BackgroundEvidence demonstrates that measures are needed to optimise therapy and improve administration of medicines in care homes for older people. The aim of this study is to determine the clinical and cost effectiveness of a novel model of multi-professional medication review.MethodsA cluster randomised controlled trial design, involving thirty care homes. In line with current practice in medication reviews, recruitment and consent will be sought from general practitioners and care homes, rather than individual residents. Care homes will be segmented according to size and resident mix and allocated to the intervention arm (15 homes) or control arm (15 homes) sequentially using minimisation. Intervention homes will receive a multi-professional medication review at baseline and at 6 months, with follow-up at 12 months. Control homes will receive usual care (support they currently receive from the National Health Service), with data collection at baseline and 12 months. The novelty of the intervention is a review of medications by a multi-disciplinary team. Primary outcome measures are number of falls and potentially inappropriate prescribing. Secondary outcome measures include medication costs, health care resource use, hospitalisations and mortality.The null hypothesis proposes no difference in primary outcomes between intervention and control patients. The primary outcome variable (number of falls) will be analysed using a linear mixed model, with the intervention specified as a fixed effect and care homes included as a random effect. Analyses will be at the level of the care home. The economic evaluation will estimate the cost-effectiveness of the intervention compared to usual care from a National Health Service and personal social services perspective.The study is not measuring the impact of the intervention on professional working relationships, the medicines culture in care homes or the generic health-related quality of life of residents.DiscussionThis study will establish the effectiveness of a new model of multi-professional clinical medication reviews in care homes, using novel approaches to recruitment and consent. It is the first study to undertake an examination of direct patient outcomes, together with an economic analysis.Trial RegistrationISRCTN: ISRCTN90761620

Most neonatal intensive care units have approaches to manage patients at the end of their lives. Published guidelines to help direct practitioners are lacking, and these management approaches, commonly referred to as comfort care, are often based on tradition. Recently, our neonatal staff experienced a unique situation that involved giving comfort care to a previable neonate who lived much longer than anticipated. Our staff identified the need for an evidence-based practice guideline to focus on four key care issues: provision of warmth, close physical contact, nutritional support, and sedation and pain management. The purpose of this article is to supply health care providers with evidence-based comfort care guidelines for neonates at the end of who either are previable of have had life support withdrawn. The process used for developing the guidelines is included.

IntroductionA local health needs assessment indicated a need for end of life beds in a care setting for patients who did not want to, or could not, die at home or in hospital and did not have the level of need requiring a Hospice bed. Population predictions suggest this need will increase. A model of a Hospice commissioning and supporting beds in a nursing home was created and is currently being piloted.AimsThe overall aim was to develop a new model of end of life care in a care setting providing high quality care for patients and families.Project planThis included: developing eligibility criteria, a contract, operational policies, budget; undertaking publicity; preparing environment; planning evaluation; providing education.ResultsThe first 4 months indicateBenefits include:High quality of carePositive patient and carer satisfactionSaving of hospital bed days through admission avoidance and earlier discharge.Increased choiceRapid access to bedsReduced paperwork and administration time for professionalsIncreased psychological support for patients and familiesTraining and development of care home staffimproved care for all residentsImproved partnership working with acute trust, hospice and communityRapid access to medicines through Hospice nurses prescribingChanged perceptions of care homesCost effectiveChallenges includeIdentifying patients for referralEstablishing new referral pathwaysIssues around communicationLack of understanding by relatives of medical condition and prognosisTransfers felt rushed for some relativesConclusionsImplementing new models across hospitals and community takes time and presents challenges. However, early indications are that this model of high quality care is successful and has many benefits to patients, families and professionals. It could be replicated in other care homes.

In 2014 Clinical Commissioning Group undertook a Health Needs Assessment (HNA) for adult end of life care (EoLC) services. The results of the (HNA) formed the City EoLC Commissioning Strategy 2014–2019. A priority was to develop a model where specialist palliative care clinical nurse specialists provide 7 days of care in community and hospital settings. To take forward the two Hospices in the city worked in partnership with the acute Hospital to set up a community service that could be provided across the city. The service sought to provide support to patients, families and professionals to allow patients to be cared for in their preferred place of care and avoid hospital admission where possible. The service has been operating for over a year has been evaluated by Healthwatch. Healthwatch interviewed 59 people that had used the service between Oct–Dec 2014. They spoke to patients, families and professionals; 98% respondents said the service was useful. One person said it was not useful.In what way was it useful – key themes:Emotional supportFamily/carer supportPain management/medical adviceChoice and involvementGateway to other servicesHealthwatch allowed the service and the commissioners to capture the patients and families views without any bias. The service is continuously monitored and demand is increasing. A CNS will provide a 7 day service within the Hospital later this year, all three CNSs will continue to work together with primary care to provide comprehensive EoLC to the people of the city.The project has been successful as a result of listening to the people of the city; working collaboratively, providers and commissioners and continuing to learn from patients, carers and professionals as the service develops.