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Acute care in the community

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VOL: 102, ISSUE: 17, PAGE NO: 40

Kathryn Godfrey

An acute care at home (ACAH) service set up in Cornwall in 2003 with an eight-nurse team caring for patients with a...

An acute care at home (ACAH) service set up in Cornwall in 2003 with an eight-nurse team caring for patients with a limited number of conditions has now increased to a 15-strong team coping with a much wider range of patients.

The service was developed as part of modernisation plans to take pressure off the hospital trust and to offer patients more accessible care. The acute trust, the Royal Cornwall Hospitals Trust, covers a wide geographical area, with some patients having to travel up to 50 miles to the hospital.

Initially the team worked with patients with chronic obstructive airways disease, cellulitis and chest infections. The two teams of four, led by a team leader, spent a month's induction period setting up the service, including the design of protocols, before starting to see patients in their own homes.

One of the team leaders, Stephen Collings, has had 20 years' experience of nursing, the majority in the acute sector. In his previous post he was a clinical governance manager in the community.

Talking about the initial steps of the new service he said: 'At the beginning we were extra careful to make sure that our knowledge met the patients' needs. We took on simple cases, but as our knowledge and confidence has grown so has the service.'

A wider group of patients is now referred to the service, including the immunocompromised, oncology patients, some surgical patients, those needing blood transfusions, and patients with deep-vein thrombosis and pulmonary embolism.

Cannulation and the administering and monitoring of intravenous therapy are the mainstays of the service, with about 70% of the patients needing this aspect of care. Others, for example those with heart failure, require intensive assessment and monitoring.

The ACAH service is available from eight in the morning to 10 at night, seven days a week. Staff work a variety of shift patterns and are employed by two local primary care trusts - Central Cornwall and West of Cornwall PCT.

The nurses on the ACAH team all have solid experience of working in the acute setting. They are offered additional training in the form of an extended assessment course. Some of the team, Mr Collings included, have taken a degree or master's course on advanced practitioner care.

Each of the two teams receives about 60 referrals a month, half of which come from the hospital consultant. The remainder come from local GPs, from rapid assessment teams and, increasingly, from community matrons.

'The initial response from GPs was slow,' said Mr Collings. 'It has taken time for them to refer on a regular basis. There are some who are keen on the service and we are hoping that in the next few years with the onset of GP commissioning they will use us more.'

The service offered by the ACAH team dovetails with the rapid assessment team (RAT), whose members are more focused on social needs. Patients with complex needs are cared for by the RAT, who call in the ACAH team when acute care is needed.

Members of the acute team visit the hospitals regularly to assess patients who are being discharged early, have regular contact with the medical admissions unit and are developing links with A&E.

The team has been promoting the service by visiting GP surgeries, developing protocols and producing information leaflets. Reassuringly, the number of cases referred has increased steadily, partly because patients with recurrent past hospital admissions who have been referred to the service now ask to be referred.

The service has had to fit in with other community nursing services and this has required some careful handling. 'There were ripples at first,' said Mr Collings. 'Our focus is on acute illness, whereas the focus of the district nurses is on chronic disease management. We have to make it explicit that we are offering a different service and that it is not a threat.

'We are now developing good relationships and working together on complex cases. If a patient is being cared for by another specialty we do try to keep our intervention to the minimum.'

Making the transition from working in the acute setting to caring for patients in their own home, miles from any back-up, should not be underestimated.

A recent report from the Department of Health (2005) suggested that 'nurses who move from the hospital environment to the community, irrespective of level of clinical expertise, become novice practitioners again'.

The report highlights the differences in the two settings. In the community the patient is in control of all decisions whereas in a hospital decision-making is led by professionals. When patients and carers undertake most of their treatment and care at home, the nurse contribution is a much smaller part of the patient's daily experience. At the same time, the nurse in the community has to make clinical and professional decisions, sometimes rapidly in less than ideal circumstances and at a physical distance from professional colleagues.

The report concludes that a successful transition requires supported learning as well as support and recognition from all stakeholders in the organisation. Mr Collings agreed: 'Initially we found the transition quite challenging. It was daunting. Working in someone's living room is very different. You find yourself questioning everything that you do, which is good practice, but shows that we were under-confident at the beginning.'

In the early days, the team members received support from the community nurse manager who established the service, and its members continue to have regular meetings with the lead consultant at the hospital. New team members are now mentored by more experienced members of the team.

The service is proving to be an economic success. An audit carried out from July 2003 to March 2005 found 692 completed care episodes, which translates into 4,229 saved in-patient bed days.

A patient satisfaction survey of over 300 patients found high levels of satisfaction: they liked being cared for at home as they felt more in control of their illness. Furthermore, fears of hospital-acquired infection meant patients were happy not to be admitted.

In the future, the service will become part of locality teams and will aim to increase out-of-hours contact with patients.

Mr Collings says there has been a lot of interest from other trusts, which are considering setting up a similar service. Now fully acclimatised to providing acute care in the community, he can now see the similarities with acute care in hospital: 'During each day we have a core group of patients whom we look after as well as new referrals and patients being discharged. In many ways it is not dissimilar to having a ward out in the community.'

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