The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine

Background Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team’s service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. Methods The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team’s first 12 months of operation using the prospectively maintained service database. Results Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. Conclusion Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

SP2.2.8Teams, performance, and trust: a perspective from the vanguard

Aims The aim of this study was to determine surgical trainees’ perspective regarding team environment, function, performance, and trust. Methods A 44-point, anonymous survey was distributed to all doctors working in surgery in a single UK Statutory Education Body with responses received from 116 (n = 17 Foundation Year 1 (FY1), n = 50 Senior House Officer (SHO), n = 49 Specialist Registrar (SpR)). Results Psychological safety was associated with trainee grade; SHO perception of support (60.4%, n = 29), FY1 (88.2%, n = 15), SpR (82.4%, n = 42), p = 0.016; and ability to ask for help: SHO (70.8%, n = 34), FY1 (100.0%, n = 17), SpR (92.2%, n = 47 p = 0.043). Dependability among colleagues was perceived to be poorer by women (69.8%, n = 30) than men (87.5%, n = 63, p = 0.009). Clarity of team structure was associated with grade and perceived to be poor by SHOs (60.4%, n = 29) vs. FY1 (94.1%, n = 16) vs. SpR (78.4%, n = 40), p = 0.014. Meaningfulness and impact of team achievement was associated with grade: SHO (68.8%, n = 33) vs. FY1 (76.5%, n = 13) vs. SpR (94.1%, n = 48), p = 0.005. Inverse correlations were observed between the prevalence of harassment/bullying and markers of psychological safety (rho -0.382, p < 0.001), dependability (rho -0.270, p = 0.003), and clarity of team structure (rho -0.355, p < 0.001). Conclusion Important deficiencies in psychological safety impacted two in five of SHOs adversely. Countermeasures (Enhanced Surgical Resilience Training) are needed to protect morale, patient safety, and clinical outcomes.

Unenhanced computed tomography as a diagnostic tool in suspected pulmonary hypertension: a retrospective cross-sectional pilot study

Background: Computed tomography pulmonary angiography (CTPA) has been proposed to be diagnostic for pulmonary hypertension (PH) in multiple studies. However, the utility of the unenhanced CT measurements diagnosing PH has not been fully assessed. This study aimed to assess the diagnostic utility and reproducibility of cardiac and great vessel parameters on unenhanced computed tomography (CT) in suspected pulmonary hypertension (PH). Methods: In total, 42 patients with suspected PH who underwent unenhanced CT thorax and right heart catheterization (RHC) were included in the study. Three observers (a consultant radiologist, a specialist registrar in radiology, and a medical student) measured the parameters by using unenhanced CT. Diagnostic accuracy of the parameters was assessed by area under the receiver operating characteristic curve (AUC). Inter-observer variability between the consultant radiologist (primary observer) and the two secondary observers was determined by intra-class correlation analysis (ICC). Results: Overall, 35 patients were diagnosed with PH by RHC while 7 patients were not. Main pulmonary arterial (MPA) diameter was the strongest (AUC 0.79 to 0.87) and the most reproducible great vessel parameter. ICC comparing the MPA diameter measurement of the consultant radiologist to the specialist registrar’s and the medical student’s were 0.96 and 0.92, respectively. Right atrial area was the cardiac measurement with highest accuracy and reproducibility (AUC 0.76 to 0.79; ICC 0.980, 0.950) followed by tricuspid annulus diameter (AUC 0.76 to 0.79; ICC 0.790, 0.800). Conclusions: MPA diameter and right atrial areas showed high reproducibility. Diagnostic accuracies of these were within the range of acceptable to excellent, and might have clinical value. Tricuspid annular diameter was less reliable and less diagnostic and was therefore not a recommended diagnostic measurement.

To improve the communication between a community mental health team and its service users, their families and carers

This article describes the application of quality improvement (QI) to solve a long-standing, ongoing problem where service users or their carers felt they were not given enough information regarding diagnosis and medication during clinic assessments in a community mental health setting. Service users and carers had shared feedback that some of the information documented on clinic letters was not accurate and the service users were not given the opportunity to discuss these letters with the clinician. The aim of this QI project was to improve the communication between the community mental health team (CMHT) and service users and their carers. Wardown CMHT volunteered to take on this project. The stakeholders involved were the team manager and deputy manager, the team consultant, the team specialist registrar, team administrative manager, two carers and one service user. The project had access to QI learning and support through East London NHS Foundation Trust’s QI programme. The team organised weekly meetings to brainstorm ideas, plan tests of change to review progress and to agree on the next course of action. The outcome was an increase in service user satisfaction from 59.9% to 78% over a period of 6 months, and a reduction in complaints to zero.

A new approach to managing follow-up patients with sino-nasal disorders: the rhinology panel

Background/aims There is a growing backlog of patients with sino-nasal disorders waiting for a follow-up appointment. This study aimed to identify rhinology patients on the outpatient follow-up list who could be removed from the waiting list for a face to face follow-up appointment and instead either given a phone consultation by a clinical nurse specialist or discharged from the service. Methods The clinical records of patients on the waiting list for a follow-up appointment at a nasal disorders clinic were reviewed by a panel comprising a consultant rhinologist, a rhinology fellow, a specialist registrar and two nurse specialists. Results A total of 300 clinical records of patients on the follow-up list of the Rhinology clinic were identified, of which 253 were found to have a sino-nasal disorder. Of these, 137 patients (54%) were discharged from the rhinology face to face follow-up clinics, while 116 patients (46%) were given face to face review appointments. Conclusions A multi-professional rhinology review panel is an effective way of managing the waiting list of an outpatient rhinology clinic and providing nurse-led telephone consultations could decrease the strain on resources while maintaining patient safety.

78 Does Time ‘Out of Programme’ Offer Increased Academic Output? The South East London Geriatrics Training Programme Experience

Introduction In contrast to other medical specialties, trainees in Geriatrics have historically provided an increased contribution to clinical workload in General Internal Medicine and a reduced output of academic achievements. More recently, development of non-clinical skills has been recognised to have similar importance to clinical skills and the South East (SE) London Geriatrics Training Programme has thus supported trainees in applications for Out of Programme (OOP) opportunities to optimise career progression. Methods Doctors who had undertaken specialist registrar training in the SE London Geriatrics Training Programme at any time between 2011 and 2019 were sent a questionnaire to assess whether they had completed time OOP and whether they had been awarded research grants, published papers in peer-reviewed journals, had abstracts accepted for presentation at conferences, and/or published book chapters during their training programme. Chi-squared and Wilcoxon rank-sum tests were used to compare data between registrars who had completed time OOP and those who had not taken time OOP. Results 77 (24 male; 53 female) registrars completed training in the SE London Geriatrics Training Programme between 2011 and 2019. 71 registrars (92%) completed the questionnaire, of whom 31 (44%) completed time OOP. In total, registrars were awarded 15 research grants, published 86 papers in peer-reviewed journals, had abstracts accepted for 184 conference presentations and published 20 book chapters. A notably increased proportion of registrars who took time OOP had an output of research grants, papers published in peer-reviewed journals, abstracts accepted for presentation at conferences and/or book chapters respectively compared with registrars who had not taken time OOP (23% vs 5% ; 61% vs 23%; 84% vs 33%; 45% vs 5%). This equated to a combined academic output in 94% of registrars who completed time OOP compared with 48% who did not (p <0.001). Conclusions A very strong association existed between registrars in Geriatrics taking time OOP and academic achievement substantiating the training programme’s aspiration to support development of non-clinical skills that may be helpful to trainees in their future careers. It would be worthwhile further work being undertaken in this area in other regions.

304 ED-FASU: A Novel ‘Front Door’ Multidisciplinary Service Assessing Patients with Falls and Syncope in the Emergency Department

Background Patients with falls/syncope/presyncope frequently present to the emergency department (ED) and many that could be managed safely in an ambulatory care setting are admitted for extensive diagnostic work-up. A pilot intervention commenced in March 2019, with direct access to specialist assessment in the ED for patients presenting with falls/syncope/presyncope, aiming to provide appropriate testing and early diagnosis to reduce unnecessary hospitalizations. This pilot study assessed the feasibility of embedding this service within the ED, as well as the effectiveness of the intervention in terms of admission avoidance. Methods The study was conducted between 25th March and 19th April 2019 in a large urban teaching hospital with a dedicated Falls & Syncope Unit and compared to similar data from March/April 2018. The core ED-FASU team comprised a consultant geriatrician, specialist registrar in geriatric medicine and clinical nurse specialist. Inclusion criteria were those of all ages, presenting with falls/syncope/presyncope/dizziness between 0800-1800 Monday-Friday. Patients were reviewed directly from triage or after referral from the ED team. Results In total, 203 patients were assessed during the pilot, an average of 10 assessments per day. The median age of those seen was 63 (58.0-67.0) years. Almost one third (57/203) were aged ≥75 years. After excluding those who were already admitted to the acute hospital and awaiting a bed when seen in the ED (n=29), 24% (41/174) of those seen were admitted to hospital. This compares to an admission rate of 33% (73/223) for the 2018 comparison group (p = 0.045). Conclusion This pilot study shows that it is feasible to embed specialist assessment for falls/syncope/presyncope in the ED. Initial pilot data suggests a significant reduction in admission rates for those seen by this service but needs to be confirmed over a more prolonged assessment period and alongside data on readmission and length of stay.