HSCP Innovation Awards Finalists
Pen to pad: Health and Social Care Professionals come together to lead and drive change from paper to electronic records at St James's Hospital (Marie Byrne & Deirdre Gilchriest)
Name: Marie Byrne (SCOPe Informatics lead), Joanne Dowds (Physiotherapist), Joanne Finn (Physiotherapist), Deirdre Gilchriest (Speech and Language Therapist), Aine Higgins (Dietitian), Sarah Lavan (Speech and Language Therapist), (Ruth McKnight (Occupational Therapist), Halog Mellett (Dietitian), Neans Ni Rathaille (Medical Social Worker), Patricia Reilly (SCOPe Administrator), Kate Tierney (Physiotherapist)
How it works
The SCOPe directorate comprises 5 HSCP departments; Social Work, Speech and Language Therapy, Clinical Nutrition, Occupational Therapy and Physiotherapy. SCOPe aimed to move from a paper based to an electronic documentation system. Each of the five departments, together with the hospital IT department, were responsible for the design and implementation of clinical assessments and notes, outcome measures, patient reported questionnaires, standardised assessments, discharge documentation and referrals to other agencies including PCCC. Electronic documentation is now used across emergency department, inpatients, outpatients and outreach services. With the electronic record multiple users can access patient information at the point of care to assist patient care and decision making. Information is readily available to use for management of services, research, audit and QI purposes.
The transition of all SCOPe departments to electronic documentation started in May 2014 and was completed by June 2016. As part of the evaluation of the project surveys of patients and staff were conducted. The use of electronic documentation has been perceived positively by patients, HSCP and non HSCP staff. Staff feedback stated that electronic documentation was more efficient than paper records and improved access to patient records.
Benefit to patients
- Multiple users can access patient information at the point of care to assist in patient management; no time is wasted waiting to access notes.
- There is reduced duplication in recording information from the patient.
- Patients feel the system is more secure and as or more efficient
- Concerns were expressed by patients regarding potential hacking and access. As an action to diminish these concerns, a FAQ on electronic documentation was developed in collaboration with the hospital Patient Advocacy Group. These are posted on the hospital web page.
- Having a clear vision and objectives which are shared early with clinical staff
- A pragmatic approach of working with what you have helps with implementation and providing proof of concept.
- It is never the right time, don’t wait for it, just do it.
- Highlighting and celebrating early successes.
Scope to grow
St. James’s Hospital is embarking on a large hospital wide project aimed at transferring all patient documentation, including prescriptions from paper to an electronic patient record. Our learning has proved invaluable. Identified risks and benefits of our project are transferable. Experience with a variety of mobile devices has been useful. We helped begin a cultural change within the hospital, whereby the electronic patient record is seen as a valuable source of clinical documentation. We have linked with colleagues in the HSE regarding the National Shared Record and have had a focus group to share our learning. This project is in line with the National eHealth strategy aiming to create a national individual electronic health record allowing for integrated healthcare across all settings.
Striving for Excellence in Care for People with Motor Neurone Disease: The Evolving Journey of the Multidisciplinary Team (Deirdre Murray, Lesley Doyle and Kitty McElligott)
Our submission is Striving for Excellence in Care for People with Motor Neurone Disease: The Evolving Journey of the Multidisciplinary team because, achieving best quality care inherently means constantly evolving, evaluating and improving services.
Motor Neurone Disease (MND) is a rapidly progressive neurological disease with no known cure. MND results in rapid decline in the function of muscles used for hand movements, walking, talking, swallowing and breathing with cognitive and behavioural change in some patients. Death from respiratory failure occurs within 3 to 5 years. Symptoms develop and progress at an often rapid pace requiring prompt identification and timely management by the team.
Our HSCP care is predominantly provided through our out-patient multidisciplinary clinic. The MND clinic in Beaumont Hospital has been designated the national centre for expert management of MND by the HSE National Rare Diseases Office. We see about 80% of people in the Republic of Ireland living with MND. The HSCP team is comprised of Dietetics, Occupational Therapy, Physiotherapy and Speech and Language Therapy. We work with doctors, CNSs and researchers. Patients avail of multiple services within one clinic appointment. We help people with MND to adjust and cope with the impact of this devastating disease.
We communicate clinic outcomes to HSCPs working in other clinical settings and offer advice on managing the complex issues of these patients. We also prioritise education including running an annual multidisciplinary study day.
The beneficial effects of a multidisciplinary clinic are well established and evidence based. Survival in patients attending the Beaumont Hospital multidisciplinary clinic has been compared to devolved care and Irish patients attending our multidisciplinary clinic live significantly longer.
As a team, we always aim to maximise the patient outcome through real time communication with the wider MND team and are frequently involved in complex iterative decision making processes. This can result in the more timely identification of problems and allows immediate holistic plans to be made for our patients.
The HSCPs have been involved in many quality improvement initiatives. A patient flow whiteboard is used to maximise the efficiency of the patient’s time in clinic. The current format was developed based on a number of PDSA cycles and a patient activity mapping study. A discussion record sheet was devised to capture all key patient discussions. This includes decisions made regarding gastrostomy insertion, ventilation, spasticity management etc. We have developed rapid access pathways to important interventions such as RIG tube change and shoulder injection. Patient feedback during patient activity mapping has been used to prioritise interventions and development of services.
A culture of research embedded within the clinical service promotes innovation and excellence in care and maintains the clinical focus of the research. We continue to make adjustments to the structure of our clinic to make our clinic as efficient and effective as possible. We also aim to develop resources for patients attending our clinic for the first time. This multi-disciplinary approach to care has produced an exemplary service driven to ensure best practice in this complex patient group.
lntroduce a virtual fracture clinic in OLOLH with the aim to reduce the number of consultant clinical re-views in the fracture clinic in OLOLH from 100% to 85% by March 2017 (Ian McGovern):
The aim of this project is to reduce the number of consultant led clinical reviews from 100% to 85% percent in Our Lady of Lourdes Hospital (OLOLH) fracture clinic by March 2017.
Our lady of Lourdes Hospital Drogheda is the trauma centre for the north east region of Ireland with 7 fracture clinics per week seeing 19,586 patients in 2016. Clinics can have as many as 100 attendances with some patients waiting 3 hours to be seen. A re-designed fracture clinic process creates the opportunity for simple fractures to be managed by the multi-disciplinary team via a protocol driven Virtual Fracture Clinic (VFC).
The HSE Framework for quality improvement was used to guide the initiation, planning and implementation of the project. Data was collated to determine condition trends, which demonstrated that many patients can be safely managed by self care or physiotherapy rather than the need to see a consultant. The voice of the patient was captured to ensure any re-design meets the needs of the service user. Protocols were agreed with all health-care providers for conditions suitable to be managed in a re-designed patient pathway. Stakeholders were engaged with the planning and formation of project. Each suitable patient is treated in the emergency department (ED) and thereafter x-rays and ED notes reviewed virtually by the consultant. The patient does not need to attend the clinic, but is contacted by phone and a plan of care initiated.
Results & Conclusion
The new process is evaluated by auditing the numbers attending the virtual fracture clinic and analysing patient satisfaction and experience. Results to date indicate a positive trend towards reduced number of consultant led appointments with 994 patients successfully managed in the new pathway. These patients are all spared at least one unnecessary attendance to hospital. An estimated cost saving of €56,985 has been achieved. Data indicates an enhanced patient experience, with a difference of 4 points in median scores on a 10 point likert scale, between a virtual clinic group and a traditional fracture clinic group. Developing the initiative across all regional sites is the next step in mainstreaming the new process.
Redefining and reconfiguring the Longford-Westmeath Primary Care Lifespan Psychology Service to meet the needs of Longford- Westmeath individuals and fami-lies (Jennifer Edgeworth & Fergal McLoughlin)
Our title reflects our experience of changing an existing system of service delivery to one that better meet the needs of our clients, whilst also addressing the reality of reduced staffing, resources, and multiple locations for service delivery.
This initiative involved a Principal Psychologist Manager, 2.5 WTE Senior Psychologists, 2 WTE Staff Grade Psychologists and 3 Assistant Psychologists more recently .
How it works: Prior to this initiative referrals were processed by individual psychologists, and clients were typically offered a 1-1 clinical intervention. Now a range of interventions are available which work from least intensive (monthly Advice Clinics accessed through self/GP referral); through to a diversity of group interventions; and on to more intensive individual interventions.
Once received, all referrals are reviewed (to determine urgency/risk), then formally processed at a weekly referrals meeting by a rotating team of two Psychologists. Decisions about the most appropriate level of intervention are taken -which can involve direct collaboration with clients, to ensure the service best meet their needs. Referrals to groups are sent to Assistant Psychologists who operate as group coordinators, contacting clients, providing information about the group intervention and when it will run. Referrals not suited for a group are waitlisted for individual intervention. Both group and individual client progress is monitored via pre-post intervention measures. If clinically indicated additional interventions/supports are offered.
- Average wait time reduced from 52 to 22 weeks (Aug 17 vs. Aug 18).
- Number of DNAs fell from 94 (Jan- Aug 17) to 38 (same period in 2018).
- Most clients (80%) attended group intervention as their first step in their care pathway.
- More individual cases opened due to greater time efficiency.
- Number and range of groups offered increased fourfold since this time last year
Benefits for Clients
- Reduced waiting time to intervention.
- Greater choice of evidence-based interventions.
- Equitable access across Longford-Westmeath to group interventions.
- Timely interventions can prevent problem escalation and entrenchment.
- By attending group interventions, clients can gain a social support network.
- Working differently it’s possible to provide a quality, timely and evidence-based assessment and intervention service: even with reduced resources and increased demands.
- Given a choice many people opt for and benefit from less intensive interventions.
- Group provision has reduced mental-health stigma and increased attendance of people traditionally reluctant to attend psychology services.
- Change in service delivery, if managed properly and with buy in from colleagues can happen quickly, and lead to more dynamic work practices.
- Excellent administrative support is required to provide responsive delivery.
- Team members must be open and willing to change.
Scope to Grow
- Additional group interventions will be offered.
- Build capacity by training other health professionals/volunteers to deliver Paths to Wellness and Solihull group interventions.
- Enhance further the Assistant Psychologist role.
- Consolidate links with universities & provide additional clinical placements.
Stay Steady Falls Prevention Programme (Mary Jordan & Caitlin Woods)
Stay Steady Mayo is an eight week exercise programme aimed at reducing falls risk and improving balance in older people living in the community. Reducing falls reduces healthcare costs.
This programme has run twice yearly since 2010. It is centred on the evidence based Otaga Exercise Programme, proven to be effective in reducing falls and improving strength, balance and cognition in older people. This programme is run by community Physiotherapists and involves the multidisciplinary team with educational talks given by the Dietitian, Pharmacist, Occupational Therapist and Continence Nurse.
Referrals are received from G.P.’s, Public Health Nurses, Acute Services and MSK Physiotherapist working in the catchment area.
The criteria for referral
- Have fallen
- Have fear of falling
- Unsteady gait or balance issues
The Outcome Measures used are: Berg Balance Scale, Timed Up and Go, Short Falls Efficacy Scale and Five Times Sit to Stand.
We pre-assess all participants individually. The participants attend for one group class per week for eight weeks and they do the exercises themselves at home twice before the next class. We provide them with our Stay Steady Booklet which contains all the exercises along with information on medications, vision, foot care, nutrition and bone health, staying active, home hazards and what to do if you have a fall. We also encourage participants to progress their walking on the days when they are not doing the exercises.
After the eight weeks the participants continue with the exercise programme at home three times a week. We follow up with a phone call at twelve weeks. The participants return at sixteen weeks when we redo the Outcome Measures.
Our results for the first five years show an improvement in balance in all three groups of the Berg Balance Scale, an improvement in TUG and an improvement in the SFES.
In the more dependant participants at pre-assessment the improvement was best seen at eight weeks though there continued to be an improvement at sixteen weeks. The more able participants showed an improvement at eight weeks and which at sixteen weeks.
The feedback from participants was that they enjoyed exercising as a group, reported increased confidence walking and surprise that they were able to do so many exercises, and generally feeling better after the class.
Key learning to date
- The best predictor of success is the participants own motivation to improve
- People do better when they can attend group classes
- As the Otaga is a progressive programme it can be used for wide variety of participants
- More dependant older people would benefit from continuing the programme for longer
- Contacting participants individually improves participation rates
- Roll out this programme in south and west Mayo.
- Link as a community resource with new Elderly Day Hospital opening in Castlebar as part of the Integrated Care Programme for Older People.
- We would like to link with Mayo Sports Partnership to provide step down programme in the community.
Improving Ulcer Preventative Offloading Care for the At-Risk Foot – An Integrated Approach (Alison Wellwood & Anita Murray)
It all began when a patient was admitted into hospital with an infected foot ulcer. On taking his medical history, we discovered that 9 months earlier he had been assessed and prescribed foot orthoses to off-load the area which had now ulcerated. This infected ulcer could have been prevented by improving the service of Offloading Care for the At Risk Foot and the provision of orthotics. There were 1,297 hospital stays for Diabetic Foot Ulcer management in Ireland in 2008 with a conservative cost estimated at €23,489.63 per stay. The National Model of Care for the Diabetic Foot recommends the use of pressure relieving / offloading measures such as Foot Orthoses to be prescribed as a preventative measure to reduce the development of foot ulcers and their recurrence once they have healed. Offloading services have presently been delivered locally by multiple private providers without any clear governance structure.
Review of Service
We decided to review what behaviour excited around management of the At Risk Foot. A review of how the service delivery for Foot Orthoses existed in the Wicklow Primary Care and St.Columcilles catchment Area, led by Senior Diabetes Podiatrist Anita Murray and Senior Community Physiotherapist Alison Wellwood was undertaken. Long waiting times (over 52 weeks), lack of clarity of procedures, clinical risk of a patient’s condition deteriorating and requiring in-patient care were some of the challenges observed.
Lack of communication and collaboration between hospital referral and community care follow up and uncontrolled costs due to outsourcing to external companies. We knew we could do better for the patient and with the support of management and budget holders we began to make changes around the patients’ needs.
Aims, Objectives & Results
The Aim of this Service was to implement the National Model of Care for the Diabetic Foot in our area in relation to Improving Ulcer Preventative Offloading Care. Our objectives we’re related to reducing wait times, reducing patient journey steps, improving functional ability and mobility, documenting satisfaction with the service and cost savings. We achieved all of our objectives, having an impact on both quality and cost. Waiting times reduced from 52 week to 6 weeks, patient journey steps significantly reduced due to the ability of the practitioner to assess and prescribe on the same day. 95% patient satisfaction with the service speaks for itself. All these efficiencies were achieved without additional staffing or other resources to the service.
Embedding into Practice
Service models, Care Pathways and effective governance put in place for sustainable care.
- Integrated Care.
- Person Centred Care.
- Hospital and Community Collaboration.
- Engagement with service users.
- Sharing of knowledge and expertise.
- Best Practice National Study Day for the At Risk Foot.
- Ease of Spread.
“I tended not to walk at all before my orthotics, now I am quite comfortable doing 6km, I find great support in them and am absolutely thrilled”
The coordinated implementation and evaluation of dialectical behaviour therapy in adult and child/adolescent mental health services at a national level across Ireland (Daniel Flynn, Mary Kells & Mary Joyce c/o Louise Dunn)
Borderline personality disorder (BPD) is a mental health diagnosis characterised by patterns of cognitive, emotional and behavioural dysregulation that often manifests in self-harm and suicidal behaviours. Dialectical Behaviour Therapy (DBT) is the evidence based therapy for the treatment of this personality disorder, delivered by multi-disciplinary teams in a community setting, which allows service users to continue to live at home with their families and to attend school/college or to continue working and to have a ‘a life worth living’.
The National DBT Project Office was established in 2013 and is responsible for coordinating training of Community Mental Health Service staff (psychologists, mental health nurses, OTs, social workers, social care workers, art therapists, family therapists, psychiatrists, addiction counsellors) to establish DBT programmes in their service. The office also coordinates training on an annual basis which facilitates the addition of new staff to existing DBT teams in community services and ensures the sustainability of programmes. In total, 23 new teams have been trained since 2013 (13 Adult and 10 Child/Adolescent Mental Health teams). In addition to these new teams, we have trained 168 multi-disciplinary staff to sustain/enhance existing teams’ provision of DBT.
Research outcomes on 109 adult and 84 CAMHS participants found reductions in suicidal ideation, depression, frequency of self-harm and the number of Emergency Department visits and inpatient admissions, both during the programme and several months after programme completion. This resulted in improved quality of life for participants and also savings to the health service through reductions in resource utilisation.
Therapists across mental health services have also introduced ‘Skills Only’ programmes to work with people with other diagnoses, who may have emotion dysregulation, but not a history of self-harm. Research undertaken on the Cork based programme is showing positive outcomes for participants.
We have also worked in collaboration with the Brothers of Charity Intellectual Disability service in Galway to train staff and they have a sustainable DBT programme in place for their client population.
In Cork, two adult mental health teams have established links with Arbour House Addiction treatment centre. Five addiction counsellors have trained as DBT therapists and work collaboratively with the mental health teams in their area to deliver their programmes. Arbour House has also introduced a DBT informed programme within their service; this is a DBT skills based programme for individuals with a dual diagnosis (mental health and addiction). Preliminary results of the findings on this programme report positive outcomes for participants, with increased emotion regulation and decreased substance misuse. Other DBT teams have also worked with addiction counsellors or members of the National Counselling Service in their areas to share knowledge and make the therapy available to a larger client/service user group.
The challenges facing family members and significant others of individuals with personality disorders are often of such a magnitude that they can, over time, deplete a person’s capacity to cope effectively. Family Connections is a programme which aims to provide information, skills and a support network for family members. This programme also teaches them how to look after their own emotional well-being, which has a positive knock-on effect on the wellbeing of their loved one. Following training provided by the National DBT Office in 2016, the programme is now available in Cork, Kerry, Wexford, Meath, Louth, Dublin and Galway.
We have also collaborated with post-primary schools, NEPS, CAMHS and HSE Health and Wellbeing on the implementation and introduction of a schools based programme – DBT STEPS-A. This is a social, emotion learning curriculum that trains teachers to deliver skills. Students showed significant reductions on measures assessing depression, anxiety and social stress. Through structures put in place linking schools, NEPS and CAMHS, students who were potentially experiencing high distress and not communicating were identified and it assisted promoting resilience in adolescents through inter-agency collaboration. We are currently working with Minister Daly, Minister of State for Mental Health and representatives the Dept. of Education to expand this programme to other schools.
We will finish our summary with a quote from one of the participants in our programme “I’m alive and I want to live”
BabyGrow: Translating Research into Improved Nutritional Care for Preterm Infants (Ann-Marie Brennan)
BabyGrow: Translating Research into Improved Nutritional Care for Preterm Infants is a dietitian-led, multi-disciplinary project, delivering data driven innovations in intravenous nutrition. This collaboration in preterm nutrition between Cork University Maternity Hospital (CUMH), INFANT Centre University College Cork (UCC), the HSE and industry was initiated over a decade ago and continues to grow.
In Ireland, ~1 in 100 babies (~600 babies per annum) are born preterm and very low birth weight (VLBW <1500g). One in four preterm infants has evidence of developmental delay by the time they reach school-age. Appropriate nutrition during early life is essential for healthy growth and neurological development. As these vulnerable infants transition from exclusively intravenous nutrition onto milk feeds over the first 7 to 10 days of life, nutrition provision is complex and challenging, with a high risk for adverse short and long term effects. In the absence of evidence-based practice guidelines, nourishing preterm infants during this critical period has traditionally been based on a ‘best guess’ approach.
In 2010, the BabyGrow nutrition and growth study revealed substantial nutrient deficits and growth failure in VLBW infants during the first weeks of life. Using the robust BabyGrow data, two nutritionally superior intravenous nutrition products were developed to safely achieve international nutrition recommendations, without exposing infants to the risk of excessive intakes, as they progress from exclusive intravenous nutrition onto exclusive milk feeds.
An innovative nutrient modeling technique was employed to develop the nutritional composition of the intravenous nutrition products. This is the first time nutrient modeling has been used to determine the composition of intravenous nutrition that fully meets the needs of VLBW infants on this complex nutritional journey. The team partnered with industry to translate this research into clinical practice and embarked on a 6 month product development phase.
In February 2018, following a dietitian-led implementation strategy, the two new intravenous nutrition products, supported by an evidence-based guideline, were introduced into CUMH. The post implementation audit shows full adoption with infants receiving safer and better nutrition. To date, this work has been published in four international peer-reviewed publications and the lead dietitian has been awarded a PhD by UCC.
The evaluation of this innovation is ongoing. As part of a Science Foundation Ireland funded preterm nutrition study from the same team, infants receiving the new intravenous nutrition products are having detailed growth, developmental and neurological assessments throughout their hospital stay and during infancy. Our belief is that there is untapped potential for other applications of this nutrient modeling approach to inform further nutritional product development in this and other patient populations.
The National Clinical Programme for Paediatrics and Neonatology Parenteral Nutrition Expert Group have endorsed the new products and evidence-based guideline and national rollout is planned. Utilising the improved intravenous nutrition products instead of bespoke individualised prescriptions on a daily basis will deliver cost savings of ~€60,000 per annum to CUMH, a 20% saving on our overall intravenous nutrition costs supply, with potential for far greater cost savings nationally. Very positive feedback has been received from a staff evaluation, who have reported the new developments as “user friendly”, “easy to follow”, “prescribing is easier and safer” and, “babies in my care are receiving better and safer nutrition”.
This collaborative project, between HSE dietitians, neonatologists, pharmacists and nutrition scientists at UCC, has delivered innovative, evidence-based solutions to a long-standing unmet need for the benefit of the most vulnerable people in society.
Establishing a Reactive Home Nasogastric feeding service for Head and Neck Cancer patients undergoing Radiotherapy and/or Chemotherapy (Yvonne Donnelly)
The incidence of malnutrition at diagnosis in Head and Neck Cancer patients is estimated to be 30-50%. Treatment toxicities from radiotherapy and chemotherapy exacerbate the risk of malnutrition during treatment and as a result patients frequently require artificial nutrition support. Current literature suggests that compared to reactive enteral feeding, prophylactic enteral feeding does not offer advantages in terms of nutritional outcomes, interruptions to radiotherapy or survival.
Nasogastric (NG) feeding is the preferred choice if artificial nutrition support is expected to be required for 6 weeks or less. Even though medically stable, these patients often remain inpatients solely for their nutrition via NG feeding.
This project aimed to assess whether it was feasible to manage patients with reactive nasogastric (NG) feeding in an outpatient setting with input from the acute multidisciplinary team only, a first in the adult Irish population.
Head and neck cancer patients were screened for suitability for home NG feeding. Suitability criteria included clinically significant weight loss, dysphagia, meeting <65% of dietary requirements for more than 72 hours and enteral feeding anticipated for <6 weeks. Patients needed to demonstrate that they would be able to care for the NG tube at home either independently or with family support. Initial results were reviewed after the pilot phase which demonstrated that patients were successfully managed on NG feeding as outpatients without any adverse events. A policy and procedure document was developed and implemented. Data collected was analysed using Microsoft Excel.
17 patients were successfully managed at home on NG feeding over a 40 month period (Dec 2014 - March 2018). 15 patients were male and 2 female. 16 patients had their NG tubes placed due to <65% requirements for more than 72 hours and had at least 5-10% weight loss. 1 patient was placed nil by mouth and discharged home on NG feeding whilst awaiting a RIG placement. The cost of a patient at home on NG feeding for 1 day was estimated to be €11 versus €800 euro per day if the patient remained in hospital. The mean home feeding time period was 21 days resulting in a total cost saving of €283,251.
This was a Dietetic led project with close collaboration with medical and nursing staff. One of the key learning points from this project was that a small change can make a difference to the quality of life of a patient with limited impact on resources. However, it is vital that patients are selected on a case by case basis as home NG feeding is not suitable for all patients. Training for Dietitians on placing NG tubes has the potential for advancing scope of practice for the profession.
This initiative is transferable to other Dietetic Departments in Ireland especially centres which specialise in radiotherapy and chemotherapy.
Broadening the approach to a limiting condition: Improving the way Chronic-Pain is managed at the Mater Hospital (Damien Lowry, Dearbhail Flanagan & Máire-Bríd Casey)
The Mater Misericordiae University Hospital (MMUH) is a voluntary sector, level 4, teaching hospital based in Dublin's north inner city. Its pain clinic sees approximately 1600 patients per year and until 2013, these patients were offered a solely biomedical service run by dedicated nursing and medical staff. The location of the clinic was also in a cramped, dark, windowless part of the old hospital building. Two critical events took place to align with pain clinic with best practice guidelines and innovative service development. The arrival of Dr Conor Hearty, Consultant in Pain Medicine to the Mater Hospital Pain Clinic in 2012, followed by the redevelopment of the Mater Hospital Campus, brought about the basis of our project, ‘Broadening the approach to a limiting condition: Improving the way Chronic-Pain is managed at the Mater Hospital’.
Bridging the Gap
Dr Conor Hearty, in consultation with the Physiotherapy and Psychology Department Managers at the Mater Hospital, explored ways to bridge the gap between best clinical guidelines for chronic pain management and existing service provision. Whilst the guidelines highlighted the importance of assessment and medical interventions, it also stressed the need for supported self-management, psychological support and physical therapy. To that end, the innovative foresight of all involved brought about a pilot project offering an interdisciplinary model of care, which would be provided through a reconfiguration of existing resources.
The pilot project was evaluated after one year and deemed a resounding success, leading to the hospital executive agreeing to fund two half-time, permanent, Psychology and Physiotherapy positions on the pain clinic team. As a consequence of these HSCPs being added to the team, the following service developments have been achieved. Over 75 patients have received a multidisciplinary team assessment, where the patient, whose issues are typically complex, meets with the entire team in order for a clear and comprehensive treatment plan can be formulated. Seven supported self-management groups have been run, benefiting over 60 patients, three of who have completed the training to run these groups in the hospital. Over 250 patients have benefited from individualised physiotherapy and psychology, during their pain management attendance. The psychologist and physio have also successfully run 20 inter-disciplinary pain management programs, benefiting close to 200 patients. And finally, research activity has grown out of these clinical interventions, resulting in two peer-reviewed scientific journal publications to date, and multiple oral and poster presentations at both domestic and international conferences.
A randomised control trial is currently underway, examining and comparing two standalone HSCP interventions for chronic pain patients: an exercise / education only arm versus a combined psychology and exercise / education group. This RCT is the basis of a HRB fellowship award and data collection is due to be complete in December 2018. It is hoped this activity will lead to more publications and help to inform best practice for chronic pain patients.
Physiotherapy led injection of Botulinum toxin (BTx) in an advanced practice role: Beaumont Multidisciplinary Team leading the way for spasticity management in Ireland (Roisín Vance, Deirdre Murray, Fiona Molloy & Sara Crolla)
Spasticity is a common problem in conditions such as Stroke, Multiple Sclerosis and Brain Injury which limits mobility, arm function and independence. The cost of care escalates with increased severity of spasticity therefore early management is key. Botulinum Toxin (BTX) injection is a safe, evidence-based intervention, aimed at improving function. Best practice guidelines advocate that BTX injection must be part of a rehabilitation programme to achieve an optimal clinical effect (RCP Guidelines 2018). In Ireland however, access to medically led BTX clinics, and to assessment and rehabilitation is limited.
In the UK, HSCPs have successfully administered and prescribed BTX for many years and the need to adopt this model of care to benefit patients with spasticity in Ireland was clear. The legislative and professional scope of practice framework was in place.
A number of areas for improvement were identified: 1) Access to pre-assessment, goal setting and follow-up by Physio- and Occupational Therapists. 2) Ensuring quality and safety through education, compliance with governance structures and securing resources. 3) Cost effectiveness; as a physiotherapist rather than consultant administered injection and evaluation of outcome improved efficiency of discharge.
In 2015, a pilot monthly physiotherapy led BTX clinic for patients with spasticity commenced within existing staffing resources, under the governance of Dr. Fiona Molloy, Consultant Neurophysiologist. Roisin Vance became the first physiotherapist in Ireland to complete the BTX injector training and implement these skills in the clinic. Access pathways to occupational therapy were developed.
Roisin Vance and Dr. Deirdre Murray are currently both injecting at this Physiotherapy led clinic. All new patients are pre-assessed, set goals and attend for follow-up. The service was audited against published best practice tool with 75% adherence to key standards. Thirty new patients were seen in 2017 with 26 patients discharged ensuring sustainability of the service. A Quality of Life questionnaire, the EQ-5D-5L was completed and showed a mean 5% change pre and post injection. Patients identified that the access to MDT and rehabilitation maximised the benefit of the BTX injections.
The initiative highlighted that engaging stakeholders was key to success. Building confidence in the feasibility of the project, along with negotiating for treatment space and administrative support required effective communication skills. Furthermore, it was essential to prove the concept regardless of funding. The use of quality improvement methodologies to evaluate and analyse the project strengthened the successful development.
This initiative has huge scope to be rolled out in other hospitals in Ireland. We have already developed a national interest group for current injectors and have developed a mentorship process for those requiring support. We have also built governance structures and policies that will enhance safety and provide a template for others embarking on this journey.
The development of Ireland’s first HSCP led Spasticity management BTX clinic has proven that HSCPs working in an advanced practice role can provide a high quality, effective and safe service.
Evolving Respiratory Services to improve care for chronic respiratory disease patients in Donegal (Krista Hegarty, Vera Keatings & Sonya Murray)
Since 2012 the respiratory services in Co. Donegal have been restructured incrementally to offer timely specialist interventions as close to the patient’s home as possible. This has increased accessibility and improved equity of services within a large geographical area using finite resources.
The community services are provided by the Pulmonary Rehabilitation team (PR) and the Respiratory Integrated Care (RIC) team which both consist of a Respiratory Senior Physiotherapist and Respiratory Clinical Nurse Specialist (CNS). The guidance and support of the Respiratory Working Group and Respiratory Steering group and the dedication and enthusiasm of the clinical staff have enabled the service developments to be achieved.
Pulmonary rehabilitation services expanded into 3 Primary Care networks (2012). The referral pathway was reviewed and amended to accept referrals from non Respiratory Consultants, COPD Outreach (2012), GPs (2016) and Respiratory Integrated Care (RIC) (2017). Additional respiratory services were provided in the Primary Care setting including: Respiratory assessment and management clinics; Ambulatory oxygen assessment clinics; Clinical review appointments; Respiratory Physiotherapy and CNS clinics (2015). The Respiratory Steering Group was developed to provide governance and strategic oversight for the operational Respiratory Working Group (2016). Geographical split of respiratory services between RIC and Pulmonary Rehabilitation teams (2017). Respiratory screening commenced within 2 Primary Care networks (2017 & 2018). A maintenance exercise programme was developed in Letterkenny (2014) and in Inishowen (2018).
The expansion of Respiratory services into 3 Primary Care networks has resulted in a significant reduction in the travel time and distance for patients accessing the service. The realignment of the PR and RIC teams into two geographical areas has ensured patients now have one point of contact for ongoing support and advice which permits greater continuity of care. The direct referral pathway has ensured patients no longer have to wait up to 4 years to see the Respiratory Consultant prior to accessing Physiotherapy and Respiratory CNS clinics or Pulmonary Rehabilitation. The result is patients can be offered earlier intervention in a timely manner. Evaluation of services have shown that patients who have attended the pulmonary rehabilitation programme have achieved clinical significant differences in symptoms, quality of life and exercise tolerance alongside reduced hospital admissions, bed days and length of stay.
Service user feedback and focus groups were essential in ensuring patient centred care. Respiratory Working group and Respiratory Steering group enabled collaboration and communication and the development of weekly multidisciplinary respiratory education meetings has enabled interdisciplinary learning. Restructuring of services and provision of clerical support has achieved improved efficiency of clinicians’ time. Recording of KPI’s and outcome measures for regular reflection, evaluation and audit of service has been critical in development of the respiratory service.
The development of a third community respiratory team would allow the expansion of GP screening into three further Primary Care Networks thus ensuring complete equity of services. Owing to the success of the Letterkenny exercise maintenance class in terms of clinical outcomes and peer support there are plans to develop into other primary care networks in collaboration with community centres. In response to patient feedback the development of a COPD support group in Donegal is being explored.
The development of a Serum Eye drop programme in Galway Blood and Tissue Establishment (Aoife Conroy)
Galway University Hospital (GUH), comprising of University Hospital Galway (UHG) and Merlin Park University Hospital (MPUH), provides a comprehensive range of emergency and elective services to patients on an inpatient, outpatient and elective basis across the two sites. GUH is part of the Saolta Healthcare group comprising of 7 hospitals in the West of Ireland.
Galway Blood and Tissue Establishment (GBTE) provide a routine and emergency blood, blood product and tissue service to GUH and hospitals in the surrounding area. GBTE is also the only hospital based laboratory in the Republic of Ireland to hold a Good Manufacturing Practise (GMP) license which was awarded by the Health Product Regulatory Authority (HPRA) in 2011 for the production of Serum Eye drops (SE’s).
SE’s are a serum derived product used to treat a range of conditions from severe dry eye, Sjorens syndrome, neurotrophic ulcers and stem cell deficiencies to chemical burns, Graft Versus Host Disease (GVHD) and other ocular surface disorders. Autologous Serum Eye drop’s (ASE’s) are produced from the patient’s own serum’, yielded from a unit of donated whole blood. In 2015, an extension to the GMP license was granted to produce allogeneic serum eye drops (ALSE’s) from a unit of AB whole blood obtained from the National Blood Centre (NBC). ASLE’s are used to treat patients who may be unsuitable for donation of a unit of autologous blood.
Serum contains a large variety of growth factors, fibronectin, vitamins and immunoglobulins, some in higher concentrations than in natural tears. These substances contribute to the therapeutic effect of serum in Serum Eye Drops. ASE’s and ALSE’s are prepared by diluting the serum with sterile normal saline in a grade A Laminar Air Flow Cabinet (LAF). The product is then dispensed into dropper bottles for home use. The bottles should be kept frozen and one bottle thawed daily for use as directed by the patients’ ophthalmic consultant.
The ASE team in GBTE carried out extensive research into the manufacture of the product in various sites worldwide and the therapeutic benefits of the treatment, and felt that they had the resources, skill and knowledge to address this service need in Ireland. Every step of the process was thoroughly validated, a stringent acceptance criteria and assessment process was developed, standard operating procedures and service level agreements were devised, all consumables suitable for manufacturing the product were sourced. All documents were encompassed into the well established and licensed GBTE Quality System.
Since its introduction, GBTE have produced over 170 batches of serum eye drops. This therapy has been shown to improve the effects of ocular surface disorders in patients throughout the country. GBTE remain the only hospital based laboratory to maintain a GMP license in order to manufacture this product and look forward to expanding the programme both nationally and internationally in the near future.