bluuebunny/crossref_metadata_2025 huggingface dataset:
Microbiomes of Unreactive and Pathologically Altered Ileocecal Lymph Nodes of Slaughter Pigs
Authors: Mann Evelyne , Dzieciol Monika , Metzler-Zebeli Barbara U. , Wagner Martin , Schmitz-Esser Stephan
Published: October 2013

Microbe-laden dendritic cells are shifted to ileocecal lymph nodes (ICLNs), where microbes are concentrated and an adequate immune response is triggered. Hence, ICLNs are at a crucial position in immune anatomy and control processes of the local immune system. Pathological alterations in ICLNs, such as reactive hyperplasia,
lymphadenitis purulenta
, or
granulomatosa
, can harbor a multitude of pathogens and commensals, posing a potential zoonotic risk in animal production. The aim of this study was to characterize the microbial diversity of unreactive ICLNs of slaughter pigs and to investigate community shifts in reactive ICLNs altered by enlargement, purulence, or granulomatous formations. Pyrosequencing of 16S rRNA gene amplicons from 32 ICLNs yielded 175,313 sequences, clustering into 650 operational taxonomic units (OTUs). OTUs were assigned to 239 genera and 11 phyla. Besides a highly diverse bacterial community in ICLNs, we observed significant shifts in pathologically altered ICLNs. The relative abundances of
Cloacibacterium
- and
Novosphingobium
-associated OTUs and the genus
Faecalibacterium
were significantly higher in unreactive ICLNs than in pathologically altered ICLNs. Enlarged ICLNs harbored significantly more
Lactobacillus
- and
Clostridium
-associated sequences. Relative abundances of
Mycoplasma
,
Bacteroides
,
Veillonella
, and
Variovorax
OTUs were significantly increased in granulomatous ICLNs, whereas abundances of
Pseudomonas
,
Escherichia
, and
Acinetobacter
OTUs were significantly increased in purulent ICLNs (
P
< 0.05). Correlation-based networks revealed interactions among OTUs in all ICLN groups, and discriminant analyses depicted discrimination in response to pathological alterations. This study is the first community-based survey in ICLNs of livestock animals and will provide a basis to broaden the knowledge of microbe-host interactions in pigs.
Role of the Twin Arginine Protein Transport Pathway in the Assembly of the Streptomyces coelicolor Cytochrome
bc
1
Complex
Authors: Hopkins Adam , Buchanan Grant , Palmer Tracy
Published: October 2013

The cytochrome
bc
1
-cytochrome
aa
3
complexes together comprise one of the major branches of the bacterial aerobic respiratory chain. In actinobacteria, the cytochrome
bc
1
complex shows a number of unusual features in comparison to other cytochrome
bc
1
complexes. In particular, the Rieske iron-sulfur protein component of this complex, QcrA, is a polytopic rather than a monotopic membrane protein. Bacterial Rieske proteins are usually integrated into the membrane in a folded conformation by the twin arginine protein transport (Tat) pathway. In this study, we show that the activity of the
Streptomyces coelicolor
M145 cytochrome
bc
1
complex is dependent upon an active Tat pathway. However, the polytopic Rieske protein is still integrated into the membrane in a Δ
tatC
mutant strain, indicating that a second protein translocation machinery also participates in its assembly. Difference spectroscopy indicated that the cytochrome
c
component of the complex was correctly assembled in the absence of the Tat machinery. We show that the intact cytochrome
bc
1
complex can be isolated from
S. coelicolor
M145 membranes by affinity chromatography. Surprisingly, a stable cytochrome
bc
1
complex containing the Rieske protein can be isolated from membranes even when the Tat system is inactive. These findings strongly suggest that the additional transmembrane segments of the
S. coelicolor
Rieske protein mediate hydrophobic interactions with one or both of the cytochrome subunits.
ExsA and LcrF Recognize Similar Consensus Binding Sites, but Differences in Their Oligomeric State Influence Interactions with Promoter DNA
Authors: King Jessica M. , Schesser Bartra Sara , Plano Gregory , Yahr Timothy L.
Published: October 2013

ExsA activates type III secretion system (T3SS) gene expression in
Pseudomonas aeruginosa
and is a member of the AraC family of transcriptional regulators. AraC proteins contain two helix-turn-helix (HTH) DNA binding motifs. One helix from each HTH motif inserts into the major groove of the DNA to make base-specific contacts with the promoter region. The amino acids that comprise the HTH motifs of ExsA are nearly identical to those in LcrF/VirF, the activators of T3SS gene expression in the pathogenic yersiniae. In this study, we tested the hypothesis that ExsA/LcrF/VirF recognize a common nucleotide sequence. We report that
Yersinia pestis
LcrF binds to and activates transcription of ExsA-dependent promoters in
P. aeruginosa
and that plasmid-expressed ExsA complements a
Y. pestis lcrF
mutant for T3SS gene expression. Mutations that disrupt the ExsA consensus binding sites in both
P. aeruginosa
and
Y. pestis
T3SS promoters prevent activation by ExsA and LcrF. Our combined data demonstrate that ExsA and LcrF recognize a common nucleotide sequence. Nevertheless, the DNA binding properties of ExsA and LcrF are distinct. Whereas two ExsA monomers are sequentially recruited to the promoter region, LcrF binds to promoter DNA as a preformed dimer and has a higher capacity to bend DNA. An LcrF mutant defective for dimerization bound promoter DNA with properties similar to ExsA. Finally, we demonstrate that the activators of T3SS gene expression from
Photorhabdus luminescens
,
Aeromonas hydrophila
, and
Vibrio parahaemolyticus
are also sensitive to mutations that disrupt the ExsA consensus binding site.
The γ-Aminobutyrate Permease GabP Serves as the Third Proline Transporter of Bacillus subtilis
Authors: Zaprasis Adrienne , Hoffmann Tamara , Stannek Lorena , Gunka Katrin , Commichau Fabian M. , Bremer Erhard
Published: October 2013

PutP and OpuE serve as proline transporters when this imino acid is used by
Bacillus subtilis
as a nutrient or as an osmostress protectant, respectively. The simultaneous inactivation of the PutP and OpuE systems still allows the utilization of proline as a nutrient. This growth phenotype pointed to the presence of a third proline transport system in
B. subtilis
. We took advantage of the sensitivity of a
putP opuE
double mutant to the toxic proline analog 3,4-dehydro-
dl
-proline (DHP) to identify this additional proline uptake system. DHP-resistant mutants were selected and found to be defective in the use of proline as a nutrient. Whole-genome resequencing of one of these strains provided the lead that the inactivation of the γ-aminobutyrate (GABA) transporter GabP was responsible for these phenotypes. DNA sequencing of the
gabP
gene in 14 additionally analyzed DHP-resistant strains confirmed this finding. Consistently, each of the DHP-resistant mutants was defective not only in the use of proline as a nutrient but also in the use of GABA as a nitrogen source. The same phenotype resulted from the targeted deletion of the
gabP
gene in a
putP opuE
mutant strain. Hence, the GabP carrier not only serves as an uptake system for GABA but also functions as the third proline transporter of
B. subtilis
. Uptake studies with radiolabeled GABA and proline confirmed this conclusion and provided information on the kinetic parameters of the GabP carrier for both of these substrates.
Exploring the relationship between baseline physical activity levels and mortality reduction associated with increases in physical activity: a modelling study
Authors: Minton Jonathan , Dimairo Munyaradzi , Everson-Hock Emma , Scott Emma , Goyder Elizabeth
Published: October 2013

Background

Increasing physical activity (PA) levels among the general adult population of developed nations is important for reducing premature mortality and the burdens of preventable illness. Assessing how effective PA interventions are as health interventions often involves categorising participants as either ‘active’ or ‘sedentary’ after the interventions. A model was developed showing that doing this could significantly misestimate the health effect of PA interventions.

Methods

A life table model was constructed combining evidence on baseline PA levels with evidence indicating the non-linear relationship between PA levels and all-cause mortality risks. PA intervention scenarios were modelled which had the same mean increase in PA but different levels of take-up by people who were more active or more sedentary to begin with.

Results

The model simulations indicated that, compared with a scenario where already-active people did most of the additional PA, a scenario where the least active did the most additional PA was around a third more effective in preventing deaths between the ages of 50 and 60 years. The relationship between distribution of PA take-up and health effect was explored systematically and appeared non-linear.

Conclusions

As the health gains of a given PA increase are greatest among people who are most sedentary, smaller increases in PA in the least active may have the same health benefits as much larger PA increases in the most active. To help such health effects to be assessed, PA studies should report changes in the distribution of PA level between the start and end of the study.
Increases in HIV screening in primary care clinics through an electronic reminder: an interrupted time series
Authors: Avery Ann K , Del Toro Michelle , Caron Aleece
Published: October 2013

Objective aim

Identify and eliminate barriers to HIV testing in primary care and to decrease the rates of patients never being tested, and limit unnecessary repeat testing.

Setting

Primary care clinics within an urban publicly funded safety net hospital and community health system in Cleveland, Ohio. Reported HIV prevalence among male Cleveland residents is 1193.5/100 000.

Design

A time series analysis using statistical process control was used.

Methods

Primary care encounters of patients aged 13–64 years from selected sites were reviewed throughout the initiative for HIV testing prior to the visit and associated with the visit.

Results

Run charts of the proportion of men and women never tested for HIV demonstrated marked improvement and special cause variation with six sequential quarters falling outside of the trend lines. Evaluation of encounters associated with a first HIV test confirmed testing occurring within primary care rather than elsewhere in the health system.

Conclusions

Implementing an electronic medical record-based reminder effectively increased HIV testing among primary care patients not previously tested, while education and practice feedback alone did not.
01 Our deeds determine us, as much as we determine our deeds
Authors: Turnbull Ian
Published: October 2013

Introduction

In March 2012 Willowbrook started to support the rehabilitation of currently serving offenders by offering volunteer placements in our Warehouse. This was a very bold move by the Hospice which had previously relied on traditional volunteering methods.

Aims

The Hospice’s Strategic Business plan is to broaden the diversity of its volunteering by giving volunteer opportunities to young people who may not have come across the Hospice movement in their lives. Willowbrook could provide work experience to prisoner’s approaching the end of their sentence supporting the Prisons Outreach Placement programme and raise extra funds to provide for patient care.

Methods

The views of all the participants needed to be taken into account - a visit to the prison arranged meeting with the Prison Placement Officer, a business case was proposed to the Hospice Trustees, Senior Managers and Warehouse Staff. In May 2012 the first prisoners arrived at the warehouse.

Results

For the Hospice - over the 18 months the 10 prisoners have made a fantastic contribution with over 5000 hours of support the warehouse has been able to increase its contribution to patient care by 12%, all the prisoners have settled in quickly with both Hospice staff and existing volunteers.

For the Prison Service - Willowbrook is a highly reputable organisation, they know the prisoners will be supervised and provided with training.

For the Prisoner - they feel more fulfilled and have more skills to take them back into ‘normal’ life.

Conclusions

The Hospice Prison Volunteer Placement programme continues to be a highly successful partnership between the Prison Service, prisoners and the Hospice. The hospice gains more volunteering time and funds, the prisoners have gained confidence, team working and independence skills that they can utilise outside the prison and the Prison Service has a professional, reliable organisation to work with.
010 Inspiring compassionate care in an acute hospital setting – the power of QELCA
Authors: Standfield Robert , Wellings Val , Harrison Alison , Garside Jennifer
Published: October 2013

Transforming the traditional delivery of specialist end-of-life care education and training for nursing staff in acute hospital settings through the Quality End of Life Care for All (QELCA) education and training programme has resulted in immediate positive benefits for both the hospice and the local acute hospital Trust.

The prevalence of a top-down target driven culture has meant that persuading hospital managers in hospital settings that compassionate care is directly relevant to improving acute care has been a challenge. The opportunity to transform this thinking was taken by the local acute hospital when they embarked on the Transforming End of Life Care in Acute Hospitals Programme that includes the adoption of the AMBER care bundle and incorporates QELCA training.

Through the delivery of the prescribed QELCA curriculum, that combines and integrates theory with experiential learning through working alongside experienced hospice nurses, there has been a transformational change in the nursing care. This is underpinned by changed thinking and delivery of care that focuses directly on the needs of the patient rather than the needs of the organisation.

The impact in the Acute trust has included:

82% of relatives said they were aware that their relative’s recovery was uncertain.

91% of patients received care supported by the AMBER care bundle had a patient and family meeting.

1.5% of patients who received care supported by the AMBER care bundle, who were discharged were admitted back to the hospital in an emergency.

100% patients had a DNACPR Form completed.

Successful partnership working has also resulted in a renewed interest in furthering specialist palliative and end-of-life care education within secondary care and the CCG extending the AMBER care bundle/QELCA as part of their CQUIN investment. Further funding for the QELCA training has been provided through a successful bid to the Strategic Health Authority.
P78 Clinical leaders forum - “This is place where I always feel heard, I love the energy of our meetings”
Authors: Clarke Karen , Wass Tricia
Published: October 2013

Background

The forum reflects an aspiration to bring the patients’ voice into strategic developments through greater engagement of front-line clinical staff with senior decision makers in an innovative and interactive way.

Aims

Create an open, participative culture that seeks to improve strategic decision making by integrating professional clinical practice into strategy.

Demystify and model senior level/ strategic decision making

Capitalise on the benefits of integrating disciplines, working across departments and breaking down hierarchy.

Approach

Facilitated monthly gatherings; involvingCEO, Directors, Doctors, Nurses and AHP’s, were set up in 2009. Facilitation used to ensure: ample time for differing views to be heard; an open environment to discuss both challenging and/or controversial issues; and time to thoroughly explore topics. A stable membership has created a trusting environment where other colleagues including volunteers have been invited if the topic requires wider participation.

A forum, not a meeting, promotes information exchange and enables some distillation of thinking whilst encouraging strategic leaders to consider and remain grounded in clinical practice and encouraging clinical managers to think strategically.

The forum was reviewed in 2011 and again in 2013 resulting in new and increased membership and some changes to the running of the forums.

Outcomes

Catalyst for change

An integrated and transparent business planning and strategic decision making process

Closer collaboration between Trustees and Clinical leaders.

Application

This forum enables the hospice to achieve the top four key operating principles contained within the Commission’s “Preparing for the future: Key operating principles”: We have developed our strategic leadership, and improved the capabilities of the workforce, while using our discussions at the forum to inform rigorous strategic analysis. Finally, our innovative and inclusive approach has enabled us to think beyond what we currently do and positively influence our culture.
P79 Using SBAR to enhance the Multi-Disciplinary Team Meeting (MDTM)
Authors: Bass Maddy
Published: October 2013

SBAR is a quality and service improvement tool developed by the NHS Institution for Service Innovation & Improvement. It has been designed to streamline conversations between health and social are professionals, ensuring relevant, succinct information is shared.

At St Mary’s Hospice there was not a recognisable MDT meeting. Although in-patients were discussed weekly, it was called a “communication meeting”, with little structure or outcome. On joining the organisation in 2012, I carried out a “snapshot” survey of the current MDT meeting and found that it lacked structure, outcomes, was very physically focussed, and did not include full MDT discussion. In October I wrote up my findings, stressing the positives as well as the challenges. This was shared with staff at one of these communication meetings. The response of all staff was very supportive.

I therefore devised an MDTM based on SBAR. This had been used in my previous place of work for MDT meetings but I further developed this into specific documentation, and planning paperwork (this will be shared at the conference). “Situation” covers patient information such as diagnosis, family tree, reason for referral and input; background includes relevant medical history, events leading up to referral, any other holistic issues; assessment includes what has been found / assessed since involvement, including advance care planning; recommendations include the plan of care.

The new format began trial in February and will continue until July 2013. It will then be audited: this will include staff surveys, audit of how the documentation has been utilised, and a full review. Details will be included at the conference, if this is accepted.

Early feedback shows increased attendance by the MDT, patients from all departments now being discussed, clearer documentation informing succinct relevant discussion, and clear being plans made each week for patients discussed.
P80 Applying the clinical governance toolkit in the hospice setting; a potential strategy to improve care through staff engagement in clinical governance
Authors: Twomey Colin
Published: October 2013

Introduction

Clinical governance is essential to the delivery of high quality safe and effective patient care. It provides a framework to continuously improve the quality of hospice services.

Aims

To critically appraise the current clinical governance systems within our hospice and to re-design these to be efficient, transparent and encourage staff engagement.

Methods

Workshops were held to examine existing governance structures and highlight areas of need and develop a solution which was both readily implementable and effective. The workshops reviewed current literature and examples of good practice surrounding clinical governance in hospices.

Results

A consensus decision was reached to construct clinical governance under the ‘three pillars’ of patient safety, clinical effectiveness and patient experience as described by the Clinical Governance Toolbox (1). In order to enhance engagement with clinical governance three new groups were created for each ‘pillar’. Each group consists of a multi-professional membership of clinical and non-clinical staff and is Chaired by a member of the senior management team. The group members will be responsible for disseminating information and educating staff and volunteers in their day-to-day work as well as in a monthly newsletter. The Clinical Governance board, drawing together the work of the three pillars, will provide organisational oversight. The Clinical Governance Board is comprised of staff members, Trustees and an external scrutinizer.

Conclusions

In adopting this clinical governance structure we believe we have developed a streamlined system that will promote best practice in all members of staff through clarity, communication, accessibility and inclusiveness. Importantly this process has also improved awareness of clinical governance throughout our team through the dynamic workshops responsible for re-designing our systems.
P81 Significant event analysis in a hospice setting
Authors: Gregory Amanda , Myers Laura
Published: October 2013

Monthly significant event analysis (SEA) sessions, which all clinical staff are invited to attend, were introduced at an independent Hospice in 2010. SEA allows opportunity for a team to come together and reflect on a clinical event that has had a significant impact for them; in either a positive or negative way. The chair of the clinical quality (now clinical audit) group introduced SEA in recognition that it forms an important part of clinical governance. Guidance was developed outlining how a significant event may be identified, how the sessions would be structured (through use of a specific proforma) and facilitated, ground rules to be followed and including background information on the role of SEA in a clinical setting. Pathways for staff support are also outlined in the guidance. Dates of SEA sessions are issued in advance. The significant event to be discussed and session facilitator are decided at the organisations’ "Implementing Clinical Governance Group (ICGG)". Since it’s introduction, the structure of SEA has been reviewed and adjusted to ensure it is robust from both a governance and learning perspective. This includes ensuring ground rules are set at the beginning of each session and that action points are followed up through ICGG. An aspect we are keen to further develop is the link between SEA learning outcomes and staff education. Examples of topics reflected on at SEA include management of terminal agitation, vulnerable adults, communication, boundaries, expectations, capacity and preferences. SEA is well attended and has received positive verbal, informal feedback with staff voicing they enjoy the sessions and are keen for them to continue. Recently a questionnaire has been developed and sent to all clinical staff to obtain formal feedback to support the development of future SEA sessions.
P82 The introduction of electronic patient records on a hospice In-Patient Unit (IPU)
Authors: Butterfield Nicola
Published: October 2013

Background/Context

Healthcare information systems have evolved to play a major role in healthcare in modern society and the introduction of the electronic patient record aims to improve patient safety and documentation quality. SystmOne is a centralised clinical system developed by TPP (The Phoenix Partnership) and its introduction at the Hospice was due to a need to introduce an updated medical activity system that incorporated patient records.

Aim

To successfully up-skill the hospice staff and to safely and effectively introduce SystmOne onto the IPU.

Approach used

The introduction of SystmOne was seen as a major change for the IPU and hence a change management model was used to support this. The main areas addressed were process mapping, to identify areas where we could work more effectively and staff training. Staff training was of paramount importance as 26% of the IPU staff had no basic IT skills. This was given to those staff before embarking upon the SystmOne training.

The ward staff were all involved in the development of new IPU documentation and the review of nursing care plans.

The change has been anchored by the alteration in ward routine, staff job descriptions and the change in hospice policies.

Outcomes

Improved communication between departments and external organisations who use SystmOne

Reduced amount of time spent completing documentation

Improved documentation standards

Reduction in patients being asked the same questions on several occasions

More than one person/department being able to access the patient notes at any one time

Elimination of time spent searching for patient notes

Enhanced management of out of hours phone calls thereby improving clinical safety

Improved audit and monitoring

Application to hospice practice

We were one of the first IPU’s to ‘go-live’ with Systmone and the improvements have been wide-reaching for both patients and staff.

Nicola Butterfield

Lead Nurse, IPU

Birmingham St Mary’s Hospice
P83 Applying NHS productive series model to hospice care – releasing time to care
Authors: Goodchild Cathryn , Draper Maggie
Published: October 2013

Introduction

Productive Ward and Productive Community are a series of modules designed to deliver sustainable service improvement, and are well established in the NHS. We decided to adopt the model, fund the education and development and apply it to:

Hospice Inpatient Unit

Hospice Day Care provision

Hospice Community Palliative Care team

Hospice Lymphodema Service

Aims

To use the series across the organisation to improve efficiency and consider processes in a systematic way using a tested methodology. This will lead to reduction in time wasted, duplication, frustrations etc and the aim is that the time saved can be re-invested in direct patient care. This involves a culture shift within the organisation to adopt new ways of working and is unique within the Hospice movement. The aim is to embed new improved ways of working across the organisation and to empower staff from the “ground up“.

Methods

External training delivered

Steering group established

Launch in different teams and establishment of champions

Work streams to deliver 2 modules in first year :

Knowing How We Are Doing– public display of information e.g.: response times, no of referrals, falls, staffing levels/ sickness rates/ caseload averages/RAG rating etc.

Well Organised Working Environment/Ward–review of referral process and pathway, evaluating stock levels and standardisation of store cupboards/ clinician’s bags etc.

Evaluation

The Productive Series model encourages:

Continuous evaluation and feedback to teams.

Ownership of changes, sustaining improvement and embedding practice

Empowering of staff across bands and settings to deliver the organisation’s vision and release time to care.

Further information to follow regarding roll out, changes adopted and impact evaluated by October 2013
P84 Quality monitoring in a hospice
Authors: Flanagan Pauline , Roberts Michelle
Published: October 2013

Background/context

Hospices are expected to quantify the quality of care and demonstrate outcome improvements1,2. There has been a change in emphasis from system and process to outcome1-4. However, little hospice-specific guidance is available1-6.

The DMH produces quarterly quality monitoring (QM) reports and is seeing useful intelligence.

Aim

To produce hospice-specific intelligence

To evidence that the hospice remains low risk.

Approach used

QM is part of the hospice’s well-established clinical governance function. Reports use monthly (& rolling annual) data with published statistics (Office of National Statistics; National End of Life Care Intelligence Network).

Electronic patient-notes enable data collation in a way that was impossible with paper notes.

Hospice-specific outcome indicators have been developed to evidence compliance with outcome measures given in the NICE 2011 quality statements2and the essential standards of quality and safety4.

Outcomes

The hospice has robust evidence of the following:

Number (%) and diagnosis of patients receiving care

Primary care aim

Equity of access

Impact of the 24/7 advice line

Percentage of hospice

deaths of patients offered an ACP

patients achieving their preferred place of care.

Percentage of in-patients

on the LCP at the time of their death.

assessed for risks associated with moving and handling.

experiencing minor/serious injury.

assessed for tissue viability within 6 hours of admission.

Waterlow score - an indication of patient frailty.

The DMH can demonstrate that twice as many EOL patients receiving care die at home as those not referred to the hospice.
P85 Developing audit in a hospice
Authors: Gregory Amanda , Myers Laura
Published: October 2013

The clinical audit group (CAG) at an independent hospice aims to motivate and encourage staff to undertake audit and to provide support and education for this activity. Many clinical staff have audit included in their job description. It was, however, observed that, while some staff regularly and competently carry out audit, some have not participated in audit and others find it difficult to conduct audit and report on their work, with variable knowledge of the theory and practice of audit. The CAG have, therefore, sought to implement a more robust audit registration and approval system alongside a programme of education to develop audit skills across the hospice in order to be able to produce credible and appropriate audit that demonstrates quality and areas for improvement. A set of resources to support audit was produced and made accessible to hospice staff electronically. A local step by step guide to registering an audit was produced. This included ensuring that CAG members review all audit registrations and recommendations for refinements are made before an audit is approved to start. The education team provides support to plan audits, including survey design, analysis and presentation of data. An audit of audits revealed that the quality of audits had improved (following implementation of some of these steps), while highlighting the a need to strengthen audit reporting, action plans and re-audit planning. A regular newsletter, highlighting audit activity within the organisation has been produced and audit activity has been reported in the general hospice newsletter. More recently, a questionnaire issued to the CAG members demonstrated gaps in knowledge and understanding, suggesting the need for further training to enable them to support their colleagues in undertaking audit. A programme of education has been designed to meet this need. The structure and membership of CAG is also being reviewed.
P86 Audit mapping against CQC Outcomes
Authors: Stanford Jo , Phillips Ruth
Published: October 2013

Audit mapping against CQC Outcomes

Introduction

The Care Quality Commission (CQC) requires agencies to provide evidence that they are meeting the CQC outcomes. Clinical Governance is a framework through which organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care.

Aims

The Clinical Governance Reporting Guidelines have been reviewed and restructured inline with the Care Quality Commission (CQC) outcomes. The purpose of this exercise was to streamline the audit reporting process inline with the CQC, make the audits more meaningful, and avoid duplication of work.

Methods

Using the hospices existing Clinical Governance Audit Programme, where possible, each CQC outcome was allocated to an audit. Some audits were allocated more than one ‘outcome’

Results

Below is an example of how some of the audits are mapped against the CQC Outcomes.

CategoryAudit titleReference numberFrequency of auditCQC OutcomeInvolvement and InfoPeer – Activities1.16 monthly1a, 1b, 1c,1f,Safeguarding and SafetySafeguarding3.7Quarterly4b, 4i, 7a, 7b,Personalised Care, treatment and supportSymptom Management2.46 monthly1a, 1b, 1c, 4d, 4e, 4k, 4w, 9a,Quality of managementA&I5.1Quarterly4b, 11a, 11c, 16c, 20a, 20bComplaints5.2Quarterly16a, 17a, 17e, 20f, 20h, 20i

Discussion

The children’s hospice audit programme meets and provides evidence for many of the CQC Outcomes. Evidence for those the outcomes that are not met, can be provided in various other ways.

Conclusion

This mapping exercise has been helpful in identifying how the hospice was already providing evidence for the CQC, but also helped to identify any shortfalls. Some audits have been reviewed to ensure that they serve a purpose and also can provide evidence for the CQC.
P87 May I?: Audit of documentation of consent for care
Authors: Birch Helen , Baldry Catherine , Groves Karen , Balmer Shirley
Published: October 2013

Aims

Consent to valid treatment and care is central in all forms of healthcare: patients have a fundamental, legal and ethical right to determine what happens to them. Hospice at Home works with community services to fill gaps in end of life care for patients whose preferred place of care is home. Care is provided predominantly by health care assistants, and a few registered nurses (RN’s). RN’s receive consent training in their nursing studies. The aim was that all hospice at home evaluations should clearly state ‘consent status documented for all care interventions given’.Many patients are unconscious and unresponsive when care interventions occur. Hospice policy states ‘Consent status must be documented for all personal and invasive procedures’. It was difficult to see at a glance if consent status was recorded in the care plan.

Method

A retrospective (random) audit of 204 care plans was performed to determine if consent status for personal care was documented. Confidentiality was maintained at all times. 77% records completed by HCAs and 23% by RNs

Result

Cycle 1-74% of care plans had consent status recorded. 26% records had no evidence of consent status documented. Further analysis identified only 37% of RNs had recorded consent status. Training needs were identified and implemented in various ways to include Consent, Mental Capacity Act (2005), and Record keeping.Cycle 2Re- audited 6 months later using same criteria and data collection tools. - 93% of care plans had consent status recorded for personal care, improvement in the number of RN’s recording consent status- 77%ResultsCare plans now checked daily to identify staff not adhering to policy. The need to replicate audit in other areas of the Palliative Care Services was highlighted. Induction and in- service training now includes education on consent and good record keeping for all grades of staff. Re-audit in 12 months to ensure improvement continues
011 A Hospice Experience of Patient-Led Assessments of the Care and Environment
Authors: Flanagan Pauline , Williamson Nicci , Grocott Ruth , Scaife Geoff
Published: October 2013

Background/context

In April 2013, the Department of Health (DH) introduced patient-led assessment of the care environment (PLACE) to give patients a strong voice in the assessment of privacy, dignity, food and cleanliness in hospitals offering NHS-funded care. Carers are eligible to undertake this assessment on behalf of the patient.

The DH and NHS Commissioning Board recommend that hospices participate in this initiative, which provides a non-technical view of the buildings and non-clinical services and is based on a visual assessment against defined criteria and guidance.

Aims

To undertake the first PLACE assessment of the DMH.

To use members of the Carers’ Forum to undertake an assessment of the organisation.

Approach used

The Carers’ Forum members were invited to complete the PLACE assessment. Those involved needed to be objective, unbiased and have the confidence to be open and honest.

Two carers agreed to undertake the assessment, accompanied by the Clinical Governance Manager (CGM) and the deputy Infection Control Nurse; this gave the required PLACE Team ratio of patient to staff assessors.

The carers were classified as volunteers, underwent a standard CRB check and were issued with a name badge.

All assessors undertook training provided by the Health and Social Care Information Centre (HSCIC).

PLACE scoring was made against standard criteria and reflected what was seen on the day.

Outcomes

DMH results were published on the HSCIC website.

The hospice is working with the PLACE team to make the assessment more applicable to hospices.

The carers felt that they were contributing to the quality process in a positive and constructive way.

Application to hospice practice

Participation in a national initiative to measure quality from a patient/carer perspective.

Access to national benchmarked data, which is accessible to the CQC, NICE, NHS Commissioning Board, DoH, Local commissioning groups and local Healthwatch.
P88 Using an outcome measure in specialist palliative care settings
Authors: Walker Gail , Cochrane Evelyn
Published: October 2013

Background

More and more people are living with chronic disease near the end of their life, therefore palliative care needs are increasing. Outcome measurement has a major role to play in improving the quality, efficiency and availability of palliative care.

Aim

To capture what patients think about the impact of care on quality of life and their major concerns and on key symptoms.

Method

Patients were invited to participate in a 6-month pilot using the St Christopher’s Index of Patient Priorities (SKIPP) questionnaire within the Hospice, Day Care and Community Macmillan Nurse Team.

Data was collected and analysed using the recognised tool from St Christopher’s Hospice.

Results

Findings from this pilot would suggest that patients did benefit from input from the Hospice, Day Care or Community Macmillan Nurse Team and identified a positive shift in how things were going for patients over a period of time. Though the number of patients was small and there were some patients who were unable to complete the questionnaire in full, there was still significant evidence to suggest a positive impact on patients’ quality of life, key symptoms and major concerns.

Discussion

It is recognised that obtaining valid and reliable measurement of the outcomes achieved by palliative care for patients is extremely challenging often because patients are too ill or because of fluctuating and changing needs. However the questionnaire takes account of response shift, a well known phenomenon in which a persons’ perception of subjective sensations can change over time.

Conclusion

Having a tool such as SKIPP has been deemed a very useful way of evaluating the impact three areas within Specialist Palliative Care have on a patients quality of life, key symptoms and major concerns. It is planned to repeat this exercise again for a 6 month period.
P89 You don’t get a second chance to make a first impression…
Authors: Finnerty Jane , Haywood Chris , Ellis John , Turnbull Ian , Jones Debbie , Bennett Pat
Published: October 2013

Background/context

Fostering good first impressions of a care setting are an important component of building confidence and providing reassurance for patient’s, carers, relatives and visitors. The 15 Steps Challenge is a toolkit devised by the NHS Institute for Innovation and Improvement in 2012 to help staff, patients and others to identify improvements that enhance the patient experience and environment. Initially15 Stepswas developed for use in Hospital wards but we adapted it for the whole Hospice environment.

Aims

To use an accredited quality improvement tool and clear framework to facilitate in depth observations of quality care across four domains:

Welcoming

Safe

Caring and Involvement

Well organised and calm

Approach used

Readily available easy to use literature to guide implementation

PowerPoint slides for awareness sessions and training

Small team to undertake the review (included 1 patient/carer representative, 1 non-clinical staff and 2 clinical staff)

Dedicated toolkit

Engagement with internal stakeholders

A structured walk around the entirety of the Hospice environment

Presentations to different staff groups on findings

Focus on positive feedback and sharing good practice

Repeated at 6 months to show achievements and improvements

Outcomes

Explicit patient/carer perspectives were taken into account.

Detailed action plans with key positive impacts on the working environment.

Supports the Care Quality Commission’s Essential Standards

Case study for evaluation (IES) by telephone survey.

Application to Hospice Practice

Use of the 15 Steps toolkit clearly effective as a quality improvement initiative

Re-audit has shown improvements in all domains

Heightened staff awareness; quality is everyone’s business

Strengthened communication across services

Adaptable for use in Fundraising/Trading Company improving quality across the organisation.

The Challenge can be repeated on a regular basis to cover all areas and to ensure that improvements are being progressed and maintained.
P90 Delivering an integrated end of life care service for greenwich – the benefits and learning two years on
Authors: Heaps Kate
Published: October 2013

Background

The Greenwich Care Partnership (GCP) was born out of the Marie Curie Delivering Choice Programme (DCP). Three service providers were asked to develop the service, the Hospice acts as the prime contractor and sub-contracts others to deliver specific elements of the service.

Aim

The service aims to increase the number of people who die in their place of choice by ensuring that appropriate health and personal care services are available and that their families have sufficient support.

Approach used

The service operates alongside core services to support high quality care across four areas:

Care co-ordination

Rapid Response Service

Personal care and support

Night care

Although the elements of service are provided by different providers, they work together to ensure care is seamless 24/7.

Outcomes

The GCP was commissioned as a “test and learn project”; now in it’s 3rdyear, the service has developed in response to local need and resources have been flexibly allocated to provide responsive, high quality care.

Each provider has signed up to the success of the project and each has an equal stake in ensuring that the service meets its key performance indicators.

The project has succeeded in supporting an increase in home and hospice deaths and a reduction in hospital admissions, length of stay and deaths.

Application to hospice practice

The model and contracting arrangements have attracted National interest amongst Hospices and commissioners, and has been cited as a model of good practice for others to build on.

Thinking strategically about the role of hospices

The GCP model is a natural extension of the Hospice service, producing efficiencies and quality improvements. With the current proposed model for palliative care funding, Hospices will need to take on the role as prime contractors in order to survive.
P91 Partnerships: A public health interpretation of living well and dying well
Authors: Zammit Rachel , Horton Siobhan , Atkin-Ward Julie
Published: October 2013

Aim

The overarching aims of the Cheshire Living Well, Dying Well Programme are to improve health and well-being by supporting a change in public knowledge, attitude and behaviour towards death, dying and loss and therefore make living well and dying well the norm.

Background

St. Luke’s Cheshire Hospice engaged in a community consultation process which highlighted that local partner organisations supported a co-ordinated public health approach to raise awareness and change behaviours in relation to death and loss. St. Luke’s secured funding and a commitment of engagement from Macmillan Cancer Support, which included establishing a dedicated role to centrally lead and drive forward the agenda in Cheshire.

Methodology

As death, dying and loss is a cross-cutting issue, it is important that a multi-faceted approach is developed and delivered in partnership. It is also important that the work is championed and embedded at strategic, operational and community level. The programme of work provides structure and support to enable partners to work together towards achieving the shared aim.

Findings and Recommendations

Following consultation, six strategic areas have been identified; Partnership and Strategy Development, Financial Housekeeping and Future Planning, Resource Development, Public Education, Compassionate Communities and Healthy Workplace.

The work is also being championed at Health and Well-being Board Level.

Highlights include:

The formal launch and implementation of Cheshire Living Well, Dying Well Partnership

Identification of Cheshire Living Well, Dying Well Champions

Development and implementation of a range of resources (including support and training sessions for the public, staff and volunteers)

Development and implementation of Compassionate Community Volunteer Models

Presentation of the Programme at a local, regional, national and international level

Conclusion

Improving the well-being of communities by normalising death and loss is a multi-agency issue and not singularly confined to those in the health arena.

This innovative approach identifies and enables partnership activity and the collation of evidence to progress further, with a view to mainstreaming the work.
P92 Isabel hospice benefits advisor partnership
Authors: Ford Lesley , Dodd Helen
Published: October 2013

Is a bel Be nefits Advisor and East Herts Citizens Advice Ser vice Partnership and supported by the Big Lottery Fund.

The partnership between the Isabel Hospice and East Herts Citizens Advice Service (EHCAS) was formed in 2010 to enhance the services for patients assessed as requiring support for financial, legal matters, employment, utilities, debt, housing, immigration and nationality, taxation and discrimination as well as relationship advice to ensure that the most up to date information is made available.

Evidence has shown that people living with life limiting illness such as cancer do not receive benefits and other forms of support for which they are eligible. The complexities of the welfare system can seem overwhelming at a time when they are struggling to come to terms with their situation. Isabel Hospice is the service provider for Specialist Palliative Care in Eastern Hertfordshire that has a population of around 358, 000.

From October 2010 to June 2012 the Isabel Hospice Clinical Nurse Specialists provided benefits assistance to more than 1,700 clients. The Benefits Advisor was then able to offer more specialist advice to 400 clients.

It is imperative that the Benefits Advisor role is kept fully up to date with welfare reform and able to ensure that the Clinical Nurse Specialists are kept updated with changes.

It is estimated that the annual amount awarded to those under the care of Isabel Hospice as a result of the Partnership was in excess of £368,000. The top five benefits in which assistance has been given were for Disability Living Allowance, Carers Allowance, Bereavement Support and funeral payments, council tax benefit and employment allowance.

The Partnership has enabled the East Herts Citizens Advice Service to reach clients that it would not have been able to before. At such a stressful time it can be difficult to fit in a further appointment or even travel to the EHCAS - working collaboratively has enabled more patients and carers to receive the appropriate services to enhance the challenges faced when living with Life Limiting Illness either in the home, Day Services or our In- patient Unit.