Design
A two phase sequential qualitative design was employed in this study:
- Phase one: consisted of focus groups with consumers and clinicians with the aim of generating components of an ideal model of ESD for foot disease; and
- Phase two consisted of a three round Delphi survey (14, 15) that aimed to gained consensus on the components that should be included in an ideal model of ESD for foot disease.
Setting
Northern Health (NH) is the major provider of acute, sub-acute and ambulatory specialist services in Melbourne’s north. It provides comprehensive primary, secondary and tertiary healthcare services. Residents in the NH catchment area are ethnically and culturally diverse and originate from more than 165 countries and speak more than 100 languages. The area has lower levels of income, educational attainment and health literacy and higher rates of unemployment than Victorian state averages (16-18).
Currently, patients admitted with foot disease at the hospital may be admitted on a number of different wards, and may be admitted under vascular, endocrinology or infectious diseases bed cards, depending on the primary diagnosis on admission. Patients may be admitted on a planned admission, but most often they are admitted following presentation to the emergency department. Over the past 5 years the hospital has worked hard to improve the fragmentation of services for patients admitted with foot disease and most patients are now cared for by a multidisciplinary team consisting of vascular, podiatry, infectious diseases, orthotics, dietetics, occupational therapy and physiotherapy. Most patients undergo surgical revascularisation and/ or amputation and/ or debridement during their hospital stay, followed by a period of in hospital treatment with antibiotics, dressings and implementation of offloading (use of such as orthotics that reduce pressure at the site of ulceration) strategies.
Participants
For phase one we employed purposeful sampling to identify clinicians with recognised expertise in the treatment and management of foot disease, with additional snowballing technique (invited participants could suggest additional participants). Patient participants were purposefully sampled from individuals who were over the age of 18 years and who had experienced one or more hospital admissions for foot disease in the previous 12 months. The clinician focus groups were held separately to the consumer focus groups to ensure the consumers felt comfortable and confident to speak up about their needs.
For phase two (Delphi study) we invited all participants who were invited to participate in the focus groups, independent of whether they had been able to attend. We allowed new participants to join in round 2 if they had been unable to participate in round 1 (as round 1 was not a scoring round), however no new participants were allowed in round 3 (final round). The Dillman tailored design method was used to invite clinicians (19), with the initial invitation sent via a personalised email with a link to the survey, with up to three additional reminder email reminders sent at weekly intervals. For consumers, the Delphi surveys were completed during outpatient follow up appointments. The patient participants were supported to complete the surveys by a research assistant who provided a description of each component in layman terms to help them with their understanding. We permitted patient participants to also be assisted by family or an interpreter as required. We established a participation rate of at least 70% would ensure credibility and validity of the results (14, 20).
Data collection
Three focus groups were conducted in phase one, one group with consumers and two with clinicians. We aimed for 6 to 12 participants per focus group based on the optimum number to ensure broad representation across disciplines and experience while also ensuring enough opportunity for all participants to share their insights and observations (21). At each focus group a clinical case scenario of a ‘typical’ (fictional) patient was presented and attendees were invited to suggest solutions to support an early discharge to home and prevention of unplanned hospital readmissions. Box 1 provides an example of the clinical vignette used for the staff focus groups, as well as the seeding questions used to generate discussion. A modified version of this same scenario was used for the patient focus group, however all health care terminology was replaced with lay terms.
Box 1. Example of clinical vignette and seeding questions used in the staff focus groups
Clinical vignette
Mr Andrew Johns, a 68 year old man with a 20 year history of type 2 diabetes, presents to the emergency department at TNH feeling very unwell with a very high blood sugar level (BSL) of 25mmol/L (normal < 7.8 mmol/L). He also reports fevers and rigours for the past 2 nights. He says there is also an ulcer under his left big toe, which he consulted his GP about over six months ago, and has since been dressing himself.
Upon examination, the area around his ulceration is red and swollen, with the redness and swelling spreading to the tip of his first toe and laterally across his foot. The wound is malodorous with wet necrosis and purulent discharge present on a gauze dressing.
Mr Johns has peripheral neuropathy and a toe pressure of 40mmHg indicating peripheral arterial disease.
Mr Johns is admitted to the ward under vascular with a diagnosis of diabetic foot ulcer infection and is commenced on IV antibiotics immediately He is referred for an x-ray of his foot in ED, which later confirms osteomyelitis in his 1st metatarsophalangeal joint. That night, Mr Johns undergoes an amputation of his left 1st toe including the infected metatarsal head. He remains in hospital for a further 16 days while the diabetes educators and endocrinologists work on getting Mr John’s blood glucose levels under control and while his ongoing dressing regime is being arranged by the podiatry and vascular services. Infectious Diseases are also reviewing Mr Johns to adjust his antimicrobial regime based on the cultures sent off from theatre.
Total length of stay in hospital: 17 days
Focus group seeding questions
- Do you recognise this patient? (i.e., is this a familiar scenario)
- What sort of supports/ care/ interventions would Mr Johns require if he were to be discharged home earlier?
- What sort of patients do you feel should be excluded from an early supported discharge model?
- Do you have any additional suggestions for an early discharge model that you have not had the opportunity to bring up yet?
Phase two of the study consisted of a three round Delphi survey (Figure 1). The first round comprised two parts: part one included questions relating to respondents characteristics (for staff this included current role in the organisation, for consumers this consisted of age and gender only). Part two asked each participant to review components of the model identified in the focus groups in phase one, and provide additional potential components (if they felt any were missing) with a brief justification. This round also acted as a form of member checking for the themes arising from the focus groups in phase one.
The second and third rounds were both scoring rounds. In the second round, respondents were asked to complete a questionnaire based on the information provided in the first round (i.e. a list of original components of the model as well as any additional components proposed in the first round) (Figure 2, A). Respondents were invited to score how important they felt each component of the model was to providing an ‘ideal’ model of early supported discharge on a 5-point Likert scale (not at all important through to essential). Participants were provided with a free text section for supporting comments.
In the third and final survey round, participants were provided with the results of the second round in the form of a mean group response and any qualifying (free text) statements. They were asked to re-score the components, taking into consideration the mean importance of each as rated by the panel in the previous round (Figure 2, B). The top two highest categories on the Likert scale (very important and essential) were considered to be agreement from a participant that the component should form part of the final model.
Data analysis
Two researchers (RJ and JK) independently and systematically coded the focus group transcripts from phase one using an iterative constant comparative method (22). The process involved two stages – initial coding to gain the broadest range of themes, followed by focused coding to reduce overlap and redundancy of coding (23). Two cross-checks to compare emerging themes was performed to ensure accuracy of inferences. Where conflicts arose between coders and agreement could not be reached a third reviewer (SH) was consulted. A pragmatic approach was adopted when drawing final inferences from the transcripts, with a focus on the development of useful knowledge directly related to an optimal model of early discharge. Final inferences were verified by subject specialists (IB and SH). Most importantly, and consistent with the co-design process, the data was then referred back to those who attended the workshops (final respondent validation) in the first round of the Delphi survey.
Achieving consensus in the Delphi was defined as ≥80% of the respondents in agreement on the value of a given component, with agreement being set as the two highest scale response options (very important and essential) (24). We aimed for a 70% response rate in each round to ensure validity of results (25).
Ethics approval and informed consent to participate
Ethics approval was obtained by the Northern Health Low Risk Ethics Committee, reference number 55150. All staff and consumers provided written informed consent prior to participation in the research. Ethics approval was provided by the Northern Health LREC and consent to written informed consent to participate was gained from all participants in accordance with the Australian National Statement on Ethical Conduct in Human Research 2007 and the Australian Code for Responsible Conduct of Research 2007.