1 Quality of Care Transitions: Older Adults’ Experiences in An Integrated Care Trust

Introduction

The transition of care from hospital to home is a high-risk time for older adults. The Partners at Care Transitions (PACT) programme aims to improve safety and quality of care transitions. We aimed to test the feasibility of using the Partners at Care Transitions Measure (PACT-M) to evaluate older adults’ experiences of the transition from hospital to home in an Inner London Integrated Care Trust and to identify factors impacting transition quality.

Methods

The PACT-M, a validated patient-reported questionnaire designed to evaluate care transitions, was administered to patients ≥65 years at 7, 30 and 90 days post-discharge. Likert scores were analysed quantitatively and manual thematic analysis performed on free-text comments.

Results

101 participants were recruited. Mean age 77.8 years. 84, 70 and 65 participants completed follow-up at 7, 30 and 90 days, respectively.

Factors impacting patients’ experience of transition quality are shown in Table 1.

Conclusions

117 Hospital @Home and the Amber Care Bundle: Introducing the Concept of Uncertainty of Survival to Improve Advance Care Planning

Introduction

GSTT@home is a hospital@home providing multi-disciplinary acute care in peoples’ homes throughout Lambeth and Southwark. AMBER is an internationally recognised care bundle to improve care for hospital inpatients where survival is uncertain. The bundle prompts recognition of survival uncertainty, communication and advance care planning (ACP)- principles relevant to many hospital@home patients. This quality improvement project aimed to embed these principles into GSTT@home by adapting AMBER to this community setting.

Methods

Cycle 1 Plan- Determine whether @home patients might benefit from principles of AMBER. Do and Study- Audit patients >80 years that died within a 3-month period after @home admission (January–June 2018); one in 10 patients died (10.9%), median age 82 and median CFS 8. Act- Inpatient AMBER bundle adapted for @home setting to systemically identify and prompt ACP. Cycle 2 Plan and Do- AMBER@Home bundle formally introduced and piloted with @home, education using posters and lanyard cards.

Study

Audit use of AMBER@Home for patients >80 years who died within three months of discharge from @home (August–October 2019). Act- AMBER@Home incorporated into daily handover document. Cycle 3 Plan and Do- Further education embedded AMBER@Home, increased consultant and GP support. Study- Use of AMBER@Home re-audited as above for November 2019–January 2020.

Conclusions

Using AMBER@Home appears to have changed practice without the AMBER bundle being formally used. Throughout 3 audit cycles there was a steady increase in ACP. Future planned interventions include appointing a frailty nurse to @home team to further embed AMBER@Home, distributing lanyard cards more often and using “Coordinate My Care” to improve accessibility to ACP decisions including PEACE.

SU-E-T-171: Missing Dose in Integrated EPID Images

PURPOSE

A dosimetric artifact has been observed with Varian EPIDs in the presence of beam interrupts. This work determines the root cause and significance of this artifact.

METHODS

Integrated mode EPID images were acquired both with and without a manual beam interrupt for rectangular, sliding gap IMRT fields. Simultaneously, the individual frames were captured on a separate computer using a frame-grabber system. Synchronization of the individual frames with the integrated images allowed the determination of precisely how the EPID behaved during regular operation as well as when a beam interrupt was triggered. The ability of the EPID to reliably monitor a treatment in the presence of beam interrupts was tested by comparing the difference between the interrupt and non-interrupt images.

RESULTS

The interrupted images acquired in integrated acquisition mode displayed unanticipated behaviour in the region of the image where the leaves were located when the beam interrupt was triggered. Differences greater than 5% were observed as a result of the interrupt in some cases, with the discrepancies occurring in a non-uniform manner across the imager. The differences measured were not repeatable from one measurement to another. Examination of the individual frames showed that the EPID was consistently losing a small amount of dose at the termination of every exposure. Inclusion of one additional frame in every image rectified the unexpected behaviour, reducing the differences to 1% or less.

CONCLUSIONS

Although integrated EPID images nominally capture the entire dose delivered during an exposure, a small amount of dose is consistently being lost at the end of every exposure. The amount of missing dose is random, depending on the exact beam termination time within a frame. Inclusion of an extra frame at the end of each exposure effectively rectifies the problem, making the EPID more suitable for clinical dosimetry applications. The authors received support from Varian Medical Systems in the form of software and equipment loans as well as technical support.

Oltipraz concentrations in plasma, buccal mucosa cells, and lipids: pharmacological studies

Oltipraz is considered one of the most potent cancer chemoprevention agents, as shown in preclinical studies. Its pharmacological effects in humans have been associated with unusual toxicity affecting the fingers and toes. This study was designed to test intermittent dosing schedules using two dosage levels: 500 mg as a single weekly dose and 200 mg as a biweekly dose, each for 30 days. Fifteen men and women were studied in each dosing group. All were heavy smokers considered to be at high risk for developing lung cancer. Plasma, buccal mucosa cell, and lipoprotein concentrations were measured at different intervals corresponding to the time period when most of the adverse effects occur. No serious toxicities were observed using these doses and schedules. The plasma and buccal mucosa cell concentrations of Oltipraz showed substantial interindividual variations at each sampling. Some subjects had no detectable plasma or buccal mucosal cell Oltipraz concentrations. The distribution of Oltipraz incorporation into the lipid fractions and albumin was changed by the administration of different schedules of Oltipraz. The results of this study suggest that the intermittent dosing is well tolerated and does not result in steady state in plasma or buccal mucosa cells. The variation and lack of detectable Oltipraz concentration in plasma, buccal mucosa cells, and lipids may affect both the toxicity and the pharmacological effects when these doses and schedules are used.

Modes of thought, feeling, and action in infant pain assessment by pediatric nurses

The components of the assessment process are identified and compared from an ethnography of the methods used by 65 pediatric nurses to assess the level of pain in a sample of infants younger than 1 year of age. Nine different modes of thought, feeling, and action were referenced in reaching judgments about pain levels. The five predominant modes were: deductive, clinical, inductive, testing, and knowing the infant. Over time, the participants had developed a preference for particular combinations of the elements which constitute these modes: repeated use of these preferred assessment methods gave more experienced pediatric nurses distinctive styles of pain assessment. Nurses demonstrated a wider "repertoire" of knowledge about how to assess pain than they customarily used: the selection of particular repertoire items varied by nurses' initial estimates, experience level, and personal assessment style. Findings support the proposition that an understanding of the infant pain assessment process must include nurses' selection and customary use of knowledge and data available to them, as well as the intrinsic nature of that information.

Sources and consequences of satisfaction and dissatisfaction in nursing: findings from a national sample

The implications for the current nursing shortage of the job satisfaction and dissatisfaction described by 252 members of the American Nursing Association are discussed. Comparison of sources of dissatisfaction by the frequency with which they were mentioned, the strength of emotion with which they were expressed and their potential to provoke defection from nursing, indicate inadequate working conditions and counter-productive attitudes within employing organizations to be the most serious sources of dissatisfaction. Dissatisfaction with remuneration and benefits rank second to structural problems, by each measure. The relative importance of problems with gender and family roles, colleagues, education, and professional associations, and of respect, recognition, and autonomy issues are also discussed.

On my own terms: the redefinition of success in nursing

Studies seeking predictors of success among professional women, including nurses, define "success" largely in extrinsic terms. In the findings of two studies of nurses (N = 200; N = 722), intrinsic forms of success emerge as more highly valued than externally measured achievements. Other studies of nurses and professional women show similar findings. This is argued to reflect realism about the structural obstacles and personal costs involved in vertical careers and the balancing of priorities important to women. Success defined as personal satisfaction is particularly appropriate in an economic climate where the success ethic is less viable and self-evaluation in extrinsic terms is psychologically risky.

The token economy in the National Health Service: possibilities and limitations

The effects after 1 year of the introduction of a token economy system into a long-term male psychiatric ward of 45 mainly schizophrenic patients are described. The main objectives were (1) to define the limits of such programmes in "average" National Health Service conditions, where additional resources in staff, finance, and facilities are very limited and (2) to introduce the principles and techniques of behaviour modification to nursing staff. The programme succeeded in reducing social withdrawal and apathy and in increasing self-care skills and involvement in constructive activity. There was no change in the level of socially embarrassing behaviour. The major limitation affecting the maintenance of the programme was found to be the rapid turnover and unpredictable changes in nursing staff. It was concluded that such programmes are feasible with very little in the way of increased resources, and that such efforts will continue to be necessary in view of the existing large numbers of long-tern patients and the slow but significant accumulation of new patients.