Medically safe for discharge (MSFD): reducing doctor input in MSFD patients across geriatric medicine wards at a DGH in Somerset

ContextMusgrove Park Hospital is a district general hospital in Taunton, Somerset, in the South West of England.Issue/ChallengeIncreasingly NHS hospitals are under capacity pressures. Since the COVID pandemic, Musgrove Park Hospital is struggling with high numbers of medical admissions, coupled with increasing lengths of patient stay. This is multifaceted but largely due to a lack of social care packages and pressures on community services.Assessment of issue and analysis of its causesThe pressure on social care has resulted in increased numbers of patients in acute hospital beds that do not have a ‘criteria to reside’. These patients are deemed medically safe to be residing in their own homes or residential care. They do not require inpatient medical care and therefore a routine daily doctor review.ImpactThis project looked to trial a system where medically safe for discharge (MSFD) patients are identified by the medical team (senior doctor) and are flagged as not requiring daily ward round reviews. These patients are discussed daily at board rounds and continue to receive nursing care and therapy input. The MDT are encouraged to escalate concern about a ‘MSFD patient’ to the medical team who will then review as clinically indicated. This would allow rationalisation and re-prioritisation of doctor-time to the most unwell patients.InterventionWe initially trialled this project on Mendip, a 19 bedded care of the older person (COOP). A rapid PDSA cycles allowed the creation and improvement of a sticker to identify MSFD patients. This A6 sticker was placed in the medical notes as soon as a patient was deemed MSFD. It included an option for highlight any ongoing issues that would otherwise be addressed as an outpatient, and signalled that the patient would not be included on daily ward rounds.Data collected during the 3 week trial period showed 46% of bed days were occupied by MSFD patients. An average of 8 MSFD patients were not reviewed each day, with 0.6 unplanned reviews of these patients needed due to MDT concern, saving an average of 7.4 patient reviews per working day. In addition, 3.3 hours/day were saved, allowing rationalisation of doctor time and resources to understaffed, busier wards whilst not causing detriment to patient care. This equates to half a doctor per day per medical ward.Involvement of stakeholders, such as patients, carers or family members:Creating a MSFD process required multi-disciplinary working from medical teams alongside nursing and therapy colleagues, as well as the wider hospital management team. There were no complaints from patients or family members as a result of this change, and no adverse outcomes to patient care were noted either.Key MessagesThe use of a MSFD process has helped our hospital to address the challenges of capacity and demand for limited NHS resources, with respect to both the physical bed-space and precious doctor time. This has enabled reallocation of that saved time to care for and treat more patients, as well as provide education to the next generation of medics.Lessons learntThe current NHS bed crisis will not be solved by a ‘quick-fix' as the situation is complex and multi-faceted. However, projects like this enable the resources we do have to be used effectively and efficiently. We were fortunate to have buy-in from the hospital management when our trial was still in infancy which enabled rapid testing and development of the process, due to support from members of the MDT throughout the hospital. This may not always be the case for other projects.Measurement of improvementData was collected to measure the number of patients being seen each day on the ward, and the time saved from not seeing MSFD patients. We balanced our intervention by measuring the number of complaints from patients or families, as well as the number of unplanned reviews from patients who became sick. The work on Mendip was presented to the hospital clinical leadership group alongside the date we had collected to support its efficiency and safety, who subseque tly approved the standard operating procedure we wrote to formalise our work. This is currently being rolled out within the care of the older person department at Musgrove Park.Strategy for improvementThe next step of the project is to establish MSFD ward. This cohorts the patients who would otherwise be discharged into the community if their pathway/care was available. The ward will require reduced doctor input, allowing medical staff to be redistributed to busier parts of the hospital, with the ultimate aim to run this as a ‘doctor-free' ward, similar to the care provided in the community.

Has COVID-19 impacted the global fight against adolescent obesity?

Aims• Explore international literature published in the years 2020-2021 to determine the prevalence of adolescent obesity and identify any changes following the introduction of COVID-19 lockdown measures.• Determine changes in weight and anthropometric measurements in adolescents during this period (2020-2021).• Consider correlations between changes in physical activity, eating habits and screen-time following COVID-19 lockdowns and changes in anthropometric measures.• Explore the impact of economic and environmental inequalities on weight gain and obesity.MethodsPeer-reviewed publications published between 1st January 2020 - 1st December 2021 were identified via systematic searching of three electronic databases, CINAHL, PubMed and OVID. Designated medical subject headings (MeSH) terms and free text search terms relating to the research question including ’COVID-19’, ‘obesity’, and ‘adolescents’ were used to identify relevant articles for inclusion. Those executed in all global settings, published in the English language, and with participants aged 10-18-years-old were included. Any anthropometric measure of obesity, including body mass index, body weight and body fat index were considered. Grey literature searches were also conducted using Goggle Scholar. Data was extracted onto a pre piloted data collection form capturing population, intervention/exposure, comparators, and outcomes (PICO). A narrative analysis was produced based around identified themes.ResultsOverall nine studies were deemed suitable for inclusion. No UK based studies were identified, but global findings were captured including those conducted in the USA, China, South Korea, Germany, India, and Italy. Two studies compared anthropometric measures before and after school closures due to COVID-19. Six reported anthropometric changes before and after/during COVID-19 lockdowns, and one reported pre-pandemic versus pandemic changes in anthropometry. COVID-19 resulted in increased screen times, reduced physical activity and changes in nutritional habits. Key themes included gender- weight gain was higher in adolescent males than females, ethnicity- those from Hispanic backgrounds showed higher levels of obesity, parental factors- obese parents increased the likelihood of adolescent obesity (70%), lower socioeconomic status presented with 2.5 times increase in body weight, and behavioural changes- this included reduced physical activity, increased sedentary behaviour and dietary changes with increased snacking reported.ConclusionOur findings show that there was an increase in the prevalence of adiposity, obesity prevalence and weight gain alongside changes in eating habits and activity levels across several regions between 2020-2021. COVID-19 infection control measures such as school closures increased sedentary behaviours e.g. screen-time for both education and leisure, and negatively influenced nutrition. There is a need for ongoing surveillance and intervention in particular for those identified at risk groups from our included articles. All healthcare professionals and governmental bodies have a role to play in addressing this issue. Further work will be required in order to explore the long-term effects of COVID-19 and its true impact on adolescent obesity.

Supporting junior doctor and physician associate participation in clinical research during the COVID-19 pandemic

BackgroundCovid-19 enabled clinicians to engage with urgent public health (UPH) randomised controlled trials (RCTs) investigating potential treatments. University Hospital Bristol and Weston (UHBW) prioritised three trials;Recovery, REMAP-CAP and TACTIC-R. Due to the rise in cases, it became difficult to screen, approach and recruit all patients. It is recognised that junior clinicians struggle to participate in research whilst working in fulltime clinical roles, therefore this project aims to address both issues.MethodsA senior research team was formed, including the Principal Investigator (PI), supporting consultant and five junior doctors, who enrolled in the Associate Principal Investigator (API) scheme.APIs encouraged and trained junior clinicians, increasing their involvement in trials.APIs facilitated two virtual education events delivering trial updates and review of local adverse events.A consultant–led recruitment rota, including weekends, was implemented to maximise recruitment.A WhatsApp group was created to enable secure communication between team members.ResultsJunior clinician participation in research increased;99 junior doctors and 4 physician associates (PAs) completed Recovery trial training. 76 were recognised as Recovery Trial collaborators.UHBW recruited 457 patients to the Recovery trial, 378 since the senior research team was implemented. UHBW reached the top 20 of 181 sites for% recruitment regularly.Over 550 patients have been recruited to Recovery, REMAP–CAP and TACTIC–R.ConclusionClear leadership from the senior research team enabled UHBW to increase recruitment to UPC RCTs, contributing to vital Covid-19 research. A research rota and clear communication via secure networks enabled this. Expanding the research team to include junior clinicians created effective and sustainable trial recruitment. Four APIs completed the scheme, and four PAs have enrolled, ensuring ongoing clinician training.

Impact of the COVID-19 pandemic on elementary schoolers' physical activity, sleep, screen time and diet: A quasi-experimental interrupted time series study.

BACKGROUND: COVID-19 school closures pose a threat to children's wellbeing, but no COVID-19-related studies have assessed children's behaviours over multiple years . OBJECTIVE: To examine children's obesogenic behaviours during spring and summer of the COVID-19 pandemic compared to previous data collected from the same children during the same calendar period in the 2 years prior. METHODS: Physical activity and sleep data were collected via Fitbit Charge-2 in 231 children (7-12 years) over 6 weeks during spring and summer over 3 years. Parents reported their child's screen time and dietary intake via a survey on 2-3 random days/week. RESULTS: Children's behaviours worsened at a greater rate following the pandemic onset compared to pre-pandemic trends. During pandemic spring, sedentary behaviour increased (+79 min; 95% CI = 60.6, 97.1) and MVPA decreased (-10 min, 95% CI = -18.2, -1.1) compared to change in previous springs (2018-2019). Sleep timing shifted later (+124 min; 95% CI = 112.9, 135.5). Screen time (+97 min, 95% CI = 79.0, 115.4) and dietary intake increased (healthy: +0.3 foods, 95% CI = 0.2, 0.5; unhealthy: +1.2 foods, 95% CI = 1.0, 1.5). Similar patterns were observed during summer. CONCLUSIONS: Compared to pre-pandemic measures, children's PA, sedentary behaviour, sleep, screen time, and diet were adversely altered during the COVID-19 pandemic. This may ultimately exacerbate childhood obesity.

‘Let them eat cake’: the introduction of a weekly cake rota in the acute medical unit (amu) to improve trainee wellbeing during the COVID-19 crisis

The outbreak of COVID-19 had substantial impact on trainees. Examinations were cancelled, rotations to other specialties were suspended with little information available regarding the immediate impact and enduring consequences of the pandemic. Trainee morale in AMU dropped during this uncertain period, which this project aimed to address.To identify baseline levels of morale, an anonymous survey was distributed to all AMU trainees at Musgrove Park Hospital via social media, asking to rate level of agreement using a Likert scale with several wellbeing statements such as ‘I feel happy at work’ and ‘I feel part of the AMU team’. The introduction of a cake rota encouraged trainees to pick a date they would provide cake for the team. Every Friday, after AMU ward round had finished, the team could eat together, whilst also offering an opportunity to socialise as a group. The survey was then redistributed to ascertain post-intervention levels of wellbeing.Responses to the question ‘I look forward to coming to work’ were scored more positively post-intervention, with 50% now strongly agreeing with this statement, compared to 0% prior. Similarly, trainees demonstrated an increasingly positive response to the statements ‘I feel part of the AMU team’, ‘there is a spirit of co-operation and teamwork within my team’ and ‘I get along well with my co-workers’, as 100% of trainees now strongly agreed, compared to 43% pre-intervention. This was echoed in the free text comments at the bottom of the survey, where one individual commented this was a ‘great idea to encourage team camaraderie’.Introducing simple measures (such as a weekly cake rota) promoted teamwork, collaboration, and a sense of unity, to help address a decline in trainee morale resulting from the COVID-19 pandemic. Longer term, this could improve individual wellbeing and maintain enthusiasm for a job which can be challenging and unpredictable, attributes which could be valuable as we enter a post-COVID world.

COVID-19 Leads to Accelerated Increases in Children's BMI z-Score Gain: An Interrupted Time-Series Study.

INTRODUCTION: The COVID-19 pandemic may have negatively impacted children's weight status owing to the closure of schools, increased food insecurity and reliance on ultraprocessed foods, and reduced opportunities for outdoor activity. METHODS: In this interrupted time-series study, height and weight were collected from children (n=1,770 children, mean age=8.7 years, 55.3% male, 64.6% Black) and were transformed into BMI z-score in each August/September from 2017 to 2020. Mixed-effects linear regression estimated yearly BMI z-score change before the COVID-19 pandemic year (i.e., 2017-2019) and during the COVID-19 pandemic year (i.e., 2019-2020). Subgroup analyses by sex, race (i.e., Black, White, other race), weight status (overweight or obese and normal weight), and grade (i.e., lower=kindergarten-2nd grade and upper=3rd-6th grade) were conducted. RESULTS: Before the COVID-19 pandemic, children's yearly BMI z-score change was +0.03 (95% CI= -0.10, 0.15). Change during the COVID-19 pandemic was +0.34 (95% CI=0.21, 0.47), an acceleration in BMI z-score change of +0.31 (95% CI=0.19, 0.44). For girls and boys, BMI z-score change accelerated by +0.33 (95% CI=0.16, 0.50) and +0.29 (95% CI=0.12, 0.46), respectively, during the pandemic year. Acceleration in BMI z-score change during the pandemic year was observed for children who were Black (+0.41, 95% CI=0.21, 0.61) and White (+0.22, 95% CI=0.06, 0.39). For children classified as normal weight, BMI z-score change accelerated by +0.58 (95% CI=0.40, 0.76). Yearly BMI z-score change accelerated for lower elementary/primary (+0.23, 95% CI=0.08, 0.37) and upper elementary/primary (+0.42, 95% CI=0.42, 0.63) children. CONCLUSIONS: If similar BMI z-score accelerations occurred for children across the world, public health interventions to address this rapid unhealthy BMI gain will be urgently needed.