A new model to deliver scheduled outpatient care

Here we describe an integrated model for scheduled care (the ‘cluster clinic’). Following a pilot in April 2018, cluster clinics were established across Aberdeen City from April 2019 but not the area surrounding Aberdeen (ie, Aberdeenshire). There were 2360 referrals in 2017/2018 (pre-cluster clinic), and 2615 in 2019/2020 (post-Aberdeen City cluster clinics). The proportions of referrals from City practices seen pre-cluster and post-cluster were 72% and 56%, respectively, and from Shire practices the corresponding proportions were 70% and 65%. The cluster clinic received positive feedback from parents and referring clinicians and was not associated with increased ‘missed diagnoses’ compared with business as usual clinic. The cluster clinic model is a realistic and effective method to deliver integrated scheduled care for children.

SP3.1.14 NELA; what happens after discharge?

Aims NELA has been instrumental at improving perioperative care and 30–day mortality following emergency laparotomy (EmLap); long-term outcomes and follow-up are less well reported. This study aims to establish the unscheduled and scheduled service use of EmLap patients after discharge. Methods This is a single-centre service evaluation. Patients were included if they had an EmLap recorded from 2016-2019 at our local institute and were alive on discharge. Outcomes were 30-day readmission rate and outpatient follow-up. Results 944 patients were included. 11.9% re-presented to the surgical department within 30-days; 58.0% of these needed readmissions. The most common causes for re-presentation (n = 112) were management of a wound issue (15.2%), ongoing pain without evidence of complication (10.7%) and ongoing intra-abdominal sepsis (9.8%). 1-year survival was 81.4%. Of these (n = 856); 74.3% were invited to outpatients; DNA rate was 8.8%, with only 67.8% of patients having a follow-up review. Median time to follow up was 9 weeks. Patients were more likely to be invited for outpatient review if they had a new stoma (OR 2.56, 95% CI 1.81 – 3.56), and less likely if adhesiolysis was the primary procedure (OR 0.55, 95% 0.39-0.76). Patients who failed to attend an appointment were significantly younger (median age 53 vs. 60 years, p = 0.0033) and from more deprived areas (average WIMD 673.6 vs 977.3, p = 0.002). Conclusion This study demonstrates higher levels of unscheduled care and lower levels of scheduled care than expected. Care standards should be extended beyond the 30-day milestone to fully appreciate the morbidity associated from EmLap.

The clinically extremely vulnerable to COVID: Identification and changes in health care while self-isolating (shielding) during the coronavirus pandemic

Background In March 2020, the government of Scotland identified people deemed clinically extremely vulnerable to COVID due to their pre-existing health conditions. These people were advised to strictly self-isolate (shield) at the start of the pandemic, except for necessary healthcare. We examined who was identified as clinically extremely vulnerable, how their healthcare changed during isolation, and whether this process exacerbated healthcare inequalities. Methods We linked those on the shielding register in NHS Grampian, a health authority in Scotland, to healthcare records from 2015-2020. We described the source of identification, demographics, and clinical history of the cohort. We measured changes in out-patient, in-patient, and emergency healthcare during isolation in the shielding population and compared to the general non-shielding population. Results The register included 16,092 people (3% of the population), clinically vulnerable primarily due to a respiratory disease, immunosuppression, or cancer. Among them, 42% were not identified by national healthcare record screening but added ad hoc, with these additions including more children and fewer economically-deprived. During isolation, all forms of healthcare use decreased (25%-46%), with larger decreases in scheduled care than in emergency care. However, people shielding had better maintained scheduled care compared to the non-shielding general population: out-patient visits decreased 35% vs 49%; in-patient visits decreased 46% vs 81%. Notably, there was substantial variation in whose scheduled care was maintained during isolation: younger people and those with cancer had significantly higher visit rates, but there was no difference between sexes or socioeconomic levels. Conclusions Healthcare changed dramatically for the clinically extremely vulnerable population during the pandemic. The increased reliance on emergency care while isolating indicates that continuity of care for existing conditions was not optimal. However, compared to the general population, there was success in maintaining scheduled care, particularly in young people and those with cancer. We suggest that integrating demographic and primary care data would improve identification of the clinically vulnerable and could aid prioritising their care.

Audit of follow-up within 7 days on discharge from the mental health unit, Forth Valley Royal Hospital

AimsTo determine compliance with the new discharge policy of review within 7-days for all General Adult Psychiatry patients discharged from Forth Valley Royal Hospital.BackgroundIt is well established that there is an increased risk of suicide following discharge from Inpatient Psychiatric Wards. This risk is significantly increased in the first month, and particularly high in the first week.In their 2016 Guidance, NICE recommends follow-up within 7 days of discharge. It is not known whether seven day follow-up reduces suicide risk but it is clearly an opportunity for risk assessment and management during a particularly risky period.This standard was adopted by the General Adult Wards in Mental Health Unit at Forth Valley Royal Hospital in April 2019.MethodAll discharges from Wards 1, 2 and 3, Forth Valley Royal Hospital were reviewed during three distinct, month-long periods:November 2018 (prior to the introduction of the new discharge policy)May 2019 (shortly after the introduction of the new discharge policy)September 2019 (six months after the introduction of the new discharge policy)A list was obtained from Medical Records of all General Adult patients discharged in these periods. The paper and electronic records were checked for each patient, and the first scheduled care episode post discharge was taken as follow-up.ResultIn the1st round of audit (November 2018): 41 patients were discharged and 26 patients (64%) received follow-up within 7 days.In the 2nd round of audit (May 2019): 46 patients were discharged, 39 patients (84%) received follow-up within 7 days.In the 3rd round of the audit (September 2019), 50 patients were discharged and 49 (98%) received follow-up within 7 days.ConclusionThere has been a clear improvement in the provision of follow-up on discharge from the General Adult Psychiatry Wards in Forth Valley Royal Hospital.The new discharge policy was implemented in April 2019 and a “Discharge Pause” was introduced (initially a sticker, now an electronic form) to be completed by the medical team at the point when it was decided to discharge.Community Mental Health Teams have also been reminded of their need to facilitate seven day follow-up as a priority. A flowchart was produced in May 2019, which provided guidance as to who should provide the seven day follow-up.

572 Virtual Reality Operative Simulation in Orthopaedic Surgical Training During Periods of Restricted Clinical Hours: Systematic Review

Introduction The public health response to the coronavirus pandemic-imposed limitations upon orthopaedic surgeon’s scheduled care practice, with a consequential diminution of training time for residents. A potentially viable option for maintenance of operative competency is the use of virtual reality (VR) simulation. This review looks at the effectiveness of (VR) as a pedagogical method of learning for orthopaedic trainees. Question Can VR be a viable method of learning and skill retention for orthopaedic trainees during periods of diminished operative time? Method A systematic search using Google Scholar, EMBASE and PubMed was conducted in July 2020. Results Following the PRIMSA guidelines; initial search revealed 779 studies. 35 full text articles were analysed by two reviewers with a final total of 30 articles used in this review. A thematic analysis revealed three broad categories: quality and validity of VR teaching simulations studies (n = 8); learning curves and subject performance (n = 14) and VR simulators utility in orthopaedics reviews (n = 8). Conclusions We demonstrated that VR has the capacity to help trainees maintain their technical skills, enhance their precision, and retain rudimentary competency during this pandemic. Additional improvements are necessary to ensure its safety as a training tool.

Hospitals and the Covid19 pandemic: challenges and opportunities for transformation

Short, medium and long term changes made in hospitals for delivery of care, teaching and training, and research during the crisis arising from the SARS-CoV-2 pandemic are analyzed. The transformation has implications both for patients with covid19 and for patients free of the disease but who require urgent, semi-urgent or scheduled care for medium or high complexity conditions.

Scheduled care – as a way of caring. A phenomenological study of being cared for when suffering from alcohol use disorders

Excessive alcohol consumption is health damaging and is also recognized as one of the major avoidable health risk factors. Alcohol use disorders are classified among one of the most harmful, debilitating disease categories and patients are frequent visitors in the emergency departments. The meeting between patient and healthcarer is considered contradictory and characterized by dilemmas and arbitrariness. Furthermore, this patient group differs from the regular patient. They are often characterized by very complex health pictures and chaotic social problems spawned by turbulent lifestyles. However, the experience of a hospitalization from a patient perspective is sparsely documented in a scientific context. The aim of this study was to elucidate the lived experience of how patients with alcohol use disorders experience being cared for when admitted to acute medical units. The data set consists of 15 in-depth interviews with patients suffering from alcohol use disorders admitted to an acute medical unit. The study is anchored in the phenomenological philosophy and the methodology applied is a descriptive phenomenological method as defined by Dahlberg. The intention is to identify and understand the essences, patterns, and structures of the lived experience of being cared for when hospitalized and suffering from alcohol use disorders. Data has been analysed according to the guidelines in Reflective Lifeworld Research, given by Dahlberg. Being cared for was experienced as a two-staged process that changed throughout the hospitalization from an experience of scheduled care experienced as caring to an experience of scheduled care experienced as non-caring. Four constituents further described the variable experiences: being in a safe haven, sharing a tacit but mutual goal, being in a chaotic space, and being on your own. The study showed that patients suffering from alcohol use disorders call for an intentional and distinctive attentiveness from the carers throughout their hospitalization. Being both seen and met in an authentic presence by carers was a powerful tool that helped ease the hospitalization. Likewise the absence of the authentic presence during the second stage may have hindered the carers notice and respond to a transfer of attention within the patients, and thus adapting the care provided.

Proof of Concept trial of diagnostic ultrasound in the orthopaedic triage setting.

Purpose: This study aims to investigate the benefits of Point of Care (POC) ultrasound and Scheduled Ultrasound Clinics using a Proof of Concept approach in the orthopaedic triage setting.Materials and Methods: The trial ran for a six week period sourcing all patients referred to the orthopaedic triage service. The trial collected three measurable outcomes i.e. two Patient Reported Outcome Measures: MSK-HQ and The Care Measure, and a Proof of Concept clinician survey via Survey Monkey. These were completed by the clinicians and patient cohort during the scheduled clinic and POC clinical contact.Results: A total of 135 patients received a diagnostic ultrasound scan over the six week trial period. 34 patients received a diagnostic ultrasound scan from the Extended Scope Practitioner (ESP) Physiotherapist in a Scheduled Care setting. 101 patients received a diagnostic ultrasound scan from the ESP Podiatrist in orthopaedic triage over the six week period (74 in Scheduled care clinics and 27 at Point of Care). The outcome measure suggest that patients recieved a rapid diagnosis (n.135), implementation of appropriate treatment pathway (86.36%), a positive impact on Referral to Treatment (88.55%), appropriate implementation of conservative treatment (91.11%) and had excellent co-production during the trial with an 88% average CARE Measure Score. The MSK-HQ results suggested a wide variety of muscuoskeletal conditions were asseessed during the trial with a mean MSK-HQ score of 27.6 with a Standard Deviation of 12.Conclusion: Results from clinician sourced Survey Monkey data, The CARE Measure and MSK HQ suggest that POC ultrasound and Scheduled care clinics offer a positive benefit for the patient’s care pathway, are beneficial clinically and suggest adequate demand for the service.