Impact of a dedicated cancer-associated thrombosis service on clinical outcomes: a mixed-methods evaluation of a clinical improvement exercise

Objectives Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation. Setting Specialist cancer centre, district general hospital and primary care. Participants Patients with CAT and their referring clinicians. Intervention A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic. Primary and secondary outcome measures The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals. Results Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management. Conclusions A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care

A mixed-methods study to evaluate a patient-designed tool to reduce harm from cancer-associated thrombosis: The EMPOWER study

Introduction Venous thromboembolism (VTE) is a common and serious complication of systemic anticancer therapies. Delays in presentation increase risk of death or long-term morbidity. Background A patient charity developed an information video for patients receiving systemic anticancer therapy including what to do if they developed symptoms of VTE. This was introduced into clinical practice in a regional cancer center and its impact compared with a district general hospital where the video was not used. Methods A mixed-methods approach was used, comprising clinical audit data, patient surveys, and key informant interviews. The time between development of VTE symptoms and seeking medical evaluation was routinely recorded on patients attending a regional cancer-associated thrombosis service with systemic anticancer therapy–provoked VTE. The video was then embedded into clinical practice at the regional cancer center for 3 months. The primary outcome was the difference in time to presentation with VTE symptoms, between patients attending the regional cancer center and the district general hospital (which acted as control). Other outcomes included impact on radiology resources, patient knowledge, and perspectives of chemotherapy nurses. Results Addition of the video was associated with a lower mean time to presentation from 8.9 to 2.9 days (0.33 hazard ratio; 95% confidence interval, 4.5-7.4; P < .0001). This may reflect greater awareness of VTE, resulting in earlier clinical presentation when they developed attributable symptoms. Conclusion The video was associated with reduced delays in diagnosis of systemic anticancer therapy–associated VTE by 6 days, thereby reducing long-term complications

Impact of paramedics carrying just-in-case end-of-life care medication

Early in the COVID-19 pandemic, it was predicted that frail community patients with symptoms of severe COVID-19 infection may need urgent symptom management—and that unless they had already been identified as being in their last weeks of life, they would be unlikely to have just-in-case (JIC) medications at home. The Welsh Ambulance Services NHS Trust therefore placed JIC medications on emergency ambulances to increase symptom management options for paramedics treating patients with symptoms of severe COVID-19 infection and/or associated with advanced end-stage illness. Abstract published with permission

Palliative medicine doctor and paramedic join to form a palliative care rapid response car. A pilot study

Aim To pilot a palliative medicine doctor and paramedic working together within the community to respond to urgent ‘999’ calls. Is the concept feasible, beneficial to patients and cost effective? Method Four palliative medicine doctors across South Wales partnered the End of Life Care Lead Paramedic for WAST (EO’B) to form a PCRRC. Potential patients were identified from the list of contemporaneous logged calls for paramedics to respond to. The PCRRC responded to any calls where it seemed likely that it could have a positive impact upon the care of patients. Result During the four pilot shifts the PCRRC attended four calls and gave telephone advice to three calls. In total 21 hours of doctor time was spent ‘on the road’. The anecdotal feedback from the four doctors is mixed. There was not felt to be an overwhelming need for the service but on two occasions it did have an impact upon decision making, including two decisions not to admit patients. The experience improved doctors’ insight into paramedic care of patients with palliative care needs. Conclusion This is a small feasibility study with inherent biases. The PCRRC concept is feasible and can benefit acute clinical decision making but this pilot suggests that it is unlikely to be an efficient use of resources. There are benefits of the PCRRC model for learning, co-ordination of care, and facilitating shared decision making. We are considering other interventions to improve the interaction between palliative care teams and WAST. https://spcare.bmj.com/content/9/Suppl_1/A43.1 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/openhrt-2015-00028

Paramedics and serious illness: communication training

Abstract Objectives The need to empower Ambulance Service staff at the point of delivery of end of life care (EoLC) is crucial. We describe the delivery, outcomes and potential impact of the Serious Illness Conversation project delivered to Welsh Ambulance Service Trust (WAST) staff. Over an 18-month period, 368 WAST staff attended face-to-face teaching, which included serious illness conversation communication skills, symptom control and ‘shared decision making’. Method Data collected from WAST staff were used to gain insight on perception of their role and challenges within the context of EoLC, understand the impact of teaching on self-confidence and identify impact on the wider service. A mixed methods approach was used for data analysis. Results WAST staff view themselves in several important roles, acting as ‘facilitators’ to patient-centred, seamless care, providing support, liaison between services and practical help in patient care at the end of life. The difficult questions and situations pertaining to EoLC were related to discussions on death and dying and managing expectation. The predominant barriers identified related to communication. Quantitative outcomes on the six communication domains indicate statistically significant improvement in self-assessed confidence. The overall impact to the wider ambulance service suggests a trend towards better use of resources. Conclusion The perceived roles and challenges identified by paramedics can help in customising training objectives. The initial outcomes from the ongoing project with WAST demonstrate increased confidence in handling communication issues. Initial successive surveys suggest teaching is making a real life impact on patient care at end of life. https://spcare.bmj.com/content/12/e2/e248 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/openhrt-2015-00028