Research ProjectResearch Project“what are the factors that “what are the factors that

cause unplanned admission cause unplanned admission for patients in receipt of for patients in receipt of Poole Intermediate Care Poole Intermediate Care

Service ”Service ”Pilot StudyPilot StudyDawne GarrettDawne Garrett

Consultant NurseConsultant Nurse Intermediate CareIntermediate Care

Bournemouth and Poole Teaching Primary Care Bournemouth and Poole Teaching Primary Care TrustTrust

What is PICSWhat is PICS

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

Admission AvoidanceAdmission Avoidance

The admission avoidance arm of the The admission avoidance arm of the service offers locality based service offers locality based Assessment by a registered nurse or Assessment by a registered nurse or

social worker within 2-4 hours. social worker within 2-4 hours. A Rapid Access Clinical Examination A Rapid Access Clinical Examination

ClinicClinic Monday –FridayMonday –Friday Consultant VisitsConsultant Visits Dedicated Intermediate Care AssistantsDedicated Intermediate Care Assistants

The HunchThe Hunch

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

ProtocolProtocol Literature review and initial focus group Literature review and initial focus group

with staffwith staff Identification of patients through the Identification of patients through the

weekly virtual ward rounds.weekly virtual ward rounds. Coded case note review-prior to admission Coded case note review-prior to admission

and following dischargeand following discharge Qualitative interviews with patients, carers Qualitative interviews with patients, carers

and staff one month post dischargeand staff one month post discharge Data analysis - identification of key Data analysis - identification of key

factorsfactors Further study to resolve or ameliorate Further study to resolve or ameliorate

factors which cause unplanned admissionsfactors which cause unplanned admissions

Early ProtocolEarly Protocol

..

Identify patients who haveunplanned 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

LimitationsLimitations

Local ServiceLocal Service Local PopulationLocal Population Unable to interview patients Unable to interview patients

researcher has had personal researcher has had personal involvement withinvolvement with

Vulnerable participantsVulnerable participants Time / funding available for researchTime / funding available for research

Time Span Time Span

12 months data collection 12 months data collection ResearchersResearchers

MyselfMyself Consultant Geriatrician – acute notes Consultant Geriatrician – acute notes

reviewreview

Initial Qualitative FindingsInitial Qualitative Findings

SampleSample A convenience sample was selected. 20 A convenience sample was selected. 20

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

Interviews Interviews

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

Data AnalysisData Analysis

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

Findings- 11 CatergoriesFindings- 11 Catergories

Having Confidence- the art of the Having Confidence- the art of the possiblepossible

Capacity of the serviceCapacity of the service Patients/carers beliefs and valuesPatients/carers beliefs and values Quality of clinical assessmentQuality of clinical assessment Education for familyEducation for family

Findings -contFindings -cont

Having a transparent pathwayHaving a transparent pathway Symptom ControlSymptom Control Protecting home lifeProtecting home life Family fatigueFamily fatigue Planning for the worst not the bestPlanning for the worst not the best Trying to make a home a hospitalTrying to make a home a hospital

Expected FindingsExpected Findings

Family fatigueFamily fatigue Capacity of the serviceCapacity of the service Quality of AssessmentQuality of Assessment Symptom controlSymptom control

Less expected Less expected

Having Confidence- the art of the Having Confidence- the art of the possiblepossible

““Yes, they took advice. They trusted us Yes, they took advice. They trusted us on – I think this is the concern with on – I think this is the concern with these three and they are lovely but these three and they are lovely but not everybody can be turned around not everybody can be turned around in 24 - 48 hours”in 24 - 48 hours”

Protecting home lifeProtecting home life

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

Planning for the worst not the Planning for the worst not the bestbest

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

Patients/carers beliefs and Patients/carers beliefs and valuesvalues

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

Education for familyEducation for family

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

Trying to make a home a Trying to make a home a hospitalhospital

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

Having a transparent Having a transparent pathwaypathway

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

Quantitive FindingsQuantitive Findings

Currently being examinedCurrently being examined

QuestionsQuestions