West of England Academic Health Science Network

Background:There is significant unmet need for effective and efficiently delivered care for people with Parkinson’s disease (PwP). We undertook a service improvement initiative to co-develop and implement a new care pathway, Home Based Care (HBC), based on supported self-management, remote monitoring and the ability to trigger a healthcare contact when needed.Objective:To evaluate feasibility, acceptability and safety of Home Based Care.Methods:We evaluated data from the first 100 patients on HBC for 6 months. Patient monitoring, performed at baseline and 6-monthly, comprised motor (MDS-UPDRS II and accelerometer), non-motor (NMSQ, PDSS-2, HADS) and quality of life (PDQ) measures. Care quality was audited against Parkinson’s UK national audit standards. Process measures captured feasibility. Acceptability was assessed using a mixed-methods approach comprising questionnaires and semi-structured interviews.Results:Between October 2019 and January 2021, 108 PwP were enrolled onto HBC, with data from 100 being available at 6 months. Over 90% of all questionnaires were returned, 97% were complete or had < 3 missing items. Reporting and communications occurred within agreed timeframes. Compared with baseline, after 6m on HBC, PD symptoms were stable; more PwP felt listened to (90% vs. 79%) and able to seek help (79% vs. 68%). HBC met 93% of national audit criteria. Key themes from the interviews included autonomy and empowerment.Conclusions:We have demonstrated acceptability, feasibility and safety of our novel remotely delivered Parkinson’s care pathway. Ensuring scalability will widen its reach and realize its benefits for underserved communities, enabling formal comparisons with standard care and cost-effectiveness evaluation.

BackgroundUrgent and emergency care health services are overburdened, and the use of these services by acutely ill infants and children is increasing. A large proportion of these visits could be sufficiently addressed by other health care professionals. Uncertainty about the severity of a child’s symptoms is one of many factors that play a role in parents’ decisions to take their children to emergency services, demonstrating the need for improved support for health literacy. Digital interventions are a potential tool to improve parents’ knowledge, confidence, and self-efficacy at managing acute childhood illness. However, existing systematic reviews related to this topic need to be updated and expanded to provide a contemporary review of the impact, usability, and limitations of these solutions.ObjectiveThe purpose of this systematic review protocol is to present the method for an evaluation of the impact, usability, and limitations of different types of digital educational interventions to support parents caring for acutely ill children at home.MethodsThe review will be structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and Population, Intervention, Comparator, and Outcome (PICO) frameworks. Five databases will be systematically searched for studies published in English during and after 2014: Medline, EMBASE, CINAHL, APA PsycNet, and Web of Science. Two reviewers will independently screen references’ titles and abstracts, select studies for inclusion based on the eligibility criteria, and extract the data into a standardized form. Any disagreements will be discussed and resolved by a third reviewer if necessary. Risk of bias of all studies will be assessed using the Mixed-Methods Appraisal Tool (MMAT), and a descriptive analysis will be used to evaluate the outcomes reported.ResultsThe systematic review will commence during 2021.ConclusionsThis systematic review will summarize the impact, usability, and limitations of digital interventions for parents with acutely ill children. It will provide an overview of the field; identify reported impacts on health and behavioral outcomes as well as parental knowledge, satisfaction, and decision making; and identify the factors that affect use to help inform the development of more effective and sustainable interventions.International Registered Report Identifier (IRRID)PRR1-10.2196/27504

Abstract Background: COVID-19 is an infectious disease, typically characterised by a dry cough, shortness of breath, fever, fatigue, and/or loss of taste and smell. National Early Warning Scores (NEWS2) are used to detect deterioration in hospital and out-of-hospital settings. The Royal College of Physicians (RCP) recommend NEWS2 for management of COVID-19 patients, but there is little evidence to support this.Aim: To investigate the relationship between NEWS2 values (and component scores) and hospital mortality in hospitalised COVID-19 patients in the West-of-England.Methods: Electronically recorded, routinely collected, observational physiological measurements (e.g. pulse, temperature, etc) were collated on all adult patients in participating hospitals between March and June 2020. First and maximum NEWS2 values, and their component scores, were calculated from the physiological measurements. Mortality status was presented by first and maximum NEWS2 and component scores, and areas under the curve (AUC) for 2, 7 and 30-day mortality were calculated.Results: Of 1,263 patients, 26% died during their hospital admission, 7% were admitted to ICU and subsequently discharged from hospital, and 67% were discharged without ICU.Most patients had low first NEWS2 values: 50% NEWS2=0-2, 27% NEWS2=3-4, 14% NEWS2=5-6, and 9% NEWS2=7+. However, many patients had a high maximum score: 14% NEWS2=0-2, 22% NEWS2=3-4, 17% NEWS2=5-6, and 47% NEWS2=7+. Patients with higher first and maximum scores were more likely to die, require ICU admission, and have longer length of stay. The AUCs for 2-day, 7-day and 30-day mortality were 0.77, 0.70 and 0.65, respectively. An increase in most first and maximum component scores were associated with an increased risk of mortality.Conclusion: NEWS2 is a reasonably good predictor of short-term mortality in this population, and the respiratory components are of the most value individually. These findings support the RCP’s recommendations to use NEWS2, alongside clinical judgement, in the assessment of COVID-19 patients.

BackgroundThe National Early Warning Score (NEWS) was introduced to standardise early warning scores (EWS) in England. It has been recommended that NEWS should be used in pre-hospital care but there is no published evidence that this improves outcomes. In 2015, the West of England Academic Health Science Network region standardised to NEWS across all healthcare settings. Calculation of NEWS was recommended for acutely unwell patients at referral into secondary care.AimTo evaluate whether implementation of NEWS across a healthcare system affects outcomes, specifically addressing the effect on mortality in patients with suspicion of sepsis (SOS).Design and settingA quality improvement project undertaken across the West of England from March 2015 to March 2019, with the aim of standardising to NEWS in secondary care and introducing NEWS into community and primary care.MethodData from the national dashboard for SOS for the West of England were examined over time and compared to the rest of England. Quality improvement methodology and statistical process control charts were used to measure improvement.ResultsThere was a reduction in mortality in the SOS cohort in the West of England, which was not seen in the rest of England over the time period of the project. Admissions did not increase. By March 2019, the West of England had the lowest mortality in the SOS cohort in England.ConclusionTo the authors’ knowledge, this is the first study demonstrating that use of NEWS in pre-hospital care is associated with improved outcomes in patients with SOS.

Surgery to stabilise my spine sorted the pain and power was restored to my leg. I was re-admitted feeling vaguely unwell and with a CRP of 600, but that had returned to normal and I arrived home, admittedly with a PICC line in place, but relishing the peace and the contrast to a busy Nightingale Ward. A few hours later I was deeply asleep, but suddenly woke with a profound feeling of doom. My husband called 999 saying something had happened but I was not making sense. Within minutes an ambulance crew were running into our house and, blue lights flashing, I was transferred to hospital. I remember doors swinging as the F1 ran onto the ward, but this was followed by a very disjointed conversation when I kept saying ‘I feel really, really ill’ and …

The purpose of this study was to determine any benefit from a discharge transfer of care service from hospital to community pharmacy. A cross-sectional cohort design was used to compare actioned and non-actioned transfers of care. Of the 1130 transfers of care referrals to pharmacies in 2017, 365 patients received an actioned community pharmacy service after discharge. The 30-day readmission rate was 8.5% (31/365) in those who received an actioned community pharmacist service compared to 23.3% (178/765) in those who did not. Odds ratio for readmission at 30days was 3.26 (95% CI 2.04 to 4.59, P<0.0001), significantly higher in those not receiving an actioned transfer of care service. Involving community pharmacy at patient discharge appears to contribute to lower rates of readmission.

Mental health difficulties are the norm in diabetes not the exception.1 They span from dementia and depression to anxiety and addictions, and of course diabetes distress and diabulimia. All mental illnesses can negatively affect a person’s ability to self-manage and self-management is the central tenet of diabetes care. It is not surprising then, to learn that addressing mental health difficulties not only improves mental health outcomes but diabetes outcomes too.2 We need to embed and integrate mental health care into the entire diabetes care pathway. But in diabetes commissioning, mental health is usually an afterthought and often seen as a ‘nice to have’ part of the pathway rather than an integral component. Can we really afford to leave it there? The Too Often Missing report1 is an extensive survey of people with diabetes (PWD), GPs, and other professionals about mental health and wellbeing in diabetes. It found that 70% of PWD feel overwhelmed by the demands of their condition. Of these, three-quarters said that their self-management was affected by their emotional struggle and three-quarters felt that they could not access the specialist mental health support they needed. The report also found that healthcare professionals often lack confidence in raising the issue of mental health and wellbeing with PWD and so they avoid it.1 In particular, they struggle to support people who are not engaged with their management plan (often referred to as ‘non-adherent’ or ‘non-compliant’) and they are concerned …

Objective‘Core information sets’ (CISs) represent baseline information, agreed by patients and professionals, to stimulate individualised patient-centred discussions. This study developed a CIS for use before colorectal cancer (CRC) surgery.DesignThree phase consensus study: (1) Systematic literature reviews and patient interviews to identify potential information of importance to patients, (2) UK national Delphi survey of patients and professionals to rate the importance of the information, (3) international consensus meeting to agree on the final CIS.SettingUK CRC centres.ParticipantsPurposive sampling was conducted to ensure CRC centre representation based upon geographical region and caseload volume. Responses were received from 63/81 (78%) centres (90 professionals). Adult patients who had undergone CRC surgery were eligible, and purposive sampling was conducted to ensure representation based on age, sex and cancer location (rectum, left and right colon). Responses were received from 97/267 (35%) patients with a wide age range (29–87), equal sex ratio and cancer location. Attendees of the international Tripartite Colorectal Conference were eligible for the consensus meeting.OutcomesPhase 1: Information of potential importance to patients was extracted verbatim and operationalised into a Delphi questionnaire. Phase 2: Patients and professionals rated the importance information on a 9-point Likert scale, and resurveyed following group feedback. Information rated of low importance were discarded using predefined criteria. Phase 3: A modified nominal group technique was used to gain final consensus in separate consensus meetings with patients and professionals.ResultsData sources identified 1216 pieces of information that informed a 98-item questionnaire. Analysis led to 50 and 23 information domains being retained after the first and second surveys, respectively. The final CIS included 11 concepts including specific surgical complications, short and long-term survival, disease recurrence, stoma and quality of life issues.ConclusionsThis study has established a CIS for professionals to discuss with patients before CRC surgery.

BackgroundQuality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.MethodWe searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.ResultsOf the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.ConclusionsQICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.