORY SERVICES: INVESTIGATING SYSTEM-WIDE INTEGRATION OF FALL PREVENTION EVIDENCE INTO PRACTICE

demonstrated across age groups. Conclusions: In carers of people with dementia, the HADS measures three factors of anxiety, depression and negative affectivity. This has implications for interpretation of a commonly used clinical instrument and may enhance understanding of previous clinical trial results, which have use the HADS as a primary outcome but interpreted it as a one or a two-factor measure. The depression subscale of the HADS can detect and measure depression, but the HADS anxiety and negative affectivity scales are not useful in this group. Measurement invariance results suggest the HADS can be used to measure differences in depression across gender and kinship but not across age groups.