Development Of Care Pathway Research Articles

Evidence assessment and narrative synthesis of the key characteristics of older people living in service-integrated housing facilities, and their ‘accommodation journey’

PurposeThis paper aims to provide an evidence assessment and narrative synthesis of literature regarding the key characteristics of older people living in service-integrated housing (SIH) facilities and their “accommodation journey”.Design/methodology/approachA rapid evidence assessment was conducted: 22 research publications met the inclusion criteria and were analysed using narrative synthesis.FindingsThe quality of studies in this area is low, but consistency across components of the results of studies included in the review is apparent. Results suggest key characteristics of older people that drive moves into SIH are a decline in health, increased dependency, increased health service use and carer burden. Suggested key characteristics of SIH residents are high levels of health problems, dependency and health service use, but high self-reported health and well-being. Results indicate that the key driver for older people leaving SIH is a lack of workforce competency to manage further declines in health and dependency status.Research limitations/implicationsCurrent policy may not realise or account for the complex health and care needs of SIH residents. Investment into integrated care, robust community health services and workforce development to facilitate a comprehensive assessment approach may be required to support residents to remain in SIH and live well. Further longitudinal studies are required to map the progression of SIH residents’ health status in detail over time to provide an understanding of preventative and enablement support, development of care pathways and workforce planning and development requirements.Originality/valueThis evidence assessment is the first to consider the accommodation journey of older people residing in SIH.

TP9.2.16Peri-operative Delirium in the Emergency Laparotomy Population

Abstract Aims To determine the incidence of peri-operative delirium in our emergency laparotomy population. Methods Utilising our local prospectively maintained Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database all cases over a two-month calendar period were identified. Case notes were reviewed retrospectively for all patients. The 4 A's Test (4AT) assessment tool was used to screen for the presence of delirium (a score ≥4 = delirium), performed throughout the peri-operative period. For all patients baseline characteristics were recorded including NELA risk score, 30 day survival, length of stay (LOS), ASA score, age, sex and presence of pre-morbid cognitive dysfunction. Results Thirty-two patients were identified through the ELLSA database. Incidence of peri-operative delirium as determined by 4AT was 10/32 patients (31.25%). The thirty day mortality was 4/32 (12.5%). Peri-operative delirium was identified in all non-survivors. NELA risk score for those with delirium 14% / 21% (median / mean) versus 2.5% / 2.3% (median / mean) without (p 0.0015). The LOS for those with delirium 26 / 24.6 days (median / mean) versus 11 / 13.6 (median / mean) without (p 0.0194). Conclusions Delirium is a common peri-operative event. In our population it is associated with a higher NELA score. The presence of delirium is associated with poorer outcomes, with an increased mortality and LOS. This single site survey indicates that there is a need to develop care pathways that identify those at risk of delirium and implement treatment guidelines. Our survey suggests that the NELA score could be used as a triage tool for the risk of delirium.

Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions

PurposeIn India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country’s needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.MethodsIn Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway.ResultsThe Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country’s immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging.Discussion/ConclusionIn Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways.Level of EvidenceLevel III.

Limiting the Risk of Osteoarthritis After Anterior Cruciate Ligament Injury: Are Health Care Providers Missing the Opportunity to Intervene?

To understand what sports orthopedic surgeons (OS), primary care physicians (PCPs) with sports medicine training, and physical therapists (PTs) managing nonelite athletes with anterior cruciate ligament (ACL) injury tell their patients about their osteoarthritis (OA) risk. An electronic survey was distributed by the Canadian Academy of Sport and Exercise Medicine (PCPs, OS), the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association (PTs), and to OS identified through the Royal College of Physicians and Surgeons and the Canadian Orthopaedic Association. The survey included 4 sections: demographics, factors discussed, timing of discussions, and discussion of risk factors and their management. Proportions or means with 95% confidence intervals were calculated. A total of 501 health care professionals (HCPs) responded (98 PCPs, 263 PTs, and 140 OS). Of those responding, 70-77% of physicians reported always discussing OA risk, but only 35% of PTs did. All HCPs reported that patient activities perceived as detrimental to knee health, ACL reinjury, and simultaneous injury to other structures in the knee were most often the reason for discussing OA risk. OA risk was discussed at initial management post-injury (65-94%), with few discussing risk subsequently. Eighty percent of physicians and 99% of PTs indicated that PTs were suited to provide OA risk and management information. HCPs routinely managing people with ACL injury do not consistently discuss OA risk post-injury with them. Educational strategies for HCPs are urgently needed to develop care pathways inclusive of support for OA risk management following ACL injury.

Lessons from an Educational Invasive Fungal Disease Conference on Hospital Antifungal Stewardship Practices across the UK and Ireland.

Invasive fungal disease (IFD) is a growing health burden. High mortality rates, increasing numbers of at-risk hosts, and a limited availability of rapid diagnostics and therapeutic options mean that patients are increasingly exposed to unnecessary antifungals. High rates of prescriptions promote patient exposure to undue toxicity and drive the emergence of resistance. Antifungal stewardship (AFS) aims to guide antifungal usage and reduce unnecessary exposure and antifungal consumption whilst maintaining or improving outcomes. Here, we examine several AFS approaches from hospitals across the UK and Ireland to demonstrate the benefits of AFS practices and support the broader implementation of AFS as both a necessary and achievable strategy. Since the accuracy and turnaround times (TATs) of diagnostic tools can impact treatment decisions, several AFS strategies have included the development and implementation of diagnostic-driven care pathways. AFS informed treatment strategies can help stratify patients on a risk basis ensuring the right patients receive antifungals at the optimal time. Using a multidisciplinary approach is also key due to the complexity of managing and treating patients at risk of IFD. Through knowledge sharing, such as The Gilead Antifungal Information Network (GAIN), we hope to drive practices that improve patient management and support the preservation of antifungals for future use.

American Society for Metabolic and Bariatric Surgery: Preoperative Care Pathway for Laparoscopic Roux-en-Y Gastric Bypass.

In 2017, the American Society for Metabolic and Bariatric Surgery (ASMBS): Care Pathway Development for Laparoscopic Sleeve Gastrectomy (SG) was published in recognition of the importance of clinical care maps that guide evidenced-based healthcare, with a focus on value of the care delivered [1]. As part of this process, the Quality Improvement and Patient Safety Committee of the ASMBS sought to develop a care map for laparoscopic Roux-en-Y gastric bypass (RYGB). This current RYGB care map focuses solely on preoperative care, defined as the medical care and education provided to a patient from introduction into a bariatric program up to the day of surgery.

Optimising frontline learning and engagement between consultant-led neonatal teams in the West Midlands: a survey on the utility of an augmented simulation training technique

BackgroundIn England, neonatal care is delivered in operational delivery networks, comprising a combination of the Neonatal Intensive Care (NICU), Local-Neonatal (LNU) or Special-Care Units (SCU), based on their ability to care for babies with different degrees of illness or prematurity. With the development of network care pathways, the most premature and sickest are mostly triaged for delivery in services linked to NICU. This has created anxiety for teams in LNU and SCU. Less exposure to sicker babies has resulted in limited opportunities to maintain expertise for when these babies unexpectedly deliver at their centre and thereafter require transfer for care, to NICU. Simultaneously, LNU and SCU teams develop skills in the care of the less ill and premature baby which would also be of benefit to NICU teams. A need for mutual learning through inter-unit multidirectional collaborative learning and engagement (hereafter also called neonatal networking) between teams of different designations emerged. Here, neonatal networking is defined as collaboration, shared clinical learning and developing an understanding of local systems strengths and challenges between units of different and similar designations. We describe the responses to the development of a clinical and systems focussed platform for this engagement between different teams within our neonatal ODN.MethodAn interactive 1-day programme was developed in the West Midlands, focussing on a non-hierarchical, equal partnership between neonatal teams from different unit designations. It utilised simulation around clinical scenarios, with a slant towards consultant engagement. Four groups rotating through four clinical simulation scenarios were developed. Each group participated in a clinical simulation scenario, led by a consultant and supported by nurses and doctors in training together with facilitators, with a further ~two consultants, as observers within the group. All were considered learners. Consultant candidates took turns to be participants and observers in the simulation scenarios so that at the end of the day all had led a scenario. Each simulation-clinical debrief session was lengthened by a further ~ 20 min, during which freestyle discussion with all learners occurred. This was to promote further bonding, through multidirectional sharing, and with a systems focus on understanding the strengths and challenges of practices in different units. A consultant focus was adopted to promote a long-term engagement between units around shared care. There were four time points for this neonatal networking during the course of the day. Qualitative assessment and a Likert scale were used to assess this initiative over 4 years.ResultsOne hundred fifty-five individuals involved in frontline neonatal care participated. Seventy-seven were consultants, supported by neonatal trainees, staff grade doctors, clinical fellows, advanced neonatal nurse practitioners and nurses in training. All were invited to participate in the survey. The survey response rate was 80.6%. Seventy-nine percent felt that this learning strategy was highly relevant; 96% agreed that for consultants this was appropriate adult learning. Ninety-eight percent agreed that consultant training encompassed more than bedside clinical management, including forging communication links between teams. Thematic responses suggested that this was a highly useful method for multi-directional learning around shared care between neonatal units.ConclusionSimulation, enhanced with systems focussed debrief, appeared to be an acceptable method of promoting multidirectional learning within neonatal teams of differing designations within the WMNODN.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway.

We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

Implementing a Care Pathway for Complex Chronic Patients from a Nursing Perspective: A Qualitative Study.

A care pathway constitutes a complex care strategy for decision-making and the organization of processes in the care of complex chronic patients, avoiding the fragmentation of care. Health professionals play a decisive role in the implementation, development, and evaluation of care pathways. This study sought to explore nurses’ opinions on the care pathway for complex chronic patients three years after its implementation. The study participants were thirteen nurses with different roles who were involved in the care pathway. Thematic content analysis of the semi-structured interviews resulted in four major themes: (a) the strengths of the route; (b) the impact of the route on caregivers; (c) the weaknesses of the route; and (d) the future of the route. Overall, the pathway was positively valued for the benefits it provides to patients, the caregiver, and the administration of professional health care. Participants voiced their concerns regarding: communication and coordination difficulties among professionals across the different levels of care, the need for improved teamwork and consensus among professionals at the same center, and human and material resources. The ongoing evaluation and monitoring of facilitators and barriers is necessary throughout the implementation process, to ensure continuity and quality of care in the health system.

Redesigning community care for safer staff and patient experiences: quality improvement project to improve safety and reduce incidents of violence and aggression in a community mental health team

AimsViolent or aggressive incidents can be relatively common in community settings, and perhaps more difficult to manage than at inpatient wards due to the relative isolation and peripatetic delivery model, which can put staff at higher risk during incidents. Carshalton and Wallington Recovery Support team was identified as an outlier in the Trust and was invited to partake in a Safety Collaborative across South London Partnership.Stakeholders agreed on the aim of reducing incidents by 20% over 1 year by the end of 2020.MethodData about incidents were analysed and staff surveys conducted to evaluate violent events. Patient discharge was highlighted as a particular time of increased aggression. Involvement of patients and carers through patient focus groups and co-production was essential to elicit areas of improvement. These included staff confidence and awareness of existing guidelines. Additional secondary drivers were communication with patients, care pathway development, discharge process and multidisciplinary approach, which each had associated change ideas.The team identified change ideas that have been tested over one year using the Quality Improvement methodology of small-scale testing and PDSA. Example ideas tested include multidisciplinary Risk meetings, Safety huddle tool, Staff Safety training, co-produced Welcome and Discharge Packs with informed care pathways.ResultThere has been a 30% reduction in incidents by December 2020 across a total of 280 patients. Surveys have shown an increase in staff confidence and safety protocol awareness from 40% to 70% by October 2020. 100% of patients in focus groups found the Welcome and Discharge Packs helpful.ConclusionA structured improvement approach focused on staff safety and minimisation of known and potential contributing factors can lead to a reduction in incidents. Safety huddles and risk meetings allow a formal multidisciplinary approach to management of violence and aggression. Staff feel more reassured about safety policies in the trust, with better communication between senior management and colleagues to highlight risk and provide support. A culture of open discussion and transparency was implemented through provision of Welcome Packs including Care and Discharge Pathways details at point of entry to the service. Support was provided to patients with Discharge Packs including information about community services. This enabled a meaningful support model at the end of their recovery journey and an improved discharge process.The team is now working with additional teams and administrative and clerical staff to improve safety. We hope to replicate this approach in our Trust.

Bariatric surgery in patients with advanced heart failure: A proposed multi-disciplinary pathway for surgical care in medically complex patients

BackgroundThe objective of this study was to develop a multi-disciplinary care pathway to minimize perioperative complications in patients with advanced heart failure undergoing bariatric surgery. Patients with severe obesity and heart failure carry increased perioperative surgical risk compared to patients with no heart failure due to the severity of their cardiac disease state and associated comorbidities. Our bariatric program routinely excluded patients with advanced heart failure from undergoing bariatric surgery due to the high reported perioperative risk. However, knowing the potential beneficial impact of bariatric surgery for advanced heart failure, our program hoped that the thoughtful development of a perioperative pathway before inclusion of patients with advanced heart failure in the bariatric surgery program could minimize the morbidity of these high-risk patients in comparison to prior publications in the literature. MethodsTwo multi-disciplinary care pathways were developed, including advanced heart failure, anticoagulation specialists, and transplant cardiologists, to optimize bariatric care for severely obese patients with advanced heart failure with or without mechanical circulatory support and implementation was evaluated for short-term 30-day complications and 6 month cardiac and weight-loss outcomes. ResultsTwo multi-disciplinary care pathways were developed and implemented on 5 patients with heart failure with reduced ejection fraction (pathway 1) and 3 patients requiring mechanical circulatory support (pathway 2). There were no in-hospital complications or mortality following either pathway, and there was only 1 emergency room visit and 1 re-admission. The average length of stay for patients with heart failure with reduced ejection fraction without mechanical circulatory support was 2.4 days and for heart failure with reduced ejection fraction with mechanical circulatory support was 4.3 days. Three patients met body mass index criteria for transplant listing at 6 months. Ejection fraction increased an average of 9% at 6 months postoperatively for patients with heart failure with reduced ejection fraction not requiring mechanical circulatory support. ConclusionWith multi-disciplinary care pathway development designed to maximize safety by intensely supporting preoperative cardiac optimization and medication titration postoperatively, bariatric surgery can be performed in patients with advanced heart failure with or without mechanical circulatory support, allowing patients the opportunity for weight loss as a bridge to transplant or potentially meaningful cardiac recovery.

A UK survey of nutritional care pathways for patients with COVID-19 prior to and post-hospital stay.

BackgroundDuring the global COVID‐19 pandemic, UK dietitians have delivered the best care to help patients recover from the infection. The present study examined the development and evaluation of care pathways to manage nutritional care of patients following COVID‐19 infection prior to and after discharge.MethodsRegistered UK dietitians completed an online questionnaire comprising 26 questions about the development of a pathway, its use, evaluation and training needs.ResultsOf 57 responses from organisations, 37 (65%) were involved in the planning/management of nutritional care. Only 19 responses had a new or adapted COVID‐19 pathway. Of these, 74% reported involvement of dietetic services, 47% reported > 1 eligibility criteria for pathway inclusion and 53% accepted all positive or suspected cases. All respondents used nutritional screening, first‐line dietary advice (food first) and referral for further advice and monitoring. Weight and food intake were the most used outcome measure. All pathways addressed symptoms related to nutrition, with the most common being weight loss with poor appetite, not being hungry and skipping meals in 84% of pathways. Over half of respondents (54%) planned to evaluate their pathway and 83% reported that they were ‘very or reasonably confident’ in their team's nutritional management of COVID‐19. Less than half (42%) reported on training needs.ConclusionsDespite challenges encountered, pathways were developed and implemented. Dietitians had adapted to new ways of working to manage nutritional care in patients prior to and after discharge from hospital following COVID‐19 infection. Further work is needed to develop strategies for evaluation of their impact.

Point-of-care testing technologies for the home in chronic kidney disease: a narrative review.

Point-of-care testing (POCT) performed by the patient at home, paired with eHealth technologies, offers a wealth of opportunities to develop individualized, empowering clinical pathways. The non-dialysis-dependent chronic kidney disease (CKD) patient who is at risk of or may already be suffering from a number of the associated complications of CKD represents an ideal patient group for the development of such initiatives. The current coronavirus disease 2019 pandemic and drive towards shielding vulnerable individuals have further highlighted the need for home testing pathways. In this narrative review we outline the evidence supporting remote patient management and the various technologies in use in the POCT setting. We then review the devices currently available for use in the home by patients in five key areas of renal medicine: anaemia, biochemical, blood pressure (BP), anticoagulation and diabetes monitoring. Currently there are few devices and little evidence to support the use of home POCT in CKD. While home testing in BP, anticoagulation and diabetes monitoring is relatively well developed, the fields of anaemia and biochemical POCT are still in their infancy. However, patients’ attitudes towards eHealth and home POCT are consistently positive and physicians also find this care highly acceptable. The regulatory and translational challenges involved in the development of new home-based care pathways are significant. Pragmatic and adaptable trials of a hybrid effectiveness–implementation design, as well as continued technological POCT device advancement, are required to deliver these innovative new pathways that our patients desire and deserve.

Reorganisation of obstetric services during the COVID pandemic - Experience from National Maternity Hospital Dublin Ireland.

The 2020 SARS-CoV-2 pandemic posed significant challenges to the health service. Many services cancelled all routine appointments and surgery, which allowed them to redirect care towards large numbers of infected patients requiring respiratory and other support. Maternity services are relatively unique in that most of the care is time sensitive and cannot be rescheduled. Assessment such as routine bloods need to be taken in early pregnancy, anatomic surveys are best conducted at 20–22 weeks' gestation, and births continue regardless of a pandemic. In this paper we describe how National Maternity Hospital Dublin, with an annual delivery rate of 8000 births, reorganised services to continue to care for our mothers and babies. This included the development of a ‘hospital within a hospital’ approach, and separate physical and care pathways for positive cases. The delivery of virtual outpatient appointments and a comprehensive online patient education portal have proved successful.

Perinatal psychiatry and families’ mental health: Evidence from some french graduated and integrated practices

Abstract BodyThe first years of life represent a crucial period for psycho-affective development - the critical first 1000 days - because the events that happen to infants and babies during this period have psychosocial as well as epigenetic repercussions, with potential consequences throughout life and even for generations to come. The interactive circle that will develop between the skills (and/or vulnerabilities) of infants and parents and the interactive features arising from each triad, must be supported by perinatal mental health policies, of which the joint care of parents and infants in perinatal psychiatry is a pivotal element. It is necessary to develop care pathways, with systems integrated into “usual” care that take into account families from the prenatal or even pre-conceptual period to the postnatal period,Joint care must also be scalable and thus encompass everything from parent-child psychotherapy to joint mother-baby hospitalisation. This intervention will present and discuss an example of a graduated, integrated and coordinated system of care, and will open up the perspective that perinatal clinicians must bear in mind that joint care is above all "a way of doing things", based on the notions of multidisciplinarity and prevention.DisclosureNo significant relationships.

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions. Objective This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013. Design For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost. Data sources Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set. Results In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower. Limitations A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders. Conclusions Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways. Future work Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital. Study registration This study is registered as PROSPERO CRD42015024492. 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. 8. See the NIHR Journals Library website for further project information.

Detecting and Treating Psychosocial and Lifestyle-Related Difficulties in Chronic Disease: Development and Treatment Protocol of the E-GOAL eHealth Care Pathway.

Many patients with lifestyle-related chronic diseases find it difficult to adhere to a healthy and active lifestyle, often due to psychosocial difficulties. The aim of the current study was to develop an eHealth care pathway aimed at detecting and treating psychosocial and lifestyle-related difficulties that fits the needs and preferences of individual patients across various lifestyle-related chronic diseases. Each intervention component was developed by (1) developing initial versions based on scientific evidence and/or the Behavior Change Wheel; (2) co-creation: acquiring feedback from patients and health professionals; and (3) refining to address users’ needs. In the final eHealth care pathway, patients complete brief online screening questionnaires to detect psychosocial and lifestyle-related difficulties, i.e., increased-risk profiles. Scores are visualized in personal profile charts. Patients with increased-risk profiles receive complementary questionnaires to tailor a 3-month guided web-based cognitive behavioral therapy intervention to their priorities and goals. Progress is assessed with the screening tool. This systematic development process with a theory-based framework and co-creation methods resulted in a personalized eHealth care pathway that aids patients to overcome psychosocial barriers and adopt a healthy lifestyle. Prior to implementation in healthcare, randomized controlled trials will be conducted to evaluate its cost-effectiveness and effectiveness on psychosocial, lifestyle, and health-related outcomes.

Establishing a Cardiac Amyloidosis Clinic: A Practical Primer for Cardiologists

Cardiac amyloidosis is an emerging and important cause of heart failure, arrhythmia, and other cardiovascular disease in Canada. In this context, many centres have expressed interest in the development of effective care pathways for screening, evaluating, and treating this rapidly growing patient population. In October 2019, a group of Canadian stakeholders met, including specialists in cardiac amyloidosis, experts in heart failure and chronic disease management, and academic and community-based cardiologists at various stages of cardiac amyloidosis clinic development. Objectives of the meetings included discussion of existing care pathways, consideration of barriers to program development, and achieving a consensus on essential and desirable components of a best-practice cardiac amyloidosis program. Topics discussed included optimal settings for cardiac amyloidosis clinics and integration with other specialty clinics, funding limitations that act as barriers to program development and potential solutions to these barriers, the roles of the multidisciplinary team and specialist physicians in amyloidosis care, and diagnostic pathways and strategies for the identification of patients with cardiac amyloidosis. In this report, we summarize the discussion points and key recommendations for the development of a cardiac amyloidosis clinic that emerged from this meeting, focused on program integration and care coordination, human resource elements, access to care, and quality improvement and outcome measures in cardiac amyloidosis.

Referral patterns for catheter-directed thrombolysis for iliofemoral deep venous thrombosis.

Post thrombotic syndrome (PTS) is a serious complication of deep venous thromboses (DVTs). PTS occurs more frequently and severely following iliofemoral DVT compared to distal DVTs. Catheter directed thrombolysis (CDT) of iliofemoral DVTs may reduce PTS incidence and severity.We aimed to determine the rate of iliofemoral DVT within our institution, their subsequent management, and compliance with NICE guidelines. Retrospective review of all DVTs diagnosed over a 3-year period was conducted. Cases of iliofemoral DVT were identified using ICD-10 codes from patient notes, and radiology reports of Duplex scans. Further details were retrieved, such as patient demographics and referrals to vascular services. NICE guidance was applied to determine if patients would have been suitable for CDT. A survey was sent to clinicians within medicine to identify awareness of CDT and local guidelines for iliofemoral DVT management. 225 patients with lower limb DVTs were identified. Of these, 96 were radiographically confirmed as iliofemoral DVTs. The median age was 77. 67.7% of iliofemoral DVTs affected the left leg. Right leg DVTs made up 30.2% and 2.1% were bilateral DVTs. Of the 96 iliofemoral DVTs, 21 were deemed eligible for CDT. Only 3 patients (14.3%) were referred to vascular services, and 3 received thrombolysis.From our survey, 95.5% of respondents suggested anticoagulation alone as management for iliofemoral DVT. Only one respondent recommended referral to vascular services. There was a knowledge deficiency regarding venous anatomy, including superficial versus deep veins. CDT and other mechanochemical procedures have been shown to improve outcomes of patients post-iliofemoral DVT, however a lack of awareness regarding CDT as a management option results in under-referral to vascular services. We suggest closer relations between vascular services and their "tributary" DVT clinics, development of guidelines and robust care pathways in the management of iliofemoral DVT.

Exploring peoples’ lived experience of complex regional pain syndrome in Australia: a qualitative study

Complex regional pain syndrome (CRPS) is a persistent pain condition which is often misunderstood and poorly managed. Qualitative studies are needed to explore the lived experience of the condition and to better understand patient perspectives on their management experiences and needs. The aim of this study was to explore the lived experience of CRPS in Australia, including exploration of their perceptions of care and advice received from healthcare professionals. A qualitative study with individual in-depth semi-structured, face-to-face interviews was performed (n=15, 80% female, average time elapsed since diagnosis 3.8 years). Qualitative data were analysed using an inductive thematic analysis approach. Four main themes with associated subthemes were identified, representing the participants' journey: (1) Life Changing Impact of CRPS (Subthemes: Impact on self, Impact on others); (2) Variable Experiences of Care (Subthemes: Helpful experiences of care, Unhelpful experiences of care); (3) Making Sense of CRPS (Subthemes: Knowledge and understanding, Dealing with unpredictability); and (4) Perceptions on Lessons Learned from Living with CRPS (Subthemes: Acceptance was an important part of the journey, Trial and error was necessary to find an individual way forward, Coping strategies). The themes identified align to and expand on prior qualitative research findings in people with CRPS. It highlights the challenges people face related to their personal self, their close relationships and their social and work roles. It highlights the difficulties these people have in finding reliable, trust-worthy information. These findings suggest that healthcare professionals may benefit from education about how to better support people with CRPS, including helping people to navigate to the right care. Engaging people with CRPS in the development of educational resources should be a future research goal. It is recommended that patient perspectives are incorporated into the development of care pathways for CRPS.