1231 MANAGING THE DETERIORATING PATIENT IN A REHABILITATION HOSPITAL: THE ROLE OF TREATMENT ESCALATION PLANNING

Introduction

The pandemic has shown how vital patient-centred treatment escalation planning (TEP) is for older people. Locally we have seen inappropriate transfer of dying patients to acute hospitals from rehabilitation units. Mortality review found a lack of useful TEPs in these cases. Baseline data in our rehabilitation hospital showed 54% of patients had a TEP and 16% a decision made about repatriation during acute illness. We aimed to increase the proportion of patients in this setting with a TEP to 80% over six months.

Methods

A multidisciplinary team of doctors, ANPs and senior nurses worked together. We conducted stakeholder engagement to understand the factors that result in transfer of patients and found that completion of TEPs was felt to be an effective way to improve communication out of hours. Our first test of change involved an ANP raising the CPR status and TEP for all new patients at the weekly MDT. We measured the process of what decisions were made once a fortnight. Outcome data on the overall completion of TEPs and repatriation decisions was collected each month.

Results

New decisions were made at each MDT – for example, on one date two new DNACPRs and six new TEPs were completed. Overall TEP completion rate varies however since our first intervention we have seen a sustained increase in the number of TEPs which include consideration of repatriation – from 16% to 60%. Ongoing conversation with doctors in training reveals challenges with ward staff awareness of TEP content and their ability to guide unexpected events out of hours.

Conclusion

Involvement of motivated permanent staff across disciplines has allowed us to ensure escalation plans are being made each week and see a sustained increase.

Assessment by relatives of elderly patients with psychiatric illness

Participation of relatives to provide clinical information on psychiatric patients is frequently under-utilized resulting in valuable data being bypassed. In an attempt to formalise the gathering of data from relatives we used the Geriatric Evaluation by Relatives Rating Instrument (GERRI), a 49-statement questionnaire in which the relative rates the patient's behaviour in terms of frequency of occurrence, The information obtained from relatives was then compared with that obtained from other forms of patient-assessment—the London Psychogeriatric Rating Scale completed by nursing staff, the Minimental State Screening Test and the Visual Analogue Scale for Depression completed by the patient, and the Activities of Daily Living Instrument completed by the occupational therapist. These instruments were chosen as being valid and reliable procedures with which to compare the GERRI. Subjects were 100 patients aged 65 yr. and over who were admitted consecutively to a psychogeriatric unit in a large psychiatric hospital. Significant correlations between relatives' assessment of cognitive and social function and those completed by the patients and other staff were noted. The relatives' assessment of the patients' mood, however, did not correlate with the patients' self-assessment of mood, suggesting that depression in the elderly may be “masked.”

Monoclonal antibodies to serotype 2 and serotype 15 outer membrane proteins of Neisseria meningitidis and their use in serotyping

A series of murine monoclonal antibodies to serotype 2 and serotype 15 strains of Neisseria meningitidis were produced which were specific for outer membrane proteins of classes 1, 2, 3, and 5. A panel of eight monoclonal antibodies that exhibited a high degree of serotype specificity when reacted with prototype strains of known serotype were selected for study. Each of the corresponding epitopes was localized on a specific outer membrane protein by means of immunoprecipitation, electroblotting, or both. The serotype 2a-, 2b-, and 2c-specific antibodies bound to the class 2 protein, the serotype 15-specific antibody bound to the class 3 protein, two antibodies (3-1-P1.2 and 3-1-P1.16) bound to class 1 proteins, and two antibodies (1-1-P5.1 and 3-1-P5.2) bound to class 5 proteins. Six of these monoclonal antibodies were used in a spot-blot procedure to survey 122 case isolates (groups B, C, Y, and W135) and 363 carrier isolates (all serogroups) for the presence of the 2a, 2b, 2c, 15, P1.2, and P1.16 epitopes. A total of 66% of the case isolates and 30% of the carrier isolates reacted with one or more of the monoclonal antibodies. The use of monoclonal antibodies for serotyping of meningococci appears to be feasible and easy and appears to have significant advantages over the use of polyclonal typing sera.