Acute Trusts Research Articles

BRIDGING THE GAP BETWEEN PRIMARY AND SECONDARY CARE POST-HIP FRACTURE WITH A NOVEL PATIENT ADVOCATE ROLE

Within an ageing population, the morbidity and mortality burden of neck of femur fractures will only worsen. Financially incentivising acute Trusts via the Best Practice Tariff for inpatient care has yielded good results(1,2,3,4) but post-discharge care is still variable. Most importantly, restoring patients to their pre-fracture mobility is key to their quality of life(5,6) and reducing both readmissions to hospital(7,8) and expensive local authority residential care. Unfortunately, physiotherapist vacancies are in their thousands(9,10) leading to waiting times of around three months once discharged(11).In 2019, the Royal Derby Hospital created a novel Hip Fracture Patient Advocate (HFPA) to observe those who have fallen through gaps in community services. It involves monitoring patients’ progression, signposting to appropriate services, flagging issues to the responsible consultant and assisting in physical mobilisation.A retrospective review examined data from patients discharged to their own homes. This included demographics, residential status and mobility, both pre-fracture and at 120 days post-fracture. Mobility was classified into five categories, in line with the national hip fracture database.In 2018, of 238 patients, 41.2% returned to their baseline or increased mobility, and, after the introduction of the HFPA in 2019, this figure increased to 48.2%.In one year, there was a 7% increase in patients recovering their baseline mobility. This is a cost-effective intervention that can successfully improve mobility, leading to improved long-term outcomes. This includes the potential to reduce acute readmissions and the need for residential care, appealing to Integrated Care Boards. It also bridges the gap to primary care to optimise medical management and after further development, could be financially-incentivised via the Best Practice Tariff. Rather than thinking more expensive clinicians are required, this study proposes that a HFPA can garner better outcomes for both the patient and the wider system.

A strategic solution to preventing the harm associated with ambulance handover delays.

Ambulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised. A two-phase strategic quality improvement project was implemented at the authors' acute trust. Ambulance handover data from between 2 November 2020 and 26 July 2021 provided a benchmark for the project. The first phase was implemented between 2 November 2021 and 26 July 2022 and aimed to reduce 60-minute ambulance handover delays. The second phase was implemented between 2 November 2022 and 26 July 2023 and aimed to eradicate 60-minute ambulance handover delays and improve overall performance. Phase one resulted in a 32% reduction in 60-minute ambulance handover delays. Phase two resulted in a 97% reduction in 60-minute ambulance handover delays. Over the course of the project there was a 24% increase in handovers completed within 15 minutes. This project demonstrates how strategic planning and collaboration between healthcare teams can reduce the potential for avoidable patient harm, while simultaneously promoting workforce well-being and retention.

Trends and determinants of clinical staff retention in the English NHS: a double retrospective cohort study

ObjectivesTo investigate how demographic, contractual and organisational factors are related to the retention of hospital workers in the English NHS. The study will specifically examine the trends in age-retention profiles.DesignA...

17 A third treatment pathway: is there a place for a nurse-led Best Supportive Care service for the management of patients diagnosed with lung cancer at an acute NHS Trust?

17 A third treatment pathway: is there a place for a nurse-led Best Supportive Care service for the management of patients diagnosed with lung cancer at an acute NHS Trust?

37 PLB Lung Biopsy Audit (Worcestershire Acute Hospitals NHS Trust)

37 PLB Lung Biopsy Audit (Worcestershire Acute Hospitals NHS Trust)

Characterising trends in the initiation, timing, and completion of recommended summary plan for emergency care and treatment (ReSPECT) plans: Retrospective analysis of routine data from a large UK hospital trust

AimTo assess patient socio-demographic and disease characteristics associated with the initiation, timing, and completion of emergency care and treatment planning in a large UK-based hospital trust. MethodsSecondary retrospective analysis of data across 32 months extracted from digitally stored Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans within the electronic health record system of an acute hospital trust in England, UK. ResultsData analysed from ReSPECT plans (n = 23,729), indicate an increase in the proportion of admissions having a plan created from 4.2% in January 2019 to 6.9% in August 2021 (mean = 8.1%). Forms were completed a median of 41 days before death (a median of 58 days for patients with capacity, and 21 days for patients without capacity). Do not attempt cardiopulmonary resuscitation was more likely to be recorded for patients lacking capacity, with increasing age (notably for patients aged over 74 years), being female and the presence of multiple disease groups. ‘Do not attempt cardiopulmonary resuscitation’ was less likely to be recorded for patients having ethnicity recorded as Asian or Asian British and Black or Black British compared to White. Having a preferred place of death recorded as ‘hospital’ led to a five-fold increase in the likelihood of dying in hospital. ConclusionVariation in the initiation, timing, and completion of ReSPECT plans was identified by applying an evaluation framework. Digital storage of ReSPECT plan data presents opportunities for assessing trends and completion of the ReSPECT planning process and benchmarking across sites. Further research is required to monitor and understand any inequity in the implementation of the ReSPECT process in routine care.

Workforce wellbeing centres and their positive role for wellbeing and presenteeism in healthcare workers during the COVID-19 pandemic: secondary analysis of COVID-Well data

BackgroundSupported wellbeing centres established during the COVID-19 pandemic provided high quality rest spaces and access to peer-to-peer psychological first aid for healthcare workers (HCWs). The centres were well accessed and valued by HCWs, but their relationship with wellbeing and job-related factors is not well established. The aim of this study was to explore the relationship between wellbeing centre use, HCWs wellbeing and job-related factors (job stressfulness, job satisfaction, presenteeism, turnover intentions).MethodsSecondary analysis of data from 819 HCWs from an acute hospital trust who completed an online survey in April-July 2020, as part of the COVID-Well study. Measures included the Warwick Edinburgh Mental Wellbeing Scale, and four single-item global measures of job stressfulness, job satisfaction, presenteeism and turnover intentions. ANCOVA models and regression analyses were conducted on these data.ResultsHCWs who had not accessed the wellbeing centres had lower wellbeing (β = 0.12, p < .001), higher job stressfulness (β = − 0.22, p < .001), lower job satisfaction (β = 0.39, p < .001), higher presenteeism (β = − 0.22, p < .001) and were of younger age (β = 0.09, p = .002). Centre use was associated with wellbeing irrespective of job stressfulness. Those reporting presenteeism and who accessed the centre (M = 3.30, SE = 0.04) had higher wellbeing than those who accessed the centre but did not report presenteeism (M = 3.06, SE = 0.04) (F(1, 791) = 18.65, p < .001, ηp2 = 0.02). Centre use was not significantly associated with turnover intentions (B = − 0.30, p = .13; Wald = 2.26; odds = 0.74), while job stress and job satisfaction showed significant effects.ConclusionsAccessing wellbeing centres was associated with higher wellbeing of HCWs, particularly for those reporting presenteeism. Therefore, the centres may have provided greatest respite and restoration for those present at work but not in optimal health. Younger workers were disproportionately affected in terms of wellbeing, and targeted support for this population is needed. Strategies to decrease presenteeism and maximise job satisfaction are urgently required. Healthcare organisations should provide rest spaces and psychological support to HCWs for the long-term, as part of a systems-wide approach to improving workforce health and wellbeing.

Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation.

Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Three Trusts, one orthopaedic and one older person ward in each. Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. This study is registered as PROSPERO CRD42020184458. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study.

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. This study is registered as ISRCTN10863045. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Digitally Recording Comfort Observations in the Last Days of Life.

Background: 37.5% of deaths in our area occur in hospital. There are known high unmet needs of adult patients dying in hospital, this unmet need can be reduced by using an individualised care plan and specialist palliative care review. Intervention: In 2022 UHSussex developed an electronic comfort observation chart and individualised care plan, with a centralised dashboard allowing Palliative Care Teams (SPCT) to view trends, target interventions, and a rolling prospective audit. Results: 3000 patients have had their care supported with electronic comfort observations (e-comfort obs). Over 72% of all deaths in the Trust in the last 3months have been on e-comfort obs, with 2/3 of all deaths in the first 12months on e-comfort obs. The average length of time on e-comfort obs is 4days resulting in 70,000 sets of e-comfort obs recorded since launch. Seven percent of e-comfort obs record moderate or severe symptoms. We have identified benefits to people who are dying, those important to them, ward staff, SPCT and on a systems level. Conclusion: E-comfort obs can be successfully embedded in a large acute Trust. This development should improve quality of end of life care in our hospitals both for individuals and for future patients, through on-going targeted education and intervention. Further work is needed to develop the system further including integrating data from electronic prescribing.

Spatial inequalities in charitable fundraising and income generation for NHS acute trusts in England

IMPACT This article presents novel analyses of the income sources of National Health Service (NHS) acute trusts in England. The results suggest that there are variations according to deprivation in the extent of private financial resources available to NHS institutions. They suggest a need to open up discussions about how best to mitigate spatial differences in the charitable and private patient income of NHS trusts, particularly if these sources of income grow in importance going forward.

2050 Scoping an Oncogeriatric Pathway in Acute Care

Abstract Introduction Oncogeriatrics is relatively new concept aligning geriatric services with oncology, whereby older cancer patients have a comprehensive geriatrics assessment (CGA) to support oncology decision-making and improve outcomes and quality of care. Despite the rationale, evidence for effective oncogeriatric services is largely based upon specialist centres. We initiated a feasibility study February 2021, to establish criteria and pathway implications for an Acute Trust without oncology beds. Method Following an iterative process, a pathway was established between the Lung MDT and the established frailty unit. Patients with lung cancer who met criteria would be seen within a week and underwent a CGA by a frailty practitioner, consultant geriatrician, physiotherapist, occupational therapist. Referrals were made as appropriate to allied services e.g. dietician, pharmacy, continence teams etc. Results We refined the referral criteria and process, identifying the presence of a geriatrician at Lung MDT as key to ensuring incorporation of CFS (Rockwood) for effective MDT case discussion. Defining the cohort and pathway was challenging given the complex interplay of cancer symptom burden and comorbidity set against COVID, workforce pressures and cancer targets. Final referral criteria were: age over 70, Rockwood 4 or more, a formal lung cancer diagnosis, and a plan to undergo active treatment. Referral numbers were low during the feasibility phase. Only 38 patients were referred and we saw 23 patients over a 2-year period. Referral rates increased in the final 3 months of the pilot although only 9 of 22 who met criteria were referred. Conclusion Establishment of an effective oncogeriatrics service is challenging. The feasibility study has established a baseline for potential activity and job planning. Analysis of individual patient benefit is ongoing. Longer term we aim to extend the service to support patients after treatment has started, provide prehab, and include patients with all types of cancer.

P25 Nowhere to hide: broad-spectrum antimicrobial guideline adherence in outpatients

Abstract Background The NHS Acute Trusts Standard1 contract requires a 10% reduction in broad-spectrum antibiotics by 10% by March 2024 from a 2017 baseline. Co-amoxiclav is a broad-spectrum antibacterial that comprises 30% of broad-spectrum consumption at University Hospitals Birmingham. It is widely used across all specialities and is a perfect candidate to review to influence downward trend in consumption. Outpatient prescriptions do not receive the same level of scrutiny from pharmacy or antimicrobial stewardship team as inpatient prescriptions. If deviations from guidelines are identified, then this could be a potential area to address to reduce consumption. Methods Sixty outpatient co-amoxiclav prescriptions were reviewed to assess appropriateness of prescribing during December 2022. Parameters assessed included the indication and duration of co-amoxiclav therapy and adherence to Trust antimicrobial guidelines. The speciality prescribing outpatient co-amoxiclav was also documented to identify whether prescribing trends could be identified. Results Of 60 reviewed outpatient prescriptions written in December 2022, 54 were issued by acute medicine with other specialities including cardiothoracic, renal medicine, elderly care, ENT, urology and cardiology. All prescriptions had a documented indication and duration, however only three were adherent to Trust antimicrobial guidelines. The graph below represents the different indications co-amoxiclav was prescribed for to outpatients across all three hospital sites. Co-amoxiclav was most frequently prescribed for respiratory tract infections, followed by skin and then urinary tract infections. Conclusions This audit has highlighted that outpatient co-amoxiclav is commonly prescribed inappropriately and does not comply with Trust antimicrobial guidelines. The speciality most frequently prescribing outpatient co-amoxiclav inappropriately was acute and emergency medicine. The lack of clarity regarding the infection indication is a potentially important factor in this setting, resulting in broad-spectrum antimicrobial use to cover multiple potential bacterial infections. A limitation of this audit is it was carried out over a short and busy winter period.

A multivariable analysis to predict variations in hospital mortality using systems-based factors of healthcare delivery to inform improvements to healthcare design within the English NHS.

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research.

Establishing the size and configuration of the imaging support workforce: a census of national workforce data in England.

The imaging support workforce is a key enabler in unlocking imaging capacity and capability, yet no evidence exists of the workforce size and configuration. This research provides the first comprehensive analysis of workforce data to explore the deployment of the support workforce within National Health Service (NHS) imaging services in England. Using a census methodology, an anonymized electronic staff record (ESR) data set extracted in December 2022 was analysed to identify support workers and their employment bandings at NHS Trust, regional and national (England) level. Support workforce proportions, median values, and Spearman's rank correlations were calculated. Analysis of 137 NHS Trusts, comprising 100% of acute trusts (n = 124) and specialist trusts with imaging services (n = 13), identified that the support workforce (pay bands 2-4) constitutes 23.6% of the imaging staff base. Ranking trusts into 3 categories based on the proportion of support workers in their imaging establishment, median values ranged from 30.7% (high) to 22.2% (medium) and 10.5% (low). Two opposing deployment models of band 2 and band 3 support workers were identified. Comprising almost one-quarter of the imaging establishment, models of deployment at bands 2 and 3 are highly variable. Assistant practitioners (band 4) are under-utilised, providing an opportunity to introduce innovations to address workforce demands. This census is the first to provide evidence of the size and structure of the support workforce, the first step in enabling effective workforce transformation. Further research is required to explain the two opposing deployment models.

Integrated Care Systems in England: Progress towards forming new multi-stakeholder partnerships to develop quality.

Background: Health and social care services in England have been restructured to 42 Integrated Care Systems (ICS). ICSs are responsible for delivering integrated services in their local area to prevent illness; identify and treat illness effectively; and provide support to improve quality of life for people with long-term illness or disability. Under the umbrella of ICSs, previously siloed organisations need to work together to deliver quality care. This study aimed to understand how these new ways of working impact on the development of their quality agenda.&#x0D; Methods: Semi-structured interviews were undertaken with senior representatives in demographically and geographically diverse ICS. Interviews were audio recorded, transcribed verbatim and analysed in NVivo using a thematic framework approach. Two Patient and Public Involvement team members contributed to the study design and data analysis. The study is conducted at two points in time; the data reported here is the baseline collected shortly (November 2021 to May 2022) before the ICSs’ formal constitution in July 2022.&#x0D; Results: Sixty interviews across four ICSs were conducted with senior representatives (e.g. ICS CEO, chief nurse, quality leads, director of social services, director of public health, the public and local communities). Across all ICSs, progress had been made with creating ICS specific committees, with new roles created and leaders appointed, and new partnerships emerging. Positive learning on collaborating with diverse partners had occurred during the COVID-19 pandemic and through previous local initiatives to integrate services. In two ICSs, there was less history of such collaborative work and their new partnerships were emerging more slowly. &#x0D; Generally, it was agreed that strong leadership, supported by broad and effective system partnerships, was essential to develop the ICSs’ structure and to deliver quality. Key partners to support the leadership were senior partners in acute hospital trusts, primary care, social care, public health, Healthwatch (the health and social care champion for service users), voluntary services, and patient representatives. &#x0D; Some concerns were raised that made collaborations more challenging, including differences in language and work culture between the key partners, and health dominating the quality agenda. Overall, it was felt that social care, public health and voluntary services were heard less. They were being consulted, but rarely had leadership roles and leaders from these communities often felt that they were not equal partners. Most participants highlighted the importance of consulting patients and the public and acknowledged that this was not done effectively yet with too few people, who lacked diversity, consulted; and an overreliance on Healthwatch. &#x0D; Discussion: This restructure of the health and social care system shows that new partnerships can be formed between previously siloed organisations but that these take time to develop. In particular, organisations or people who have traditionally been less consulted such as social care, public health, and patients and the public still need to become more equal partners in developing the quality agenda. Follow up interviews will bring greater clarity on how this restructure will maintain and promote quality across services. &#x0D;

Antimicrobial consumption in an acute NHS Trust during the COVID-19 pandemic: intervention time series analysis.

To determine the impact of the COVID-19 pandemic on antimicrobial consumption and trends of therapeutic drugs for COVID-19 treatments, including corticosteroids, remdesivir and monoclonal antibodies (tocilizumab) from April 2017 to September 2022 in a secondary care NHS Trust in England. A retrospective intervention time series analysis was conducted for April 2017 to September 2022 at the Mid Yorkshire Teaching NHS Trust. Data were retrieved from the pharmacy dispensing system as defined daily doses (DDDs) monthly and reported per 1000 occupied bed days (OBDs). Antimicrobial consumption and COVID-19 treatment options were measured. DDDs were calculated according to the classification of antimicrobials for systemic use (J01) and for other drugs classification. Trends for antimicrobial consumption and other therapeutic drugs for treating COVID-19 were also determined in each wave in England. During the pandemic: total antibiotic consumption decreased from 826.4 to 728.2 DDDs per 1000 OBDs (P = 0.0067); piperacillin/tazobactam use increased (P < 0.0001) and ciprofloxacin use decreased (P < 0.0001); there were no changes in Access, Watch, Reserve antibiotic use, and the proportion of antifungal consumption was consistent throughout the study. The use of total antibiotics (P = 0.024), levofloxacin (P = 0.0007), piperacillin/tazobactam (P = 0.0015) and co-amoxiclav (P = 0.0198) increased during wave one. Consumption of COVID-19 treatment drugs was highest during wave two, with 624.3 DDDs per 1000 OBDs for dexamethasone (P = 0.4441), 6.8 DDDs per 1000 OBDs for remdesivir (P < 0.0001) and 35.01 DDDs per 1000 OBDs for tocilizumab (P = 0.2544). This study determined the consumption of antimicrobials trends before and during the pandemic. The individual wave antimicrobial consumption indicates maximum consumption in the first wave, advocating for antimicrobial stewardship and preparedness for future pandemics.

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation.

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. The availability and quality of data imposed limitations on the reliability of some analyses. Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

Mental Health Simulation Training for Pharmacy workforce in Secondary Care

Abstract Introduction Simulation involves life-like scenarios followed by reflection within a facilitated debrief and is widely used in healthcare education. The NHS Long Term plan1 and HEE2 reports highlight the need for the pharmacy workforce in different sectors to be confident and competent in providing care for people with mental health illnesses. Similarly, local integrated care services (ICSs) are prioritising parity of esteem and bridging gaps between services through an improved workforce. Aim To increase the pharmacy workforce’s confidence in supporting and caring for patients with mental health illnesses, reduce stigma, and empower staff to provide a safe, effective, and equitable service. Specific objectives were to: become familiar with substance misuse &amp; learning disabilities; improve effective communication (verbal and non-verbal); and build confidence in formulating treatment plans, talking to patients in distress and taking appropriate histories within a mental health context. Methods Participants included medicines management pharmacy technicians (MMPTs) and pharmacists who volunteered from the acute and mental health Trusts within ICS. The training format included pre-reading clinical material, simulation scenarios co-produced with service users, multi-disciplinary team teaching, and debriefs. Ethical approval not required for the evaluation of the training. We collected quantitative and fee-text data via pre- and post-simulation questionnaires (two validated scales and course specific questionnaire). The data were subjected to descriptive statistical analysis and thematic grouping of free-text data with frequency counting. Results The whole group (n=29) showed an increase in empathy and improvement in attitudes towards people with mental health illness from pre to post simulation training. The 15 measures (course specific questionnaire) and the qualitative feedback indicated that the learning objectives were met. 100% of participants either strongly agreed/agreed that the simulation training helped improve their communication skills and found the debrief and service user participation valuable. The qualitative data supported these findings: “…gained confidence in speaking to patients with different forms of mental health conditions and patients who are in distress.” Discussion/Conclusion This project was a pioneer to assess the use of mental health simulation training within secondary care between two different practice settings. Whilst a small-scale study only, the findings showed improved communication and confidence within a mental health context, particularly in talking to patients in distress. The simulation training was well received by participants and supports the use of simulation in our aim of increasing pharmacy workforce confidence in caring for those with mental illness and reducing stigma. In addition to improving clinical knowledge and skills, simulation training can also help improve pharmacy staff perceptions, attitudes, and address stigma and hence contribute towards a high quality patient care service. This project indicates the potential value of training the pharmacy workforce on a wider scale, regardless of sector, in collaboration with MDT and service users.

Development and outcomes of a pilot risk assessment process and expert panel for medicines procured in an NHS Acute Trust

Abstract Introduction The risk assessment process for new medicines procured into NHS Acute Trusts varies between organisations. National guidance identifying categories of medicines requiring risk assessment is lacking. A UK Medicines Information (UKMi) developed risk assessment tool1 was fully completed for all new medicines procured at the Trust without exception, consuming significant clinical pharmacist resource. Completed risk assessments received review and approval by the specialty Principal Pharmacist only. Wider input from the Medication Safety team was sought if identified as required by the pharmacist completing or reviewing the tool. Aim To pilot a rationalised risk assessment process for newly procured medicines and measure the effect of implementation on clinical pharmacist workload and satisfaction, identification of risks and mitigations. Methods The rationalised risk assessment process was informed by a working group encompassing formulary, governance, medication safety and clinical service leads. The UKMi risk assessment tool was adapted and National Patient Safety Agency (NPSA) parenteral medicine risk assessment2 incorporated. A flowsheet triaging medicines requiring risk assessment was agreed. This included; unlicensed medicines, off-label use, parenteral medicines with an NPSA score over 2, controlled drugs, changes to concentration/excipients, known safety concerns e.g. due to national alerts, and any other medicine deemed high risk such as anticoagulants, cytotoxics, insulins and intrathecals. A New Drug Panel (NDP) was established, comprising a broad range of senior pharmacy leaders including the chief pharmacist. The NDP convened 6 weekly to agree the process, review risk assessments and propose additional mitigations. The process was piloted for 6 months (November 2021-May 2022). During the pilot, the number of new medicines procured and number of completed risk assessments were measured, alongside outcomes of NDP review. At the end of the pilot, users were invited to provide feedback directly via email and this was collated. Ethical approval was not required for this service evaluation. Results During the pilot, 248 requests to add medicines to the pharmacy dispensing system were made; 124 (50%) were new medicines to the Trust. 55/124 (44%) were triaged requiring risk assessment. The NDP met 4 times; 45/55 completed risk assessments were reviewed, 4 of which were considered via email due to urgency. The remaining 10 were scheduled for review at the next meeting. A total of 14 additional mitigations were advised and actioned for 12/41 (29%) new drugs reviewed, the remaining risk assessments were approved without further mitigations. Four pharmacists provided feedback and 100% was positive. The modified risk assessment was preferred due to ease of completion and improved clarity. Discussion/Conclusion A modified risk assessment process was piloted successfully; the number of required risk assessments halved releasing clinical pharmacist time and improving satisfaction with the process. Risk of patient harm was reduced through establishment of an expert NDP who identified a number of additional risk mitigations. No issues were identified from the medicines which were triaged out of the risk assessment process, though these would only be identified retrospectively. Limitations included that user feedback could have been collated more robustly, e.g., to provide more specific responses.