44 Wirral's Teletriage Service

Introduction

The Wirral Teletriage Service provides non-urgent clinical support to Wirral Care Homes in order to help avoid unnecessary hospital admissions for their residents. It also aims to provide quicker access to clinical assessment than via NHS 111 and to provide this care in the patient’s residence wherever possible.

Methods

Care homes call the Teletriage service when they have concerns about the health of one of their residents. The Teletriage nurse undertakes a clinical assessment of the resident remotely via Skype. Care Homes have been provided with a secure NHS email address to facilitate secure sharing of data. They have also been provided with iPads and training for their staff. After being assessed by Teletriage, residents are signposted to the most appropriate care pathway for their needs.

Results

76 Care Homes have signed up to the service. On average, the Teletriage Service receives 300-400 calls a month. In an 18 month period, the number of calls to NHS 111 have reduced by 76%. Out of all the calls to Teletriage, 22% of patients were managed by the Teletriage team with no onward referral, 57% were managed via community services e.g GPs, Community Geriatricians, and 10% were referred to the ambulance service. Emergency Health Care Plans (EHCPs), Preferred Priorities of Care and EOL (End of Life) wishes are taken into account.

Conclusions

The Teletriage project has reduced the number of phone calls to NHS 111 and the ambulance service, and subsequently has reduced the number of patients conveyed to hospital by 12%. The Teletriage nurses work very closely with various community services as well as GPs, NWAS and Community Geriatricians. The ongoing training and education provided to the Care Home Staff means that overall there has been good engagement with the project from the majority of the Wirral Care Homes.

Relationship between selected perinatal paratuberculosis management interventions and passive transfer of immunity in dairy calves

The objective of this cohort study was to assess the relationship between perinatal calf management practices relevant to the control of paratuberculosis and passive transfer of immunoglobulin in calves born in an endemically infected Irish dairy herd. Data from 176 calves were used to assess the effect of time spent in the calving area, individual versus non-designated calving and colostrum pasteurisation on serum total protein, zinc sulphate turbidity, globulin and γ-glutamyltransferase. In addition, the effects of colostrum quality, volume of colostrum fed, method of colostrum administration and calving season on passive transfer were quantified. Serum samples were collected as part of routine herd health monitoring from calves aged between one and seven days. Multivariate linear and logistic regression models were used to assess the effect of each variable on the test result and failure of passive transfer as determined using a cut-off point for each diagnostic test. Colostrum pasteurisation and calving area were not significantly associated with passive transfer, whereas increased time spent in the calving pen was consistently associated with a detrimental effect. In addition, a strong seasonal effect was apparent, which appeared to be unrelated to colostrum quality and calf management. The authors are unaware of published studies documenting such a significant seasonal effect on passive transfer.

Optimisation of the zinc sulphate turbidity test for the determination of immune status

Failure of passive transfer of maternal immunity occurs in calves that fail to absorb sufficient immunoglobulins from ingested colostrum. The zinc sulphate turbidity test has been developed to test bovine neonates for this failure. The specificity of this test has been shown to be less than ideal. The objective was to examine how parameters of the zinc sulphate turbidity test may be manipulated in order to improve its diagnostic accuracy. One hundred and five blood samples were taken from calves of dairy cows receiving various rates of colostrum feeding. The zinc sulphate turbidity test was carried out multiple times on each sample, varying the solution strength, time of reaction and wavelength of light used and the results compared with those of a radial immunodiffusion test, which is the reference method for measuring immunoglobulin concentration in serum. Reducing the time over which the reaction occurs, or increasing the wavelength of light used to read the turbidity, resulted in decreased specificity without improving sensitivity. Increasing the concentration of the zinc sulphate solution used in the test was shown to improve the specificity without decreasing sensitivity. Examination of the cut-off points suggested that a lower cut-off point would improve the performance.

Naltrexone plus group therapy for the treatment of opiate-abusing health-care professionals

PURPOSE

The success rate of a treatment program tailored to opioid-abusing health-care professionals that included oral naltrexone and group therapy was studied.

METHODS

20 opioid-abusing health professionals were treated over a 5-year-period. Clients received an initial assessment, supervised administration of naltrexone, and weekly attendance at a psychotherapy group for health professionals. Naltrexone was administered for the first several months, then patients continued the program without naltrexone.

RESULTS

18 patients were referred to the program after being caught diverting medication. Two patients came spontaneously. Of the 18 referred patients, 12 had no relapses, and 5 had only one relapse, followed by long-term sobriety. Mean overall duration of naltrexone administration was 8 months, and the mean duration in the program was 1.9 years. 94% of referred clients had long term abstinence, and 66% were working in their profession during the program.

CONCLUSIONS

Naltrexone in the setting of a structured program is helpful in the treatment and professional reinstatement of opioid abusing health professionals.

The effect of multiple family therapy on addict family functioning: a pilot study

Family therapy may help addicts remain drug abstinent by improving family functioning. In a outpatient pilot study eight addict families were evaluated before and after 16 weeks of multiple family therapy (MFT), while the addict was maintained on naltrexone, an opiate antagonist. The Beavers Timberlawn Family Assessment was used to rate videotapes on problem solving, family structure, individual autonomy, and affect. The 8 families showed significant improvement in global functioning, problem solving, structure, and autonomy, but not in affect. One addict relapsed during the 10 month follow up, and his was the only family that functioned worse at follow up. We concluded that MFT can help addict families progress from chaotic interactions to more stable family structures and from rigid to more flexible family functioning. This improvement in family functioning may be associated with ex-addicts remaining abstinent.

Clonidine in outpatient detoxification from methadone maintenance

Inpatient narcotic detoxification with clonidine hydrochloride has been used since 1978. Outpatient withdrawal, potentially more useful, has not been adequately studied. This report describes a double-blind random assignment of 49 methadone hydrochloride-maintained patients whose dose had been lowered to 20 mg. Twenty-five were detoxified using methadone at 1-mg decrements, 24 by abrupt substitution with clonidine. Approximately 40% of both groups achieved successful detoxification, with one third maintaining abstinence over the subsequent six months. The groups were also largely equivalent on withdrawal symptoms, but the clonidine group experienced symptoms in the first half of the study and the methadone group in the second half. Clonidine appears to be a safe and efficacious outpatient treatment for opiate withdrawal, although the results were less favorable than those obtained in open or inpatient studies.

Family denial as a prognostic factor in opiate addict treatment outcome

Opiate addicts living with family members generally have better treatment outcomes than addicts who live alone, but family support for the addict remaining drug-free depends on the family being aware of the addiction. We found that many addicts deny their drug abuse to their families and we hypothesized that these addicts would have poor treatment outcomes, even though they lived with nonaddict family members. To test this hypothesis, four groups of addicts in a naltrexone program were compared: 28 male addicts with their spouses, 27 addicts living with their parents, 23 addicts who denied their drug abuse to the family members with whom they lived, and 28 addicts who lived alone. The first two groups participated in family therapy, and these addicts remained drug-free longer than the other two addict groups (analysis of variance, p less than 0.001). The addicts who denied their drug abuse to their families remained drug-free for significantly less time than those who admitted their drug abuse to their families. Furthermore, addicts who admitted their drug abuse to their spouse, but denied it to their parents, remained drug-free for shorter times than married addicts who also told their parents. Thus, maximum family involvement in treatment including spouses and parents was associated with a better prognosis.

Multiple family therapy and naltrexone in the treatment of opiate dependence

The effect of multiple family therapy on client compliance and retention in a high intervention, naltrexone treatment program was examined retrospectively. The population consisted of 65 opiate-dependent individuals consecutively treated with naltrexone and a standard program of counseling and supportive psychotherapy. Twenty-five of these individuals, in addition, received multiple family therapy. The data presented are suggestive of the efficacy of combining multiple family therapy and high intervention in patients being treated with naltrexone. Analysis of the data demonstrated that the group receiving multiple family therapy had a larger continuous time of naltrexone ingestion and remained in the treatment program longer than clients who did not receive multiple family therapy. These effects were independent of race and employment status. The implication of the results for treatment and avenues for future research are discussed.