The BMJ Awards 2018: InnovationBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1522 (Published 06 April 2018) Cite this as: BMJ 2018;361:k1522
Teaching videos and model arm
Many patients discharged from hospital continue to need antibiotic therapy delivered through a line in their arm, usually by a community nurse. “It’s quite a big and diverse group of patients,” says Emma Nickerson, consultant in infectious diseases at Addenbrooke’s Hospital in Cambridge. “It includes people who’ve had hip or knee implants that have become infected, those with abscesses or chronic lung conditions, some kidney infections, and people who’ve been in road traffic accidents and have metal implants. A quarter of that group develop infections.”
Access to community nurses is patchy, and it’s expensive, she says. So, she has extended the use of self administration, in which selected patients are taught to mix and administer their own antibiotics daily. The patients are seen once a week in the clinic, but for the rest of the time they are on their own.
Training was aided by the use of a model plastic arm, donated by Cambridge University clinical skills laboratory, on which patients could practise. Leaflets and videos were also produced. “It’s much more convenient for patients,” Nickerson says. “Typically, community nurses give a two to three hour window for their visits, so patients are trapped at home waiting. Self administration is much more convenient. They can go away for a weekend—it’s empowering.”
The project increased self administration by 70% and saved over £5m in the first year, when 212 patients were taught. Some needed antibiotics three times a day, which would have cost £260 if delivered by a nurse. Patients are delighted by it and become quite expert. “One patient we had taught came back to clinic and picked up on a nurse doing it wrong.”
Community HIV self testing
Brighton and Hove is home to an estimated 14 000 men who have sex with men, of whom 2500 have tested positive for HIV. That leaves 11 500 potentially needing a test, says Jaime Vera, senior lecturer in HIV medicine and honorary consultant in HIV medicine at Brighton and Sussex Medical School. “In 2016 about 4000 were tested through conventional services and third sector organisations. That leaves 7500 who need tests.”
The men are often reluctant to use mainstream services, he says. Self testing might reach those missing men, particularly if they could access kits from a vending machine in a place they frequent. The Brighton Sauna, visited by around 400 men a week, was one such place where staff were aware of high levels of sexual risk taking but low levels of engagement with outreach workers to discuss HIV testing.
After detailed discussions with the owner, users, and staff of the sauna, a bespoke vending machine was designed and installed in June 2017. “We wanted something that didn’t look very clinical,” Vera says. The machine delivers BioSure self test kits which, for the pilot scheme, were free in return for some basic information.
In the first six months 212 kits were accessed by men ranging in age from 18 to 70, 4% of whom had never tested before and 11% who had tested in the past five years. Uptake was greater than from community outreach workers at the venue. “We don’t know if the kits have actually been used, or what the results are,” he says, “but we’re working on a second generation kit with smart packaging that will tell us when it’s been opened.”
Transforming emergency workforce
Four years ago, says emergency department consultant Robert Galloway of Brighton and Sussex University Hospitals, life was dire. He’d promised his wife that after years of awkward rotas, long commutes, and difficult exams, things would get better when he became a consultant. They didn’t.
The problems were overwork, understaffing, inflexible rotas, and an unmanageable work-life balance. The trust was spending £1m a year on locum junior doctors. Morale was low and delays were long. The solution needed to be bold, and it was.
They worked out how many programmed activities (PAs) a year consultants and associate specialists were obliged to deliver under their contracts. Each PA was priced as four hours’ work in the day, three in the evenings, and two between midnight and 8 am. Staff were then invited to say when they wanted to work. The rotas were filled.
Immediately they had a work pattern that suited them. “I did lots of 4 pm to midnight shifts, because it fitted in with childcare. A colleague who goes to Africa every year for ten weeks as a missionary fitted all his PAs into the rest of the year. Why didn’t everybody just go for day shifts? Because hours worked at night count for twice as many PAs.”
It works, and it has made jobs at the emergency department popular. Recruitment is easier and staff retention better; no junior locums are needed; and patient care has improved. New clinical fellow jobs have been created, with a minimum 25% for non-clinical purposes. The system is catching on, thanks to low cost software built by HealthRota in collaboration with Galloway (https://healthrota.co.uk).
More and more older people are having operations, both emergency and elective, and tend to suffer more adverse outcomes, says Jugdeep Dhesi, consultant physician at Guy’s and St Thomas’ Hospital in London and clinical lead of the trust’s POPS team—proactive care of the older patient undergoing surgery.
“We hypothesised that involving a geriatrician in the clinical pathway and using a collaborative model of care would improve results,” she says. “We started in orthopaedic elective surgery and extended across other areas.” It was successful, but could that success be matched in a district general hospital?
The opportunity to find out came in a collaboration funded by the Acute Care Collaboration Vanguard programme with Darent Valley Hospital, run by Dartford and Gravesham NHS Trust. The principles of POPS, which include a comprehensive preoperative geriatric assessment and tailored postoperative care, were applied, first for vascular surgery and, from June 2017, for general surgery.
Geriatric review went up from 20% to 100% for patients over 70 having emergency laparotomies, and 30 day readmission rates for general surgery fell from 30% to 16.6%. “We have shown that POPS can be effective anywhere, and that it is cost neutral, with the extra costs balanced by savings from reduced length of stay, readmissions, cancellations, and better coding,” she says. “Over the course of the implementation, three patient events have been held, and the feedback has been enthusiastic and appreciative. More than that, patients have helped develop and improve the service, for example in the design of leaflets.”
Hospital at home
When elderly or frail people are admitted to hospital, they often get worse. So, providing specialist care at home is attractive, if circumstances are right. In Midlothian, a semi-rural community south of Edinburgh, a rapid response team had been in operation for years, but a new Integrated Health and Social Care Partnership scheme offered a chance to extend the service in 2014 by adding a consultant geriatrician to the team and raising its ambitions to provide a “hospital at home.”
“We’re not the first or the biggest such service,” says Patricia Cantley, consultant physician at Midlothian Health and Social Care Partnership. “There are several others. But what is unique to us is that we integrate health and social care. Others offer a hospital outreach service, while ours started in community care. We have developed a lovely team, and I’m the happiest I have ever been at work.”
GPs identify about 75-80% of the patients served. “For about 15% of those, we have to convert it into a real hospital admission, but to me that’s good. If we didn’t have some that needed admission, I wouldn’t feel we were looking after really ill people.”
The service provides a rapid response—one to two hours for a chest infection, for example. Not all patients are elderly, with a quarter under the age of 75, and some younger disabled people. As the service has developed, bed occupancy in hospitals has declined, though it is hard to be sure this is cause and effect.
Cantley relishes the close collaboration with social care. “People say that our computer systems can’t talk to one another. But my desk is right next to a social work colleague. Computers don’t talk, but people do.”
Bringing CAMHS closer to home
Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) need regular checks of height, weight, blood pressure, and pulse. Guidelines say this should be done every six months, involving visits to clinics, regardless of clinical need, simply for a few basic measurements to be made.
They may be basic but they are not pointless, explains Subha Muthalagu, consultant child and adolescent psychiatrist at Sussex Partnership NHS Foundation Trust. “These patients may be taking drugs with side effects which can affect appetite and growth, or weight and blood pressure,” she says.
At the New Forest Child and Adolescent Mental Health Service, an audit showed that only 6% of patients taking ADHD drugs had their monitoring done on time. The majority of clinics, which included physical monitoring, were delayed by six to 12 months, causing family anxieties, and GPs were reluctant to issue repeat prescriptions when patients were not being properly monitored.
The team turned to local community pharmacists. “We trained staff at 15 pharmacies to carry out the checks under the supervision of the community pharmacist. The patients much prefer it. It’s closer to where they live and they don’t have to take time off school.” The tests cost £18 and the results are sent from pharmacy to clinic by a secure digital link, enabling GPs in turn to be informed and to make any necessary changes in prescriptions.
Results showed monitoring was much better, with 60% having physical checks on time. It has also reduced pressure on the clinic, while patients who do visit annually are more stable. The system is now part of routine practice and is to be trialled in adults.
The Innovation Team of the Year award is sponsored by TopDoctors. The awards ceremony takes place on 10 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.bmj.com
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.