National Clinical Programme Research Articles

Integrated Healthcare for the Frail Older Adult

Background: In Ireland, the proportion of persons aged over 65 years is set to increase from 11.4% to 18% over the next 30 years1. A significant proportion of older people presenting to hospital settings are frail and less able to adapt to stressors such as acute illness. This increased vulnerability contributes to adverse outcomes such as falls, delirium and increased hospital stays. Comprehensive geriatric assessment has been shown to be effective and improves an older persons chance of maintaining their independance at home after an acute hospital admission2. Aims: This project set out to improve the experience of care for frail older patients by: Increasing patient satisfaction Reduced length of stay (LOS) of 1 bed day for patients over 70 years of age, with no increase in readmission rate No increase in adverse events These aims were addressed by establishing a frailty pathway with a particular focus on integration between community and acute services. Methods: Development and introduction of frailty screening tool for all patients >70 years of age presenting to the hospital. Designation of a Specialist Gerontology Ward (SGW) within the hospital where frail older patients are cohorted according to an agreed Standard Operating Policy. Appointment of a nurse specialist in gerontology, to provide initial assessment of those highlighted by the screening tool, and to co-ordinate transition of care to the SGW and back to the community. Implementation of a daily multidisciplinary (MDT) meeting on the SGW. Implementation of a weekly integrated care planning meeting involving members of multidisciplinary teams both from the hospital and the community. Implementation of an interdisciplinary falls programme for frail older patients on the SGW and supported by the community falls service. A clear focus on admission avoidance where appropriate from the Emergency Department and Acute Assessment Unit. Implementation of a cross programme governance structure to oversee and drive the project. Results: A patient centered questionnaire showed an increase in patient satisfaction levels from 67% on the previous ward to 79.6%, 3 months after the SGW opened. The median length of stay for this cohort of patients reduced from 12.6 days to 10.39 days (17.5% reduction in LOS), with no increase in readmission rates or adverse events. This equates to 695.25 bed days saved over the first 6 months of this project. The turnover (median number of discharges per month) has increased by 59%. Conclusions: Our integrated care pathyway for older people has proven itself to be of high quality, effective and efficent. This is largely due to improved interdisciplinary teamwork with patient centred care at the core. Limitations of this study are its retrospective nature. We plan to complete a prospective analysis in January 2017. We propose that reinvesting costs saved, back into the frailty pathway, would lead to better outcomes for older people living in our community,

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home

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

Integrating Care and Improving Flow for Frail Older Adults through the Development of an Acute Inpatient Frailty Service

Introduction: The National Clinical Programme for Older People in Ireland recommends the implementation of methods to identify frailty in the Emergency Department (ED) and to integrate the care of frail older adults between primary, secondary and social care. Although several models of frailty assessment teams have been piloted nationally, research into their effects on healthcare outcomes is limited. Description of practice change implemented: An integrated care pathway, consisting of dedicated medical, nursing and health and social care professional (HSCP) staff, was developed through the department of geriatric medicine, to assess frail older adults at the earliest possible point following admission through the ED. All patients >75 years admitted over the preceeding 24 hours are screened for frailty using the PRISMA-7. Those screening positive are discussed by the Frailty Service Multi-Disciplinary Team (MDT) and those deemed frail are assessed by Comprehensive Geriatric Assessment (CGA) in the ED and managed as inpatients, if appropriate. The same MDT meet daily to review progress to provide consistent and integrated care linking in with community services and an intergrated care manager. Aim and theory of change: To evaluate the experience of developing and integrating a Frailty Medicine strand within an University Hospital with existing medical, nursing and HSCP models of caring for frail older adults and to investigate whether this new model has a positive impact on healthcare outcomes including hospital length of stay (LOS) and 30-day readmission rates. Targeted population: Consecutive older adults (aged ≥75 years) that were medically stable (not requiring immediate resuscitation, intensive care or specialist medical care) and admitted through a University Hospital ED, on service operational days, were targeted. Frailty was screened using the PRISMA-7 (cut-off ≥3) and confirmed by a Consultant Geriatrician using CGA. Those admitted overnight and remaining on ED trolleys were prioritized. Timeline: We examined differences in outcomes for frail older adults after the introduction of the new service during 14 days in October 2016. Highlights: In total, 102 older patients were screened for frailty; their median age was 81 years (interquartile +/-8) and their median PRISMA-7 score was 5 (+/-4). Of these, 22 frail inpatients admitted overnight and remaining on ED trolleys were assessed and managed on the new integrated frailty pathway. Of the remainder, 54/80 (67.5%) patients were confirmed as frail but were not managed due to limited service capacity or exclusionary criteria. There was no statistically significant difference in median age (82.5+/-6 versus 83+/-8, respectively, z=-0.46, p=0.65) or PRISMA-7 scores (5+/-2 versus 5+/-2, respectively, z=-0.49, p=0.63) between those managed on the frailty pathway and frail patients receiving usual care. The median LOS of those taken over and managed throughout their admission on the frailty pathway (n=21) was 7 days (9-5=+/-4) compared to 8.5 days (12-6=+/-6), for those receiving usual care, z=-1.2, p=0.23. Likewise, no significant differences in 30-day readmission rates were found. Comments on Sustainability: Sustainability of this Frailty Service is dependent on targeted goal setting, enhanced resources and the incorporation of patient important outcomes particularly the quality of care (access, effectiveness and patient-centeredness). Wider integration with community services is planned. Comments on Transferability: Different models of frailty assessment have been created as a response to the increasing numbers of older adults attending and admitted through Irish ED’s. This new model incorporating dedicated medical with nursing and HSCP resources shows potential but requires comparison and validation against existing models nationally and internationally. Conclusions: While no statistically significant differences in outcomes were shown, a trend towards reduced LOS and readmission rates over those receiving usual care was found. Discussions: These results suggest that targeting frail older adults (≥75), screening positive for frailty with CGA and management, directly after admission into an ED, may improve healthcare outcomes. Further research with larger samples (as the sample is likely underpowered), measured over longer periods, is now required to overcome potential sources of bias. Lessons learned: This project shows the potential to identify and manage frail older adults with interdisciplinary integrated care from ED admission throughout their inpatient stay until discharge. While the Frailty Service is yet limited, there is scope to further integrate with existing hospital and community-based services for older adults to improve patient flow and transitions of care.

A Realist Evaluation of a National Model of Care for the Diabetic Foot

Introduction: Diabetic foot disease is a common and costly complication of diabetes and is a leading cause of lower extremity amputations worldwide. It requires coordinated input from multi-disciplinary teams (MDT) for prevention, monitoring and treatment. In Ireland, in 2012, the national clinical programme for diabetes recruited additional podiatrists and introduced a model of care for the diabetic foot. It outlined appropriate risk-stratified pathways, with the aim to reduce foot ulcers, lower extremity amputations and hospital costs. However, international evidence suggests complex interventions do not always translate into routine practice. Our aim is to identify and explain which aspects of the model of care are working (or not working), for whom and in what circumstances. Methods: This study is a realist evaluation, adopting a multi-stage mixed-methods design. Analysis of documents pertaining to the design, development and implementation of the model of care and semi-structured interviews with national stakeholders (n=19) were carried out to develop initial theories about how the model of care was intended to work. These theories were tested at a regional level using a multiple case study design (n=4 regions). Interviews are ongoing with local stakeholders including general practitioners, integrated care nurses, podiatrists and endocrinologists (n=15/case), supplemented with analysis of routine activity data. Data will be analysed to refine or revise the initial programme theories. Results: It was envisaged that by publishing and disseminating the model of care document, which outlined appropriate risk stratified pathways and clinical governance at each stage, healthcare professionals would ‘re-align’ their work and the appropriate patients would be referred and managed in the appropriate setting. According to national stakeholders, implementation was hindered from the outset; there were gaps in the pathways across both primary and secondary care because there was variation in existing services and limited new resources to support full implementation of the model of care. Preliminary findings from regional case studies concur, suggesting that health professionals are unable to make appropriate referrals where gaps exist in the pathways, for instance in areas where there are no community podiatrists. However, the regional case studies have also identified additional contextual factors that influence the implementation of the pathways. These factors include an awareness around the diabetic foot and an understanding of the role of podiatrists as well as the presence of an established MDT for diabetes care. Discussions/conclusion: Our realist evaluation suggests that while the successful implementation of the risk-stratified pathways is dependent on the presence of all necessary healthcare professionals along the care continuum, it is also influenced by additional contextual factors, particularly awareness around the diabetic foot and the presence of an established MDT. Lessons learned: It is important that integrated care is adequately resourced across the care continuum. Lack of awareness around the diabetic foot and the role of podiatrists hinders the full implementation of the model of care. Limitations: In the absence of a national diabetes register and audit data, the quantitative component of the study has relied on routine activity data. Future research: Refinement of programme theories is ongoing.

ICD-10-AM to CCS diagnostic codes: an exercise in clinical process mapping

Introduction: There is an increasing need for accurate hospital and health metrics in a bid to continue to improve the quality and delivery of health care. Using ICD-10-AM, the Irish health service has access to a diagnostic database that allows for richer and more flexible coding of conditions. Unfortunately, a rich database with 19,000 commonly reported diagnoses makes clinical coding and reporting more onerous. The Clinical Classification Software (CCS) collapses the 19,000 ICD codes into a more manageable 260 clinically more meaningful codes. Clinician feedback and intuitive study have shown a number of areas where we believe that there has been inappropriate mapping of ICD to CCS codes. Our aim was to identify any areas of clinical ambiguity, and to suggest changes on the basis of: a number of parameters (see Table 1). Method: In an attempt to identify possible changes that may be required to make the coding allocation more clinician friendly, we undertook a review of both ICD databases, the mapping algorithm provided by CCS, and the final CCS designations for ICD-10-AM diagnostic codes. Results: On initial study, we identified 1674 ICD1-10-AM codes for review. Of these, 1455 were believed to warrant re-coding, either to a different CCS code; a different CCS category; or a different clinical specialty (see below). Suggested changes based on: Accuracy: 2 changes Alcohol: 6 Anatomical site: 442 Cause: 437 Clinical specialty: 481 Sepsis: 7 Stroke: 61 Tuberculosis: 5 Residual: 14 Discussion: We determined that a little over 7% of the current ICD-10-AM codes could be recoded under a more clinical focus. Stroke is a special case in point. Different causes of stroke are treated differently, and this must be reflected in the coding. In partnership with the National Clinical Programme for Stroke, we have suggested re-mapping these codes to six new CCS groups. We have suggested that a number of other codes should be re-mapped using similar parameters Lessons Learned: We have developed a dialogue with the Healthcare Cost and Utilization Project (HCUP) in Washington, D.C., a division of the Agency of Healthcare Research and Quality. We have made suggestions on the basis of our findings and feedback from our clinical colleagues, and we hope that these suggestions can be added to future iterations of the CCS diagnostic codes and categories. Suggestions for future research: We believe that this is an example of inter-disciplinary and international co-operation in a bid to map together clinical codes in a manner which best represents the process flow and management protocols used to treat those conditions. Ultimately, this will make clinical coding more meaningful for the clinician, as well as providing increased accuracy and richness of hospital data. This will allow much greater access by clinicians to their own data in a manner that makes sense, and allows them to participate more fully in clinical audit and research and to drive service and quality improvement.

Developing a National Patient Transfer Letter for use by both the Nursing Home (NH) & Acute Hospital (AH) Sectors

Background: This project was initially undertaken by the Department of Medicine for Older people in two Academic Teaching Hospitals in Dublin. It is led by two Clinical Nurse Specialists in Gerontology and is supported by geriatricians in both sites. It has recently gained the support of the Irish Hospice Foundation (IHF) Nursing Homes Ireland (NHI) and National Clinical Programme for Older People (NCPOP). Problem: Information sent from local nursing homes to the acute hospital Emergency Department often lacks the information required to provide safe quality care to the older person in an emergency situation. Hence, members of the interdisciplinary team spend inordinate amounts of time contacting these NH’s in order to obtain basic information that will support important care and treatment decisions in the acute setting for this complex, frail patient group. Information on medications, infection status, diet, cognition, functionality, advanced care planning are essential if we are to determine patient need. Assessment of problem and analysis of its causes: A prospective audit was carried out in 2011 to assess the problem outlined above in which 35 transfer letters from 29 different NHs were reviewed. A questionnaire was used to assess 24 aspects of information been received at the point of hospital entry. A template transfer letter was devised from the questionnaire to capture demographic information, baseline medical information, physical information and the cognitive status of the patient being transferred to hospital from each NH. The template was sent at the end of the audit period to all Directors of Nursing in each NH. All were requested to send feedback on the template so it could be modified for phase 2 of the project. Intervention: As a result of the consultative process a new transfer document was developed. Support from the national advisory body Nursing Homes Ireland (NHI) was ascertained. In order to enhance accessibility and promote usage, the document was made available on both hospital websites and a care planning database ‘Epicare’ which is used by 60% of NH’s nationally. Strategy for change: From the outset of the project in 2011, we consulted with Directors of Care from NH’s through NHI; in order to ascertain that: 1) the proposed content of the Transfer letter was appropriate and, 2) that updates on the transfer document were communicated to reflect national standards / guidance. Measurement of improvement: Continuous audit cycles (4) and on-going consultation with NH’s; allowed us measure improvements in the quality of transfer information. In 2015, 62% of NH were using the standardised template document (n=37) a decrease from 73% in 2012. However, baseline demographic & medical information was well documented, as were Functional Scores (90-100%). Other Results show improvements & areas for concern Effects of changes: Improvements in transfer communication meant clinicians in Acute Hospitals (AH)’s and NH’s spent less time looking for information deemed vital to patient care. One of the challenges was that NH’s wanted more information on the document at each stage of the consultation process. Its’ success as a single page document at local level allowed the document to trialled at regional level with funding support from the IHF. 189 NH’s were contacted and 83% (81 replies) used the document and reported it to be useful and comprehensive. Lessons learnt: The document is currently undergoing an integrated consultation process between both the NH & AH Sectors for National application with the support of NCPOP. Other stakeholders challenge its single page status and its’ scope has been be broadened to include other areas of the residential care sector. Quality of transfer information from AH to NH will need to be considered following this phase as requested by NH’s. Messages for others: A single page document with key information that represents patient need is vital during transitions of care. It helps reduce incidences of missed care through the provision of appropriate information between healthcare stakeholders. Consultation with Directors of Care or Clinicians from both NH & AH respectively is essential on behalf of NH patients to ensure that the information been transferred is satisfactory and that patient need is been met through appropriate transfer of information when developing or using a standardised template.

Role of the Dietitian within the Frail Elderly Pilot in Connolly Hospital Blanchardstown from February to June 2016

Introduction : The Specialist Geriatric Services Model of Care aims to improve the quality and efficiency of care for the older person with complex health care needs whom may warrant a comprehensive multidisciplinary assessment. Nutritional status should be a component of the CGA (HSE, 2012). 27% of those admitted to hospital are at risk of malnutrition (BAPEN, 2012). The Frail Elderly Pilot Programme commenced in Connolly Hospital Blanchardstown in January 2016. Aims : - Development of referral criteria to the Dietitian within the Frail Elderly Team - Early identification and nutritional assessment of those at risk of malnutrition - Early identification of those requiring management of chronic disease Methods : - A specialist geriatric team was established within the emergency department (ED) and acute medical assessment unit (AMAU) in CHB - Patients 75 years or more were screened for frailty indicators during core hours including social factors, mobility, swallowing problems and weight loss - A Health and Social Care Professional common screen is performed on selected patients on admission to the ED or AMAU - Development of a referral pathway to Dietitian within the Frail Elderly Team - Same day nutritional assessment of patients following receipt of referral from the Frail Elderly Team from February to June 2016 Results : There was 136 referrals to the Dietitian from the ED and AMAU. There has been an 83% increase in Dietitian referrals of those aged ≥ 75 yrs from February to June 2016 compared to the same months in 2015. 31% of those referred to the Dietitian were at high risk of malnutrition. Patients classified as high risk of malnutrition had a longer length of stay in hospital. Of the recorded anthropometric measurements, 84% were below the 25th centiles for hand grip strength. 26% of Dietitian referrals in ED / AMAU were secondary to management of chronic disease. A standard operating precedure regarding the role of the dietitian within the Frail Elderly Team is also being developed throughout the pilot. Conclusions : - Malnutrition increases a patient’s risk of serious but potentially avoidable complications (IrSPEN, 2015). - The main reason for referral to the Dietitian was secondary to high risk of malnutrition and weight loss which accounted for 45% of all referrals. - Nutrition screening on admission is recommended for the early identification of those at risk of malnutrition whom may warrant nutrition support (HIQA, 2016). - 26% of Dietitian referrals in ED / AMAU were secondary to management of chronic disease e.g. diabetes, heart failure. - The National Clinical Programme for Older Persons recommends that the Dietitian should be part of the multidisciplinary team (HSE, 2012). The Frail Eldely Pilot in Connolly Hospital Blanchardstown plans to continue into 2017. Lessons Learned : Importance of early multidisciplinary assessment of the frail older person on admission to the emergency department and promotion of frail elderly pilot hospital wide

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.

Integrated Care Pathway for Patients with Spinal Cord Injury in Ireland

Introduction: Trauma and rehabilitation networks in Ireland are largely underdeveloped and there is significant variance in patient pathway within and across acute hospital services, specialist rehabilitation services and post-acute regional or community based rehabilitation services. Currently, in the absence of established clinical pathways across existing acute and rehabilitation services, patient pathway is convoluted. For patients with the most complex and severest injuries access to complex specialist rehabilitation services is compromised and outcomes such as discharge to community is poor. The vision for this project was to develop an all systems approach to support the patient journey for patients with Spinal Cord Injury from acute hospitals, post-acute rehabilitation services, disability services and long term care. Short description of practice change implemented: The National Clinical Programme for Rehabilitation Medicine has developed a care pathway in collaboration with all key stakeholders which describe the ideal patient journey for all those with a spinal cord injury, including those who are ventilator dependent. This is the first time such a pathway has been developed and will promote a patient centred approach to the management of this cohort of patients while also giving clear parameters against which patient journey can be measured going forward. Currently there is a cohort of patients in Ireland with high level spinal cord injury including some who remain in need of chronic ventilation who are unable to be served through within existing services. These patients are experiencing prolonged stays in acute hospital and some are unable to access complex specialist rehabilitation services. Implementation of the pathway will see patients who are ventilator dependent being able to access specialist rehabilitation services in Ireland for the first time and will also see the possibility of a discharge home realised for many. Aim and theory of change: The reduction in unnecessary variation in the care pathway of patients with spinal cord injury was felt to be achievable through the development of an ICP in collaboration with all key stakeholders. Targeted population and stakeholders: The ICP for patients with spinal cord injuries spans numerous service delivery sites, as such, collaboration with a wide number of stakeholders including acute hospitals, critical care, rehabilitation services, disability and community services, patients and patient support groups was necessary. Timeline: This project was identified as an area needing development in the 2016 workplan of the Rehabilitation Medicine Programme. Highlights: The project is small in numbers but significant in terms of process changes. It requires services working together across organisational boundaries in a way that is not often seen within the Irish healthcare system. Implementation will see patients with complex disability being able to access services in Ireland which they previously would have had to travel oversees to access. Comments on sustainability: The Principles supporting the care pathway are reflective of evidence based practice. The extensive consultation process undertaken by the programme has supported multi-agency collaboration and buy-in which will sustain this new way of working. The parameters set out in the patient pathway will afford us the opportunity to objectively measure patient journey and identify unnecessary variation in a way previously not possible. Comments on transferability: While this pathway is for spinal cord injury, the underpinning principles should be consistent for all with a need for specialist rehabilitation service and thus applicable across other diagnostic groups. Conclusions: The high level objectives for the project are: Process Improvements: - Improved access to both the National Spinal Unit (NSIU) and NRH for all patients requiring the tertiary level services they provide - Allow access to post acute specialist rehabilitation services at the NRH, particularly for those who are ventilator dependent Quality: - Reduce the number of patients being discharged back to acute hospital setting post rehabilitation services - Improve patient experience Discussions: Quality care is care which is patient centred. To be truly patient centred, a move away from individual service priorities is required with a focus on aligning priorities to support the patient journey. Lessons learned: The patient voice should be central to all health care planning

Optimising the Comprehensive Geriatric Assessment

Introduction: Carew House Day Hospital is an outpatient assessment unit for patients aged 65 years and over and is operated by the Medicine for the Elderly service in St. Vincent’s University Hospital (SVUH). Patients attending Carew House undergo multidisciplinary Comprehensive Geriatric Assessment (Medical, Nursing, Physiotherapy, Occupational Therapy and Social Work) with further access to Speech and Language Therapy, Dietician and Smoking Cessation services as required. The service assesses approximately 600 new patients annually. The National Clinical Programme for Older People advocates a Comprehensive Geriatric Assessment (CGA) of frail older patients as a means to increase independence in the home and reduce inappropriate admissions to nursing homes. Short Description of Practice Change Implemented: Deficiencies in the CGA were identified and discussed at a meeting of the Day Hospital Management involving medical, nursing and allied health staff. These deficits were demonstrated through an initial pilot and retrospective review of patients assessed in the Day Hospital. It was recognised that additional resources and staff for the Day Hospital would not be an available option to alleviate this problem. Once deficits in the CGA were identified and outlined, staff were empowered to engage with the change process immediately in order to develop improvement solutions. Aim and Theory of Change: The aim of this project was to empower members of the multidisciplinary team (MDT) to generate efficiencies within the service and to identify areas where the CGA could be streamlined. In December 2014, the following interventions were implemented: A new vetting process for patient referrals to ensure appropriate MDT members would be available on the date of assessment Nomination of designated nurse leader and senior clinician in the absence of regular staff An additional and timely referral pathway for physiotherapy and occupational therapy assessment using pre-existing additional community services Alternative access routes for medical social work input involving redesign of the referral pathway Targeted Population and Stakeholders: This included all patients assessed in Carew House Day Hopsital and all members of the MDT. Timeline: September 2014 - April 2015 Highlights: Having a Consultant’s clinical opinion directly available for each patient increased from 79% to 88%. The presence and input of a Nurse Manager on the day of assessment increased from 30% to 99%. Completion of Physiotherapy and Occupational Therapy assessment for patients increased from 65% to 73%, and 96% to 99% respectively. In addition to these improvements in the CGA, systems were implemented to ensure that a senior clinical opinion (Registrar or Consultant) was available at all times via telephone and a Deputy Nurse Lead was appointed in the absence of a Nurse Manager. An additional 15% of patients received Physiotherapy assessment via the newly implemented alternative referral pathway. Comments on Sustainability: It is recognised that while this suite of interventions has resulted in progress, our service is in constant need of review and regeneration in order to continue to improve for our patients. Comments on Transferability: This change process engaged staff across the MDT and highlighted that positive change in a service is achievable through improving efficiency and redesigning processes, without budgetary expansion. This model is transferable. Conclusions: Changes in Carew House Day Hospital resulted in improvements in the constituents and overall quality of the CGA for our catchment community. Discussions: While this project resulted in some improvement, the main barrier encountered was in recognising the deficits in our service that required change. Lessons Learned: Resource limitations should never stand in the way of improvement!

Developing a National Model of Care for Paediatric and Neonatal Healthcare Services

Introduction: The National Clinical Programme for Paediatrics and Neonatology, a joint clinical initiative between the Faculty of Paediatrics, Royal College of Physicians of Ireland and the Health Service Executive, has developed a national model of care for paediatric and neonatal healthcare services in Ireland. Methods: Extensive consultation took place with healthcare professionals and management working in the child health sector in Ireland when developing the model of care. It was recognised from the onset that in order to ensure success and widespread acceptance of the model, there would need to be a ‘ground up’ approach, where staff were heard, acknowledged and encouraged to contribute to the shared national vision for the specialty. In addition, the Programme recognised the importance of engaging with parents, children and young people, and this took place throughout the development of the model of care to ensure that their views were incorporated. Achievements: The model of care addresses the changing healthcare needs in Ireland and describes a vision for high quality, accessible healthcare services for children in Ireland, from birth to adulthood. It spans a range of care settings from community services to tertiary and quaternary care. It sets out requirements in a range of paediatric subspecialties for infrastructure, staffing and processes, and the expected outcomes for children accessing each service. The model of care is a blueprint for the development of paediatrics and neonatology over the next 10 years in Ireland. Next steps: The model of care has been approved by the relevant authorities and it must now be implemented through the service delivery functions. An implementation structure is being developed which will require stakeholders to work in an innovative integrated way. Implementation teams will require membership from each of the relevant HSE divisions; health and wellbeing, primary care, social care, acute hospitals and mental health services.

The development of a strategic vision and educational framework for Gerontological nursing

Background: Population ageing is causing important and fundamental changes for health and social care services nationally and internationally. Many people remain well, engaged and active into later life and continue to make a major contribution to local communities and society. However increasing age also brings an increasing chance of long-term medical conditions, frailty, dementia, disability, dependence or social isolation. Life expectancy at age 75 increased by 29% (female) and 39% (males) between 1993 and 2013 (Eurostat 2014) and the number of people over 80 in Ireland will doubled in the next ten years (CSO 2011). People aged 65 and over now constitute 11.7% of the population and use 61%% of acute hospital inpatient bed days (HIPE 2014). The growing older population has consequences for the nursing profession and for nurse education. An increasing demand for nurses to work with older people over a wide range of services including hospitals, residential care, health and community services is inevitable. If nurses are to gain a holistic perspective and expertise in this specialist area of care, their preparation and ongoing professional development will need to focus on the competencies required for working with older people.Therefore, nurse education and curricula need to be responsive to the diverse and holistic needs of older people and changing care environments. It is imperative that the future of gerontological nurse education is designed to equip nurses with the knowledge skills and competencies necessary to meet those needs. Project: While the Clinical Strategy & Programmes Division seek to implement models of care (HSE 2012), a parallel vision for the future of gerontological nursing is necessary to ensure we provide age attuned services into the future. The National Clinical Programme for Older People (NCPOP) in collaboration with the Office Nursing Midwifery Services Directorate (ONMSD) are developing a strategic vision and educational framework for nurses working with older people across the spectrum of healthcare. The aim of this work is to develop a nursing service that has the knowledge, skills and competencies to meet the needs of the older population into the future. The proposed framework will incorporate a vision for gerontological nursing to include career pathways and the competencies and educational requirements required to effectively fulfil these roles. The methodology applied by the National Cancer Control Programme has been replicated to inform and direct this body of work. In 2016 a systematic literature review was undertaken by the McAuley School of Nursing & Midwifery, University College Cork, to inform the development of an educational framework to enable nurses to acquire and maintain the necessary knowledge, skills and competence, at the appropriate level to deliver quality person centred care to older people, throughout the Irish health service.The second part of the methodology was the completion of a number (n=5) national focus groups with relevant stakeholders which will included older people, healthcare professionals, educators, policy makers, carers and other interested parties (n=280). The overall research question to be answered is “What knowledge, skill and competence are required to produce a nursing workforce that can provide quality person centred care to older people wherever they access healthcare? The final framework document will be completed in November 2017

Health and Social Care Professions Rise to the Challenge Admission Avoidance in Emergency Departments

Patients with mobility issues with potential for same day discharge in EDs This paper describes how Emergency Department (ED) based initiatives, developed by Health and Social Care Professionals (HSCP’s) enhance cost effective access to timely high quality patient care in the ED Initiatives have been introduced in response to Increasing demands on healthcare services, including patient flow Escalating health costs and the need to direct funding where it is most effective “best person – best place –best time “ Continuous developments in knowledge and skills and advanced roles of HSCP’s Nationally, HSCP’s have developed various practice initiatives in ED. However the largest growth in HSCP activity nationally is one that addresses the increased number of patients with mobility issues who have the potential for same day discharge. These initiatives support interdisciplinary and cross programme partnerships (e.g. with the National Clinical Programmes for Older Persons and the Acute Medicine Programme) as well as bridging hospital and community practice. Examples of these initiatives include Mobility Assessment and Discharge Rapid Admission Prevention Interdisciplinary Frail Intervention Therapy Team SWOT Social Work and Occupational Therapy PhAst Physiotherapy Assessment and Treatment HSCP Rapid Access and Treatment Benefits demonstrated include admission avoidance, reduced length of stay in ED, increased discharge rates, reduction in re-attendance and improved patient and staff satisfaction. The presentation will detail these initiatives and their benefits Rosie Quinn rosie.quinn@hse.ie Clinical Specialist Physiotherapist (Our Lady of Lourdes Hospital Drogheda) and Therapy Lead Emergency Medicine Programme (all HSCP leads on these initiatives have been contacted and have agreed to share their data – they will be acknowledged individually in any presentation given)

Standardising care for heart attack (STEMI) patients, Ireland

Under a reform agenda, the Health Service Executive (HSE) in Ireland initiated the National Clinical Programme for Acute Coronary Syndrome (ACS) in 2010, as a joint venture with the Royal College of Physicians of Ireland (RCPI). Early attention was focussed on treatment of patients with ST elevation myocardial infarction (STEMI) as treatment varied nationally depending on distance from a Cardiac centre offering 24/7 primary Percutaneous Coronary Intervention (PPCI) (direct clot removal), a more effective treatment with less complications but requiring specialised facilities compared with thrombolysis (clot dissolving drug treatment) available in all general hospitals. The aim of the programme was to save lives by standardising the care of patients with STEMI nationally through implementing a national Optimal Reperfusion Service (ORS) protocol. Following development and consultation 2011-2012, the protocol was implemented nationally in 2013, ensuring that: 1. All acute services were aware of the ORS protocol, (early detection of suspected STEMI patients, rapid transfer within 90 minutes drivetime to nearest PPCI centre) 2. Ambulances were equipped and paramedics trained (to undertake 12 –lead ECG, recognise STEMI, transmit ECG, communicate directly with cardiology staff (Code STEMI) and transport the patient rapidly to the Catheter Lab in PPCI centre thus bypassing local hospitals and emergency departments. 3. Primary PCI centre hospitals were designated based on criteria: a) two catheter laboratories, b) ability to provide a cardiology roster of 1:5 minimum. There are 5 designated 24/7 PPCI centres and one 9-5, Monday to Friday PPCI centre. 4. General hospitals were clear on implementing early detection and rapid transfer to PPCI centres similar to (2) above. 5. A monitoring system was put in place to measure the performance of the ACS programme. There was active participation of a) National Ambulance Service, b) Emergency medical services regulatory body), c) RCPI who supported an Advisory Forum of interventional cardiologists, c) Cardiac nurses and those in cardiac rehabilitation. Consultation was held with Irish Heart Foundation and CROI charity. Finally, to ensure provision for patients in the North West region, cross border discussions with the health service in Northern Ireland led to contracting a service with similar parameters across the border in Derry, Northern Ireland. The ACS programme successfully implemented an early detection and by-pass programme to reach a small number of PPCI centres in conjunction with all parties in hospital and pre-hospital environment in an era of recession. The result is that PPCI is now the dominant form of reperfusion treatment, 94% in 2015 compared with 55% in 2011. To promote sustainability and address quality improvement, a real time feedback loop is currently being finalised. Lessons learnt: importance of professional co-operation, acknowledging that change takes time, persistence and keeping the long term goal in view, using old and new communications. Also there are answers outside the box e.g. cross border development which allowed both communities to benefit from newer treatment. The protocol and lessons learnt are eminently transferable especially to other emergency situations e.g. advice has been sought by colleagues developing a thrombectomy service for ischaemic stroke.

‘The NCEPOD Method’ – How the National Confidential Enquiry into Patient Outcome and Death designs and delivers national clinical outcome review programmes

Introduction This publication describes the method used by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) to run confidential enquiries. With its history based around the review of surgical mortality, NCEPOD has now grown into a medical as well as surgical review and expanded its remit to review overall quality of care of all patients. Methods and analysis The work will describe the qualitative method used by NCEPOD to conduct a national confidential enquiry, starting with how a topic is selected through to report production. Covering all hospitals in the UK and using a network of local contacts, NCEPOD reviews a sample of cases from each hospital and provides in-depth multidisciplinary peer review to give a national picture on the quality of care provided. The peer review data collected is underpinned by quantitative data collected using questionnaires, and all analyses are undertaken using pivot tables in Excel. The paper will highlight the strengths, limitations and challenges of this qualitative method. Ethics and dissemination NCEPOD does not interact directly with patients and therefore does not require ethics approval. NCEPOD does, however, gain approvals through the relevant regulations in all UK countries to collect identifiable or anonymised data without consent. Conclusion The paper will be useful for those who need a reference document for the general approach to enquiries that NCEPOD now uses. It could also be read by those who would like to undertake their own local enquiry and would like a method to base it on.

The National Trauma Research Repository: Ushering in a New ERA of trauma research (Commentary).

Despite being the leading cause of death in the United States for individuals 46 years and younger and the primary cause of death among military service members, trauma care research has been underfunded for the last 50 years. Sustained federal funding for a coordinated national trauma clinical research program is required to advance the science of caring for the injured. The Department of Defense is committed to funding studies with military relevance; therefore, it cannot fund pediatric or geriatric trauma clinical trials. Currently, trauma clinical trials are often performed within a single site or a small group of trauma hospitals, and research data are not available for secondary analysis or sharing across studies. Data-sharing platforms encourage transfer of research data and knowledge between civilian and military researchers, reduce redundancy, and maximize limited research funding. In collaboration with the Department of Defense, trauma researchers formed the Coalition for National Trauma Research (CNTR) in 2014 to advance trauma research in a coordinated effort. CNTR's member organizations are the American Association for the Surgery of Trauma (AAST), the American College of Surgeons Committee on Trauma (ACS COT), the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA), and the National Trauma Institute (NTI). CNTR advocates for sustained federal funding for a multidisciplinary national trauma research program to be conducted through a large clinical trials network and a national trauma research repository. The initial advocacy and research activities underway to accomplish these goals are presented.

Feasibility of Group Cognitive-Behavioral Treatment of Insomnia Delivered by Clinical Video Telehealth.

Clinical video telehealth provides a means for increasing access to psychotherapy. Insomnia is prevalent, is associated with a number of negative sequelae, and can be effectively managed with cognitive behavioral treatment of insomnia (CBT-I). Telehealth technologies can provide a means for increasing access to CBT-I. The Tele-Insomnia program is a Veterans Health Administration (VHA) initiative in which CBT-I is delivered in a group format by telehealth. Veterans received six weekly sessions of group CBT-I, completing the Insomnia Severity Index (ISI) and daily sleep diaries throughout treatment. Paired-samples t-tests were used to examine differences in each measure from the first to the last session of treatment. There were statistically and clinically significant improvements in the ISI and all sleep diary variables with the exception of total sleep time. Video quality was excellent, and there were few connectivity problems. Clinical video telehealth technology can be used to deliver group CBT-I in a manner that produces clinically significant improvement. This model is scalable and has been used to develop a national clinical telehealth program.

Continuous subcutaneous insulin infusion therapy for Type 1 diabetes mellitus in children.

Continuous subcutaneous insulin pump therapy (CSII or pump therapy) is a well-recognised treatment option for Type 1 diabetes mellitus (T1DM) in paediatrics. It is especially suited to children because it optimises control by improving flexibility across age-specific lifestyles. The NICE guidelines (2008) recognise that pump therapy is advantageous and that it should be utilised to deliver best practice. In Ireland, the National Clinical Program for Diabetes will increase the availability and uptake of CSII in children and thus more clinicians are likely to encounter children using CSII therapy. This is a narrative review which discusses the basic principles of pump therapy and focuses on aspects of practical management. Insulin pump management involves some basic yet important principles which optimise the care of diabetes in children. This review addresses the principles of insulin pump management in children which all health care professionals involved in caring for the child with diabetes, shoud be familiar with.

Evaluating the implementation of a national clinical programme for diabetes to standardise and improve services: a realist evaluation protocol.

BackgroundOver the last three decades in response to the growing burden of diabetes, countries worldwide have developed national and regional multifaceted programmes to improve the monitoring and management of diabetes and to enhance the coordination of care within and across settings. In Ireland in 2010, against a backdrop of limited dedicated strategic planning and engrained variation in the type and level of diabetes care, a national programme was established to standardise and improve care for people with diabetes in Ireland, known as the National Diabetes Programme (NDP). The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended.Methods/designThis mixed method realist evaluation will develop theories about the relationship between the context, mechanisms and outcomes of the diabetes programme. In stage 1, to identify the official programme theories, documentary analysis and qualitative interviews were conducted with national stakeholders involved in the design, development and management of the programme. In stage 2, as part of a multiple case study design with one case per administrative region in the health system, qualitative interviews are being conducted with frontline staff and service users to explore their responses to, and reasoning about, the programme’s resources (mechanisms). Finally, administrative data will be used to examine intermediate implementation outcomes such as service uptake, acceptability, and fidelity to models of care.DiscussionThis evaluation is using the principles of realist evaluation to examine the implementation of a national programme to standardise and improve services for people with diabetes in Ireland. The concurrence of implementation and evaluation has enabled us to produce formative feedback for the NDP while also supporting the refinement and revision of initial theories about how the programme is being implemented in the dynamic and unstable context of the Irish healthcare system.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0464-9) contains supplementary material, which is available to authorized users.