Greta Westwood

A primary care specialist genetics service: a cluster-randomised factorial trial.

BACKGROUND GPs do not have the confidence to identify patients at increased genetic risk. A specialist primary care clinical genetics service could support GPs with referral and provide local clinics for their patients. AIM To test whether primary care genetic-led genetics education improves both non-cancer and cancer referral rates, and primary care-led genetics clinics improve the patient pathway. DESIGN AND SETTING Cluster-randomised factorial trial in 73 general practices in the south of England. METHOD Practices randomised to receive case scenario based seminar (intervention) or not (control), and referred patients a primary (intervention) or secondary (control) care genetic counsellor (GC)-led appointment. OUTCOME MEASURES GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, patient satisfaction, clinic costs, and case management (secondary). RESULTS Eighty-nine and 68 referrals made by 36 intervention and 37 control practices respectively. There was a trend towards an overall higher referral rate among educated GPs (referral rate ratio [RRR] 1.34, 95% confidence interval [CI] = 0.89 to 2.02; P = 0.161), and they made more appropriate cancer referrals (RRR 2.36, 95% CI = 1.07 to 5.24; P = 0.035). No indication of difference in clinic attendance rates (odds ratio 0.91, 95% CI = 0.43 to 1.95; P = 0.802) or patient satisfaction (P = 0.189). Patients spent 49% less travelling (£3.60 versus £6.62; P<0.001) and took 33% less time (39.7 versus 57.7 minutes; P<0.001) to attend a primary than secondary care appointment; 83% of GC-managed appointments met the 18-week referral to treatment, NHS target. CONCLUSION An integrated primary care genetics service both supports GPs in appropriate cancer referral and provides care in the right place by the right person.

A fundamental conflict of care: nurses’ accounts of balancing patients' sleep with taking vital sign observations at night

Aims and objectives To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night. Background Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patients condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why. Design A qualitative interpretative design informed this study. Methods Seventeen semi‐structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used. Results At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night‐time frequency of these observations was determined by clinical judgement, ward‐level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under‐monitored, while patients nearing the end of life could be over‐monitored. Conclusion In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long‐term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions. Relevance to clinical practice Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under‐monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.

Relationships between healthcare staff characteristics and the conduct of vital signs observations at night: Results of a survey and factor analysis

To explore the association of healthcare staff with factors relevant to completing observations at night.

Building clinical academic leadership capacity: sustainability through partnership

Background A national clinical academic training programme has been developed in England for nurses, midwives and allied health professionals but is insufficient to build a critical mass to have a significant impact on improved patient care. Aim We describe a partnership model led by the University of Southampton and its neighbouring National Health Service partners that has the potential to address this capacity gap. In combination with the Health Education England/National Institute of Health Research Integrated Clinical Academic programme, we are currently supporting nurses, midwives and allied health professionals at Master’s (n = 28), Doctoral (n = 36), Clinical Lecturer (n = 5) and Senior Clinical Lecturer (n = 2) levels working across seven National Health Service organisations, and three nurses hold jointly funded Clinical Professor posts. Results Key to the success of our partnership model is the strength of the strategic relationship developed at all levels across and within the clinical organisations involved, from board to ward. We are supporting nurses, midwives and allied health professionals to climb, in parallel, both clinical and academic career ladders. We are creating clinical academic leaders who are driving their disciplines forward, impacting on improved health outcomes and patient benefit. Conclusions We have demonstrated that our partnership model is sustainable and could enable doctoral capacity to be built at scale.

Creating Learning Environments for Compassionate Care (CLECC): a feasibility study

BACKGROUND: Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable. OBJECTIVES: To assess the feasibility of implementing Creating Learning Environments for Compassionate Care programme (CLECC) in acute hospital settings and evaluating its impact on patient care. DESIGN: Pilot cluster randomised controlled trial (CRT) and associated process and economic evaluations. SETTING: Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n=4) or control (n=2) PARTICIPANTS: 639 patients, 211 staff, 188 visitors. INTERVENTION: CLECC, a workplace educational intervention focused on developing sustainable leadership and work-team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. Control: no planned staff team-based educational activity. MAIN OUTCOME MEASURES: Quality of Interaction Schedule (QuIS) for staff-patient interactions; patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy). DATA SOURCES: structured observations of staff-patient interactions; patient, visitor and staff questionnaires and qualitative interviews; qualitative observations of CLECC activities. RESULTS: CRT: Pilot proceeded as planned and randomisation was acceptable to teams. There was evidence of contamination between wards in the same hospital. QuIS performed well achieving a 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more positive (78% versus 74%) and less negative (8% versus 11%) QuIS ratings for intervention wards versus control wards. 63% of intervention ward patients scored lowest (i.e. more negative) scores on PEECH connection subscale, compared with 79% of control group patients. These differences, while supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: The CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. We found strong evidence of good staff participation in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: We also identified the costs associated with using CLECC and recommend that an impact inventory be used in any future study. LIMITATIONS: Findings are not generalizable outside of hospital nursing teams and this feasibility work is not powered to detect differences due to CLECC. CONCLUSIONS: Use of experimental methods is feasible. The use of structured observation of staff-patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research but further validation is required. Further development of the CLECC intervention should focus on ensuring it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers.

Universal Screening for Alcohol Misuse in Acute Medical Admissions Identifies Cohort of Patients with High Risk of Alcohol Related Liver Disease - An Analysis of 50,000 Hospital Admissions

Contact: liver@porthosp.nhs.uk 4. Conclusions • Universal screening for alcohol misuse is achievable and can be delivered 24 hours a day, 7 days a week. • Screening identifies a highly dependent cohort with frequent ED attendances, recurrent admissions and an elevated risk of ARLD. • Additional patients at increasing risk of alcohol harm can be identified in a range of general medical presentations. • These patients can be targeted with effective interventions to reduce the burden of alcohol related harm.