PALLIATIVE AND END OF LIFE CARE EXPERIENCES OF PEOPLE OF AFRICAN AND CARIBBEAN DESCENT (PEACE) DURING COVID-19

Background and Aims People of African and Caribbean descent experienced the highest mortality rates during the pandemic, yet often have the poorest access to palliative care. This study aims to identify how palliative care services can better meet the needs of people of African and Caribbean descent, by exploring patients' (by proxy), families' and health, social care and community workers' experiences of end-of-life-care during the pandemic. Methods Bereaved relatives, and professionals were recruited using social media, community networks and direct advertising to over 100 organisations. Semi-structured interviews explored experiences of end-of-life-care using a topic guide, developed with patient and public involvement partners. Participants' suggestions for care improvement were foregrounded throughout. The theoretical framework combined Critical Race Theory and Saurman's model of access. Thematic analysis was used. Results Over 40 participants were recruited. Results indicate that people of African and Caribbean descent are poorly served by current services. Interviewees identified distinct differences between the culture of care, and that of the patent. Participants reported institutional racism. Processes were insensitive to diversity in family and community support structures in different cultures. Themes describing end of life care services included: Unavailable: spiritual support, paid carers, specialist care, visitation and choice Inadequate: advertisement of services, cultural diversity and the appreciation of the importance of extended families Unacceptable: communication surrounding death and bereavement (upstream/proactive early discussions would improve engagement) and mental health and bereavement support. Conclusions People of African and Caribbean descent are often termed a 'hard to reach' group. Yet our study suggests that current configuration mean it is services that are hard to reach. Prioritisation of person-centred, culturally competent spiritual, psychological and social interventions remains an aspiration for palliative care. A focus on cultural sensitivity and communication may be a good start to enhance palliative and end of life care for all.

An Evaluation of End of Life Care Experiences in Care Homes in the UK During the Pandemic

Background/aims: Care homes in Europe have been profoundly impacted by the COVID-19 pandemic with increased resident mortality. They needed to respond to shifting government guidelines for infection control procedures and restrictions in visiting. This all occurred under the scrutiny of the media. Aim: to evaluate end of life a care experiences in care homes in the UK. Methods: A mixed method approach. We used a database of about 6000 care home residents were we could track when they interacted with health care services including community nursing input, admission to hospital (and A&E) and clinic appointments. We also conducted interviews (n=24) with care home staff, residents and families from 8 care homes which were analysed using framework analysis. Results: A large spike in deaths occurred in April/May 2020. This coincided with only about a quarter of outpatient appointments taking place. Inpatient admissions dropped by half and A&E attendance by a quarter. Community nursing input to care homes reduced by a third. Interviews suggested that staff were inundated with COVID-19 information via email but felt 'abandoned' with few nursing services operating in person. At the beginning of the pandemic some community nursing staff helped produce emergency care plans, usually over the phone, but some care homes interpreted this to mean residents were going to be 'left to die'. Care home staff felt guilt about deaths related to COVID-19 and this took a toll on their emotional well-being. This was exacerbated by needing to 'police' family visiting with residents who were actively dying. Conclusions: Care home residents experienced a dramatic reduction in services outside of the care home coupled with a large increase in deaths. Many staff wanted greater input from external services especially community nursing teams to support them.

Ankle blocks: Improving day case efficiency

Introduction: The COVID pandemic has exerted unprecedented pressure on hospital resources. Resulting in cancellation of elective operative services, increased patient waiting lists, limited surgical training opportunities along with reduced availability of staff, theatre, and inpatient bed capacity. A novel approach for day case forefoot surgery under ankle block, to mitigate the pandemic service limitations without compromising care, was developed. Method: This is a 3-month, multi-centre, prospective cohort study evaluating the novel ankle block day case forefoot surgery pathway. Patients had a minimum of three months clinical follow up with outcome scores. They were matched to a cohort undergoing similar surgery prior to the COVID pandemic. Results: The utilisation of an ankle block pathway resulted in an average reduction of inpatient stay by 2 days per patient. Over the study period conservative savings of £26,659 were calculated. Anecdotally we observed a reduction in morbidity (wound complications, SSI's) although not statistically significant. Conclusions: Our novel surgical pathway has enabled continued elective operating for procedures that previously required hospital admission during a period of severe restrictions within the NHS. We observed significant reductions in cost, surgical inpatient bed utilisation and total operative time with staff, resource, and time savings. We hypothesise that prehabilitation with physiotherapy, ankle instead of thigh tourniquets and early mobilisation may have contributed to improved morbidity scores. The findings of this project have implications for training, upper limb services and are transferrable as a template to improve service efficiency while maintaining high quality care.

Closing the UK care home data gap - methodological challenges and solutions.

UK care home residents are invisible in national datasets. The COVID-19 pandemic has exposed data failings that have hindered service development and research for years. Fundamental gaps, in terms of population and service demographics coupled with difficulties identifying the population in routine data are a significant limitation. These challenges are a key factor underpinning the failure to provide timely and responsive policy decisions to support care homes. In this commentary we propose changes that could address this data gap, priorities include: (1) Reliable identification of care home residents and their tenure; (2) Common identifiers to facilitate linkage between data sources from different sectors; (3) Individual-level, anonymised data inclusive of mortality irrespective of where death occurs; (4) Investment in capacity for large-scale, anonymised linked data analysis within social care working in partnership with academics; (5) Recognition of the need for collaborative working to use novel data sources, working to understand their meaning and ensure correct interpretation; (6) Better integration of information governance, enabling safe access for legitimate analyses from all relevant sectors; (7) A core national dataset for care homes developed in collaboration with key stakeholders to support integrated care delivery, service planning, commissioning, policy and research. Our suggestions are immediately actionable with political will and investment. We should seize this opportunity to capitalise on the spotlight the pandemic has thrown on the vulnerable populations living in care homes to invest in data-informed approaches to support care, evidence-based policy making and research.