The conversation: developing confidence to provide end of life care in Salford nursing homes

The study was funded by the Burdett Trust for Nursing and partly by Salford Primary Care Trust. A realistic evaluation design was used to collect data using a range of approaches, from before and after surveys of confidence in delivering end of life care, to participant observation and interviews. A total of 43 people were interviewed involving both staff, residents and relatives. Key Messages a) Significant resources are needed to engage staff, residents and relatives/carers with the idea of advance care planning b) Care home staff are optimistic about involving residents and relatives in planning care at the end of life and some relatives become very involved in care c) Clearly registered nurses and other care home workers such as care assistants have different roles, but the overlap between these and the appropriate boundaries would benefit from further work d) Talking to residents and relatives about their feelings and wishes for care at the end of life remains especially difficult, but education and training in key skills and knowledge can engender both ability and motivation e) Care homes need strong and well-informed leadership in order to implement the Gold Standards Framework f) Placing a relative in a care home involves strain and an ability to compromise ‘there’s no perfect place’ g) Advance care planning can reduce the distress and the number of inappropriate hospital admissions, but is challenging in the face of staff rotation and out of hours medical staff being unpredictable h) The principles of the Gold Standards Framework are widely seen as sensible, but clinical challenges include diagnosing and predicting dying trajectories, especially in heart failure, chronic pulmonary disease and dementia i) A particular concern of staff is how to approach nutrition and hydration as frailty and death approach j) Communicating about diagnosis and especially prognosis with residents who lack capacity is an increasing problem k) Natural justice suggests that resources should be allocated to the general standardisation of a good quality of care at the end of life in ALL care homes whatever their Care Quality Commission ratin

Value of hospital antimicrobial stewardship programs [ASPs]:a systematic review

Abstract Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range:$2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention

Changing health professionals’ scope of practice: how do we continue to make progress?

Executive Summary What are the issues related to health professionals’ changing scope of practice in Australia? There is evidence that the current organisation of health professionals and health practitioners, and their associated scope of practice, are not suited to meet the needs of the Australian health system. This is contributing to unsafe and inefficient care delivery. There have been substantial changes in population health needs and the technologies, structures and processes of the health care system, yet there has been little change in the health workforce to adapt to the system requirements. Many of the difficulties in adapting the workforce are created by existing legislation and regulation, the funding models for health professional services, and entrenched professional cultures. There is no agreement on coherent policy for the health workforce even though the national, state, and territory governments have focused on this issue What are the implications if these issues are not addressed? Individual health services and health systems will be unable to implement changes to their health professional and practitioner workforce that enable them to meet the access, quality and financial targets necessary for sustainable operation of the public health system. What can we do? While there have been a range of health practitioner scope of practice changes documented in the literature, there is no analytical framework to categorise the changes to enable benchmarking of achievements and outcomes. In addition, few of the scope of practice changes have been evaluated, and those that have, suffer from poor methodology and lack of economic evaluation. This suggests that there are no ready-made solutions waiting on the shelf and leads to the following recommendations. Include health professional and practitioner scope of practice as a standing item on the national, and state and territory health policy agendas, with the goal to develop national policy directions that are supported by all parties. Three actions are required to procure the data needed to enable this policy development to proceed: Establish and maintain a central repository of Australian health professional and practitioner scopes of practice. Develop inter-disciplinary agreement on essential work roles in community and primary care, mental health, aged and chronic care and Aboriginal and Torres Strait Islander health. Prioritise health services research directed to evaluation of changes in health professional and health practitioner scope of practice. Once the policy has been developed, undertake legislative changes to facilitate scope of practice changes, amend health service purchasing rules to encourage safe service delivery by a broader range of health professionals, and reform health professional education to better address the workforce needs of the health system. These changes will be required to support health workforce policy that encourages a flexible approach to health practitioner scope of practice, but that still ensures sufficient protection for the population

Antimicrobial stewardship: the need to cover all bases

Increasing antimicrobial resistance has necessitated an approach to guide the use of antibiotics. The necessity to guide antimicrobial use via stewardship has never been more urgent. The decline in anti-infective innovation and the failure of currently available antimicrobials to treat some serious infections forces clinicians to change those behaviors that drive antimicrobial resistance. The majority of antimicrobial stewardship (AMS) programs function in acute-care hospitals, however, hospitals are only one setting where antibiotics are prescribed. Antimicrobial use is also high in residential aged care facilities and in the community. Prescribing in aged care is influenced by the fact that elderly residents have lowered immunity, are susceptible to infection and are frequently colonized with multi-resistant organisms. While in the community, prescribers are faced with public misconceptions about the effectiveness of antibiotics for many upper respiratory tract illnesses. AMS programs in all of these locations must be sustainable over a long period of time in order to be effective. A future with effective antimicrobials to treat bacterial infection will depend on AMS covering all of these bases. This review discusses AMS in acute care hospitals, aged care and the community and emphasizes that AMS is critical to patient safety and relies on government, clinician and community engagement