Multidisciplinary Team Assessment Research Articles

Severe asthma in children: therapeutic considerations.

Children with poor asthma control despite maximal maintenance therapy have problematic severe asthma (PSA). A step-wise approach including objective adherence monitoring and a detailed multidisciplinary team assessment to identify modifiable factors contributing to poor control is needed prior to considering therapy escalation. Pathophysiological phenotyping in those with true severe therapy-resistant asthma (STRA) and the current array of add-on therapies will be discussed. Adherence monitoring using electronic devices has shown that only 20-30% of children with PSA have STRA and need additional therapies. Omalizumab and mepolizumab are licensed for children with STRA aged 6 years and older. Although robust safety and efficacy data, with reduced exacerbations, are available for omalizumab, biomarkers predicting response to treatment are lacking. Paediatric safety data are available for mepolizumab, but efficacy data are unknown for those aged 6-11 years and minimal for those 12 years and older. A sub-group of children with STRA have neutrophilia, but the clinical significance and contribution to disease severity remains uncertain. Most children with PSA have steroid sensitive disease which improves with adherence to maintenance inhaled corticosteroids. Add-on therapies are only needed for the minority with STRA. Paediatric efficacy data of novel biologics and biomarkers that identify the optimal add-on for each child are lacking. If we are to progress toward individualized therapy for STRA, pragmatic clinical trials of biologics in accurately phenotyped children are needed.

Educational level and management and outcomes in non-small cell lung cancer. A nationwide population-based study

ObjectivesWe examined associations between educational level and clinical presentation, patterns of management and mortality in patients with non-small cell lung cancer (NSCLC) in Sweden, a country with a National Health Care System. Materials and MethodsWe identified 39,671 patients with a NSCLC diagnosis 2002–2016 in Lung Cancer Data Base Sweden (LCBaSe), a population-based research database. In analyses adjusted for comorbidity and other prognostic factors, odds Ratios (OR) and hazard Ratios (HR) were estimated to examine associations between patients’ educational level and aspects of management and mortality. ResultsStage at diagnosis and waiting times did not differ between educational groups. In multivariable analysis, the likelihood to undergo PET/CT and assessment in a multidisciplinary team setting were higher in patients with high compared to low education (aOR 1.14; CI 1.05–1.23 and aOR 1.22; CI 1.14–1.32, respectively). In patients with early stage IA-IIB disease, the likelihood to undergo stereotactic radiotherapy was elevated in patients with high education (aOR 1.40; CI 1.03–1.91). Both all-cause (aHR 0.86; CI 0.77-0.92) and cause-specific mortality (aHR 0.83; CI 0.74-0.92) was lower in patients with high compared to low education in early stage disease (IA-IIB). In higher stage NSCLC no differences were observed. Patterns were similar in separate assessments stratified by sex and histopathology. ConclusionsWhile stage at diagnosis and waiting times did not differ between educational groups, we found socioeconomic differences in diagnostic intensity, multidisciplinary team assessment, stereotactic radiotherapy and mortality in patients with NSCLC. These findings may in part reflect social gradients in implementation and use of novel diagnostic and treatment modalities. Our findings underscore the need for improved adherence to national guidelines.

Multicentre study of multidisciplinary team assessment of pancreatic cancer resectability and treatment allocation.

Multidisciplinary team (MDT) meetings have been adopted widely to ensure optimal treatment for patients with cancer. Agreements in tumour staging, resectability assessments and treatment allocation between different MDTs were assessed. Of all patients referred to one hospital, 19 patients considered to have non-metastatic pancreatic cancer for evaluation were selected randomly for a multicentre study of MDT decisions in seven units across Northern Europe. Anonymized clinical information and radiological images were disseminated to the MDTs. All patients were reviewed by the MDTs for radiological T, N and M category, resectability assessment and treatment allocation. Each MDT was blinded to the decisions of other teams. Agreements were expressed as raw percentages and Krippendorff's α values, both with 95 per cent confidence intervals. A total of 132 evaluations in 19 patients were carried out by the seven MDTs (1 evaluation was excluded owing to technical problems). The level of agreement for T, N and M categories ranged from moderate to near perfect (46·8, 61·1 and 82·8 per cent respectively), but there was substantial variation in assessment of resectability; seven patients were considered to be resectable by one MDT but unresectable by another. The MDTs all agreed on either a curative or palliative strategy in less than half of the patients (9 of 19). Only fair agreement in treatment allocation was observed (Krippendorff's α 0·31, 95 per cent c.i. 0·16 to 0·45). There was a high level of agreement in treatment allocation where resectability assessments were concordant. Considerable disparities in MDT evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments.

Obtaining an autism spectrum disorder diagnosis and supports: New Zealand parents’ experiences

BackgroundThis study explored New Zealand parents’ experiences of obtaining an autism spectrum disorder (ASD) diagnosis for their child and aimed to identify factors that predicted parent satisfaction. MethodParents of ASD parent support groups were invited by email to participate in an anonymous online survey. Parents were asked to rate their satisfaction with a number of key aspects of the diagnostic process for ASD. Correlation analysis and ANOVA were utilized to explore possible associations between parent satisfaction and putative demographic and clinical factors and experiences. Multiple regression analysis was used to identify key predictor variables of parent satisfaction and stress. ResultsParent (n = 516) satisfaction with the diagnostic process for ASD was endorsed by 53.1%. The strongest predictor was satisfaction with the diagnostic assessment report, followed by higher levels of parent stress. Higher satisfaction was also predicted by spending less time on a wait-list for assessment, multi-disciplinary assessment and the absence of concurrent ADHD. Most parents found the diagnostic process stressful. Only 23% of parents were satisfied with post-diagnostic supports, and just 19% their coordination. ConclusionsJust over half of New Zealand parents are satisfied with the diagnostic process for ASD, despite most finding the process stressful. Streamlining referral pathways, reducing assessment wait-times and increasing rates of multi-disciplinary team assessment may raise satisfaction rates further. Receiving a satisfactory diagnostic assessment report appears to be of particular importance to parents. The very low rate of satisfaction with post-diagnostic supports indicates that further development of these services is a priority for NZ.

The impact of multidisciplinary team (MDT) management on outcome of hepatic resection in liver-limited colorectal metastases.

671 Background: Hepatic resection is the gold standard treatment for pts with liver-limited mCRC with 5- and 10-yrs survival rates reaching up to 60% and 20%. Although multidisciplinary team (MDT) management might ensure a more accurate assessment of pts and a faster referral to surgeons, reports discussing the impact of MDTs on survival are controversial and to date there are no strong evidences supporting routinely MDT discussion. The aim of this study was to evaluate the benefit of MDT management in pts with liver-limited mCRC in our single institution experience. Methods: Clinical records of pts with liver-limited mCRC who underwent radical surgery at Fondazione Policlinico “A. Gemelli” - IRCCS from Jan-2006 to Dec-2016 were retrospectively analyzed. The objective of the analysis was to compare survivals of pts managed within our MDT (MDT cohort) to those of pts referred to surgery from other hospitals without MDT discussion (non-MDT cohort). Primary endpoints were DFS and OS. Differences in baseline characteristics and in post-operative morbidity were evaluated. Results: Of the 619 pts analyzed, 230 were included in the MDT cohort and 389 in the non-MDT cohort. No significant difference between the two groups was found in terms of DFS (12vs11 m; p 0.09) and OS (55vs51 m; p 0.68). Concerning baseline characteristics, in the MDT cohort compared to non-MDT cohort there was a statistically higher number of median metastases (4.5vs2.6; p < 0.0001) and a higher rate of synchronous metastases (61.7vs39.3%; p < 0.001). Despite pre-operative CT rate was higher in the MDT group (75.8vs70.7%), the median duration of CT before surgery was significantly lower in MDT pts (7 vs 8 cycle; p < 0.001). Moreover, post-operative morbidity was significantly lower in the MDT cohort (6.2vs19.2%; p < 0.00001). Conclusions: Our study does not demonstrate a survival benefit from MDT management of pts with liver limited mCRC. However, the analysis shows that MDT assessment allows to consider eligible for surgery pts with a more advanced disease. Moreover, MDT discussion seems to reduce the median duration of pre-operative CT with a consequent lower rate of post-operative morbidities. Our data warrant prospective validation.

Management of Spasticity with Intrathecal Phenol Injections

Introduction: Spasticity is increased, involuntary, velocity-dependent muscle tone that causes resistance to movement. Intrathecal injection of phenol is a form of treatment used in a very selective group of patients with spasticity. Aim: This study aims to highlight current evidence in the treatment of spasticity with intrathecal neurolytic phenol injections. Materials and Methods: A computer-based literature search was performed using MEDLINE, EMBASE, CINAHL, and the Cochrane Library using the following key words: intrathecal, phenol, spasticity, and pain. Results: The search identified 83 articles. Of 16 articles met the inclusion criteria of being specifically relating to the use of intrathecal phenol injections in spasticity. There was a lack of randomized controlled studies addressing intrathecal phenol injections in our search. Conclusions: Intrathecal phenol can be valuable for the treatment of spasticity when adapted for each individual, and used as part of an overall program that includes multidisciplinary team assessment and goal planning.

The role of polysomnography in decannulation of children with brain and spinal cord injuries.

The objective of this retrospective review was to determine the utility of polysomnography (PSG) in influencing the decision to decannulate pediatric patients with brain and spinal cord injuries in an inpatient rehabilitation hospital setting. Between 2010 and 2016, data were collected on pediatric patients with brain and/or spinal cord injuries who had PSG performed with the goal of decannulation. Patients underwent a decannulation protocol involving toleration of continuous tracheostomy capping and bedside tracheoscopy by otolaryngology. Decision to decannulate was determined with input from multiple disciplines. Associations were examined between decannulation success and findings on PSG as well as demographic factors, injury characteristics, otolaryngology findings, and timeline from initial injury to selected events. A total of 46 patients underwent PSG, after which 38 (83%) were deemed appropriate and eight (17%) were deemed inappropriate for decannulation. Individuals who were deemed ready for decannulation had significantly lower obstructive apnea hypopnea indexes (AHI) (1.7 vs 5.4 events/h, P = 0.03), respiratory disturbance indexes (RDI) (2.4 vs 7.6 events/h, P = 0.006), and peak end tidal carbon dioxide (CO2 ) levels (50.0 vs 58.7 torr, P = 0.009) on PSG compared to those who were not decannulated. There were no complications following decannulation prior to discharge. PSG provided important additional information as part of a multidisciplinary team assessment of clinical readiness for decannulation in pediatric patients with brain and spinal cord injuries who underwent a decannulation protocol. Obstructive AHI, RDI, and peak end tidal CO2 level were associated with successful decannulation prior to discharge from inpatient rehabilitation.

ICF-basiertes Assessment von Patienten mit chronischen Rückenschmerzen durch ein multidisziplinäres Schmerz-Team

Referat zur Arbeit von Bagraith KS, Strong J, Meredith PJ, McPhail SM. What do clinicians consider when assessing chronic low back pain? A content analysis of multidisciplinary pain centre team assessments of functioning, disability, and health. Pain 2018; 159: 2128–2136

Multidisciplinary Intervention and Acceptance and Commitment Therapy for Return-to-Work and Increased Employability among Patients with Mental Illness and/or Chronic Pain: A Randomized Controlled Trial.

Background: People on long-term sick leave often have a long-lasting process back to work, where the individuals may be in multiple and recurrent states; i.e., receiving different social security benefits or working, and over time they may shift between these states. The purpose of this study was to evaluate the effects of two vocational rehabilitation programs, compared to a control, on return-to-work (RTW) or increased employability in patients on long-term sick leave due to mental illness and/or chronic pain. Methods: In this randomized controlled study, 427 women and men were allocated to either (1) multidisciplinary team management, i.e., multidisciplinary assessments and individual rehabilitation management, (2) acceptance and commitment therapy (ACT), or (3) control. A positive outcome was defined as RTW or increased employability. The outcome was considered negative if the (part-time) wage was reduced or ceased, or if there was an indication of decreased employability. The outcome was measured one year after entry in the project and analyzed using binary and multinomial logistic regressions. Results: Participants in the multidisciplinary team group reported having RTW odds ratio (OR) 3.31 (95% CI 1.39–7.87) compared to the control group in adjusted models. Participants in the ACT group reported having increased employability OR 3.22 (95% CI 1.13–9.15) compared to the control group in adjusted models. Conclusions: This study of vocational rehabilitation in mainly female patients on long-term sick leave due to mental illness and/or chronic pain suggests that multidisciplinary team assessments and individually adapted rehabilitation interventions increased RTW and employability. Solely receiving the ACT intervention also increased employability.

Pirfenidone in patients with unclassifiable progressive fibrosing interstitial lung disease: design of a double-blind, randomised, placebo-controlled phase II trial

IntroductionDespite extensive multidisciplinary team (MDT) assessment, some patients have interstitial lung disease (ILD) that is considered unclassifiable (uILD), for which there are currently no approved treatments. This study will assess...

Environmental scan of Canadian and UK policies for autism spectrum disorder diagnostic assessment.

Many jurisdictions across Canada and internationally are grappling with providing diagnostic and intervention services for children with autism spectrum disorder (ASD). The objective was to compare Canadian and United Kingdom (UK) policies governing ASD diagnosis. The policy scan extended from January 2000 to December 2017. Canadian federal, provincial/territorial, and UK government publications related to ASD diagnosis were retrieved from official websites by searching for ASD and related terms. Retrieved documents were filtered for relevance, with all relevant documents undergoing full text review. Data extracted included personnel and testing requirements for diagnosis, wait times, and eligibility for ASD services and funding. The included jurisdictions varied substantially in their approach to ASD diagnosis and eligibility for intervention. Nine of the 13 provinces/territories restrict which clinicians can diagnose ASD by requiring certain documentation for service eligibility. Three provinces require multi-disciplinary team assessment (British Columbia [BC], Quebec, and Nova Scotia [NS]). Three provinces (BC, NS, and Prince Edward Island [PEI]) require specific diagnostic tests for diagnosis. Only two provinces, BC and NS, have target wait times for assessment. Jurisdictions differed in whether they allowed children with a provisional diagnosis of ASD to access services. At a national level, the UK provides more clinical guidance for ASD diagnosis, which can be attributed to its centralized system of national healthcare delivery. ASD diagnostic assessment policies vary across Canada, and between Canada and the UK. Further evidence supporting ASD diagnostic practices is needed to streamline the journey from identification to intervention.

What do clinicians consider when assessing chronic low back pain? A content analysis of multidisciplinary pain centre team assessments of functioning, disability, and health.

Beyond expert suggestions as to the appropriate subject matter for chronic pain assessments, little is known about the actual content of multidisciplinary pain centre (MPC) clinical assessments. The International Classification of Functioning, Disability and Health Low Back Pain Core Set (ICF LBP-CS) provides a universal language to support the consistent description of LBP-related assessments across disciplines within multidisciplinary teams (MDTs). This study sought to map the content of MPC clinical assessments to the ICF to: (1) identify and compare the content of clinical MDT assessments using a cross-disciplinary framework and (2) examine the content validity of the LBP-CS. A qualitative examination of MPC team clinical assessments of chronic low back pain was undertaken. Multidisciplinary team (pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology) assessments were audio-recorded and transcribed. Concepts were extracted from transcripts using a meaning condensation procedure and then linked to the ICF. Across 7 MDT assessments, comprised 42 discipline-specific assessments and 241,209 transcribed words, 8596 concepts were extracted. Contextual factors (ie, the person and environment), except for physiotherapy, accounted for almost half of each discipline's assessments (range: 49%-58%). Concepts spanned 113 second-level ICF categories, including 73/78 LBP-CS categories. Overall, the findings revealed novel insights into the content of MPC clinical assessments that can be used to improve health care delivery. International Classification of Functioning, Disability and Health-based assessment profiles demonstrated unique contributions from each discipline to chronic low back pain assessment. Finally, users of the LBP-CS can be confident that the tool exhibits sound content validity from the perceptive of MDT assessments of functioning, disability, and health.

Violence and aggression in psychiatric settings: reporting to the police

SUMMARYViolence and aggression are relatively common and serious occurrences in health and social care and rates are higher in mental health settings. Despite the National Health Service's policy of ‘zero tolerance’ of such behaviour, reporting of violence and aggression against mental health staff remains low. This article considers the nature of violence and aggression against staff in psychiatric settings and the process of involving the police to ensure an effective outcome. It outlines each step, from the initial the multidisciplinary team assessment of the incident and its reporting to the police to the making of witness statements, should the case come to court. It also explains the discretionary role of the police in deciding whether to charge and of the Crown Prosecution Service (CPS) in deciding whether to prosecute. The article stresses that NHS organisations need to provide an effective, streamlined and time-efficient reporting process, as this should reduce levels of patient violence, improve staff's well-being and morale, save costs and make the working environment safer for all.LEARNING OBJECTIVES•Raise awareness of the underreporting to the police of incidents of violence and aggression against staff by psychiatric patients and recognise the benefits of reporting such incidents•Develop a framework for assessment and reporting of such incidents committed to the police and to the Crown Prosecution Service (CPS), in the event of possible or actual criminal proceedings•Develop an understanding of the role of the healthcare organisation, the police and the CPS when such incidents are reported to the policeDECLARATION OF INTERESTNone.

The Australian Aged Care and Its Implications for the Korean Aging Crisis.

The Australian aged care system has evolved for >50 years to support frail older adults and allow them to make informed decisions about their care. Hospitals provide streamlined geriatric services from visits at the Emergency Department to discharges from acute and subacute geriatric care units. Moreover, nonhospital aged care services, including Transition Care Program, Commonwealth Home Support Program, Home Care Packages Program, and Residential Care (nursing home) are provided under the auspices of the Australian Government. These various specialized hospital and nonhospital services are integrated and coordinated by the multidisciplinary assessment team called ACAT (Aged Care Assessment Team). Korea does not have a similar amount of time to prepare a well-organized aged care system because of a rapidly increasing older population. The Korean government and aged care experts should exert vigorous efforts to improve the last journeys of the Korean older population.

Strengthened General Self-Efficacy with Multidisciplinary Vocational Rehabilitation in Women on Long-Term Sick Leave: A Randomised Controlled Trial

Purpose To investigate the effects of two vocational rehabilitation interventions on self-efficacy, for women on long-term sick leave ≥ 1 year due to chronic pain and/or mental illness. Methods This study uses data from a randomised controlled trial consisting of two phases and comprising 401 women on long-term sick leave. They were allocated to either (1) a multidisciplinary team assessment and multimodal intervention (TEAM), (2) acceptance and commitment therapy (ACT), or (3) control group. Data were collected through repeated measurements from self-reported questionnaires before intervention, 6 and 12 months later and registry data. Data from measurements of general self-efficacy, sociodemographics, anxiety and depression were analysed with linear regression analyses. Results During the intervention period, the women in the TEAM group’s self-efficacy mean increased from 2.29 to 2.74. The adjusted linear regression model, which included group allocation, sociodemographics, self-efficacy pre-treatment, anxiety and depression showed increased self-efficacy for those in the TEAM intervention at 12 months (B = 0.25, 95% CI 0.10–0.41). ACT intervention had no effect on self-efficacy at 12 months (B = 0.02, 95% CI − 0.16 to 0.19). The results in the adjusted model also showed that higher self-efficacy at pre-treatment was associated with a higher level of self-efficacy at 12 months (B = 0.68, 95% CI 0.54–0.81). Conclusion A multidisciplinary team assessment and multimodal intervention increased self-efficacy in women on sick leave for an extremely long time (mean 7.8 years) who had a low mean level of self-efficacy prior to inclusion. Thus, self-efficacy needs to be addressed in vocational rehabilitation.

Multi-disciplinary team assessments

The article by Simpson and De Silva in the September issue ( Psychiatric Bulletin , September 2003, 27 , 346-348), outlining two team referral models of multidisciplinary teams (MDT) working in Old Age Psychiatry, was of interest to us, primarily as the debate echoed changes which have occurred

Relationship between fatigue after acquired brain injury and depression, injury localization and aetiology: An explorative study in a rehabilitation setting.

Fatigue after acquired brain injury may be related to the subcortico-frontal attention network. Depression is also strongly related to fatigue. This study investigates whether injury localization, diagnosis and depression are related to self-rated mental fatigue in patients with an acquired brain injury. Retrospective cross-sectional cohort study. Sixty-one patients diagnosed with stroke, subarachnoidal haemorrhage, traumatic brain injury, or brain tumour were included in the study. Patients who underwent a multidisciplinary team assessment during September 2011 to June 2012, and who were assessed with the Mental Fatigue Scale, were included in the study. A significantly higher number of patients with posterior and non-specific lesions experienced fatigue compared with those with subcortical/frontal injuries. Fewer stroke patients experienced fatigue compared with the other patient groups. How-ever, after logistic regression, only depression remained as an explanatory variable for self-rated fatigue. Nevertheless, although all patients with depression were fatigued, not all fatigued patients were depressed. Although depression explains a high degree of fatigue after an acquired brain injury, mental fatigue after brain injury should be viewed as a condition partly separate from depression. Future extensive comparative studies are required, preferably including neuropsychological measures.

Narrative review of contemporary treatment options in the care of patients with obstructive sleep apnoea

Snoring and obstructive sleep apnoea (OSA) are increasingly common conditions, and confer a significant health and socioeconomic burden. Furthermore, untreated OSA represents a significant mortality risk. Patients require careful assessment, including detailed clinical history and examination, sleep study and drug-induced sleep endoscopy (DISE). Although nasal continuous positive airway pressure (nCPAP) is the gold standard treatment for moderate and severe OSA, multidisciplinary team assessment is often required to develop the best treatment plan for an individual, especially when nasal CPAP is poorly tolerated. There is a wide range of medical and surgical treatment options, and following appropriate patient selection and assessment, a focused site-specific, often multilevel, intervention is indicated. There is an increasing body of evidence in the literature supporting these multilevel interventions and with agreement on standardized outcome measures more trials are likely to improve the robustness of these data further.

Timely identification of frailty & comprehensive multidisciplinary assessment on a newly established specialist geriatric ward

Introduction: Beaumont Hospital catchment area has a 20% higher proportion of over 65’s and over 85’s than the national average. Between 2011 and 2026 it is predicted that there will be 44% increase in the population of North Dublin over 65 years of age 1. Older people are admitted to hospital more frequently, have longer length of stay and occupy more bed days in acute hospitals than any other patient group. Many older people are frail and present to hospital with acute or sub-acute illnesses often accompanied by functional and/or cognitive deteriorations. Furthermore, once hospitalised frail older people are at huge risk of further hospital based deconditioning due to reduction in habitual activity and sleep deprivation. Once identified, the gold standard for the acute management of frailty in older people is early multidisciplinary team (MDT) assessment and delivery of high quality care with an emphasis on reduction in unnecessary delays and proactive case-management.Extensive research has shown that frail older patients who receive timely access to coordinated care under specialist geriatric teams (SGT) on a specialist geriatric ward (SGW), in the form of comprehensive geriatric assessment, have an increased likelihood of returning home, as well as reduced mortality rate following acute hospital admission 2. Aim and practice change implemented: This change management project was completed in conjunction with the SGT on a newly established SGW (Hardwicke ward). It was carried out as part of a larger ward redevelopment project. This particular project took place over a 4 week period in April/May 2016. The following key stakeholders were involved; patients, MDT, Clinical Nurse Managers, Geriatricians, Project Sponsor (Physiotherapy Manager). This project utilised quality improvement (QI) methodology incorporating; process mapping, development of a driver diagram, data collection and implementing multiple plan-do-study-act cycles to rapidly test changes (IHI, 2016). The following project aim was established: To standardise a process to identify 100% of frail patients over 75 years of age who are admitted to Hardwicke ward under the care of a Geriatrician and ensure referral to all relevant multidisciplinary team members within 24 hours of admission by May 13th 2016. Highlights: (innovation, impact and outcomes) A number of standardised processes have now been successfully implemented on Hardwicke ward for frailty triage, prompt referral to MDT and completion of common MDT assessment documentation. These standardised processes have led to 100% of new patients over 75 years of age being screened for frailty and all relevant MDT referrals being sent via a standardised method (electronic referral) within 24 hours of admission to the ward. This has increased from a baseline of 40% at initial data collection on week one. The result is a more efficient, standardised, co-ordinated and patient-focused process which has led to a reduction in unnecessary wait times and thus a reduction in the risk of hospital-associated de-conditioning in frail older people. The use of QI methodology and interdisciplinary working were key factors in the success of this project. A clear line of sight with the National Clinical Programme for Older People 3 was also crucial to its success. Sustainability and trasferability: Future areas for further development are focused on the following; Stabilise and embed the current standardised processes into practice on Hardwicke ward (incorporating succession planning and ongoing training for Junior rotational staff) Further streamline the processes to reduce inefficiencies utilising QI methodology Spread the learning to other acute wards & MDTs initially focusing on a 2nd SGW

Hardwicke: transition from a surgical ward to an exemplar Specialist Geriatric Ward

Introduction: Beaumont hospital catchment area, North Dublin, has a 20% higher proportion of over 65’s and over 85’s than the national average. Between 2011 and 2026 it is predicted that there will be a 44% increase in over 65’s in this area. (CSO 1996; 2011) In 2015 an external review of Beaumont Hospitals Care of the older person services was completed. A Beaumont hospital improved performance plan was developed with a view to delivering the objectives of the National Clinical Programme for Older People (NCPOP, 2012). The clinical needs of older patientsare substantially more complex than other patient groups. They frequently present with multiple co-morbidities accompanied by functional decline, cognitive deterioration and complex social care needs. Moreover, once hospitalised frail older people are at a higher risk of further deconditioning. Services for older patients should provide access to comprehensive multi-disciplinary team (MDT) assessments and appropriate treatment in the right setting, without unnecessary delay. As part of the Beaumont Hospital improvement performance plan, Hardwicke ward which was historically a surgical ward was chosen to be converted into a Specialist Geriatric Ward (SGW) in June 2015. Aims: Deliver the patients’ care as close to their own home as possible No patient will spend a night longer in hospital (on Hardwicke) than they need to Develop an ethos of daily decision making, communication and planning for discharge from admission Prevent deconditioning by promoting an ethos of independence and therapeutic engagement Description of practice change implemented In October 2015, a multidisciplinary clinical subgroup was formed with the aim of supporting the transformation to a SGW. A QI methodology approach was adopted and evidence based Clinical Performance Improvements (CPI’s)were generated. This provided structure to our developments, accountability for staff and a formal way to identify gaps and streamline the service. Monthly meetings were held and the subgroup prioritised a number of CPI’s for the first year, broadly categorised into: 1. Communication 2. Rehab ethos Highlights/CPI’s: A number of service developments were introduced and are now embedded into daily practice to ensure comprehensive geriatric assessment, rapid access to MDT treatment, clear communication with interdisciplinary goal setting and early decision making to reduce potential delay. Communication CPI’s: A daily Hardwicke Plan for Every Patient (PfEP) board meeting with full MDT attendance with an emphasis on collaborative discussion regarding outstanding needs, goals and predicted dates of discharge. A member of the Beaumont Patient Flow team attends the PfEP allowing for early identification and management of potential delayed discharges Standardised documentation for identification of frailty and referral to the MDT Improved MDT referral response times to 24hrs Enhanced pharmacy role delivering in-depth pharmaceutical care (medicines reconciliation and optimisation) and participation in consultant led ward rounds Promotion of independence and activity to prevent deconditioning Weekly ward based staff education sessions Communication boards for self care and functional mobility Rehab Ethos CPI’s Environmental changes - patient orientation charts and dementia friendly signage Day room redesign including kitchen installation and homely art-work Establishment of a Daily Breakfast Club and Cognitive Stimulation Therapy group Nutrition and Hydration developments: Implementation of the Malnutrition Universal Screening Tool, the Red Mat system and a Plate Pals volunteer programme Outcome and future: Over the past year Hardwicke has become an exemplar ward in the provision of care of older personsthrough dedication, hard work and belief from a fantastic MDT. We have successfully improved staff satisfaction, reduced length of stay, and created a rehab ethos and a dementia friendly environment. Our focus is now on sustaining, embedding and further streamlining our CPI’s, emphasising continued alignment with the NCPOP and Beaumont Improved Performance Plan. In addition we are now sharing our experiences and learning with other MDT’s initially focusing on spreading to a second SGW.