Research Project “what are the factors that cause unplanned admission for patients in receipt of Poole Intermediate Care Service ” Pilot Study Dawne Garrett Consultant Nurse Intermediate Care Intermediate Care Bournemouth and Poole Teaching Primary Care Trust

What is PICS Poole Intermediate Care Service provides admission avoidance and enhanced discharge. It is an integrated team which has built on the successes of a partnerships for older people project involving the local community. PICS sits within a wide variety of well developed intermediate care services. Poole Intermediate Care Service provides admission avoidance and enhanced discharge. It is an integrated team which has built on the successes of a partnerships for older people project involving the local community. PICS sits within a wide variety of well developed intermediate care services.

Admission Avoidance The admission avoidance arm of the service offers locality based The admission avoidance arm of the service offers locality based Assessment by a registered nurse or social worker within 2-4 hours. Assessment by a registered nurse or social worker within 2-4 hours. A Rapid Access Clinical Examination Clinic A Rapid Access Clinical Examination Clinic Monday –Friday Consultant Visits Monday –Friday Consultant Visits Dedicated Intermediate Care Assistants Dedicated Intermediate Care Assistants

The Hunch Some patients, despite intensive support by the PICS service, had emergency admissions to the acute trust. The study aims to investigate the factors that cause this in order to develop a tool to assist assessment. Some patients, despite intensive support by the PICS service, had emergency admissions to the acute trust. The study aims to investigate the factors that cause this in order to develop a tool to assist assessment.

Protocol Literature review and initial focus group with staff Literature review and initial focus group with staff Identification of patients through the weekly virtual ward rounds. Identification of patients through the weekly virtual ward rounds. Coded case note review-prior to admission and following discharge Coded case note review-prior to admission and following discharge Qualitative interviews with patients, carers and staff one month post discharge Qualitative interviews with patients, carers and staff one month post discharge Data analysis - identification of key factors Data analysis - identification of key factors Further study to resolve or ameliorate factors which cause unplanned admissions Further study to resolve or ameliorate factors which cause unplanned admissions

Early Protocol. Identify patients who have unplanned emergency admissions at MDT Case note review to code factors Identify potential factors Qualitative interviews with patients, staff and significant others Data Analysis Literature review & staff focus group Unplanned admission screening tool

Limitations Local Service Local Service Local Population Local Population Unable to interview patients researcher has had personal involvement with Unable to interview patients researcher has had personal involvement with Vulnerable participants Vulnerable participants Time / funding available for research Time / funding available for research

Time Span 12 months data collection 12 months data collection Researchers Researchers Myself Myself Consultant Geriatrician – acute notes review Consultant Geriatrician – acute notes review

Initial Qualitative Findings Sample Sample A convenience sample was selected. 20 people took part in the study. Identification of patients was through the weekly virtual ward rounds. The patient and carers were invited by letter to take part in the study and then followed up by the principle investigator to confirm their participation. Staff who were involved with the patient were also invited to a separate focus group or individual interview. A convenience sample was selected. 20 people took part in the study. Identification of patients was through the weekly virtual ward rounds. The patient and carers were invited by letter to take part in the study and then followed up by the principle investigator to confirm their participation. Staff who were involved with the patient were also invited to a separate focus group or individual interview.

Interviews Interviews took place in the patients/carers own home or in NHS premises for staff. The interviews were tape recorded and transcribed verbatim. Interviews took place in the patients/carers own home or in NHS premises for staff. The interviews were tape recorded and transcribed verbatim.

Data Analysis The data was coded and categorised for emergent themes. Due to the principle investigators familiarity with the service the codes were analysed by two independent health care researchers to check interpretation and confirm categories. Through an iterative process the final categories emerged. The data was coded and categorised for emergent themes. Due to the principle investigators familiarity with the service the codes were analysed by two independent health care researchers to check interpretation and confirm categories. Through an iterative process the final categories emerged.

Findings- 11 Catergories Having Confidence- the art of the possible Capacity of the service Capacity of the service Patients/carers beliefs and values Patients/carers beliefs and values Quality of clinical assessment Quality of clinical assessment Education for family Education for family

Findings -cont Having a transparent pathway Having a transparent pathway Symptom Control Symptom Control Protecting home life Protecting home life Family fatigue Family fatigue Planning for the worst not the best Planning for the worst not the best Trying to make a home a hospital Trying to make a home a hospital

Expected Findings Family fatigue Family fatigue Capacity of the service Capacity of the service Quality of Assessment Quality of Assessment Symptom control Symptom control

Less expected Having Confidence- the art of the possible Having Confidence- the art of the possible “Yes, they took advice. They trusted us on – I think this is the concern with these three and they are lovely but not everybody can be turned around in hours”

Protecting home life “I think it’s better without an audience because then you can talk to the patient and they respond better when it’s ‘one-to- one’ rather than a whole group of people together. Not only that but there’s their privacy. It’s not right with the neighbour…..” “I think it’s better without an audience because then you can talk to the patient and they respond better when it’s ‘one-to- one’ rather than a whole group of people together. Not only that but there’s their privacy. It’s not right with the neighbour…..”

Planning for the worst not the best “you can’t account for everybody who’s going to drop down dead but you can try and do it where you have a predictable illness.”

Patients/carers beliefs and values “Well, as I said, I couldn’t cope at all but the doctor came in. It was too much toing and froing at that time. We’ve got two daughters bumbling about trying to help, the PICS Team and then the doctor would roll up.” “Well, as I said, I couldn’t cope at all but the doctor came in. It was too much toing and froing at that time. We’ve got two daughters bumbling about trying to help, the PICS Team and then the doctor would roll up.”

Education for family “Also, they just let the husband put a lump of wood under her back because a slide sheet had come in and obviously they’d put the sheet the wrong way round and he put a lump of wood underneath to keep the slide sheet in place. I sort of had to say ‘No’ and not to use the slide sheet without being shown how to use it. They had it the wrong way round.” “Also, they just let the husband put a lump of wood under her back because a slide sheet had come in and obviously they’d put the sheet the wrong way round and he put a lump of wood underneath to keep the slide sheet in place. I sort of had to say ‘No’ and not to use the slide sheet without being shown how to use it. They had it the wrong way round.”

Trying to make a home a hospital “Mr P reported that she had very poor fluid intake despite encouragement and assistance from himself. I suggested that we keep a fluid chart and left him a piece of paper for them to record everything. I suggested that they use straws and beakers to make it easier for her to drink.” “Mr P reported that she had very poor fluid intake despite encouragement and assistance from himself. I suggested that we keep a fluid chart and left him a piece of paper for them to record everything. I suggested that they use straws and beakers to make it easier for her to drink.”

Having a transparent pathway Ah, no, X was going to go and see her but the GP went and the GP went instead and the GP admitted her which is why she went in really which is disappointing. I don’t know if X had managed to get hold of the GP or not. I mean X knew the GP was going. Therefore, she felt there was no point in her going as well but when the GP went he admitted her and probably if he hadn’t gone, X might have looked at the blood results and we could have treated her and kept her at home. Ah, no, X was going to go and see her but the GP went and the GP went instead and the GP admitted her which is why she went in really which is disappointing. I don’t know if X had managed to get hold of the GP or not. I mean X knew the GP was going. Therefore, she felt there was no point in her going as well but when the GP went he admitted her and probably if he hadn’t gone, X might have looked at the blood results and we could have treated her and kept her at home.

Quantitive Findings Currently being examined Currently being examined

Questions