Bethany Simmonds

What works in ‘real life’ to facilitate home deaths and fewer hospital admissions for those at end of life?: results from a realist evaluation of new palliative care services in two English counties

BackgroundWe evaluated end of life care services in two English counties including: coordination centres, telephone advice line, ‘Discharge in Reach’ nurses, a specialist community personal care team and community nurse educators. Elsewhere, we published findings detailing high family carer satisfaction and fewer hospital admissions, Accident and Emergency attendances and hospital deaths for service users compared to controls. The aim of this paper is to discuss what contributed to those outcomes.MethodsUsing realist evaluation, data collection included documentation (e.g. referral databases), 15 observations of services and interviews with 43 family carers and 105 professionals. Data were analysed using framework analysis, applying realist evaluation concepts. Findings were discussed at successive team meetings and further data was collected until team consensus was reached.ResultsServices ‘worked’ primarily for those with cancer with ‘fast track’ funding who were close to death. Factors contributing to success included services staffed with experienced palliative care professionals with dedicated (and sufficient) time for difficult conversations with family carers, patients and/or clinical colleagues about death and the practicalities of caring for the dying. Using their formal and informal knowledge of the local healthcare system, they accessed community resources to support homecare and delivered excellent services. This engendered confidence and reassurance for staff, family carers and patients, possibly contributing to less hospital admissions and A&E attendances and more home deaths.ConclusionsWith demand for 24-hour end of life care growing and care provision fragmented across health and social care boundaries, services like these that cut across organisational sectors may become more important. They offer an overview to help navigate those desiring a home death through the system.

Objectively assessed physical activity and lower limb function and prospective associations with mortality and newly diagnosed disease in UK older adults: an OPAL four-year follow-up study

Background: objective measures of physical activity and function with a diverse cohort of UK adults in their 70s and 80s were used to investigate relative risk of all-cause mortality and diagnoses of new diseases over a 4-year period. Participants: two hundred and forty older adults were randomly recruited from 12 general practices in urban and suburban areas of a city in the United Kingdom. Follow-up included 213 of the baseline sample. Methods: socio-demographic variables, height and weight, and self-reported diagnosed diseases were recorded at baseline. Seven-day accelerometry was used to assess total physical activity, moderate-to-vigorous activity and sedentary time. A log recorded trips from home. Lower limb function was assessed using the Short Physical Performance Battery. Medical records were accessed on average 50 months post baseline, when new diseases and deaths were recorded. Analyses: ANOVAs were used to assess socio-demographic, physical activity and lower limb function group differences in diseases at baseline and new diseases during follow-up. Regression models were constructed to assess the prospective associations between physical activity and function with mortality and new disease. Results: for every 1,000 steps walked per day, the risk of mortality was 36% lower (hazard ratios 0.64, 95% confidence interval (CI) 0.44–0.91, P = 0.013). Low levels of moderate-to-vigorous physical activity (incident rate ratio (IRR) 1.67, 95% CI 1.04–2.68, P = 0.030) and low frequency of trips from home (IRR 1.41, 95% CI 0.98–2.05, P = 0.045) were associated with diagnoses of more new diseases. Conclusion: physical activity should be supported for adults in their 70s and 80s, as it is associated with reduced risk of mortality and new disease development.

Electronic palliative care coordinating systems (EPaCCS) may not facilitate home deaths: A mixed methods evaluation of end of life care in two English counties

Electronic palliative care coordination systems (EPaCCS) detail preferred place of death across health and voluntary sector boundaries. Quantitative studies suggest that individuals recorded on EPaCCS are more likely to die at home. This study aimed to explore this relationship between EPaCCS and home deaths. Patient records from EPaCCS were collected from 1 September 2011 to 29 February 2012, linked to death data and analysed using descriptive statistics. We interviewed 101 professionals, including community nurses, and employed framework analysis. Few eligible patients were entered on EPaCCS (9% North Somerset, 13% Somerset). Of those, the majority died in community settings (87%, 81/93 North Somerset; 93% 307/331 Somerset). However, interviews and EPaCCS record analysis suggested that EPaCCS was almost exclusively used by community nurses and GPs, so, unsurprisingly, the relationship between EPaCCS and home deaths was strong. Difficulties included professional reluctance to discuss death, and the burden of data entry falling on daytime staff for out-of-hours colleagues. These results challenge assumptions that EPaCCS facilitates increased home deaths, as qualitative investigation identified selection bias. To avoid misinterpretations, future studies should employ mixed methods. The implementation of an electronic tool is not enough on its own to ensure that advanced care wishes are available, as long-standing organisational and cultural issues, such as professionals working in silos and professional reluctance to have ‘end of life’ discussions, also need to be addressed.

Can paramedics use FRAX (the WHO Fracture Risk Assessment Tool) to help GPs improve future fracture risk in patients who fall? Protocol for a randomised controlled feasibility study.

Introduction Currently identification, and therefore, management of patients at risk of osteoporotic fracture in the UK is suboptimal. As the majority of patients who fracture have fallen, it follows that people who fall can usefully be targeted in any programme that aims to reduce osteoporotic fracture. Targeting vulnerable patients who are likely to benefit from intervention may help shift the management of fracture prevention into primary care, away from emergency departments. Paramedics who attend to patients who have fallen may be well placed to assess future fracture risk, using the Fracture Risk Assessment Tool (FRAX) and communicate that information directly to general practitioners (GPs). Methods and analysis This feasibility study takes the form of a pragmatic, randomised controlled trial aimed at exploring and refining issues of study design, recruitment, retention, sample size and acceptability preceding a large-scale study with fracture as the end point. Patients (aged >50) who fall, call an ambulance, are attended by a study paramedic and give verbal consent will be asked FRAX and fall questions. Patients who subsequently formally consent to participation will be randomised to control (usual care) or intervention groups. Intervention will constitute transmission of calculated future fracture risk to the patients’ GP with suitable, evidence-based recommendations for investigation or treatment. 3 months after the index fall, data (proportion of patients in each group undergoing investigation or starting new treatment, quality of life and health economic) will be collected and analysed using descriptive statistics. A nested qualitative study will explore issues of acceptability and study design with patients, paramedics and GPs. Ethics and dissemination This protocol was approved by NRES Committee South Central Oxford C in October 2012. Research Ethics Committee ref.12/SC/0604. The study findings will be disseminated through peer-reviewed journals, conference presentations and local public events. A publication plan and authorship criteria have been preagreed. Trial registration number ISRCTN: 36245726.

PROFESSIONALISM AND CARE: THE DAILY BREAD AND BUTTER OF A PARAMEDIC ATTENDING PATIENTS WHO FALL

Falls occur increasingly frequently with age. 35% of people aged over 65 fall each year rising to 50% at age 85. Many patients fall repeatedly. 56% of patients attending an emergency department were recurrent fallers, and 55% of patients presenting with an acute fracture had previously fallen. Fracturing bones is closely linked to falling and carries great costs both for the NHS and the individual. Paramedics do not routinely assess bone health (fracture risk) in people who fall. This is why a study called ‘The OAK Project’ is being carried out the South West of England to see if it is feasible for paramedics to collect FRAX (The Fracture Risk Assessment Tool) data and whether GPs will put patients with a high risk of fracture on osteoporosis treatment. A significant element of this feasibility study is a qualitative nested study exploring the acceptability of using FRAX amongst patients and paramedics. When shadowing paramedics (n=6), the level of professionalism and care paramedics gave to patients who fell was striking. Paramedics made clinical assessments, gave personal care, emotional support and provided patients with a high level of dignity. When questioned about frequent fallers in interviews (n=12), paramedics felt that in many cases everything possible was being done. GPs are quite often aware of their frequent falling patients, home adaptations had been made, often are already taking medications for osteoporosis, they have personal alarms, home carers who visited frequently and fall assessments had been carried out. Additionally, paramedics felt that some patients do not want to be helped and felt there is a limit to what can be done to prevent people from falling in their own homes. This presentation will provide an insight into the levels of care and professionalism that paramedics demonstrate when attending people who fall in everyday practice.

Book review: Chris Shilling, Changing Bodies: Habit, Crisis and CreativityShillingChris, Changing Bodies: Habit, Crisis and Creativity. London: SAGE, 2008, 206 pp. incl., bibliog. and index, £24.99, ISBN: 9781412908320.

The author, through a detailed analysis of the city of Halifax, Nova Scotia, Canada provides factual material to shed considerable light on these issues. Black ends his essay with a provocative alternative-to-bid scenario that is well-worth heeding for any group interested in hosting mega events (p. 129). Cornelissen’s essay deals specifically with post-apartheid South Africa. Hers is an indepth discussion as to the rationales behind South African policy to bid for, and successfully gain, the right to host major events like the 1995 Rugby World Cup (with international exposure through the film Invictus) and the 2010 FIFA World Cup. The author writes and most would concur, that sporting competition ‘has become one of the most important ways through which it has sought to forge national cohesion in the post-apartheid era’ (p. 139). V. ‘Philosophical observations as regards foreign policy’. Sport and Foreign Policy in a Globalizing World ends with what the editors describe as ‘[a] highly provocative thesis’ (p. 8). The reviewer believes Robert Redeker would welcome this description. In a rich philosophical essay, rife with sporting examples from road cycling, Redeker argues that sport is the defining characteristic of the 21st century. Indeed, he suggests that one consider sport as a historical concept comparable with those of the Enlightenment, Renaissance, or Romanticism (p. 146). His sport as religion metaphor has considerable credence, especially with the contention that sport ‘has succeeded in establishing a total and stable geographic universality’ (p. 147). Organized religion has never achieved such status. Specific religious dogmas have always been open to scrutiny, criticism, acceptance or rejection. Redeker’s sport as political opium analogy (p. 149) is equally persuasive. Overall there is much substantive content in Sport and Foreign Policy in a Globalized World that will appeal to the serious sport scholar. The reviewer, to paraphrase contributor Wolfgang Manzenreiter, would argue that the book’s content suggests that the power of sport in foreign policy is present, but there is little evidence that it is powerful and its presence should not be overrated. Neither should its presence be underappreciated (see p. 77).

Book Review: Chris Shilling, Changing Bodies: Habit, Crisis and Creativity.

The author, through a detailed analysis of the city of Halifax, Nova Scotia, Canada provides factual material to shed considerable light on these issues. Black ends his essay with a provocative alternative-to-bid scenario that is well-worth heeding for any group interested in hosting mega events (p. 129). Cornelissen’s essay deals specifically with post-apartheid South Africa. Hers is an indepth discussion as to the rationales behind South African policy to bid for, and successfully gain, the right to host major events like the 1995 Rugby World Cup (with international exposure through the film Invictus) and the 2010 FIFA World Cup. The author writes and most would concur, that sporting competition ‘has become one of the most important ways through which it has sought to forge national cohesion in the post-apartheid era’ (p. 139). V. ‘Philosophical observations as regards foreign policy’. Sport and Foreign Policy in a Globalizing World ends with what the editors describe as ‘[a] highly provocative thesis’ (p. 8). The reviewer believes Robert Redeker would welcome this description. In a rich philosophical essay, rife with sporting examples from road cycling, Redeker argues that sport is the defining characteristic of the 21st century. Indeed, he suggests that one consider sport as a historical concept comparable with those of the Enlightenment, Renaissance, or Romanticism (p. 146). His sport as religion metaphor has considerable credence, especially with the contention that sport ‘has succeeded in establishing a total and stable geographic universality’ (p. 147). Organized religion has never achieved such status. Specific religious dogmas have always been open to scrutiny, criticism, acceptance or rejection. Redeker’s sport as political opium analogy (p. 149) is equally persuasive. Overall there is much substantive content in Sport and Foreign Policy in a Globalized World that will appeal to the serious sport scholar. The reviewer, to paraphrase contributor Wolfgang Manzenreiter, would argue that the book’s content suggests that the power of sport in foreign policy is present, but there is little evidence that it is powerful and its presence should not be overrated. Neither should its presence be underappreciated (see p. 77).