Patient/ Family Involvement

Introduction

Patient and public involvement and engagement (PPIE) is essential to delivering patient centred, quality research. Older adults constitute an increasing proportion of the surgical population but are unintentionally excluded from traditional models of engagement.

We describe the process and outputs of conducting PPIE to support future research examining the scale up of CGA-based perioperative services such as POPS (Perioperative medicine for Older People undergoing Surgery).

Methods

Patients undergoing elective surgery at four NHS hospitals in England and Wales were asked to consider participation in PPIE. Twenty-two expressed interest; nine offered to participate, six declined due to their own or relative’s ill health, two withdrew, five did not respond.

Six were able to participate on proposed dates. Three had access to email and video calling to join a group Microsoft Teams call. Three took part in 30-minute individual telephone calls. A patient representative from Centre for Perioperative Care (CPOC) acted as peer facilitator for the interview structured around five pre-agreed questions.

Results

Six older patients contributed through PPIE to codesign research examining perioperative services for older people, with three volunteers for long-term involvement as part of a research steering group. The group offered insight into their experience of traditional and POPS-led perioperative pathways.

This group emphasised the need for coordinated care, delivered by clinicians with a holistic understanding of the whole perioperative pathway, the need to reduce duplication of information provision and diagnostic testing and a proactive approach to hospital discharge planning.

Participants agreed that POPS services should be established nationwide and that research should focus on implementation and scale-up. The need for PPIE in the dissemintation of future research findings was highlighted.

Conclusion

Involving older adults in PPIE is possible and necessary to deliver healthcare services, including novel perioperative care pathways, tailored to service users.

Introduction:

Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national Irish Health Service Executive (HSE) guidelines after education sessions in a Model 3 Hospital.

Methods:

A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants.

Results:

Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%.

Discussion:

This audit elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. We posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan.

Conclusion:

Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.

People from ethnic minorities face additional challenges in hospital. These contribute to poorer progress and outcomes. We set out to develop an online resource to help hip fracture teams provide answers to questions commonly posed by people presenting with hip fracture, and to address inequalities in patients’ and their families’ access to information. Method In 2021 we surveyed all 167 hospitals in England, Wales, and Northern Ireland which look after people with hip fracture – to identify which provided printed or digital information, and which made this available in languages appropriate to their local population. Results Most hospitals (70%) claimed that they routinely provided printed information about injury, surgery and recovery, but only 26% could say that they provided this in languages appropriate to their local population. The equivalent figures for digital forms of information were 23% and just 10%. We produced, piloted and finalised an English language template in discussion with people attending our hospital. Initial Google translations of this were circulated to clinicians within our department who were familiar with this patient group and able to read, edit and sign off versions in other languages. We surveyed these editors and 71% described the final document as highly useful. However, nearly two-thirds had identified limitations in the Google draft and 50% reported needing to modify technical elements of the text. One-third (36%) spent more than two hours editing the text to a form they felt would be accessible to patients. Conclusion We would recommend this approach to those working with other conditions and other patient groups, as there is clearly a need for information to meet the needs of the patient. We plan to extend our portfolio of 19 languages (the first languages of >3 million people in the UK alone) in collaboration with clinicians fluent in other languages.

Aims

Understanding patients’ wishes regarding CPR before surgery is crucial. This study aims to assess the impact of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision on anaesthetists' actions during theatre.

Methods

We used WhatsApp, to present a scenario of an 83-year-old with ischemic heart disease, cognitive impairment, and an acute hip fracture. Anaesthetists were asked how they would handle various intraoperative events and whether a prior DNACPR decision would influence their actions.

Results

A total of 74 UK anaesthetists, all but one of them consultants, completed the anonymous survey. A surprising number N=27, (37%) of respondents indicated that prior knowledge of a DNACPR decision would have altered their preparedness to anaesthetise the patient.

Despite a pre-existing DNACPR decision N=68 (92%) stated that they would attempt electrical cardioversion if a patient became hypotensive with a regular broad complex tachycardia, as would N=65 (88%) in response to ventricular fibrillation during surgery. N=36 (49%) would initiate chest compressions in theatre if patient failed to respond to electrical cardioversion, but only N=2 (3%) would continue with intubation, ventilation and discussion with critical care if the patient failed to respond to three cycles of compressions and cardioversion.

Conclusion

It is important for anaesthetists to discuss the nuances of different elements of CPR as part of patients’ pre-operative assessment, as it is much more likely to be successful in theatre than in the ward or community settings that most DNACPR discussions will consider.

Raising the topic of resuscitation can lead to anxiety among patients and their families, Our study has shown that most anaesthetists will set aside a DNACPR decision anyway if problems arise in theatre.

Introduction 

Shared decision making (SDM) is a vital element in ensuring a more personalised approach to care.  The Peri-operative Care of Older People in Surgery (POPS) Team adopts enhanced SDM in frail patients referred for elective urological or colorectal surgery using the BRAN (benefits, risks, alternatives, nothing) approach. In frail populations, there is a complex balance between providing appropriate access to surgery and minimising exposure to potentially harmful procedures. SDM can help to negotiate this balance. This study aimed to evaluate the patient perception of the SDM process.  

Method 

Patients and/or their family proxy attending the POPS clinic between December 2023 – March 2024 were invited to participate in a follow-up telephone interview. The content of the interview was based on the CollaboRATE tool, a quick 3-question, validated questionnaire used for evaluating SDM from the patient’s perspective.  

Results 

Overall, 22 out of 29 (76%) consenting patients and/or their proxy were contactable and well enough to participate in the CollaboRATE evaluation.  

All (n=22, 100%) reported that the POPS team had made ‘a lot’ or ’every’ effort in helping them understand their health issues and listening to what mattered most to them. 86% (n=19) thought they had made ‘a lot’ or ‘every’ effort to include what mattered most to them in deciding what to do next. Patients/proxies were also able to add unstructured comments which were also positive: 

 ‘the staff were excellent - my husband transformed in front of my eyes, he was so happy with the decision.’ 

Conclusion 

The SDM process within the POPS clinic is highly rated and valued by the patients.  Considering that SDM also reduced the number who opted for surgery by 30% (April – July 2023; 9 out of 30 chose not to have surgery), it can offer added value to the individual and the wider system. 

Background Osteoporosis is a global health concern that is likely to increase with a rapidly ageing world population. It affects one in three women and one in five men over the age of 50. Although there is a large body of qualitative research exploring the experience of living with osteoporosis, far fewer studies have focused on men. We aim to explore the meaning making processes of men with osteoporosis. Methods We interviewed 13 White British men aged 63 to 94 with an osteoporotic vertebral fracture We used the six stages of reflexive thematic analysis: familiarisation with the data; coding ; generating initial themes; developing and reviewing themes through discussion; refining and naming themes; writing up. Results We developed six themes giving insight into the existential losses of men with osteoporosis: there has been a step changed coming; I am no longer what I once was; the change in me is de-meaning; I want to know where I am heading; I want to know why this happened to me; I want to know what’s wrong and how to fix it? We describe moral narratives used in defence of self. Conclusions Our findings highlight the challenge of deciphering the symptoms of osteoporosis and age-related changes. We also see the impact on self and a struggle to repair self. Healthcare providers are in a unique and privileged position to accompany their patients at points of Existential Crisis. As such, they attend to the repair of both identity and body. This comes with an ethical responsibility and has implications for clinical education. Health professionals should feel equipped to be alongside people facing existential losses. Qualitative Research and can give valuable insight into the phenomenology of illness and contribute to improvements in care pathways.

Introduction: Clinical decision making for older adults with multimorbidity can be complex and demanding. When facing complex decision-making, patients may experience decisional conflicts, leading to low treatment adherence, adverse health outcomes, and increased utilization of health services, etc. To address these issues, patient decision aids (DAs) have been developed and utilized in the decision-making process to facilitate informed decisions. The aim of this study is to identify DAs developed for patients with multimorbidity and assess their quality.

Method: We searched full-text papers on nine databases. Any article utilizing a DA for patients with multimorbidity was eligible and DAs for making medical decisions at any point were eligible. We used the International Patient Decision Aid Standards (IPDAS) checklist to assess the quality of DAs.

Results： In total, ten articles including six DAs were included. Two DAs targeted for the older patients with multimorbidity. Most DAs didn’t focus on specific treatment choices but rather aimed at improving the overall quality of life for patients with multimorbidity. The targets of these DAs are including setting goals about health care, preparing for conversation with doctors and taking ownership for the decisions. IPDAS checklist revealed that only one DA met all qualifying criteria and provided comprehensive choice. Three DAs were deemed to have poor quality due to their failure to provide the pros and cons of decisions. The quality of the remaining DAs was difficult to judge due to incomplete versions.

Conclusions: DAs for patients with multimorbidity were few and had poor quality. Designing DAs for this patient population presents challenges given the complex nature of multimorbidity and its lack of specific treatment options. Future development should focus on adhering to the IPDAS checklist, provide more information and possibility, and aim at improving the quality of life for patients with multimorbidity.

Introduction

Fall-related injuries such as fractures are on the rise as the older adult population grows in New Brunswick, Canada. These injuries can lead to hospitalization and transitions in care that are complicated for patients and families. The objective was to investigate the impact of patient navigators (PNs) working alongside the healthcare team on patient and family experiences, as compared to the usual standard of care (SOC), for adults aged 65 and older admitted with a fracture to an Orthopedic Unit at one hospital in New Brunswick.

Methods

A concurrent embedded mixed methods design, in which the quantitative randomized control trial had an embedded qualitative component. The results for the family caregiver qualitative component, which used an interpretive description approach, are presented.

Results

Semi-structured interviews were conducted and thematically analyzed for 15 family caregivers (8 PN group, 7 SOC group). The SOC caregivers, six women and one man, had a mean age of 64.6 years (SD=6.9 years). The mean age of the 8 women in the PN group was 61.3 years (SD=10.1). All participants in both SOC and PN groups self reported their ethnicity as white. Thematic analysis found that SOC group caregivers discussed patients relying on support from family and friends throughout their care journey, whereas caregivers in the PN group predominantly discussed finding PNs supportive and helpful. Both groups discussed the ongoing stress that they felt throughout the care journey of the patient for which they cared for; however, for the PN group this topic was less prevalent.

Conclusions

This study provides an understanding of the positive impacts a patient navigator can have on older adult inpatient care and transitions in care. Patient Navigators were shown to be helpful to families, particularly those of patients with higher care needs and fewer family supports.

Introduction

There are multiple national drivers promoting person-centered healthcare. In the face of competing pressures, patient experience is often compromised. 

Aim: To increase the percentage of service users in our orthogeriatric rehabilitation ward rating experience as more than 6/10 to 90% by June 2024.

Methods

A multidisciplinary project using quality improvement methodology.  Patients and carers were involved throughout. Patient, staff and carer interviews shaped improvement themes and change ideas. Broad themes identified:

•             Communication

•             Provision, and facilitation of, ward activities 

•             Environment

Several, cost neutral, tests of change were studied: weekly exercise class, mobile library, ‘activities trolley’, music concerts, volunteer recruitment, improved signposting and coordinating weekly relative update.

Run and SPC charts were used to study impact. Measures used:

•             Outcome: Patient and carer satisfaction using 10-point Likert scale (1=poor, 10=excellent) in weekly, random cohort (P-chart). Mapping themes over time.

•             Process: Minutes of physiotherapy delivered/week. Number of patients participating in activity other than PT/OT (C-chart). Percentage of relatives updated by MDT/week

•             Balancing: Length of Stay (LOS). Readmission within 1-month. Staff Feedback. Inpatient falls.

Results

•             The % of patients scoring experience >6/10 increased over the project but did not meet ‘special cause’                criteria. Feedback themes shifted positively.

•             The median percentage of relatives receiving a weekly update increased (45% to 78%).

•             Participation in activities improved, with special cause variation observed. The amount of physiotherapy delivered each week increased by 3 hours due to exercise classes.

•             There was no significant change to falls, readmissions or LOS.

•             Staffing, covid outbreaks and workload impacted negatively during the project. 

Conclusions

‘Experience’ is individually unique and cannot be improved with a unilateral approach.

Using continuous feedback from patients and carers, we tested multiple interventions across several areas, demonstrating positive changes.

Patient experience is challenging to measure quantitatively but should not deter improvement work in this area

Background: Informal caregivers play a critical role in providing continuous, unpaid care to individuals with dementia, helping to improve their quality of life and reduce the demand on formal care services. The caregiving relationship is a complex, dyadic process that can have profound effects on both the caregiver and the care recipient, underscoring the need to alleviate caregiver burden and support their well-being. Understanding the motivations behind why individuals take on caregiving roles is essential, as it can predict their experiences, perceptions, and the overall impact of caregiving on their lives. A systematic review by Greenwood and Smith identified key motivators for informal caregivers. Additionally, there is substantial evidence that cultural perspectives and social values significantly influence caregiver experiences and motivations.

Methods: This systematic review aimed to update the findings of Greenwood and Smith by examining recent research on the motivations behind caregiving across different demographics, ethnicities, and cultures. Six electronic databases were searched from August 2018 to January 2024. Titles and abstracts were screened using machine learning methods (ASReview), and a subset of full texts underwent duplicate screening. Eligible studies were appraised using the Mixed Methods Appraisal Tool (MMAT), and data were extracted and organized into thematic categories.

Results: The initial search yielded 1,843 articles, of which 37 studies met the inclusion criteria after deduplication and screening. Cultural explanations for caregiving motivations included themes such as familism, ethnic identity, cultural values and beliefs, a sense of obligation, and personal fulfillment.

Discussion: Cultural perceptions and social values play a significant role in shaping caregivers' experiences and perceptions, which in turn influence families’ engagement with and acceptance of formal care and support services. These findings highlight the need for further research to guide the development of culturally sensitive psychosocial support interventions tailored for diverse caregiving populations. Such personalized approaches are essential for reducing caregiver burden and fostering an inclusive caregiving environment that respects the unique motivations and values of caregivers from various cultural backgrounds.