Abstract
Background
Healthcare inequalities can result in avoidable, unfair and systemic differences in health between different groups of people. Clinicians have unconscious biases that can impact ...on their decision making. The General Medical Council's Good Medical Practice: Maintaining Trust Domain 4, states that doctors must “treat...patients fairly without discrimination”. The Reflective Practitioner should use a variety of tools to support structured reflection. The movement disorder service in question provides care for a mix of urban and rural communities with a wide range in deprivation indices.
Methods
A single doctor's referral patterns and prescribing decisions for parkinsonian syndromes was retrospectively analysed for 99 consecutive attendees at a mixed face-to-face and telehealth clinic service over six weeks. Harvard Implicit Association Tests were completed to assess for unconscious biases. Patient characteristic data are available for: age, sex, religion, skin colour, sexual orientation, primary language, deprivation index, Trust of residence, weight, hearing loss, visual loss, Rockwood Clinical Frailty Scale, Hoehn and Yahr staging and educational attainment. Clinical decision making data are available for: referral patterns to physiotherapists, occupational therapists, speech and language therapists, continence services, psychiatry services, bone mineral density measurement, specialist nursing service, brain imaging and prescribing decisions made.
Results
The sample had 60 males, 38 females and 1 male-to-female active transition. Deprivation indices ranged from the 64th to 889th least deprived postcodes (of 890). Only one non-white attendee. Two non-heterosexual attendees. Primary language for all was English. Mean age 76.72years. Mean Hoehn and Yahr stage 2.49. 25.25% are living with dementia. 55 attendances were face-to-face. Prescribing changes were more likely to occur through telehealth clinics. Women were more likely to be referred to physiotherapy and psychiatry. Patient religion may have impacted prescribing decisions.
Conclusion
Open and honest reflection can improve patient care by identifying health inequalities and through using a metacognitive approach to clinical decision making.
Abstract
Background
The climate emergency disproportionately impacts older people. Providing low carbon-emitting care now is important for current and future healthcare. In “For a Greener NHS”, the ...NHS (National Health Service) set a target to reduce Carbon emissions for which it is directly responsible by 80% by 2028, 100% by 2040; and for emissions over which the NHS has influence by 100% by 2045. A low carbon model of care includes telehealth clinics. 3.5% of all UK road traffic is NHS travel and transport.
Methods
A sample was used to estimate modes of transport to clinics. One calendar year of telehealth clinics were reviewed to estimate distances not travelled by patients. Personal protective equipment (PPE) use was estimated. Carbon Dioxide equivalents emissions were calculated to compare face-to-face attenders with telehealth reviews.
Results
Clinician commute emitted 26.84kgCO2e. A sample of 57 face-to-face attendees indicates 89.48% travel by private vehicle, 7.02% by taxi, 1.75% by ambulance and 1.75% by bus. For the sample, this equates to 246.94kgCO2e if petrol cars used and 238.61kgCO2e if diesel cars used; 1.53kgCOe for taxi transfers; 1.92kgCOe for bus transfer. Reliable data on ambulance transport related CO2e was not found. For telehealth clinics over calendar year 2021, the total distance not travelled by patients was 14,749.8km, mean 25.51km, median 21.6km and range 1-276km. The estimated CO2e savings were: 2.30tonnes CO2e if petrol cars; 2.22tonnes CO2e if diesel cars; 215.65kgCO2e for taxis; 26.4kgCO2e for buses. The PPE related emission-savings were 128.48kgCO2e. Estimating from median travel distance 21.6km for the year: face-to-face attendances resulted in 75.17kgCO2e from taxis; 9.21kgCO2e for bus use; 801.81kgCO2e if petrol private car, 774.78kgCO2e if diesel car. 56kgCO2e in PPE related emissions.
Conclusion
Telehealth clinics can assist in reaching net zero healthcare. Sustainable and active transport needs facilitation. A specific organisational “Green Plan” is required to equitably and effectively deliver sustainable healthcare.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in interdisciplinary risk-communication in an intermediate care unit, based in a 30 bed independent care home, into which the ...hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.
Methods
Semi-structured interviews with nursing leaders and a weighted questionnaire for multidisciplinary team were used to determine baseline levels of confidence around environmental and resident-specific risk awareness.
An Ishikawa diagram analysed factors contributing to risk-communication. The ‘Chain Of Care’ vision for care home environments incorporated a Multidisciplinary Safety Brief. Five iterations occurred before reaching standardisation. A post-implementation weighted questionnaire collated qualitative information on confidence change.
The Safety Brief supplements intra-professional group handover processes. Duration ranged 90-120 seconds, occurring at shift commencement and 12.00 h daily. Retained documentation is available for inspectors.
Results
The Safety Brief as a communication tool: 86% of the team found it useful; 71% found that it had the ‘right amount’ of detail; and 62% found that it was of the ‘right duration’.
Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence in awareness of...: 72%, deaths in last 24 hours; 68%, planned discharges today; 67%, residents at risk of falling/had fallen within 48 hours; 67%, residents with same name; 66%, bed-availability; 63%, infection risks; 62%, experiencing delirium; 62%, living with dementia; 59%, scheduled appointments today; and 52%, those receiving palliative care.
Conclusion
A Multidisciplinary Safety Brief increased/slightly increased multidisciplinary team confidence in environmental and resident-specific risks in a care home environment. Risk-communication in any environment is complex especially if subject to frequent change. Communication tools need to be tailored to microsystem, systematic, comprehensive, yet brief and intuitive. Generalisability to non-intermediate care, non-geriatrician supported care home environments was considered iteratively.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in information exchange in nursing handover in an intermediate care unit, based in a 30 bed independent care home, into which the ...hospital organisation assigns a multidisciplinary team to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%. A revised electronic template was developed to complement an Intermediate Care Framework already in use, based on National Audit of Intermediate Care quality indicators.
Methods
Semi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of nursing handover.
An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for microsystem-tailored, standardised, integrated nursing handover. Four iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.
Results
Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 70%, addressing questions from residents or relatives; 70%, responding to change in a resident’s health status; 70%, giving handover to ambulance crew or doctor or fellow nurse.
Conclusion
Categorical selections across multiple information domains enabled increased/slightly increased confidence in the nursing team in the quality of the information exchanged in nursing handover in an intermediate care rehabilitation care-home setting. Focussed, free-text options permit narrative if required.
A shared electronic template facilitated accessibility and live-time editing in an environment with relatively higher bed-turnover and frequently changing functional mobility and care needs of residents.
Tailoring the nursing handover to the intermediate care environment with mitigation of variation of information provision/accessibility/language were considered in the iterations. Versions are reposited for inspectors.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in information exchange around treatment escalation plans (TEP) in an intermediate care unit, based in a 30 bed independent care ...home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.
TEP documentation is a component of RESTORE2 use, as recommended in the British Geriatric Society Good Practice Guide for Managing COVID19 in Care Homes.
Methods
Semi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of TEP.
An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for a TEP. Three iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.
Results
Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 90%, Cardiopulmonary Resuscitation (CPR) status clarity; 90%, treatment ‘ceiling of care’ e.g. ‘conveyance to the Emergency Department in any situation that the clinical team deem necessary’; 40%, conversations with out-of-hours services/external clinicians around appropriate actions; 30%, conversations with nominated persons around appropriate actions.
Conclusion
The TEP incorporates more than just CPR status and contributed to increased nursing team confidence in responding to the acutely deteriorating adult appropriately in a care home environment. Clear documentation of: capacity assessment; patient prioritisation (using ReSPECT principles); and agreed treatment escalation and limitation, enabled information exchange. Standardisation of language, and cross-fertilisation with Nursing Handover, facilitated conversations with external clinicians and nominated persons.
Tailoring the TEP to the care-home environment and rendering it generalisable to non-intermediate care, non-geriatrician supported care home microsystems was considered in the iterations.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in the recognition, monitoring, escalation and de-escalation of the acutely unwell care home resident. RESTORE2 is endorsed by the ...British Geriatric Society as the preferred tool for use in a care home setting. It incorporates: recognition of soft-signs; NEWS2 (National Early Warning Score 2); and SBAR-D (Situation Background Assessment Recommendation-Decision). Implementing RESTORE2 required a series of change interventions in a mesosystem environment in intermediate care bed-based rehabilitation setting in an independent care home.
Methods
The Flow Coaching Academy ‘5Vs’ Framework was used. A vision of ‘CHAIN of CARE’ was developed (Care Home Assessment of Intervention Need and Communicate Act Review Evaluate). Stake-holder mapping was undertaken. A Sinek Circle distilled intentions. A global aim led to specific aims and informed driver diagrams. Problems and risks were mapped out with an Ishikawa diagram. A high-level process map of future state was and cross-functional swim-lane chart for RESTORE2 use were devised. A clinical value compass map was used to consider outcomes. PDSA cycles were used.
Results
The FCA Framework methodology, albeit without the ability to undertake ‘Big Room’ meetings due to the COVID19 pandemic restrictions, enabled the development of a care-home tailored Treatment Escalation Plan; an electronic template Nursing Handover; Multidisciplinary Safety Brief; training of all nursing team in RESTORE2; and use of NEWS2 for all residents in the intermediate care setting. Additional prompt for how to use RESTORE2 was developed.
Conclusion
Bringing about complex change in a complex mesosystem benefits from different techniques than microsystem change methodology. The 5Vs: Visualisation, Vision, Value, eVidence and inVolvement in the FCA Framework are an effective approach. The residents’ voice was largely absent in the pressures of the COVID19 pandemic.
‘The Chain of Care’ proved helpful in visualising the global aims for the clinical team.
