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C-tactile afferents form a distinct channel that encodes pleasant tactile stimulation. Prevailing views indicate they project, as with other unmyelinated afferents, in lamina I-spinothalamic pathways. However, we found that spinothalamic ablation in humans, whilst profoundly impairing pain, temperature and itch, had no effect on pleasant touch perception. Only discriminative touch deficits were seen. These findings preclude privileged C-tactile-lamina I-spinothalamic projections and imply integrated hedonic and discriminative spinal processing from the body.

The 2011 report, Vision and Change in Undergraduate Biology Education: A Call to Action, provided the impetus to mobilize the undergraduate life sciences education community to affect change in order to enhance the educational experiences of life sciences majors. The work of the appointed Partnership for Undergraduate Life Sciences Education (PULSE) Vision and Change (V&C) Leadership Fellows has focused on the development of programs and resources to support departmental change. In this report, we present a qualitative assessment of several documents generated from the PULSE V&C Leadership Fellow Recognition Team. The Recognition Team developed two initiatives to provide departments with feedback on their change process. The first initiative, the validated PULSE V&C Rubrics, enables departments to collaboratively self-assess their progress in enacting change. The second initiative, the PULSE Recognition Program, involves completion of the aforementioned Rubrics and a site-visit by two Recognition Team members to provide external insights and suggestions to foster a department's change process. Eight departments participated in the Recognition Program in 2014. An evaluation of the documents yielded from the Recognition Program review of seven of the eight departments and a comparison of Rubric scores from before and three years following the site-visits uncovered several common elements required for successful department level change. These elements include an institutional culture that values and supports excellence in teaching and learning with resources and infrastructure, a departmental emphasis on program and course level assessment, and, most importantly, a departmental champion who actively supports endeavors that enhance teaching excellence.

Background and MethodsProfessionals in Liverpool have designed the IMPaCT (Integrated Mersey Palliative Care Team) model of care to improve access for patients, their families and other professionals. The COVID-19 pandemic enabled implementation of this much more quickly than envisaged. The IMPaCT service in North Liverpool was piloted over July to September 2020 and went ‘live’ in October. The ‘Hub’ accepts calls and referrals from anyone and comprises coordinators from hospice outpatient, hospital and community palliative care specialist nursing teams. This single point of access allows for sharing of information, elimination of duplication, and reduces delays in care. Patients are no longer discharged when they move between settings; once they are referred to the IMPaCT service, they remain on the locality caseload until their death.ResultsIn North Liverpool 136 patients have been regularly reviewed under the newly formed nurse-led surveillance clinic in place of the old medical outpatient system. Where medical input was required, advice could be sought from the hub doctor and patients could be seen in the new ambulatory clinic or at home as needed. Of 21 patients were referred for hospice inpatient admission, 18 were admitted within 1 day, an improvement on the 2019–2020 average time from referral to admission of 3 working days. Of 26 patients triaged for medical outpatient review 23 were reviewed within 24 hours (8 same day) ‒ the previous average was 15 working days from referral to appointment.ConclusionsThe switch to a daily ambulatory clinic has improved timeliness of medical assessment and domiciliary visits have been completed in a more timely manner due to freeing up medical availability. Co-location of team members has enhanced information sharing and transfer of care between settings. Patients, carers and staff have reported the benefits of reduced waiting times for specialist input across the services.

BackgroundPercutaneous cervical cordotomy (PCC) offers pain relief to patients with unilateral treatment-refractory cancer-related pain. There is insufficient evidence about any effects of this intervention on patients’ quality of life.MethodComprehensive multimodal assessment to determine how PCC affects pain, analgesic intake and quality of life of patients with medically refractory, unilateral cancer-related pain.This study was set in a multidisciplinary, tertiary cancer pain service. Patient outcomes immediately following PCC were prospectively recorded. Patients were also followed up at 4 weeks.ResultsOutcome variables collected included: background and breakthrough pain numerical rating scores before PCC, at discharge and 4 weeks postprocedure; oral morphine equivalent opioid dose changes, Patient’s Global Impression of Change, Eastern Cooperative oncology group performance status and health related quality of life score, that is, EuroQol-5 dimension-5 level (EQ-5D).ConclusionsDespite significant improvement in pain and other standard outcomes sustained at 4 weeks, there was little evidence of improvement in EQ-5D scores. In patients with terminal cancer, improved pain levels following cordotomy for cancer-related pain does not appear to translate into improvements in overall quality of life as assessed with the generic EQ-5D measure.

The IMPaCT (Integrated Mersey Palliative Care Team) model of care is designed to improve access for patients, their families, and professionals. The COVID-19 pandemic enabled implementation more quickly than envisaged.Waiting times for medical appointments in our integrated palliative medicine service were in excess of two weeks, restricting the clinic system’s ability to deal with acute problems. The team recognised that routine medical review of patients is often unnecessary, and with this in mind, all the referrals for outpatients are now assessed by a nurse specialist triage coordinator and those requiring routine follow-up are now fed into the nurse-led telephone assessment clinics for monitoring. There is a junior and a senior palliative medicine doctor assigned to the ambulatory medical clinic in the IMPaCT hub at Woodlands Hospice from Monday to Friday.There are a small number of pre-planned appointment slots for follow up, but the rest are used for urgent assessment of patients in person, by video consultation or by phone. Domiciliary visits can be undertaken if needed on the day.All admission requests and advice calls to the ward now come to the hub which means that the calls come into doctors with the necessary time to deal with issues as they arise, co-ordinating with other members of the team as needed. This also means the medical team on the inpatient unit have more time to see their patients. Co-location of the ambulatory medical clinics with the nurse triage coordinators has improved working relationships and means that all settings have an awareness of which patients are most complex. Admissions to the hospice are now appropriately more complex and the waiting time reduced to within 24 hours in the majority of cases in December 2020. Waiting times for medical assessments has reduced to within 24 hours of the request.

Woodlands Hospice hosts a weekly Joint Pain and Palliative Care clinic in collaboration with Aintree University Hospital and The Walton Centre. The service would qualify as a tertiary service as described by the Faculty of Pain Medicine’s framework for cancer pain management (2019). The Walton Centre offers a range of interventions and is one of only three centres in Britain offering percutaneous cervical cordotomy and patients frequently attend from a distance for this procedure.This audit was borne of a concern that we were unable to help some patients due to their short prognosis and lack of fitness for procedures or because they had died prior to assessment. It is a prospective audit of all referrals to the service and the outcome of the referrals over a six month period.Out of 43 referrals, seven patients died or were too unwell to attend for assessment within days of the referral being received. Most patients who were able to attend were offered an appointment between one and four weeks from the referral. A further seven patients were assessed by phone as unsuitable for intervention due to short prognosis, poor performance status or their pain being too diffuse to be helped by an intervention and were spared a fruitless journey to clinic.This audit highlights that referrals often come too late for the service to be of benefit and we must investigate the reasons for this, whether it be a lack of awareness of availability of procedures or reluctance on the part of patients to consider interventions. We plan to survey our local referrers and provide education about procedures and develop a pain MDT in the first instance and repeat the audit once these measures are in place in order to maximise the number of patients who may benefit from the service.

Background The Outcome Assessment and Complexity Collaborative (OACC) created a standardised, validated suite of outcome measures for use in palliative care. The key features are the holistic approach, with involvement of the Multidisciplinary Team (MDT) and the patients/families themselves. Our hospice currently uses three outcome measures: the Integrated Palliative care Outcome Scale (iPOS), the Australia-modified Karnofsky Performance Status (AKPS) and Phase of Illness. All three outcome measures are discussed in the weekly multidisciplinary team meetings, both in the in-patient unit (IPU) and the day hospice. Aim The use of outcome measures was first piloted in the IPU and day hospice in 2012, but there has been no recent audit of their use. Anecdotally the outcome measures are consistently available for review at the MDT meeting but there is not always an available explanation when the iPOS is incomplete. This audit aims to quantify the compliance. Methods This is a retrospective audit, aiming to capture all patients in a one month period who were admitted to the IPU or who attended the day hospice for assessment. The standards (all with 100% targets) will include: iPOS offered to patients on admission (IPU) or at first assessment (day hospice) iPOS offered weekly thereafter - Reason for non-compliance documented when iPOS not completed AKPS and Phase of Illness discussed weekly at the MDT meeting (both IPU and day hospice). A secondary project will involve documenting baseline scores and changes in scores during admission or time attending the day hospice. Results Full results awaited. Conclusion This project encompasses an audit to assess compliance and a secondary project to explore changes in outcome measures during an episode of care. We hope this information will help to further promote the use of outcome measures in clinical practice throughout the hospice.

Prior to the start of the COVID-19 pandemic, Woodlands Hospice Wellbeing and Support Centre ran several regular groups plus nurse-led clinics for patients well enough to attend the hospice. When the pandemic started it was clear that this would no longer be an option as most of the patients were in the shielding category.Clearly the needs of these patients would not go away but the community palliative care and district nursing services could not be expected to take on the role that the hospice had previously played, as they also faced increased demand due to the pandemic.Out of necessity and working towards a new city-wide integrated palliative care model, a decision was made to move to a system of triage coordinators and regular nurse led telephone clinics to monitor these patients. The nursing team underwent an education programme to enhance their triage and symptom management skills and they had ready access to the medical team for support if there were problems.Consultations are carried out by telephone or video consultation as well as face-to-face where needed. The nursing team gradually took over the surveillance role of the medical clinics to free capacity for urgent medical appointments so patients could be assessed by the doctors when problems arise or when symptoms are more complex. The triage coordinator now looks at all referrals coming into the hospice and assesses the patient’s needs to ensure the patient is linked into the most appropriate services. All this integrated working has reduced the time from referral to comprehensive specialist nursing assessment in the hospice from two weeks to within five working days. The working relationships with all teams has become closer and more effective, and patients are still able to access services despite the restrictions that the pandemic has brought.

It has been estimated that malnutrition affects 50% of hospice patients. Nutritional assessment and support is vital in palliative care, since inadequate hydration and nutrition results in skin and muscle wasting, vulnerability to the development of pressure ulcers, and susceptibility to infection. Method Clinical and catering staff established a nutritional steering group with the brief of introducing an assessment tool and improving the evaluation and management of nutritional risk in the hospice. The group identified several nutritional assessment tools and concluded that none were ideal for use in the hospice setting. The Nutritional Screening Tool was adapted to identify significant risk of nutritional problems in inpatients. The group devised a new policy and procedure for nutritional care along with an information leaflet for patients and families to support them in managing their own nutritional risk. Inpatients were given the opportunity to choose meals, snacks and drinks. Training for all staff on nutritional assessment using the tool and management of nutritional risk was provided Results Following staff training and implementation of the assessment tool, an audit was undertaken which showed: 96% of patients had a nutritional assessment completed within 24 h of admission. 100% of patients requiring an individualised care plan had one formulated. 89% of all patient meals were recorded by catering team. Conclusion This simple intervention made a significant improvement in the assessment and management of nutritional risk in the hospice inpatient population compared to the baseline audit prior to the revised policy. Clinical and Catering staff working together has made a positive impact on practice for inpatients. In recognition that people admitted to the hospice are often frailer and more likely to already have established malnutrition, the nutritional tool has now been introduced to the hospice outpatient services. This will hopefully delay the onset of malnutrition in these patients.

Existing quantitative evidence for the benefits of Hospice Day Services is limited. Clinical Commissioning Group funding decisions are often based on numbers of attendees, rather than overall impact on individuals engaging with those services.At Woodlands Hospice, an outcome measures questionnaire, the Integrated Palliative Care Outcome Scale (iPOS), was implemented on the inpatient unit several years ago, and, in addition to being clinically useful for individual patients, audit data showed an overall improvement in average iPOS score during patients’ admission.The use of iPOS was piloted for new patients to our Day Services at their initial assessment from December 2018. This tool was used to assist in transforming our individual patient care plan, with a change in our practice being to repeat iPOS for each patient every four weeks to update the care plan. A baseline audit showed a mean overall improvement in patients’ iPOS score when repeated after four weeks. Interventions during the four-week intervening period varied according to the patient’s own personalised plan of care. The interventions ranged from solely medical outpatient review, to multidisciplinary assessment and management, with some patients attending individual outpatient sessions only, and others attending group therapy sessions.This audit looks at the breakdown in improvement of physical symptoms and psychological wellbeing, and compares the reduction in iPOS score to changes in other outcome measures, namely the OACC Phase of illness and the Palliative Performance Scale. The use of these outcome measures will enable the hospice to monitor the effect of the care and interventions it provides to each individual patient and ensure their personal care plan is continually adapted in accordance with their specific needs as their condition changes.