Wolverhampton’s Rapid Intervention Team
Stuart Hutchinson is a consultant in Care of the Elderly in Wolverhampton. He has spent time in various jobs, covering acute hospitals, acute medicine, and most recently the community, with a special interest in care homes and deprescribing. He is currently Clinical Lead for the Wolverhampton Rapid Intervention Teams, which consists of himself, twenty nurses and more backup staff. The service has been nationally recognised.
Wolverhampton’s Rapid Intervention Team or RITS to those locally, is now a fairly large team. 21 registered nurses between bands 6 to 8a, 3 HCAs, 1 administrative assistant and 1 consultant in Care of the Elderly. At any one time, we have between 160 and 180 people under our care, and have seen emergency hospital admissions of people over the age of 75 decrease by 8.5% in Wolverhampton in the year 2017/8. And no, we don’t think they are all hiding in neighbouring hospitals for fear of poor care locally. We know that other teams in the system have contributed to this decrease in activity, but we would like to think we have played a major part.
There are times when I look round and echo the Talking Heads song Once in a Lifetime: “and you may ask yourself, how did I get here?”
The journey started 15 years ago, with the usual lament of the acute take - “how come there are so many moribund nursing home residents coming into hospital, can’t anyone do anything about it?” At the time, I was working half-time for a Primary Care Trust, so I convinced them to give me a pharmacist and a senior community nurse for a session a week, and then we went out to see what was happening in nursing homes. I’m not sure we stopped any admissions, but we produced a lot of quality reports for the PCT, saw what life was really like in nursing homes, and paid for the costs of the team in medicines stopped.
Fast forward eight years, and I was starting a new post in Wolverhampton with a commitment to the community. No-one had any great ideas what I should be doing, so I went into the nursing homes and started performing what were euphemistically called ‘medication reviews’. This would now be called de-prescribing, but the term hadn’t been invented at the time. One year and 300 or so reviews later, I was able to go back to the CCG to announced that I had trimmed £100,000 off the drug budget, and would they care to hear my next bright idea.
The idea was to loan two community matrons with the specific aim of going into nursing homes and trying to stop admissions. The nursing homes knew me, and were well disposed, because I had actually gone in and made their lives easier by cutting the number of medications that they had to order and give to their residents. It made engagement with the team easier in the early days.
The scheme was initially a five day service, funded from winter pressure money. It nearly stopped after six months, but we had collected enough data to show a small but significant decrease in admissions to hospital. “An admission avoidance team that actually avoids admissions”, as the divisional director said. Funding was made permanent and the team began to grow.
We have grown steadily since, and moved on from serving solely nursing homes to serving the entire community, although nursing and residential homes are still a major part of our activity. The service has become a 14 hours per day 7 days a week service. We developed the trust subcutaneous fluids policy, provide intravenous antibiotics at home and help to deliver palliative care. We have same-day phlebotomy, our own ECG machine and own bladder scanner.
Nurses coming to the team have brought experience from a variety of backgrounds and expertise, including ITU, pain control, renal, respiratory, community matrons, district nurses and hospital at home.
We hold regular update teaching sessions, and use some of these to reflect and debrief on emotionally challenging cases.
My role as a consultant has changed from a leader to an adviser and sometimes a figurehead. I can’t see all of the people we have under our care, but there is always a consultant on the end of the phone for advice and twice-weekly Virtual Ward Rounds for those that don’t need immediate discussion. The Virtual Ward Round title is still there, even if we don’t really have a virtual ward. I know the team, so I know that I can trust their clinical examination and what they are telling me over the phone. It means I can give advice with confidence, much as I would to a senior Core Trainee, or Specialist Registrar. I am referred to as the team’s “middle-aged bloke in a suit” – handy to go on visits when the added gravitas of the “senior consultant” is called for, although often these visits are symbolic only, or needed when the end of life is near, and a qualified medial practitioner needs to see the person before death to be able to write the death certificate. Most of my role is to provide advice, support decision making and make sure that GPs do not need to get involved until the patient is discharged from the service.
So what of the future? We have been commissioned to provide an alternative to GP home visits, and some nurses have gone to join this. The scope is nearly limitless, the problem is keeping the team accessible and effective externally, but small enough to have a trusting, family feel.
The rules (with apologies to Samuel Shem):
1) Everything will take longer than you think it should.
2) Strangle your expectations.
3) If you are happy taking a decision, take it. If you aren’t, ask for help.
4) People are illogical, get over it.