One chance to get it right: improving clinical handovers for better symptom control at the end of life

Poor communication contributes to morbidity and mortality, not only in general medical care but also at the end oflife. This leads to issues relating to symptom control and quality of care. As part of an international project focused on bereaved relatives’ perceptions about quality of end-of-life care, we undertook a quality improvement (QI) project in a general hospital in Córdoba city, Argentina.By using two iterative QI cycles, we launched an educational process and introduced a clinical mnemonic tool, I-PASS, during ward handovers. The introduction of the handover tool was intended to improve out-of-hours care.Our clinical outcome measure was ensuring comfort in at least 60% of dying patients, as perceived by family carers, during night shifts in an oncology ward during the project period (March–May 2019). As process-based measures, we selected the proportion of staff completing the I-PASS course (target 60%) and using I-PASS in at least 60% of handovers. Participatory action research was the chosen method.During the study period, 13/16 dying patients were included. We received 23 reports from family carers about the level of patient comfort during the previous night.Sixty-five per cent of healthcare professionals completed the I-PASS training. The percentage of completed handovers increased from 60% in the first Plan-Do-Study-Act (PDSA) cycle to 68% in the second one.The proportion of positive reports about patient comfort increased from 63% (end of the first PDSA cycle) to 87% (last iterative analysis after 3 months). Moreover, positive responses to ‘Did doctors and nurses do enough for the patient to be comfortable during the night?’ increased from 75% to 100% between the first and the second QI cycle.In conclusion, we achieved the successful introduction and staff training for use of the I-PASS tool. This led to improved perceptions by family carers, about comfort for dying patients.

The implementation of the nationwide out-of-hours phone number 1733 in Belgium: analysis of efficiency and safety

Background: Belgium has a problem with inappropriate use of emergency services. The government installed the number 1733 for out-of-hours care. Through a dry run test, we learned that 30% of all calls were allocated to the protocol ‘unclear problem’. In only 11.9% of all cases, there was an unclear problem. Methods: The study aimed to determine whether the adjusted protocol ‘unwell for no clear reason’ led to a safer and more efficient referral and to evaluate the efficiency and safety of the primary care protocols (PCPs). The study ran in cross-sectional design involving patients, General Practitioner Cooperatives and telephone operators. A random sample of calls to 1733 and patient referrals were assessed on efficiency and safety. Results: During 6 months in 2018, 11 622 calls to 1733 were registered. Seven hundred fifty-six of them were allocated to ‘unwell for no clear reason’, and a random sample of 180 calls was audited. To evaluate the PCPs, 202 calls were audited. The efficiency and safety of the protocol ‘unwell for no clear reason’ improved, and safety levels for under- and over-triage were not exceeded. The GP’s judged that 9/10 of all patient encounters were correctly referred. Conclusion: This study demonstrated that the 1733-telephone triage system for out-of-hours care is successful if protocols, flow charts and emergency levels are well defined, monitored and operators are trained.

Bronchiolitis: treatment and management in an urgent out of hours care setting

Justine Dexter and Gerri Mortimore explore ways to manage the common lung infection bronchiolitis in small children Bronchiolitis is an acute inflammation of the bronchioles that predominately affects children but is most common in the first 12 months of life. Viral bronchiolitis is the principal cause of admission in England and Wales, with numbers exceeding 30 000 annually. Occurrence is seasonal, in winter months incidence is typically at epidemic proportions for approximately six weeks. Bronchiolitis presents initially with coryza and a persistent cough; as the infection progresses, tachypnoea, chest recession, or both, may be present alongside wheeze or crackles. The assessment of an unwell child is challenging and as an advanced nurse practitioner, working in an out of hours service, the importance to prevent further deterioration should focus on spotting the sick child at an early stage. Therefore, an initial assessment should be undertaken, prior to taking a history and examination, to ensure patient safety. Bronchiolitis is usually a self-limiting illness, that requires supportive management only with treatment directed at fluid input. However, management approaches to bronchiolitis continue to be a subject of substantial debate with vast differences in practice exhibited in the UK, and beyond. with a lack of consensus regarding management. Therefore, the appropriate management of children presenting with bronchiolitis is challenging and can be overwhelming. Nurses must be aware of the pathophysiology, presentation, diagnosis, and management of children presenting to an out of hours service with bronchiolitis, to manage patients safely.

The implementation of the nationwide out of hours phone number 1733. Analysis of efficiency and safety.

Background In Belgium there is a problem with improper use of emergency services. The government installed an emergency number 1733 for out of hours care. Through a dry run test we learned that 10% of all calls were allocated to the protocol ‘unclear problem’. In only 10% of all cases, there was indeed an unclear problem.Methods This study aimed to determine whether the adjusted protocol ‘unwell for no clear reason’ led to a safer and more efficient referral and to evaluate the efficiency and safety of the specific primary care protocols. The study was performed in a retrospective and prospective design and involved the community, patients, General Practitioner Cooperatives, emergency departments and telephone operators.Results During 6 months in 2018, 11622 calls to 1733 were registered. 756 of these calls were allocated to ‘unwell for no clear reason’. A random sample of 180 calls was re-listened. The efficiency and safety of the protocol ‘unwell for no clear reason’ improved. The safety levels for under- and over-triage were not exceeded. The GP’s on duty judged that 9/10 of all patient encounters were correctly allocated. In less than 1% of all referrals, there was an under-triage.Conclusion This study demonstrated that the implementation of a 1733-operating system to triage patients to an adequate care level is successful if protocols, flow charts and care levels are well defined and operators well trained.

Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care

BackgroundElectronic care coordination systems, known as the Key Information Summary (KIS) in Scotland, enable the creation of shared electronic records available across healthcare settings. A KIS provides clinicians with essential information to guide decision making for people likely to need emergency or out-of-hours care.AimTo estimate the proportion of people with an advanced progressive illness with a KIS by the time of death, to examine when planning information is documented, and suggest improvements for electronic care coordination systems.Design and settingThis was a mixed-methods study involving 18 diverse general practices in Scotland.MethodRetrospective review of medical records of patients who died in 2017, and semi-structured interviews with healthcare professionals were conducted.ResultsData on 1304 decedents were collected. Of those with an advanced progressive illness (79%, n = 1034), 69% (n = 712) had a KIS. These were started a median of 45 weeks before death. People with cancer were most likely to have a KIS (80%, n = 288), and those with organ failure least likely (47%, n = 125). Overall, 68% (n = 482) of KIS included resuscitation status and 55% (n = 390) preferred place of care. People with a KIS were more likely to die in the community compared to those without one (61% versus 30%). Most KIS were considered useful/highly useful. Up-to-date free-text information within the KIS was valued highly.ConclusionIn Scotland, most people with an advanced progressive illness have an electronic care coordination record by the time of death. This is an achievement. To improve further, better informal carer information, regular updating, and a focus on generating a KIS for people with organ failure is warranted.

Self-triage at an urgent care collaboration with and without information campaign

Background: Patients in Belgium needing out-of-hours care have two options: the emergency department (ED) or the general practitioner on call. The latter is often organized in a General Practice Cooperative (GPC). At the ED, there is an overload of patients who could be helped more efficiently by the GPC. Research question: What is the proportion of patients switching from the ED to the GPC (called voluntary switchers) with and without an information campaign? What are the characteristics of these patients?Methods: Single-center prospective intervention trial during the opening hours of the GPC (only weekends: Friday 7.00 pm to Monday 7.00 am). The first 10 weekends there was no intervention. The next 24 weekends, patients in the ED were informed about the out-of-hours care in Belgium. The information contained several topics: characteristics of both services, where to go using examples, practicalities, and costs. This information was distributed through leaflets and broadcasted on a screen in five languages.Results: During the study period, 7,453 patients entered the ED of which 330 are voluntary switchers. The proportion of voluntary switchers was 1.7 percent before and 5.4 percent after the intervention (p 0.01). This effect remained stable for 10 more months after the study. The average number of patients presenting at the ED per hour was 3.1, whereas on hours with voluntary switchers was 5.1 (p 0.01). The age distribution and epidemiological profile of the voluntary switchers resembles the one of primary care patients. The general practicioners (GPs) referred 6 percent of the voluntary switchers back to the ED.Conclusion: Co-location of the GPC and the ED and informing patients is a meaningful step toward a more profound collaboration.

OP4 Accessing unplanned and emergency health services – experiences of asylum seekers, refused asylum seekers and refugees living in wales

BackgroundNumbers of asylum seekers and refugees living in Wales have increased sharply. Many are liable to have unmet health needs and difficulty accessing services. We investigated the experience of, and access to, unplanned and emergency health services by asylum seekers, refugees and those refused asylum living in Wales.MethodWe surveyed 210 asylum seekers, refused asylum seekers and refugees and conducted eight focus groups with 57 participants (with interpreters present when necessary) to explore experiences. We used descriptive statistics to analyse survey data and framework analyses to analyse interview data.ResultsSurvey data showed awareness of unscheduled health services was mixed. Best known was the 999 ambulance service (72% reportedly had heard of and could contact this outside daytime hours). NHS111 was familiar to 36% but just a quarter (26%) had heard of and could contact GP out-of-hours services. Fewer than half of respondents (44%) knew of the Emergency Department. 26% reported using a health service out-of-hours. Focus group respondents with little English reported difficulty explaining their health needs, particularly in emergencies and when seeking telephone help through 999 and 111 calls. Others said they used emergency services if they did not know how to access routine and out-of-hours care or if they felt their efforts to see a GP did not resolve their problem.ConclusionLanguage barriers and poor knowledge of UK health systems mean asylum seekers, refused asylum seekers and refugees use emergency health services to meet needs which could be seen and treated in routine primary services. Language barriers using phone lines may also result in paramedic attendance or conveyance to Emergency Departments because health needs are not clearly identified. Better information and support may help this population access services which match their needs and support their health more effectively.