Emma Regen

Older people and the relationship between hospital services and intermediate care: Results from a national evaluation

In the UK, new intermediate care services have been established to prevent unnecessary hospital admissions, facilitate effective discharge and prevent premature care home admissions. This paper reports findings from a national evaluation of intermediate care, focusing on the relationship between hospital services and intermediate care. Participants included key managers and practitioners involved in the planning, management and delivery of intermediate care in five case study sites. During the study, they identified a range of tensions between hospital services and intermediate care, including concerns about the role and involvement of acute clinicians; the safety, quality and appropriateness of intermediate care; access to and eligibility for intermediate care; a lack of understanding and awareness of intermediate care; and the risk of intermediate care being dominated by acute pressures. Although participants were able to identify several practical ways forward, resolving such fundamental tensions seems to require significant and long-term cultural change in the relationship between acute and intermediate care. Overall, this study raises questions about the extent to which intermediate care will be able to rebalance the current health and social care system and make a substantial contribution to tackling ongoing concerns about emergency hospital admissions and delayed transfers of care.

Withdrawal of ventilation at the patient's request in MND: a retrospective exploration of the ethical and legal issues that have arisen for doctors in the UK

Background Ventilatory support has benefits including prolonging survival for respiratory failure in motor neurone disease (MND). At some point some patients may wish to stop the intervention. The National Institute of Health and Care Excellence (NICE) guidance recommends research is needed on ventilation withdrawal. There is little literature focusing on the issues doctors encounter when withdrawing ventilation at the request of a patient. Aim To identify and explore with doctors the ethical and legal issues that they had encountered in the withdrawal of ventilation at the request of a patient with MND. Method A retrospective thematic analysis of interviews of 24 doctors (including palliative care, respiratory, neurology and general practice) regarding their experiences with withdrawal of ventilation support from patients with MND. Results Respondents found withdrawal of ventilation at the request of patients with MND to pose legal, ethical and moral challenges in five themes: ethical and legal rights to withdrawal from treatment; discussions with family; discussions with colleagues; experiences of legal advice; issues contributing to ethical complexity. Though clear about the legality of withdrawal of treatment in theory, the practice led to ethical and moral uncertainty and mixed feelings. Many respondents had experienced negative reactions from other healthcare professionals when these colleagues were unclear of the distinction between palliation of symptoms, withdrawal of treatment and assisted death. Conclusions Legal, ethical and practical guidance is needed for professionals who support a patient with MND who wishes to withdraw from ventilation. Open discussion of the ethical challenges is needed as well as education and support for professionals.

Identifying frailty in the Emergency Department - feasibility study

Introduction identifying the most at risk older people in Emergency Departments (EDs) may help guide clinical practice, and service improvement in emergency care, but little is known about how to implement such tools in practice. Methods consensus building was used to determine the desirable characteristics of a risk stratification process, including focus groups and literature reviewing. Candidate tools were tested using clinical vignettes in semi-structured interviews with a range of clinicians working in one large ED, assessing speed of use, ease of use and agreement with clinical judgement. The primary outcome was the likelihood of future use of a given frailty tool. Results the ideal tool characteristics included brevity (<1 min), simplicity and multidimensionality; tools selected for testing included the Identification of Seniors At Risk, Clinical Frailty Scale, PRISMA-7 and Silver Code. One hundred and twenty-one staff members (43% of the total ED workforce) were recruited from one large ED in the East Midlands. Two hundred and thirty-six individual frailty tool assessments were undertaken using 1 of 10 clinical vignettes; 75% of staff stated that they would use at least one of the tools again, with no significant differences between the individual tools. The median time to complete the tool was around 1 min per patient for all four tools. There were no significant differences in timing, ease of use or agreement with clinical judgement between tools. Discussion validated risk stratification tools are quick, simple, easy to use and 75% of staff would use the tools again in the future.

Service factors causing delay in specialist assessment for TIA and minor stroke: a qualitative study of GP and patient perspectives.

Objective To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke. Design Qualitative study using semistructured interviews, analysis by constant comparison. Setting Leicester, UK. Participants Patients diagnosed with TIA or minor stroke, at hospital admission or in a rapid-access TIA clinic (n=42), general practitioners (GPs) of participating patients if they had been involved in the patients’ care (n=18). Data Accounts from patients and GPs of factors contributing to delay following action to seek help from a healthcare professional (HCP). Results The following categories of delay were identified. First, delay in assessment in general practice following contact with the service; this related to availability of same day appointments, and the role of the receptionist in identifying urgent cases. Second, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out-of-hours services, walk-in centres and the emergency department. Third, delays in referral after a suspected diagnosis; these included variable use of the ABCD2 (Age, Blood pressure, Clinical features, Duration, Diabetes) risk stratification score and referral templates in general practice, and referral back to the patients’ GP in cases where he/she was not the first HCP consulted. Conclusions Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice, this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.

Shifting care from community hospitals to intensive community support: a mixed method study.

Aim To examine how the introduction of intensive community support (ICS) affected admissions to community hospital (CH) and to explore the views of patients, carers and health professionals on this transition. BACKGROUND ICS was introduced to provide an alternative to CH provision for patients (mostly very elderly) requiring general rehabilitation. METHOD Routine data from both services were analysed to identify the number of admissions and length of stay between September 2012 and September 2014. In total, 10 patients took part in qualitative interviews. Qualitative interviews and focus groups were undertaken with 19 staff members, including managers and clinicians. Findings There were 5653 admissions to CH and 1710 to ICS between September 2012 and September 2014. In the five months before the introduction of ICS, admission rates to CH were on average 217/month; in the final five months of the study, when both services were fully operational, average numbers of patients admitted were: CH 162 (a 25% reduction), ICS 97, total 259 (a 19% increase). Patients and carers rated both ICS and CH favourably compared with acute hospital care. Those who had experienced both services felt each to be appropriate at the time; they appreciated the 24 h availability of staff in CH when they were more dependent, and the convenience of being at home after they had improved. In general, staff welcomed the introduction of ICS and appreciated the advantages of home-based rehabilitation. Managers had a clearer vision of ICS than staff on the ground, some of whom felt underprepared to work in the community. There was a consensus that ICS was managing less complex and dependent patients than had been envisaged. CONCLUSION ICS can provide a feasible adjunct to CH that is acceptable to patients. More work is needed to promote the vision of ICS amongst staff in both community and acute sectors.