Managing Care for Adults During Clinical Uncertainty in Community Hospitals

Aims

To develop and evaluate the feasibility of a new Symptom Psychosocial & Assessment & Communication Evaluation (SPACE) tool that intends to support the management of clinical uncertainty for older people in community hospitals

Methods

The study has five stages:

1. Systematically reviewing work already published, on evidence-based tools to manage clinical uncertainty. This included tools supporting three clinical priorities of comprehensive assessment, communication with family and/or continuity of care between care settings, such as between hospital and home. The review helps us to identify the best evidence-based tools, understanding on how they work to optimise care and gaps in knowledge pursued in the research.
2. Analysing national data in England on the characteristics of adults admitted to a community hospital and nearness to death over 1 year from the admission date. We used anonymous national data on hospital use linked with death registration data. This is the first national study on adults admitted to a community hospital in England. The findings inform priorities for care and service delivery, such as strengthening the integration of palliative care.
3. Interviews with patients/families and clinical staff to test out and refine the clinical priorities to manage clinical uncertainty, the ‘package of tools’ to manage clinical uncertainty, how to use the package in clinical practice, and what the interviewees think are the main benefits for patients/families
4. Testing the feasibility of using the ‘package of tools’ in two community hospitals involving 40 patients and staff, to evaluate processes to implement in practice, explore the potential for patient/family benefit, and feasibility to recruit patients.
5. Bringing all these findings together to build understanding on using evidence-based tools in clinical care to manage clinical uncertainty for older adults, the best way to introduce and use the tools in practice, and how to evaluate working in this way for the future.

Summary of findings

1. Our systematic review included 44 papers involving 63 tools used in clinical practice to manage clinical uncertainty for older adults. We develop a logic model detailing how best to use evidence-based tools to optimise comprehensive assessment, communication with the family and continuity of care between care settings. Key causal pathways to manage care are identification of individual priorities and needs, individual care and treatment, and integrated care, such as between hospital and home. Communication of clinical uncertainty to patients is challenging for staff. This requires training and skill in using evidence-based tools to support practice.

2. This first national study on people admitted to a community hospital involved 76, 704 adults admitted to 220 community hospitals over-1 year in 2016. This is an older population with average age 81 years living with multiple chronic progressive conditions. Most had unplanned hospital admission (77%). Over one in four died within 1 year of admission to the community hospital. Risk of dying increased with multiple conditions, particularly for noncancer patients with respiratory conditions, dementia and liver disease. The findings indicate that the traditional focus on rehabilitation and recovery in community hospitals has changed with an ageing population and the need for greater integration of palliative care to orientate care towards the quality of life as the main goal of care. (see outputs, Evans et al, 2021, BMC Medicine)

3. Interviews with 30 patients from four community hospital, showed that they preferred:

• Continuous communication with healthcare staff during their stay with no restriction on time or topic
• Communication with family about care and treatment, particularly over the phone
• All information about their healthcare shared with their GP
• Community hospitals closer to home

Consultations with 48 staff from four community hospitals show that they would like evidence-based tools

• That are clear and quick to complete while capturing the complete picture of the patient
• That support communication with patients, families and other clinical teams
• With adequate training and support to ensure tools are used and interpreted correctly

4. Feasibility study in two community hospitals to evaluate the processes of using the ‘package of tools’ to manage care and during clinical uncertainty in community hospitals, and examine methods to inform a definitive trial if warranted.