Journeys by Amy Conley

“The first step towards getting somewhere is to decide that you are not going to stay where you are”…

(Chauncey Depew)

Last year I wrote a blog post about Cathy, a frail older patient, and Cathy’s journey through our hospital system.  Writing the blog was the start of a journey for me – a journey with many enthusiastic, motivated colleagues, sharing the goal of building a frailty pathway within NHS D&G.

Our frailty pathway aims to coordinate and streamline the care of frail older patients at the front door of the hospital, facilitating timely, safe discharge to a homely setting.

In November 2017 a team from DGRI was invited to join a Frailty Collaborative with Healthcare Improvement Scotland.  We have worked with HIS and other health boards to improve our pathways of care for frail older people.  We started from humble beginnings –                                                                                                                                            we had many important elements but no joined-up path, we had some enthusiasm but also disinterest and, at times, suspicion.

Our journey hasn’t been smooth – it’s been a rocky path with stumbles and setbacks, and the journey hasn’t ended – now, though, we can see where we are going and have a much better idea of how to get there.  Some achievements so far:

AWARENESS – we blogged, and talked, and talked some more about frailty – what it means, who and how it affects, interventions and changing outcomes.  We wanted to raise awareness and found a mainly receptive audience, people sharing our interest and enthusiasm.

BUILDING LINKS – we talked some more – with hospital colleagues from every background, with our community colleagues, with groups from other hospitals – we shared ideas and concerns and forged relationships we can use to help build our pathway.

PROFORMA – after some trial and error (and a little shameless theft from another board) we have produced our blue frailty proforma.  This document will allow our frailty team to capture a wealth of useful information about each frail older patient when they arrive at the front door, and use this information to inform their journey.  The information will be stored under “FRAILTY” on clinical portal.

EDUCATION – more opportunistic talking and sharing knowledge.  We have been educated by those further on the journey, and we have tried to share our understanding and experience of looking after frail older people with others working in D&G.

FRAILTY ICON – our autumn leaf!  We now have a frailty icon that can be used on IT systems within NHS D&G to identify frail older people and help to streamline their journeys.

 

FRAILTY INTEREST GROUP – we  formed a group of health and social care colleagues with an interest in frailty to discuss issues affecting frail older people in every aspect of our systems, not only those at the front door.

FRAILTY NURSE – Drew has joined us as our first Frailty nurse, based in CAU.  His role will be pivotal in our frailty team – he will be involved in identification and assessment of frail older people, coordinating care, communicating and advocating for our patients.  We hope that by showing improved outcomes with one frailty nurse, we can make the case for more.

FRAILTY TEAM – “Alone we can do so little, together we can do so much” (Helen Keller).  Our team has fluxed and flowed over the past year, but we are definitely a team – of allied health professionals, nurses, doctors, care coordinators, pharmacists, flow coordinators, and management staff.  Our team now even has a stamp so we can leave our mark in patient notes…

 

However, there is still a lot to do to improve patient journeys.  Frail older people are still spending unnecessary time in the acute setting, acquiring healthcare-associated complications and reducing chances of making it safely home…

 

Elsie, a 97 year old lady, lived in sheltered accommodation.  Elsie came into hospital after a funny turn.  Investigations were reassuring and it was hoped that Elsie could get straight home.  But concerns about possible decreased mobility, and then apparent lack of staffing at her accommodation, kept her in hospital for 17 days.  Finally getting home, Elsie was promptly returned to hospital within 24 hours – her bed was unsuitable for use with the newly-provided Stedy (moving and handling equipment).   Elsie had no acute illness, but spent another 7 days in hospital before getting home with a new bed.  Unfortunately, her time in hospital left her frailer and less able, and now she is in a community hospital waiting for care home placement.

 

Robert is 84, has multiple illnesses, but had been living at home with his wife, requiring carers only twice per week.  A few weeks ago he fell at home, a simple slip – but unable to get back up.  An ambulance was called and took him to CAU.  He had blood tests and x-rays -all normal.  He stayed in CAU for 4 days; a physiotherapist reviewed him and advised he was unsafe to mobilise.  Robert was moved downstream to the ward.  Six days after admission, he was helped to sit up out of bed for the first time.  By then he had developed a chest infection and needed antibiotics and oxygen.  Skin over his sacrum broke down due to pressure.  Over the next 18 days Robert became increasingly confused and depressed.  He was bedbound and incontinent and refused all interventions.  His wife said she could no longer look after him at home.  He now lives in residential care.

 

So, the journey goes on, and, our frailty pathway continues to take shape.  The aim of the team and for the pathway is to:

Improve outcomes and experiences for older people with frailty, who present to CAU, by

• rapid, reliable identification at the front door
• delivery of early comprehensive geriatric assessment
• ensuring co-ordinated, person-centred care
• supporting early discharge to a homely setting.

“Change will not come if we wait for some other person or some other time.  We are the ones we’ve been waiting for.  We are the change that we seek.”

 (Barack Obama)

Amy Conley is an Elderly Care Physician at NHS Dumfries and Galloway

Let’s prevent………….Type 2 Diabetes by Ellen Jardine, Fiona Green and Sheena McDonald

Type 2 diabetes… you have probably heard of it, you might have it or know somebody who has been diagnosed. Unfortunately it’s not a condition which is going away any time soon, in fact it is likely to become more and more common before it reduces.

It  can and will improve, if we work together and do something now. What some people might not know is that we can change the course of Type 2 diabetes, for ourselves if we’re at risk or have been diagnosed with pre diabetes, and for those around us. This is something to hold onto tightly…

To start, we would like to share a few facts before telling you about a new group that has been set up to start working to address the issue in Dumfries and Galloway:

• Being overweight, obese and inactive are the most significant risk factors for developing Type 2 diabetes
• Most cases of Type 2 diabetes can be prevented or delayed with weight loss, dietary improvements and increased physical activity
• 87% of people with type 2 diabetes in Scotland are above their ideal weight
• Currently about 8,500 people are living with Type 2 diabetes in our region
• Every year over 500 people living in Dumfries and Galloway are diagnosed with Type 2 diabetes,
• 50% of women diagnosed with gestational diabetes develop Type 2 diabetes within 5 years of the birth of their baby

Living with Type 2 diabetes

For those who don’t know much about Type 2 diabetes, a diagnosis can bring about strong feelings of fear, grief, guilt and even anger before a person is able to begin to make sense of the condition and what it means for life moving forward. Usually it means quite big changes, for example taking time off work, attending lots of appointments, and taking tablets or giving injections to keep the condition well controlled. It is clear that Type 2 diabetes has many costs for the person diagnosed as well as society as a whole. For anybody who would like further information about the condition please follow this link to the Diabetes UK website: https://www.diabetes.org.uk/in_your_area/scotland

What are we going to do in Dumfries and Galloway?

Lots! Work has already began and we suspect life is going to get very busy as we begin to work through a five year plan, guided by Scottish Government’s recently published framework ‘A Healthier future – Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes April (2018)’.¹

To try to summarise, we will work on prevention, early detection and early intervention. In year one, we will focus on the areas circled in orange on the diagram below:

Diagram from ‘A Healthier future – Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes April (2018)’

We have had fantastic support so far and have already learnt a lot about what support is out there for people at risk or diagnosed with Type 2 diabetes. What we plan to do next is to work closely with individuals, communities and health and social care staff to improve our early detection and intervention systems and the support that follows – always having inequalities at the forefront of our minds when it comes to the pathways or support programmes that we offer.

The development of type 2 diabetes used to be seen as irreversible but many of you will have heard the headlines about the 850kcal diet that alongside considerable dietetic support can reverse type 2 diabetes

Previous work in Finland and China using a population based intensive lifestyle intervention including increased physical activity alongside dietary advice have been shown to reduce the rates of new diagnosis of diabetes by 43%^2,3.

Who are ‘we’?

An oversight group made of different members of staff across health and social care, has formed to prepare for taking forward the plan, guided by a shared vision:

To enable all people in Dumfries & Galloway to improve their health and wellbeing by reducing their risk of developing Type 2 diabetes and associated complications, through prevention, early detection and intervention.

The teams involved are listed below:

• Diabetes Specialist Teams/ Weight Management Teams
• Council Partners
• Patient Safety and Improvement Team
• Primary Care
• Public Health

Please get in touch with us if you would like more information about anything. Alternatively, watch this space for further news!

Ellen Jardine is an Applied Psychologist in Health Improvement; Fiona Green is a Consultant Physician and Sheena McDonald is a Diabetes Dietitian for NHS Dumfries and Galloway

Contact details

Sheena McDonald

Diabetes Admin

1^st Floor North

Mountainhall Treatment Centre

Dumfries

01387 244214

Email sheenamacdonald1@nhs.net

 

References

1. A Healthier future – Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes April (2018)’
2. Lindström J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, Uusitupa M, Tuomilehto J. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes care. 2003 Dec 1;26(12):3230-6.
3. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, Li H, Li H, Jiang Y, An Y, Shuai Y. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. The Lancet. 2008 May 24;371(9626):1783-9.