Service Development Project Research Articles

Using EMDR therapy with patients in an acute mental health crisis

BackgroundDeath by suicide continues to be a global public health concern with little research demonstrating the effectiveness of treatment options. This exploratory study exams the efficacy of Eye Movement Desensitisation and Reprocessing (EMDR) Therapy delivered to patients experiencing an acute mental health crisis to explore if by treating their background trauma, improvements could be seen in their general psychopathology and if there was a resulting decrease in their desire for suicide.MethodsA practice-based service development project was conducted within a mental health hospital. A non-randomised, exploratory pre-test post-test design was utilised. Participants were identified from adult patients currently receiving care from either an inpatient mental health ward or the Crisis Resolution and Home Treatment Team (CRHTT). Those who had reported experiencing at least one event that they considered to be traumatic were offered EMDR Therapy. Notes from the electronic database were analysed to assess contact with services 12 months prior to treatment and following treatment.Results72 patients were offered treatment in the study with 57 completing treatment. Patients made significant improvements across all the psychometrics, including a reduction in suicidal ideation. The majority needed less than 10 sessions and needed no onward referral for further psychological therapy. Cost savings were realised by retracting referrals for further therapy and in early discharge from CRHTT and acute wards, and by preventing admissions. Contact with services post treatment also reduced.ConclusionsEMDR Therapy can be an effective treatment for patients experiencing a mental health crisis who have a trauma picture, resulting in significant improvements in their mental well-being and substantial cost savings for the National Health Service (NHS).

EP.47Sharing evidence-based physiotherapy for neuromuscular patients through a digital learning platform: description of a service development project

Physiotherapy is an important modality for patients with neuromuscular diseases, as individually targeted physiotherapy approaches may enhance functions in daily life, and thereby affect quality of life. In Norway, there is scarce knowledge of neuromuscular diseases among community PTs, especially related to specific hands-on physiotherapy. The physiotherapists at the National Neuromuscular Centre, Norway (NMK), sees the need for easily attainable learning resources to meet the demands from community PTs. Hence, a service development project based on digital learning to reach the community PTs that encounter the patient group in their clinical practice and need an evidence-based platform to guide their decision-making, was planned. The project was developed in close collaboration with sjelden.no, a learning platform for rare diseases funded by Norwegian National Advisory Unit on Rare Disorders (NKSD). Two introductory videos, about physical activity and exercise, and principles for physiotherapy to neuromuscular patients, were produced and published in 2017. These combined animations and real-life video. Thereafter a module-based e-learning course consisting of four modules was made: 1) General introduction to neuromuscular diseases 2) Functional challenges for persons with diseases in muscle 3) Functional challenges for persons with neuropathies 4) Specific physiotherapeutic interventions. Module 2-4 consists of real patients and physiotherapeutic interventions to address their problems. Editing of module 2-4 is still in progress. There has been positive feedback to module 1 consisting of the introductory videos. These are published at sjelden.no, and have been marketed at the webpages of NMK and NKSD, as well as at physiotherapy congresses and other venues. Modules 2-4 are yet to be published to the public, aiming for a late 2019 introduction. E-learning through a digital learning platform, as an add-on to clinical courses, can be a cost-effective way of sharing evidence-based physiotherapy knowledge to community PTs and other health-care professionals that encounter patients with rare neuromuscular diseases in clinical practice. Proper evaluation of the finished module-based e-learning program is though needed to assess its usefulness.

TIME OPTIMIZATION USING CPM, PERT AND PDM METHODS IN THE SOCIAL AND DEPARTMENT OF KELAUTAN BUILDING DEVELOPMENT PROJECT GRESIK DISTRICT

Planning a project there are many important things that affect the success and smoothness, one of which planning time implementation of the right and efficient work. The way to overcome the problem is by using several methods such as CPM (Critical Path Method), PERT (Project Evaluation and Review Teqnique), PDM (Precedence Diagram Method). From the calculation result show that the duration of project completion using CPM method is 57 weeks, project completion duration using PERT method is 78 + 7.5 weeks with the probability of achieving project completion time target is 99.87% and project completion duration using PDM method is 30 weeks. So the method that best suits the Social Service Development Project and the Office of Marine Gresik Regency is the PDM method because the PDM method is capable of producing shorter project completion periods than the CPM and PERT methods of 30 weeks.

Increasing access to computerised cognitive behaviour therapy for older people

Computerised cognitive behavioural therapy is an effective treatment of mild to moderate depression and anxiety. This article includes the reflections of a service development and evaluation project team in NHS Scotland about the barriers and facilitators experienced when working to increase access to computerised cognitive behaviour therapy for older people.

A service development project for people affected by learning disabilities and domestic abuse

A specialist learning disability team have undertaken a service development project in relation to domestic abuse amongst adults affected by a learning disability. This paper outlines the rationale for the project, progress made and future plans.

Measuring health-related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing

IntroductionResearch into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure,...

Development, integration and evaluation of nurse-led follow-up across five tumour sites at a cancer unit in Northern Ireland

The traditional model of medical oncology follow-up clinics has been challenged in recent years, partly because it cannot meet the individual needs of the growing cancer survivor population. Greater personalisation of follow-up care is required to manage cancer survivors’ clinical, psychosocial, and practical care, and many organisations are attempting to achieve this through nurse-led follow-up services. This article describes a service development project, in a cancer unit in Northern Ireland, that developed, integrated, and evaluated nurse-led follow-up clinics for five tumour groups. Evaluation was undertaken through a focus group and surveys, and the article discusses the findings that suggest successful integration of nurse-led clinics requires comprehensive planning and preparation, including professional development, and risk stratification of patients, and that nurse-led clinics enhance continuity of care, and promote patient empowerment and self-management strategies. The article concludes that nurses can deliver cancer follow-up services effectively, and are well placed to provide comprehensive survivorship care for patients.

Implementation of a metastatic malignancy of unknown primary origin service led by a palliative physician

ABSTRACTBackground: Cancer of unknown primary is the fourth most common cause of cancer death in the United Kingdom. National guidance in 2010 recommended the establishment of a dedicated unknown primary team to facilitate targeted investigation and symptom control. A service development project was undertaken to identify those affected by malignancy of unknown origin and institute a pathway for coordinating their care led by a palliative physician.Method: In order to describe the patient population and illness trajectory and to assess the effect of the new pathway on the clinical outcomes we used a retrospective and prospective comparative case notes survey to identify the pre- and post-pathway population. This took place in secondary care. Inclusion criteria were patients with metastatic disease with no known primary; exclusion criteria were where the site of metastasis was so suggestive of a primary that it would be managed as per that disease process. 88 patients were included.Results: Mean age was 72.5 years. The mean survival time from presentation was 81.8 days. There was no difference pre or during pathway implementation in age, performance status or survival time. There was no reduction in the numbers referred for tumour directed therapy. There was a non-statistically significant reduction in the number who died in hospital during the pathway implementation.Conclusions: This study suggests having a metastatic malignancy of unknown primary origin service led by a palliative physician does not reduce the number referred for tumour directed therapy. It also adds evidence of the poor prognosis and thus the need for early palliative care input.

Prediction of need for intervention in posterior urethral valves: Use of urine osmolality

AimRenal tubular dysfunction (RTD) causing obligate production of hypoosmolar urine in boys with posterior urethral valves (PUVs) has been described. It is not known how clinically significant this is. We hypothesize that a feedback loop is present in many PUV boys who suffer deterioration of their lower urinary tract (LUT). RTD results in hypoosmolar urine, obligate polyuria, and bladder stretch-injury. The increasing back-pressure worsens RTD, thus exacerbating the injury. Coexisting renal dysplasia and acquired renal scarring exacerbate this.We compared the concentrating ability (random clinic urine osmolality) of PUV boys who had no LUT deterioration to those who required intervention, examining the confounding effect of renal impairment with a subgroup analysis comparing those with plasma creatinine ≤80μmol/l. MethodsA retrospective review of our PUV database was performed. Age, intervention, and highest recorded random clinic urine osmolality (>1year) with concurrent plasma creatinine were recorded (normal urine osmolality 500–850 mOsm/kg). Data are given as median values, analyzed by Mann–Whitney u-test, with P<0.05 deemed significant. Main resultsUrine osmolality was available in 77 boys with PUV out of 125 in our series. Of these, 34 required subsequent intervention (e.g., Mitrofanoff procedure, bladder augmentation). Age at testing trended towards being higher in the intervention group [7.9 (4.3–10.9) years vs. nonintervention 6.3 (4–8.4); P=0.06]. Urine osmolality was significantly reduced in the intervention group [411(293–547) vs. 631 (441–805) mOsm/kg; P<0.001]. Subgroup analysis comparing only those with creatinine ≤80μmol/l was respectively 451 (322–567) mOsm/kg (n=22) vs. 645 (469–810) mOsm/kg (n=40), P<0.01. ConclusionThis study confirms that hypoosmolar urine is highly associated with progression of LUT dysfunction, requiring intervention. Even boys with normal creatinine values have a greater risk of LUT deterioration if they have a RTD and produce hypoosmolar urine. Level of evidenceIV (retrospective service development project).

National Clinical Programme in Surgery GP Integrated Care ENT Education Programme

Introduction: Given the background of the present limited scope of the GP contract for the provision of primary care in Ireland, it is unsurprising that an estimated 30% of referrals to ENT consultant services relate to caseload which could be managed in the community, given adequate support. The majority of these referrals could be managed in primary care if GPs had access to equipment, and were accredited and resourced to perform diagnostic and therapeutic procedures. There are currently 55,329 patients awaiting an ENT outpatient appointment, with 15,104 waiting longer than 12 months. Description of Changes: This project will enable and accredit GPs with a special interest in Otolaryngology in a defined range of ENT procedures, with a view to these procedures being provided in primary care rather than in secondary care. GPs and ENT services will be formally linked, and appropriate learning and research opportunities will be explored and developed to enable GPs obtain accreditation in ENT procedures agreed and accepted as suitable for primary care surgery. Accreditation will include recognition of symptoms and cases which still require referral to Consultant ENT services. This process will enable GPs provide a defined range of procedures without referral to ENT consultant services. In due course, primary care resourcing as well as professional support will be required for the project to fully deliver its potential. Aim & Theory: The aim of this project is to provide a greater volume of care in communities, reduce numbers of referrals to ENT outpatient departments by 30%, to reduce the ENT outpatient waiting list, to support and enable GPs perform procedures which are presently carried out in outpatients, to deliver efficiencies, and to minimize inappropriate investigations. Targeted Populations: The populations targeted are GPs with ENT special interest and patients awaiting ENT outpatient procedures such as irrigation of the ear, insertion of ear dressings, insertion of nasal packs, fibre optic nasal endoscopy. Other stakeholders include the Royal College of Surgeons, Training Hospitals, Hospital Groups, Primary Care Division, The Irish College of General Practitioners, and the Institute of Otolaryngology. Timeline: The project inception was in 2016. Planning Workshops will begin in January 2017, with reviews in July 2017 and January 2018. Highlights: The predicted outcomes are a Training Process and Accreditation for GPs in ENT Primary Care Surgery, a reduction in outpatient referrals, a reduction in existing outpatient waitlist, reduction in the return to new patient ratio by 4:1, and the creation of a scaleable process for roll-out across the country. It is also expected to improve integration of primary care and ENT hospital services. Sustainability & transferability: A National Educational Lead will be appointed to ensure consistency, validity and sustainability nationally. Attention will be given to costings for delivery of services in primary care, both in terms of the primary care re imbursement scheme, and in relation to clinic costs in primary care.The project is highly transferrable to many areas where GPs have a special interest. Conclusion: This service development project has the potential to assist in the transfer of care from secondary to primary care, reduce ENT consultant waiting lists and enable GPs to deliver a higher volume of ENT service in the Primary Care setting. Discussion: Following planned implementation across Acute Hospital in liaison with GPs this integrated care initiative is anticipated to reduce wait times and provide more timely and convenient access and treatment for ENT patients across Hospital Groups and Community Health Organisations. Lessons learned: Integrated care across Primary and Secondary Care can work by working collaboratively with GPs, HSE Outpatient Services and ENT Specialties in Acute Hospitals. Lessons learned: Integrated care across Primary and Secondary Care can work by working collaboratively with GPs, HSE Outpatient Services and ENT Specialties in Acute Hospitals.

Gradual physical decline characterises the illness trajectories of care home residents.

Three archetypal trajectories of physical decline have been identified: a short period of rapid decline; long-term limitations with intermittent acute periods; and a prolonged gradual decline. An understanding of illness trajectories can help clarify the evolving needs of people with progressive conditions, and inform the development of palliative care services to meet their needs. Many frail older people live and die in care homes; the present study is the first to explore the illness trajectories of residents in care home settings. To determine the prevailing trajectories of physical decline in care home residents; and to identify the dominant illness trajectories of residents in care homes in Lothian, Scotland. Data were collected as part of a service development project to improve palliative care in eight care homes in south Edinburgh that provided 24-hour onsite nursing care. Data on 120 residents were collected. The dominant illness trajectory, found in 78% of residents, was prolonged gradual decline. The majority of residents (67%) had two or more long-term conditions. Overall, 74% had dementia. Only 11% of residents died in hospital; of these, most died within 1 week of admission. Interventions to improve palliative care in care homes need to be modelled on the needs of residents who experience prolonged gradual decline characterised by frailty, dementia, multimorbidity and an uncertain prognosis.

Cost-effectiveness of a specialised medium secure personality disorder service

IntroductionThe Oswin unit located in the North East of England is commissioned primarily for offenders screened on the offender personality disorder (OPD) pathway based on measures of personality disorder being linked to moderate to high risks to other persons.ObjectivesThe Oswin Unit was re-designed in early 2014 meeting commissioning specifications to meet objectives based on access, measuring quality and reducing. The primary objective of this pathway is to ensure personality Disorder offenders have access to “community-to-community”, joint-up care and monitoring of risks. The Oswin unit implemented a re-designed service offering individuals formulation based assessments and risk management embedded in the OPD pathway. The overall objective of this project is to evaluate the effectiveness and risk amelioration of this hospital-based service.AimAs part of a broader service development and evaluation project, the cost-effectiveness of the current model of the unit was compared to that of the unit prior to the redesign of the service.MethodCollection of data on number of admission and length of stay and calculation of expenses per capita. Retrospective analysis of costs of care.ResultsAnalysis of comparative figures post-implementation of this new model of care found 41% more episodes of care. Cost-analysis indicated a saving of £200,000.ConclusionThe new Oswin Model meets commissioning objectives in offering access to hospital-based care and focused treatments for prisoners ‘stuck’ in prison pathways. This finding led to further investigation using thematic measures of quality of care to evaluate the effectiveness of this service and risk amelioration.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Urban transportation: innovations in infrastructure planning and development

PurposeNew services design and development are difficult to plan, execute, measure and evaluate. Particularly, new services that are capital-intensive and involve a long gestation and development time are considered extremely risky. The purpose of this paper is to discuss a list of innovative practices in various managerial aspects in designing, planning and development of a large scale infrastructure intensive public transportation service. A contemporary new public transportation service development is discussed as evidence of proven and benchmarked criteria.Design/methodology/approachThis is a technical paper, where theoretical foundations of best practices in new service development project are discussed and supported by practice-based evidences from a real-life urban transportation project. A case study approach is adopted with secondary data.FindingsWorldwide during and after economic recession of 2008, several projects were stalled or abandoned. The inference through this work is that through efficient management practices, a large capital-intensive new service development project can be made successful even during a turbulent economy in a region marred by more challenges than elsewhere.Practical implicationsSeveral issues in large scale services development, such as urban transportation are domain specific. Some of the issues faced in urban transportation are common to several Gulf countries; therefore the policy guidelines, managerial practices and development strategies reported in this paper can be replicated in many of them. The commercial impact of the service project is a significant drive towards fuel conservation and to save huge amounts of productive time.Social implicationsPublic transportation with a high quality of networked service improves the quality of life to a large extent. Unless certain measurable demands are not met, an affluent society is less likely to endorse public transportation. In addition, endorsement of public transportation is been promoted in several parts of the world as a drive towards a green, energy efficient, low-carbon emission and sustainable environment.Originality/valueTo the best of the authors’ knowledge, new services planning and development is a key operations management topic, on which very little is written about. Particularly no other paper has presented a real-world large scale infrastructure intensive project development to this detail, and along with a theoretical background to benchmark performance and development practices.

Airway trolley in the Emergency Department – A service development project case report

Background: Hamad General Hospital (HGH) houses the main Emergency Department (ED) in Qatar. This busy ED has a 27 bedded resuscitation area. Within a 24 hour period there could be any number between 1 to 10 cases that needed emergency or urgent intubation. Over the years, there has been multiple addition of new life saving devices to the resuscitation areas. All these devices add to the clutter of the already crowded resuscitation area, and may indirectly add to the chaos and occupational risk typically seen in a busy environment. Methods: We aim to develop an airway trolley (by re-cycling available parts in the hospital) which can accommodate all standard airway equipment and all of our current difficult airway devices – Glidoscope, Stortz CMAC video laryngoscope and Stortz Flexible Intubating Video Endoscope. Results: We created a robust and easy to clean trolley, with ample of work platform and storage spaces within easy reach. At the same time it is also small and mobile enough to tolerate our narrow resuscitation room floor space. It has multiple power sockets to charge all of the video intubating devices, and its main power cord is long enough to reach any wall socket without significantly obstructing medical staff movements. Conclusion: With the help of the Engineering Department, we managed to create an airway trolley that fulfills our exact requirement more than what we can find in the current medical equipment market. At the same time we also declutter our busy ED resuscitation room.

Evaluation of the safety and efficacy of same-day discharge following outpatient surgery in a US hospital.

In the US, safe and effective same-day discharge of patients, following uncomplicated, ambulatory surgery, also referred to as outpatient surgery, significantly reduces the nursing hours spent caring for patients who do not require hospital admission. Data from the last three decades show that same-day discharge for patients who undergo approved outpatient surgical procedures carries no higher risk of complications than for those who stay for 24-hour observation. This article describes a service development project which evaluated patients' perceived preparedness for same-day discharge. Results suggest that a standardised approach to managing potential complicating factors, such as pain and patients' expectations, can increase the number of successful same-day discharges. The terms outpatient and ambulatory are used interchangeably in the article, and refer to surgical procedures for which inpatient admission is not considered necessary by patients' insurance providers.

Is the introduction of a named midwife for teenagers associated with improved outcomes? A service development project

Background: The role of named midwife for teenagers was implemented in Royal Surrey County Hospital NHS Foundation Trust in order to improve outcomes for teenage mothers and their babies. The role comprised a dedicated midwife-led teenage antenatal clinic, antenatal and postnatal home visits and tailored antenatal education. Aims: This project monitored the outcomes of teenage mothers following implementation of the role, to assess improvements in outcomes. Methods: During this service development project, 31 teenage mothers aged ≤ 19 years received midwifery care and their obstetric outcomes were monitored. These outcomes were compared with 52 teenage mothers who had previously given birth. Findings: Comparing teenagers who gave birth in February–August 2014 with those who gave birth in the same period in 2013, there was an increase in the rate of spontaneous vaginal deliveries, a decrease in instrumental deliveries and increase in induction of labour; however, induction of labour for intrauterine growth restriction decreased. The rate of caesarean section increased but remained lower than in the general population. An increase in birth weight and intention to breastfeed were also observed. Conclusions: This project indicates that the role of a dedicated midwife for teenagers has a place in the care of teenage mothers.

Clinical psychologists training and supervising IAPT therapists to work with long-term conditions and medically unexplained symptoms: A service development project

An IAPT service and a clinical health psychology team piloted a service development providing Step 2 and Step 3 services for individuals with long-term health conditions. Results indicate that such services may be offered with access to specialist training and supervision.

Improving mental and physical healthcare for older adults: An inpatient service development project by frontline staff

The complexities of working in older adults services where clients often experience co-morbid conditions can highlight the necessity for collaborative working between physical and mental healthcare providers. Three older adult mental and physical health wards based in a psychiatric and community hospital started a collaborative service development project to improve holistic patient care. This article discusses how providing staff with the authority and autonomy to make organisational changes can have a positive impact for patients, staff and the trust.

PTU-333 Clostridium difficile infection rate of recurrence is lower, and mortality is higher, in a large teaching hospital trust than in clinical trials: a prospective observational study

Introduction Clostridium difficile infection (CDI) is the most common nosocomial infection in the United Kingdom. New treatments have shown reduction in CDI recurrence in clinical trials. Their high cost has been justified by savings on treatment of recurrence and reduction in financial penalties. However, in such a sick group of patients with multiple comorbidities recruitment rates to clinical trials are typically very low. A service development project was initiated to assess the current local burden of CDI and rates of recurrence. Method For one year, between 30 th October 2013 and 2014, all samples tested positive for C. difficile toxin production (Techlab Toxin AB Quikcheck) in the Microbiology department of Nottingham University Hospitals NHS Trust (NUH) were identified. Baseline age, leukocyte count, CRP, albumin and creatinine were recorded as well as use of proton pump inhibitors or other antibiotics if treatment was initiated by NUH. The main outcome measure was CDI recurrence within 6 months, with a particular focus on those treated by, and re-presenting to, NUH. At time of submission 6-month data is available for most cases with 3-month data available for all. In April 2014 the Trust adopted the use of Fidaxomicin for recurrent cases of CDI and for those receiving concomitant antibiotic treatment. Results After exclusion of samples sent during the same episode ( nd recurrence, all of whom had been treated with Fidaxomicin on 1 st recurrence. 15 others received Fidaxomicin, 9 of whom had not responded to other treatment or recurred. There was no clear predictor of likelihood of recurrence. 32/121 patients died within 6 months of CDI (26%), of whom 23 died within 3 months (19%). Conclusion CDI recurrence rates in medically treated patients were much lower than that reported for standard therapy in previous clinical trials (25%). Mortality in the medically treated group was much higher than in trials (6–7%) but similar to previous observational studies, reflecting under-representation of very sick patients in clinical trials. Treatment guidelines should recognise this limitation when applying clinical trial results to their patient population. Disclosure of interest V. Wilkinson-Smith: None Declared, L. Koay: None Declared, T. Hills: None Declared, M. Diggle: None Declared, G. Major: None Declared, R. Spiller Grant/ Research Support from: Lesaffre, Ironwood, Norgine, Falk Pharma, Consultant for: Almirall, Astellas, Yuhan, Danone.

P108. Introducing PROMs to the Royal Devon & Exeter Hospital: A service development project

P108. Introducing PROMs to the Royal Devon & Exeter Hospital: A service development project