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@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 care…one of the chief mechanisms by which cultural and social structural context affects patient-practitioner…relationships’ [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.