Transformation of an independent sector treatment centre to a regional trauma centre during COVID pandemic

ContextOn the 11th March 2020, the WHO declared SARS-CoV-2 (COVID) outbreak a global pandemic. Healthcare facilities in the UK faced an unprecedented challenge of managing the outbreak, whilst maintaining basic healthcare services such as cancer and trauma. The NHS and independent sector partnership allowed a safe work stream, a relationship that continues now to support the elective recovery coming out of the pandemic.Issue/ChallengeReorganisation of healthcare provision led to the transformation of Practice Plus Group (PPG) hospital, Ilford to a green site for Barking Havering and Redbridge NHS University Trust (BHRUT) trauma service from 30/03/2020 to 10/06/2020. PPG Hospital had to rise to the challenge mobilising quickly from an elective service to a trauma unit serving a local population of over 1 million. The hospital transformed over one weekend, mobilising staff and equipment to deliver a trauma service. Their service went on to exemplify gold standard treatment of the very sick. The unit responded, adapted and developed outpatient clinics, plaster room, trauma ward and theatres to manage COVID-negative trauma cases that BHRUT received.Assessment of issue and analysis of its causesClinical staff had to upskill to take on the very sick (ASA 4) who may require end organ support, to carry out trauma surgery and procedures that were never performed before at the unit. Surgeons and surgical trainees from the trust became part of the multidisciplinary collaboration whilst the senior leaders developed a strong relationship to ensure good governance throughout the period. All of PPG staff had to get involved in ward care. Staff were trained with regards to personal protective equipment (PPE), Aerosol generating procedures (AGPs), pressure area care and applying traction to realign bones as some of the examples. The staff involved came from the following groups: theatre staff, outpatient staff, the anaesthetic consultants, ward staff, endoscopy, pharmacy, physio, housekeeping, infection control and portering.ImpactConsultant anaesthetists had a steep learning curve to both update their trauma knowledge and sharpen their skills. The guidelines of fracture hips were reviewed. The weekly teaching meetings’ topics were all about anaesthesia for emergency surgery, trauma and COVID. Anaesthetic work rota modified to provide a suitable recovery time following long days in theatres. The necessity of rest periods improves immunity.InterventionThere were some logistic hurdles, including the lack of availability of a suitable meeting facility that can accommodate a large number of attendees. There was a need to have a combined meeting with the BHRUT team in the red zone. On the first day, the meeting was carried out on the ‘ZOOM’ platform on smart phones. Within a couple of days. The trauma meeting was held in the capacious theatre reception, using a wall-mounted big screen for audio-visual display. This allowed better communication with all clinical teams including orthopaedic surgery, anaesthesia, nursing and coordinators.Involvement of stakeholders, such as patients, carers or family members:The PPG team implemented the pillars of clinical governance to improve the quality of care. The virtual monthly morbidity meeting included clinicians from all disciplines. A brief update of previous monthly data was reviewed. An initial internal audit showed that the average anaesthetic start time was 09:39. 19 lists (out of 23, 83%) started even after 09:15. The identified causes for this delay included late sending time, and the patient not being ready at the ward due to longer pre-operative checks and staff shortage. A ‘Golden Patient' was not always identified. A collaborative multi-disciplinary approach aimed to streamline the admission processes to ensure availability of both the surgical team and the patient to ensure a prompt theatre start. A repeat audit confirmed that the average anaesthetic start time has become 09:03. Only four out of 24 lists had an anaesthetic start time of 09:15 or later (17%). Th t is an Improvement of 69%.Key MessagesAs COVID created so much pressure on BHRUT, we quickly formed a positive can do working relationship both clinically and managerially to set up the Trauma service in just a few days. The 30 day mortality rate of patients with fracture neck of femur was less than the national average. This positive approach has enabled us to continue working together to help ease pressure off the lengthy patient waiting lists in Orthopaedics and General Surgery.Lessons learntPPG was proud to receive many compliments from patients and BHR staff. A patient wrote ‘I am so humbled and impressed by the amazing team-work and skill of the staff here that I want to congratulate you on what is an outstanding success amongst all the many stories coming out of the corona pandemic. Watching the way in which staff from so many different departments and skills bases are coming to this ward and learning nursing techniques with humility and patience as well as bonding in an upbeat, joyful team is something I will always remember. A surgical trainee mentioned The Independent Sector Treatment Centre (ISTC) team has been absolutely excellent so far. They have made us feel welcome and have worked hard to optimize the service'. This COVID cooperation paved the way for the ongoing cooperation between BHR and PPG, Ilford.Measurement of improvementThe outcome data shows that the service was able to successfully manage fractured neck of femur with better outcomes against national KPI. During the period from 30/03/20 to 10/06/2020, 85 patients had surgery for an emergency fracture neck of femur (Table 1). At PPG, the 30 days mortality rate was 3.5%. The national mortality rate for patients with fracture neck of Femur was 6.1%.75 patients with fracture neck of femur had surgical fixation within 36 hours.Strategy for improvementCollaborative cooperation between NHS and PPG led to set up of new pathways, governance and processes that enable patients to be transferred directly to us as well as creating capacity for BHRUT surgeons to operate in our hospital, supported by our theatre and ward teams.

REACH-ASD: a UK randomised controlled trial of a new post-diagnostic psycho-education and acceptance and commitment therapy programme against treatment-as-usual for improving the mental health and adjustment of caregivers of children recently diagnosed with autism spectrum disorder.

BACKGROUND: Autism is a neurodevelopmental disability affecting over 1% of UK children. The period following a child's autism diagnosis can present real challenges in adaptation for families. Twenty to 50% of caregivers show clinically significant levels of mental health need within the post-diagnostic period and on an ongoing basis. Best practice guidelines recommend timely post-diagnostic family support. Current provision is patchy, largely unevidenced, and a source of dissatisfaction for both families and professionals. There is a pressing need for an evidenced programme of post-diagnostic support focusing on caregiver mental health and adjustment, alongside autism psycho-education. This trial tests the clinical and cost-effectiveness of a new brief manualised psychosocial intervention designed to address this gap. METHODS: This is a multi-centre two-parallel-group single (researcher)-blinded randomised controlled trial of the Empower-Autism programme plus treatment-as-usual versus usual local post-diagnostic offer plus treatment-as-usual. Caregivers of children aged 2-15 years with a recent autism diagnosis will be recruited from North West England NHS or local authority centres. Randomisation is individually by child, with one "index" caregiver per child, stratified by centre, using 2:1 randomisation ratio to assist recruitment and timely intervention. Empower-Autism is a group-based, manualised, post-diagnostic programme that combines autism psycho-education and psychotherapeutic components based on Acceptance and Commitment Therapy to support caregiver mental health, stress management and adjustment to their child's diagnosis. The comparator is any usual local group-based post-diagnostic psycho-education offer. Receipt of services will be specified through health economic data. PRIMARY OUTCOME: caregiver mental health (General Health Questionnaire-30) at 52-week follow-up. SECONDARY OUTCOMES: key caregiver measures (wellbeing, self-efficacy, adjustment, autism knowledge) at 12-, 26- and 52-week follow-up and family and child outcomes (wellbeing and functioning) at 52-week endpoint. SAMPLE: N=380 (approximately 253 intervention/127 treatment-as-usual). Primary analysis will follow intention-to-treat principles using linear mixed models with random intercepts for group membership and repeated measures. Cost-effectiveness acceptability analyses will be over 52 weeks, with decision modelling to extrapolate to longer time periods. DISCUSSION: If effective, this new approach will fill a key gap in the provision of evidence-based care pathways for autistic children and their families. TRIAL REGISTRATION: ISRCTN 45412843 . Prospectively registered on 11 September 2019.

Evaluation of a primary care-based collaborative care model (PARTNERS2) for people with diagnoses of schizophrenia, bipolar, or other psychoses: study protocol for a cluster randomised controlled trial.

BACKGROUND: Current NHS policy encourages an integrated approach to provision of mental and physical care for individuals with long term mental health problems. The 'PARTNERS2' complex intervention is designed to support individuals with psychosis in a primary care setting. AIM: The trial will evaluate the clinical and cost-effectiveness of the PARTNERS2 intervention. DESIGN & SETTING: This is a cluster randomised controlled superiority trial comparing collaborative care (PARTNERS2) with usual care, with an internal pilot to assess feasibility. The setting will be primary care within four trial recruitment areas: Birmingham & Solihull, Cornwall, Plymouth, and Somerset. GP practices are randomised 1:1 to either (a) the PARTNERS2 intervention plus modified standard care ('intervention'); or (b) standard care only ('control'). METHOD: PARTNERS2 is a flexible, general practice-based, person-centred, coaching-based intervention aimed at addressing mental health, physical health, and social care needs. Two hundred eligible individuals from 39 GP practices are taking part. They were recruited through identification from secondary and primary care databases. The primary hypothesis is quality of life (QOL). Secondary outcomes include: mental wellbeing, time use, recovery, and process of physical care. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action, and look for unintended consequences. An economic evaluation will estimate its cost-effectiveness. Intervention delivery and follow-up have been modified during the COVID-19 pandemic. CONCLUSION: The overarching aim is to establish the clinical and cost-effectiveness of the model for adults with a diagnosis of schizophrenia, bipolar, or other types of psychoses.