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Mapping pathways to urgent diabetic care in hospital: processes and challenges

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Title: Mapping pathways to urgent diabetic care in hospital: processes and challenges


1
Mapping pathways to urgent diabetic care in
hospital processes and challenges
  • Dr Natasha Posner, Prof. Kate Seers,
  • Prof. Vivien Coates, Jane Canny,
  • RCN Research Institute, School of Health and
    Social Studies, University of Warwick/
  • University of Ulster/ The Royal London Hospital

2
Project Details
  • Title The need for urgent care the
    perspectives and pathways of people with a long
    term condition
  • Funding NIHR Research for Patient Benefit
    programme
  • September 2008 October 2010
  • CI Professor Kate Seers, Director, RCN Research
    Institute
  • Further details from natasha.posner_at_warwick.ac.uk

3
Aims of the project 1
  • Increase understanding of the views and
    perceptions of people with diabetes who are
    provided with urgent care as a result of
    emergency admission or urgent need
  • Investigate the factors that precipitate
    admission to hospital and influence the
    routes/care pathways taken to access urgent care
    services

4
Aims of the project 2
  • Identify sources of support for people with
    diabetes and urgent care needs which would help
    to avoid unplanned admissions where appropriate
  • Determine any barriers to accessing this support
    among different sectors of the diabetic
    population
  • Develop recommendations and intervention(s) that
    can be trialled to address this situation and
    make best use of community based and self-care
    resources

5
Mixed methods
  • Semi-structured interviews with diabetic
    patients and their carers
    /families relevant doctors nurses in the
    hospital key health professional informants in
    the community
  • Focus groups with people with diabetes their
    carers/ families health care providers in the
    community (including PCT commissioners and
    ambulance service)
  • Documentary evidence such as hospital admission
    statistics, protocols admission criteria
    patient education material PCT documentation
  • In two sites

6
Project work packages
7
Project site 1 East London
  • Barts and the London NHS Trust sited in Tower
    Hamlets (TH). One of the most deprived areas in
    UK designated as a Health Action Zone. Nearly
    half the population of TH is in a black/ ethnic
    minority category, the largest group being
    Bangladeshi
  • Roughly one in four hospitalised patients has a
    diagnosis of diabetes most emergency admissions
    have type 2 with DKA, hyperosmolar non-ketotic
    coma, hypo, or infections associated with
    hyperglycaemia
  • Prevalence of diagnosed diabetes approx 5
  • General urgent care strategy developed for Tower
    Hamlets PCT

8
Project site 2 Northern Ireland
  • Altnagelvin Hospital in Western Health Social
    Care Trust
  • Area covered includes urban and remote rural
    districts
  • Population 95 caucasian
  • Prevalence of diagnosed diabetes 3
  • Admissions include DKA in patients with type 1
    and foot ulcers causing concern
  • Diabetes service framework to be developed.

9
Theoretical frameworks
  • These frameworks are intended to focus the
    analysis
  • Explanatory models of urgent care episodes
    (Kleinman 1980)
  • for patients and their families, and
  • for health care practitioners
  • Two case studies using all relevant information,
    with cross case analysis for key process units

10
Explanatory models (EMs)
  • These are the notions about an episode of
    sickness and its treatment that are employed by
    all those engaged in the clinical process. The
    interaction between the EMs of patients and
    practitioners is a central component of health
    careone of the chief mechanisms by which
    cultural and social structural context affects
    patient-practitionerrelationships
  • Kleinman, A. (1980) Patients and Healers in the
    Context of Culture p.105

11
Characteristics of explanatory models
  • EMs need to be distinguished from general beliefs
    about sickness and health care
  • Lay EMs are a response to a particular illness
    episode, integrating ideosyncratic views and
    popular health ideology - they tend to be subject
    to change and to multiple meanings - their logic
    is very different from scientific medicine.
  • Practitioners operate with both scientific and
    clinical EMs largely tacit

12
Case study framework after Yin
13
Intertwined themes
  • Living with a long term and complex condition
    diabetes type 1 or type 2, and responding to
    episodes of increased management difficulty
  • Understanding the patients perceptions of need
    and resources for urgent care
  • Assessment of current availability and use of
    community based resources
  • Culturally appropriate provision of information
    and support
  • Issues relating to integration of primary and
    secondary care

14
Intended outcomes
  • Insight into range of lay explanatory models of
    illness episodes involving urgent care needs
  • Identification of what works well, whether there
    are any barriers to access of community based
    urgent care /support that could be overcome, and
    any gaps in service provision that could be
    filled shift to more community based care
  • Recommendations based on a model of a patient
    centred, integrated and resource efficient
    approach to meeting need for diabetic urgent care
  • Development of a funding application to trial an
    intervention or interventions to improve response
    to diabetic urgent care needs
  • Possible reduction of unnecessary urgent care
    hospital admissions

15
Health services research challenges
  • Taking full account of the context will be a
    complex process a mixed methods case study to
    gather different sorts of evidence is likely to
    be valid and comprehensive enough
  • The context is likely to change over time - and
    thus during the course of the project
  • Urgent/emergency health care provision is also a
    complex process with many factors (individual and
    systemic) influencing when and how it happens
  • Identifying dimensions of the process to look at
    across the project sites is a key challenge.
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