Improving interdisciplinary care on the general medical ward

General medical wards deliver the majority of inpatient care. Despite technological and therapeutic advances, these wards expose 10% of patients to preventable adverse events, and disproportionately contribute to preventable hospital deaths. Improving ward team performance is often proposed as a mechanism to improve patient outcomes. The overarching goal of this thesis is to identify effective strategies to improve interdisciplinary team care on the medical ward. Chapter 1 introduces key concepts in healthcare quality, and specific issues in the delivery and measurement of interdisciplinary ward care. The existing literature for ward improvement strategies is then described. A narrative review identifies common targets for ward interventions [chapter 2], and a systematic review evaluates interdisciplinary team care interventions, finding little evidence of significant impact on objective patient outcomes [chapter 3]. The development and evaluation of prospective clinical team surveillance (PCTS) is then reported. PCTS is a novel interdisciplinary team care intervention, engaging staff to identify barriers to care delivery, with facilitation and feedback. A programme theory and mixed methods evaluation are presented, using a stepped wedge, cluster controlled trial [chapter 4]. Mixed-effects models show a significant reduction in excess length of stay with high fidelity PCTS [chapter 5]. Surveys, focus groups and auto-ethnography identify PCTS’ mechanisms of action, and its impact on incident reporting, safety and teamwork climates [chapter 6]. Implementation outcomes, facilitators and barriers are described in chapter 7. Other perspectives on improvement are also explored. A model of organisational alignment is developed [chapter 8], and an interview study with patients and carers elicits their priorities [chapter 9]. Finally, chapter 10 summarises the findings, highlighting opportunities to develop medical ward outcome sets and construct a model of interdisciplinary team effectiveness. These can be used to support improvements in interdisciplinary care, through changes in policy and practice.Open Acces

Rethinking medical ward quality

Medical wards deliver the majority of acute inpatient care in health systems worldwide. This care is expensive, costing the NHS around £5bn (€5.5bn; $6.2bn) a year, a quarter of its inpatient expenditure. Improving the performance of medical wards is an international priority, not only because of the scale of care that they deliver. Their core workload—treating complex, increasingly frail patients in a time pressurised setting—represents the broader challenges facing healthcare. Yet major gaps remain in our understanding of how wards perform

Translating staff experience into organisational improvement:the HEADS-UP stepped wedge, cluster controlled, non-randomised trial

Objectives: Frontline insights into care delivery correlate with patients’ clinical outcomes. These outcomes might be improved through near-real time identification and mitigation of staff concerns. We evaluated the effects of a prospective frontline surveillance system on patient and team outcomes. Design: Prospective, stepped wedge, non-randomised, cluster controlled trial; pre-specified per protocol analysis for high fidelity intervention delivery. Participants: Seven interdisciplinary medical ward teams, from two hospitals in the United Kingdom. Intervention: Prospective clinical team surveillance (PCTS): structured daily interdisciplinary briefings to capture staff concerns, with organisational facilitation and feedback. Main measures: The primary outcome was excess length of stay (eLOS): an admission more than 24 hours longer than the local average for comparable patients. Secondary outcomes included safety and teamwork climates, and incident reporting. Mixed-effects models adjusted for time effects, age, comorbidity, palliation status, and ward admissions. Safety and teamwork climates were measured with the Safety Attitudes Questionnaire. High fidelity PCTS delivery comprised high engagement and high briefing frequency. Results: Implementation fidelity was variable, both in briefing frequency (median 80% working days/month, interquartile range 65-90%), and engagement (median 70 issues/ward/month, interquartile range 34-113). 1714/6518 (26.3%) intervention admissions had eLOS vs 1279/4927 (26.0%) control admissions, an absolute risk increase of 0.3%. PCTS increased eLOS in the adjusted intention-to-treat model (OR 1.32, 95% CI 1.10-1.58, p=0.003). Conversely, high fidelity PCTS reduced eLOS (OR 0.79, 95% CI 0.67-0.94, p=0.006). High fidelity PCTS also increased total, high yield, and non-nurse incident reports (incidence rate ratios 1.28-1.79, all p<0.002). Sustained PCTS significantly improved safety and teamwork climates over time. Conclusions: This study highlighted the potential benefits and pitfalls of ward-level interdisciplinary interventions. Whilst these interventions can improve care delivery in complex, fluid environments, benefiting team and patient outcomes, the manner of their implementation is paramount. Suboptimal implementation may have an unexpectedly negative impact on performance

A stepped wedge, cluster controlled trial of an intervention to improve safety and quality on medical wards:the HEADS-UP study protocol

INTRODUCTION: The majority of preventable deaths in healthcare are due to errors on general wards. Staff perceptions of safety correlate with patient survival, but effectively translating ward teams’ concerns into tangibly improved care remains problematic. The Hospital Event Analysis Describing Significant Unanticipated Problems (HEADS-UP) trial evaluates a structured, multidisciplinary team briefing, capturing safety threats and adverse events, with rapid feedback to clinicians and service managers. This is the first study to rigorously assess a simpler intervention for general medical units, alongside an implementation model applicable to routine clinical practice. METHODS/ANALYSIS: 7 wards from 2 hospitals will progressively incorporate the intervention into daily practice over 14 months. Wards will adopt HEADS-UP in a pragmatic sequence, guided by local clinical enthusiasm. Initial implementation will be facilitated by a research lead, but rapidly delegated to clinical teams. The primary outcome is excess length of stay (a surplus stay of 24 h or more, compared to peer institutions’ Healthcare Resource Groups-predicted length of stay). Secondary outcomes are 30-day readmission or excess length of stay; in-hospital death or death/readmission within 30 days; healthcare-acquired infections; processes of escalation of care; use of traditional incident-reporting systems; and patient safety and teamwork climates. HEADS-UP will be analysed as a stepped wedge cluster controlled trial. With 7840 patients, using best and worst case predictions, the study would achieve between 75% and 100% power to detect a 2–14% absolute risk reduction in excess length of stay (two-sided p<0.05). Regression analysis will use generalised linear mixed models or generalised estimating equations, and a time-to-event regression model. A qualitative analysis will evaluate facilitators and barriers to HEADS-UP implementation and impact. ETHICS AND DISSEMINATION: Participating institutions’ Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN34806867