More Fabulous NHS Stuff!

The Rosa Parks Award - Caring for Carers

United Lincolshire Hospital Trust has developed a carers policy to ensure we consider carers as experts in care; after all they know our patients so much better than we do!!

The problem is that carers often don’t consider themselves as carers; they are a husband, a wife, a son or daughter….they don’t have ‘Carer’ tattooed on their forehead…so it can be really difficult to identify them.

To help us do so we are launching our carers badge today,  20th November, National Carers Rights day.

This badge and lanyard enables carers to be at the hospital 24/7 if they wish, to be present at ward rounds and whenever they need to be. This is our approach to Johns Campaign and goes a step beyond dementia care to incorporate all carers.

4 Candles Award - Developing a Home First Mindset

People should be in hospital for the shortest possible time; lower level care, recovery, rehabilitation and re-ablement should wherever possible happen in the persons’ usual place of residence.

Imagine leaving your home and never returning to it again

Imagine someone tells you that you are moving house tomorrow and you have no control over where you are moving to and how much it will cost

We undertake assessments of a person’s ability to live their life once they no longer require acute medical or nursing care in the acute hospital setting. This is a time consuming process, comprising a number of assessments and information gathering (described by some as interrogation) that people report feels as if they are taking an exam. It adds to the amount of time people spend in hospital physically deconditioning and is a significant percentage of the days they have left in life.

We ask people to make cups of tea in hospital Occupational Therapy kitchens, walk upstairs even when they live in a bungalow or on one level in their house.

We ask them intimate questions about how they manage their personal care and then decide whether they have passed or failed these tests. For people with dementia this is even more challenging, we decide based on their behaviour in hospital that they are not safe to be at home because they are wandering, or have challenging behaviour. They may just be trying to find home as they have forgotten they are in hospital. A person may appear incontinent overnight in hospital because they cannot get to the toilet unaided and assistance can often take a while to arrive. They may have had a catheter inserted on admission despite having no significant continence problems prior to admission. The issue of going to the toilet at night is often one of the deciding factors in the perceived need for 24 hour care.

We decide whether people have ‘rehabilitation potential’; but take away the word rehabilitation and we are suggesting that as an individual they have no potential. I find it interesting that we do not as therapists consider a person with quadriplegia to have no ‘rehabilitation potential’ yet decide this to be the case for many older people who are no longer as mobile as they were.

We decide they cannot possibly live the way they chose to live before admission because they have not reached their ‘baseline’ level of function. I don’t know about you but I struggle to make a cup of tea as efficiently in someone else’s kitchen so might appear less capable than I believe I am in my own environment. I am also not aware that we expect younger people to be at their baseline in order to be discharged from hospital.

In trying to do what we believe to be the best to keep people safe, we have become risk averse on their behalf and paternalistic in a way that would not be acceptable if we were talking about a child. The legislation that covers children requires us to involve children in the decisions being made about them. We all live differently, we are individuals and we have a responsibility to allow people to live their lives as they want to

How often do we sit in multi-disciplinary team (MDT) meetings and make decisions as a team without the person in the room, making judgements about how people live. We may then have a family meeting and, in effect inform them of our decision, appearing to consult. I have often sat in these meetings imagining they were talking about me, I find myself thinking that I would not want them to talk about me in this way without me there to express my point of view and let them know what matters most to me.

What really matters to older people are the following to their standards not ours:

• Having choice and control over their lives
• Occupation and activity, having a purpose
• Personal care and appearance
• Food and Drink
• Accommodation (cleanliness and comfort)
• Personal safety
• Social participation/inclusion
• Dignity (in care) once you are acutely ill or dependent on care

These are all part of the wider determinants of health and well being and consider the role of broader local government, benefits, housing and the social capital in communities including the voluntary sector when considering how to deliver a model that allows assessment of older people in their usual environment during and at the end of a period of recovery.

We need to work on the principle that we should support people to return home to recover from their admission to hospital and cease to make decisions about long term care in a hospital setting.

The Penguin Award - Designing and implementing an ‘Acute Hospital @ Home’ service

Dr James A Richards, Consultant Physician and Geriatrician

Departments of Medicine for Older People and Acute Medicine, Dorset County Hospital

E-mail: http://James.Richards@dchft.nhs.uk

This Future Hospital Programme case study describes how a multidisciplinary team at Dorset County Hospital created an ‘Acute Hospital @ Home’ service.

Key Recommendations

• Working closely with community teams will help to avoid duplications of other community services
• Establish robust trust pathways and procedures in order to adhere to administrative guidelines and professional standards
• A period of ‘attitude adjustment’ can help instil confidence from hospital staff
• Communicate clearly with community services in order to provide a seamless episode of care from hospital to community settings

The Challenge

The ‘Acute Hospital @ Home’ (AH@H) service was designed to provide aspects of inpatient care in the patient’s own home. We wanted the service to include:

• nursing assessment and observations
• complex dressings, wound care and surgical drain management
• consultant assessment and access to specialist care
• blood tests
• intravenous antibiotics and diuretics. Antibiotic therapy is adjusted as for ambulatory treatment of infections (eg ceftriaxone for cellulitis, or teicoplanin in the over 75s)
• nebulisers
• physiotherapy
• occupational and speech and language therapy
• input from dieticians from DCH.

Local context

Dorset County Hospital is a district general hospital providing acute inpatient and outpatient services. It has approximately 430 inpatient beds, 10 operating theatres, and provides specialist services, including oncology and renal.

The hospital covers a rural population, with a proportion of people living in more remote settings, with long distances to travel to the hospital. There was a hope that aspects of inpatient care could be provided in people’s homes.

Our solution

It was our aim to:

• reduce the number of acute medical admissions
• facilitate earlier discharge
• reduce the length of stay (LOS) in inpatient areas

We found we could avoid admissions for chronic conditions by providing appropriate home care interventions in the earlier stages of acute episode. Patients who require certain aspects of inpatient care are highlighted on admission or during assessment in ambulatory care, and referred directly to AH@H, rather than being admitted to hospital. There is an aim to receive direct referrals from general practice into AH@H in the future.

Outcomes

Initially, the service was a 3 month project funded by the clinical commissioning group (CCG). However, due to the success of the project, it became an established service funded by the Trust. Each patient is given the opportunity to complete the Friends & Family test at the end of their interventions. So far, we have 100% positive results.

Patients have informed us they:

• are better rested
• more comfortable
• are better nourished (simply because they have their preferred diet at their preferred times)
• maintain their usual roles and routines

Patients have 1:1 uninterrupted time with the health professionals providing their care. We are currently using the AusTOMS to measure patient outcomes.

Further outcomes included:

• We doubled the key performance indicator for bed days saved for the Trust, with eight bed days saved each day
• 100% of service users would recommend it
• At 90% occupancy, the cost to the Trust was less than half that of an inpatient stay. Approximately £87 per day per AH@H patient
• We expanded the service in terms of opening hours and skills provided
• We increased the numbers of referrals

Staffing

Currently we have: one team lead (band 7), one ward sister (band 7), one deputy sister (band 6) and two nurses (band 5); all full time.We also have: five band 2/3 support staff and one whole time equivalent (WTE) physiotherapist (band 6), 0.8 WTE occupational therapist (band 6), 0.4 WTE speech and language therapist, 0.1 WTE dietitian, 0.2 WTE pharmacist (band 6) and 1.6 WTE admin (band 2).

There are two sessions of consultant time spread across 5 days, and planned junior doctor time in addition to that. We have a vacant band 4 WTE pharmacy technician post which unfortunately has never been filled.

We have reset the therapies time as to begin with we have more dietician time than required. We have increased the registered nurse time as demand for nursing skills has increased with increase in patient numbers.

Three consultants have input to AH@H, one each day attending the multidisciplinary meeting – virtual ward round, reviewing clinical progress, observations, blood tests, drug chart. Home visits are made when required, or if patients require further investigations, they are reviewed in the ambulatory care department.

Methods

Originally it was anticipated we would have frail elderly patients predominately; however, it quickly became apparent that we were able to accept patients from other specialities more quickly and successfully. Frail elderly patients had more care needs than we could provide and the social needs could not be met quickly enough by the social care teams. We now have patients from all adult hospital wards and outpatient clinics. The most commonly-encountered medical conditions are: cellulitis requiring intravenous antibiotics, exacerbations of chronic obstructive pulmonary disease (COPD) and bronchiectasis, and IV antibiotics for infected joint prostheses and wound infections.

In particular we:

• Supported bed management and hospital patient flow
• Provided a supportive, multidisciplinary approach to the management of acute exacerbations of chronic conditions within the patient’s own home
• Controlled/limited the admissions depending on acuity and demand of current inpatients, with a maximum potential of 15 patients at any one time, depending on locality and acuity of patient case load
• Ensured the ‘ward’ follows admission criteria; any variation in the admission criteria needs to be authorised by the lead consultant, eg patients are medically stable, the treatment required can be safely offered in community setting, patients are living in area we can reach, have telephone access to get help in an emergency, skill mix available with the team
• Operated the service between 07.30 and 23.00, seven days a week, with access to the admitting medical and surgical team outside these hours
• Provided safe, reliable and high quality care to the patients and reducing the need for hospital readmission. Patients are referred to community rehabilitation teams, district nurses and social care as required. We use an electronic discharge summary to advise community teams and general practitioners with regards to discharge diagnoses, management and ongoing care

Key learning

The service required the establishment of pathways and protocols to deliver acute services in the community setting. Initially there were concerns with regards to duplication of current community services; however, by working closely with community teams, the AH@H service has provided a much-needed bridge between primary and secondary care. Trust pathways and procedures had to be adapted to maintain standards of practice in delivering acute healthcare in a community setting, whilst adhering to administrative guidelines and professional standards.

In addition, we had a period of ‘attitude adjustment’ with hospital staff. This was achieved through work with staff in each department, looking at conditions that could be managed safely at home; we established links with a member of each department, to facilitate care and feedback any issues that arose. Hospital staff have traditional methods of delivering acute care and so therefore needed to be assured that some patients can be safely and effectively treated away from the traditional setting. This was achieved over time by demonstration and discussion at grand rounds, and attendance at team meetings. We needed to inspire confidence that the service provided a safe and effective way of delivering acute medicine for appropriate patients.

Furthermore, we had to communicate and liaise with the community services and work to provide a seamless episode of care from the hospital to community setting, enhancing the discharge procedures and, in some cases, providing joint visits to handover patients with more complex needs or care plans.

Patient feedback

One notable case was a gentleman with Lyme disease with neurological involvement – bilateral facial nerve palsies and right lower limb weakness, leading to both speech disturbance and reduced mobility. This gentleman underwent 5 days of inpatient investigation and management, and a diagnosis was made. He then required 3 weeks of intravenous antibiotics and ongoing physiotherapy and speech and language therapy.

He was referred to the AH@H as we felt that he was an ideal candidate. He required medical input (receiving most of his course of IV antibiotics at home), but also multi-disciplinary management, including physiotherapy and speech and language therapy. He also benefited from the emotional and educational support from nursing and medical staff. He was reviewed regularly by the consultant in charge of AH@H, and also by our visiting neurologist.

Some of the key factors associated with the good patient feedback are:

• being able to sleep in one’s own bed
• eating meals at home
•  having family and friends close by
• close and regular contact with the same group of nursing, medical and therapy staff (continuity of care)