Acute Hospital Trusts Research Articles

Developing Healthcare Team Observations for Patient Safety (HTOPS): senior medical students capture everyday clinical moments

BackgroundAviation has used a real-time observation method to advance anonymised feedback to the front-line and improve safe practice. Using an experiential learning method, this pilot study aimed to develop an observation-based real-time learning tool for final-year medical students with potential wider use in clinical practice.MethodsUsing participatory action research, we collected data on medical students’ observations of real-time clinical practice. The observation data was analysed thematically and shared with a steering group of experts to agree a framework for recording observations. A sample of students (observers) and front-line clinical staff (observed) completed one-to-one interviews on their experiences. The interviews were analysed using thematic analysis.ResultsThirty-seven medical students identified 917 issues in wards, theatres and clinics in an acute hospital trust. These issues were grouped into the themes of human influences, work environment and systems. Aviation approaches were adapted to develop an app capable of recording real-time positive and negative clinical incidents. Five students and eleven clinical staff were interviewed and shared their views on the value of a process that helped them learn and has the potential to advance the quality of practice. Concerns were shared about how the observational process is managed.ConclusionThe study developed an app (Healthcare Team Observations for Patient Safety—HTOPS), for recording good and poor clinical individual and team behaviour in acute-care practice. The process advanced medical student learning about patient safety. The tool can identify the totality of patient safety practice and illuminate strength and weakness. HTOPS offers the opportunity for collective ownership of safety concerns without blame and has been positively received by all stakeholders. The next steps will further refine the app for use in all clinical areas for capturing light noise.

Seeking Excellence in End of Life Care (SEE Care): A Multi-Centered Acute Hospitals Service Evaluation.

A proportion of UK hospital inpatients have palliative care needs but do not access specialist services. To contemporaneously evaluate the significance of unmet specialist palliative care needs within the hospital inpatient population. Prospective multi-centered service evaluation was conducted through 4 snapshots across 4 acute NHS hospital trusts. All patients identified as dying in each hospital were included. Data extraction included symptom burden, medications and completion of care plans. End-of-life care plans were completed for 73%, symptom-focused prescribing present in 96%. Symptoms were not well managed for 22%, with 4% suffering moderate to severely. Specific intervention was triggered in 56% of patients, consisting of prescribing advice and holistic support. There are significant unmet specialist palliative care needs within the hospital inpatient population. Contemporaneous data collection coupled with an outreach approach helps palliative care services better understand the experiences of dying people, alongside where improvement is needed.

Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study

Background NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’. Objectives The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness. Design This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics. Methods A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision. Results Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time. Limitations Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time. Conclusions Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care. Future work Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.

Increasing staff confidence about domestic abuse identification, disclosure and safeguarding in a community mental health team

AimsTo increase staff confidence about identifying Domestic Abuse (DA), particularly regarding ‘how to ask’ to encourage disclosure and the pathways available for appropriately safeguarding survivors; in a Community Mental Health Team (CMHT) setting.BackgroundDA is bi-directionally associated with mental health (MH) disorders; 1:4 women in contact with MH services are currently experiencing DA. MH professionals (MHPs) are in a privileged position to identify DA and support survivors. However, this is dependent on MHPs receiving adequate training about DA. For this, we collaborated with Pathfinder, a national pilot project run by a consortium of five expert partners that aims to establish comprehensive health practice in relation to DA and Violence Against Women & Girls in Acute Hospital Trusts, MH Trusts and Primary Care. In Southampton, Pathfinder has funded two domestic and sexual abuse (DSA) advocates to both train MH staff and take a small caseload of MH service users who are experiencing abuse.MethodWe conducted a baseline survey of staff confidence across the following domains:Knowing the legal definition of DA,The process used to escalate a DA concern,How to make a referral,How to complete DASH forms,How and when to refer to Pathfinder,What the following acronyms mean: PIPPA, MAPPA, MARAC, IDVA, DASH,What HRDA and MASH mean,How to ask about DA,Who to signpost service users to if they make a disclosure, and when to involve the police.We presented the survey results at the regional Pathfinder strategic group, with Trust management representatives present. This project fits within the strategic group's sustainability aims to increase DA awareness and safeguarding processes across the Trust.The Pathfinder funded DSA Advisors delivered a four-hour training package targeting the surveyed questions and wider information on DA. We then re-surveyed to see if staff confidence had increased. We are currently analyzing the number of referrals to the Pathfinder service pre- and post-training.ResultStaff confidence increased across all domains following the training (% mean increase): Qs1 (35%), Qs2 (9%), Qs3 (45%), Qs4 (81%), Qs5 (25%), Qs6 (49%), Qs7 (89%), Qs8 (62%) and Qs9 (48%).We have now arranged a bi-monthly drop-in at the CMHT by the DSA advisor who provided the training, to embed the link between the services and maintain staff confidence. We will circulate these results to advocate that this training is provided across the Trust.

An evaluation of advance care planning during the COVID-19 pandemic: a retrospective review of patient involvement in decision making using routinely collected data from digital ReSPECT records

To review advance care planning (ACP) practice during the COVID-19 pandemic, evaluating the number of plans created, patient participation, cardiopulmonary resuscitation recommendations and variation between different population groups. A retrospective analysis and comparison of routinely collected data from electronic recommended summary plan for emergency care and treatment (ReSPECT) records documented in April 2020 and January to December 2019. Electronic ReSPECT documents completed for adult patients at a large, acute hospital trust in the UK. The number of plans created per 1,000 admissions in April 2020 was 333.0% higher than in 2019. A greater proportion of plans created during April 2020 were discussed with the patient and the proportion containing a 'for cardiopulmonary resuscitation' recommendation was higher across all population groups. A greater proportion of plans were created for younger adults and Black and minority ethnic groups during the pandemic. Increased ACP during a crisis can be achieved alongside increased patient participation in decision making. A tool such as ReSPECT that supports recommendations for, as well as limitations on, treatment may have enabled the expansion of ACP observed.

An investigation into prescribing errors made by independent pharmacist prescribers and medical prescribers at a large acute NHS hospital trust: a cross-sectional study

IntroductionPharmacists in the UK can register as independent pharmacist prescribers (IPPs) on completion of appropriate higher education training. IPPs have had the same prescribing privileges as medical doctors since 2009....

COVID-Well Study: Qualitative Evaluation of Supported Wellbeing Centres and Psychological First Aid for Healthcare Workers during the COVID-19 Pandemic.

Supported wellbeing centres were set up in UK hospital trusts as an early intervention aimed at mitigating the psychological impact of COVID-19 on healthcare workers. These provided high quality rest spaces with peer-to-peer psychological support provided by National Health Service (NHS) staff volunteers called ‘wellbeing buddies’, trained in psychological first aid. The aim of the study was to explore the views of centre visitors and operational staff towards this COVID-19 workforce wellbeing provision. Qualitative semi-structured interviews were undertaken with twenty-four (20F, 4M) employees from an acute hospital trust in the UK. Interviews were digitally recorded and transcribed, data were handled and analysed using thematic analysis. Interviews generated 3 over-arching themes, and 13 sub-themes covering ‘exposure and job roles’, ‘emotional impacts of COVID-19 and ‘the wellbeing centres’. Supported wellbeing centres were viewed as critical for the wellbeing of hospital employees during the first surge of COVID-19 in the UK. Wellbeing initiatives require managerial advocacy and must be inclusive. Job-related barriers to work breaks and accessing staff wellbeing provisions should be addressed. High quality rest spaces and access to peer-to-peer support are seen to benefit individuals, teams, organisations and care quality. Training NHS staff in psychological first aid is a useful approach to supporting the wellbeing of the NHS workforce during and beyond the COVID-19 pandemic.

28 Medication Compliance Aids and Acute Hospitals

Abstract Introduction An estimated 64 million Medication Compliance Aids (MCAs) are dispensed by pharmacies in England each year as a method of reasonable adjustment to improve medication adherence (NICE 2009) and support medicines administration by carers (RPS 2013). Complexities exist when implementing medication changes for patients using MCAs, particularly at hospital discharge or outpatient appointments, where practices seem to vary. This National Survey is the first to determine the current policy and service provision of MCAs by acute hospitals in England. Methods An electronic survey was emailed to Chief Pharmacists via the Regional Medicines Information Services in Spring 2019. Initial non-responders were contacted by email and telephone. Results 51% (73/144) of acute hospital trusts in England responded. 77% (56/73) dispensed medication in MCAs at discharge. Of these, 62.5% would initiate MCAs and 61% supplied a different length of MCA vs non-MCA prescription (see table). 41 hospitals had designated staff completing MCAs. The median time to complete an MCA was 59.5 minutes (range 10–200). The median time from prescription receipt in pharmacy to MCA arrival on ward was 144.5 minutes (range 60–1,440). Of the 17 hospitals not providing MCAs, the majority would, upon discharge, contact the community pharmacy that provided the MCA pre-admission to update any medication changes and request the provision of a new supply of medicines. Conclusion Despite the ubiquitous nature of the MCA, there is no standard approach to the supply of these devices from acute hospitals across England. When hospitals do provide MCAs their preparation is time consuming, often requiring additional staff. A national approach to MCAs might help patients and carers, and reduce medication-related problems and costs.

SARS-CoV-2 Testing of 11,884 Healthcare Workers at an Acute NHS Hospital Trust in England: A Retrospective Analysis.

Healthcare workers (HCWs) are known to be at increased risk of infection with SARS-CoV-2, although whether these risks are equal across all roles is uncertain. Here we report a retrospective analysis of a large real-world dataset obtained from 10 March to 6 July 2020 in an NHS Foundation Trust in England with 17,126 employees. 3,338 HCWs underwent symptomatic PCR testing (14.4% positive, 2.8% of all staff) and 11,103 HCWs underwent serological testing for SARS-CoV-2 IgG (8.4% positive, 5.5% of all staff). Seropositivity was lower than other hospital settings in England but higher than community estimates. Increased test positivity rates were observed in HCWs from BAME backgrounds and residents in areas of higher social deprivation. A multiple logistic regression model adjusting for ethnicity and social deprivation confirmed statistically significant increases in the odds of testing positive in certain occupational groups, most notably domestic services staff, nurses, and health-care assistants. PCR testing of symptomatic HCWs appeared to underestimate overall infection levels, probably due to asymptomatic seroconversion. Clinical outcomes were reassuring, with only a small minority of HCWs with COVID-19 requiring hospitalization (2.3%) or ICU management (0.7%) and with no deaths. Despite a relatively low level of HCW infection compared to other UK cohorts, there were nevertheless important differences in test positivity rates between occupational groups, robust to adjustment for demographic factors such as ethnic background and social deprivation. Quantitative and qualitative studies are needed to better understand the factors contributing to this risk. Robust informatics solutions for HCW exposure data are essential to inform occupational monitoring.

Older people’s perceptions of the impact of Dance for Health sessions in an acute hospital setting: a qualitative study

ObjectivesTo explore the perceptions of hospitalised older people and their relatives of the impact of taking part in group dance sessions in an acute hospital setting.DesignA qualitative descriptive approach was...

Development and evaluation of a temporary staff support psychology service in a busy acute NHS hospital trust during the Covid-19 crisis

The development and evaluation of a temporary staff support service during the Covid-19 peak across a busy acute NHS trust is presented. Staff reported positive experiences of the service. Recommendations for future staffsupport provision throughout the pandemic are made.

Improving the percentage of HIV tests offered to patients admitted to an acute hospital trust with community-acquired pneumonia

Young people and adults diagnosed with an HIV indicator condition should be offered an HIV test (NICE [National Institute of Clinical Excellence] guidance). Community-acquired pneumonia (CAP) is considered to be...

“Compassion Outside of the Box”: The Role of Allied Healthcare Professionals in Providing a Companion Service for Patients at the End of Life During the COVID-19 Pandemic

ContextIn response to the COVID-19 pandemic, NHS England prohibited people visiting acute hospital trusts. An end-of-life companion scheme was introduced to support the delivery of care for seriously unwell and dying patients during this time. ObjectivesThis study aims to capture the companions’ experience and activities, including qualitative feedback, as well as outline recommendations for this role in future services and training. MethodsThe companions’ service comprised Allied Healthcare Professionals working for the trust who volunteered for the role following a reduction in their normal workload due to COVID-19. They worked in shifts covering a 12-hour period every day of the week with patients identified by the palliative care team. Companions completed questionnaires containing a 4 domains mixture of Likert scale and free text responses before and after their experience. Details of the visits were recorded in daily spreadsheets. ResultsThe majority of companions were from the physiotherapy team with a range of experience working in the NHS. In total, 64 patients were seen over 382 visits. The companions often carried out more than one activity per visit including communication with the patient and next of kin, personal care, literature, and spirituality. Data showed a statistically significant association between experience as a companion and reduced anxiety around spending time with dying people. ConclusionThis study highlights an interesting approach to changing job roles for health-care professionals during the COVID-19 pandemic as well as recognizing the importance of allied health professionals in the multidisciplinary approach to palliative and end-of-life care.

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy

BackgroundIn 2013, the English National Health Service launched the policy of 7-day services to improve care quality and outcomes for weekend emergency admissions.AimsTo determine whether the quality of care of...

Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency.

The purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings. A qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n=36) and observations (n=46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis. While each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process. The paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them. The paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.

Co-construction of the family-focused support conversation: a participatory learning and action research study to implement support for family members whose relatives are being discharged for end-of-life care at home or in a nursing home

BackgroundMany people move in and out of hospital in the last few weeks of life. These care transitions can be distressing for family members because they signify the deterioration and impending death of their ill relative and forthcoming family bereavement. Whilst there is evidence about psychosocial support for family members providing end-of-life care at home, there is limited evidence about how this can be provided in acute hospitals during care transitions. Consequently, family members report a lack of support from hospital-based healthcare professionals.MethodsThe aim of the study was to implement research evidence for family support at the end-of-life in acute hospital care. Informed by Participatory Learning and Action Research and Normalization Process Theory (NPT) we co-designed a context-specific intervention, the Family-Focused Support Conversation, from a detailed review of research evidence. We undertook a pilot implementation in three acute hospital Trusts in England to assess the potential for the intervention to be used in clinical practice. Pilot implementation was undertaken during a three-month period by seven clinical co-researchers - nurses and occupational therapists in hospital specialist palliative care services. Implementation was evaluated through data comprised of reflective records of intervention delivery (n = 22), in-depth records of telephone implementation support meetings between research team members and co-researchers (n = 3), and in-depth evaluation meetings (n = 2). Data were qualitatively analysed using an NPT framework designed for intervention evaluation.ResultsClinical co-researchers readily incorporated the Family-Focused Support Conversation into their everyday work. The intervention changed family support from being solely patient-focused, providing information about patient needs, to family-focused, identifying family concerns about the significance and implications of discharge and facilitating family-focused care. Co-researchers reported an increase in family members’ involvement in discharge decisions and end-of-life care planning.ConclusionThe Family-Focused Support Conversation is a novel, evidenced-based and context specific intervention. Pilot implementation demonstrated the potential for the intervention to be used in acute hospitals to support family members during end-of-life care transitions. This subsequently informed a larger scale implementation study.Trial registrationn/a.

Trajectories of vital signs in patients with COVID-19

BackgroundThe global pandemic of coronavirus disease 2019 (COVID-19) has placed a huge strain on UK hospitals. Early studies suggest that patients can deteriorate quickly after admission to hospital. The aim of this study was to model changes in vital signs for patients hospitalised with COVID-19. MethodsThis was a retrospective observational study of adult patients with COVID-19 admitted to one acute hospital trust in the UK (CV) and a cohort of patients admitted to the same hospital between 2013-2017 with viral pneumonia (VI). The primary outcome was the start of continuous positive airway pressure/non-invasive positive pressure ventilation, ICU admission or death in hospital. We used non-linear mixed-effects models to compare changes in vital sign observations prior to the primary outcome. Using observations and FiO2 measured at discharge in the VI cohort as the model of normality, we also combined individual vital signs into a single novelty score. ResultsThere were 497 cases of COVID-19, of whom 373 had been discharged from hospital. 135 (36.2%) of patients experienced the primary outcome, of whom 99 died in hospital. In-hospital mortality was over 4-times higher in the CV than the VI cohort (26.5% vs 6%). For those patients who experienced the primary outcome, CV patients became increasingly hypoxaemic, with a median estimated FiO2 (0.75) higher than that of the VI cohort (estimated FiO2 of 0.35). Prior to the primary outcome, blood pressure remained within normal range, and there was only a small rise in heart rate. The novelty score showed that patients with COVID-19 deteriorated more rapidly that patients with viral pneumonia. ConclusionsPatients with COVID-19 who deteriorate in hospital experience rapidly-worsening respiratory failure, with low SpO2 and high FiO2, but only minor abnormalities in other vital signs. This has potential implications for the ability of early warning scores to identify deteriorating patients.

Measuring the Scale of Hospital Health Record System Fragmentation in England

Many patients experience a fragmented health care journey that involves transitions of care between different hospitals. Ineffective sharing of health data between hospitals can impair the delivery of safe, high‐quality care. This study aimed to identify the unmet need for interhospital data sharing by quantifying the movement of patients between acute hospital trusts and health record systems in the NHS in England.This retrospective observational review examined Hospital Episode Statistics (HES), a national hospital administrative dataset relating to patient encounters with the NHS in England. Outcome measures included the frequency of patient encounters with multiple hospital trusts and the frequency of consecutive encounters with hospitals using different health record systems.All adult patients with inpatient, emergency department, or outpatient encounters at acute hospitals in the NHS in England during the 12‐month period from April 2017 to April 2018 were included.21,286,873 patients were involved in 121,351,837 encounters at 152 included NHS trusts over the one‐year period. There was limited regional alignment of electronic health record (EHR) systems in the 117 (77.0%) hospital trusts that were using EHR systems. 15,736,863 (73.9%) patients had two or more encounters with the included trusts and 3,931,255 (25.0%) of those attended two or more trusts. Over half (53.6%) of these patients had encounters shared between just 20 pairs of hospitals. Only two of these pairs of trusts used the same EHR system. On 11,017,767 (9.1%) occasions, patients presented to a hospital using a different EHR, or paper record system, to their previous hospital attendance.This study found that nearly four million patients accessed care at two or more different NHS hospital trusts over the one‐year study period, highlighting the demand for effective interhospital data sharing. Most of the pairs of hospital trusts that commonly share patients do not use the same health record systems. The fragmented distribution of health record systems that exists in the NHS in England represents a significant barrier to interhospital data sharing and interoperability.To make informed and safe decisions for patients negotiating increasingly complex health care systems, clinicians need the right information about the right patient in the right place at the right time. The findings from this study provide guidance for policy makers, clinicians, service managers, researchers, software providers, and patients to better understand and improve how data may be shared between hospitals. The methods used in this research could be applied to health care systems in other settings to guide the procurement and coordination of EHR systems to promote interoperability and effective data sharing.National Institute for Health Research (UK).

A framework and toolkit of interventions to enhance reflective learning among health-care professionals: the PEARL mixed-methods study

Background Although most health care is high quality, many patients and members of staff can recall episodes of a lack of empathy, respect or effective communication from health-care staff. In extreme form, this contributes to high-profile organisational failures. Reflective learning is a universally promoted technique for stimulating insight, constructive self-appraisal and empathy; however, its efficacy tends to be assumed rather than proven. The Patient Experience And Reflective Learning (PEARL) project has used patient and staff experience to co-design a novel reflective learning framework that is based on theories of behaviour and learning. Objective To create a toolkit to help health-care staff obtain meaningful feedback to stimulate effective reflective learning that will promote optimal patient-, family- and colleague-focused behaviours. Design A 3-year developmental mixed-methods study with four interlinked workstreams and 12 facilitated co-design meetings. The Capability, Opportunity, Motivation – Behaviour framework was used to describe factors influencing the behaviour of reflection. Setting This took place at five acute medical units and three intensive care units in three urban acute hospital trusts in England. Participants Patients and relatives, medical and nursing staff, managers and researchers took part. Data sources Two anonymous surveys, one for patients and one for staff, were developed from existing UK-validated instruments, administered locally and analysed centrally. Ethnographers undertook interviews and observed clinical care and reflective learning activities in the workplace, as well as in the co-design meetings, and fed back their observations in plenary workshops. Main outcome measures Preliminary instruments were rated by participants for effectiveness and feasibility to derive a final set of tools. These are presented in an attractively designed toolbox with multiple sections, including the theoretical background of reflection, mini guides for obtaining meaningful feedback and for reflecting effectively, guides for reflecting ‘in-action’ during daily activities, and a set of resources. Results Local project teams (physicians, nurses, patients, relatives and managers) chaired by a non-executive director found the quarterly reports of feedback from the patient and staff surveys insightful and impactful. Patient satisfaction with care was higher for intensive care units than for acute medical units, which reflects contextual differences, but in both settings quality of communication was the main driver of satisfaction. Ethnographers identified many additional forms of experiential feedback. Those that generated an emotional response were particularly effective as a stimulus for reflection. These sources of data were used to supplement individual participant experiences in the nine local co-design meetings and four workshops to identify barriers to and facilitators of effective reflection, focusing on capability, opportunity and motivation. A logic model was developed combining the Capability, Opportunity, Motivation – Behaviour framework for reflection and theories of learning to link patient and staff experience to changes in downstream behaviours. Participants proposed practical tools and activities to enhance reflection ‘in-action’ and ‘on-action’. These tools were developed iteratively by the local and central project teams. Limitations Paper-based surveys were burdensome to administer and analyse. Conclusions Patients and health-care staff collaborated to produce a novel reflective learning toolkit. Future work The toolkit requires evaluating in a cluster randomised controlled trial. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 32. See the NIHR Journals Library website for further project information.

Examining the variation across acute trusts in patient delayed discharge

Delayed transfers of care, or delayed discharges, adversely affect patient care and increase costs to England's National Health Service. The main objective of this paper is to explain variation in the probability of delayed discharge from an acute trust and patient perspective. A novel approach is employed in using the Adult Inpatient Survey over the period 2007–2014. We use a two stage regression model to assess the impact of various patient, acute hospital trust, and regional characteristics on the probability of delayed discharge. In the first stage we model the patient-level probability of delayed discharge and estimate hospital trust-specific fixed-effects. Stage two includes multiple linear regressions to explain acute trust fixed effects from stage one by using acute trust characteristics and regional observable characteristics as explanatory variables. Results indicate the probability of delayed discharge varies among acute trusts and patients. Patient-mix complexity, staff skill-mix, size and scope of acute trust are among those factors affecting the trust-specific discharge efficiency.