Clinical Quality

Introduction: An acute hospital-regional nursing home service (EAGLEcare ACT) were established with an aim to reduce preventable emergency department visit and inpatient hospitalisations of nursing home residents. We aim to explore the experiences of nursing home nurses using the service. Method: Ten focus group discussions were conducted in six partnering nursing homes. A total of 57 nursing home nurses with an average of 4.9 years of working experience participated in the discussions. Transcripts were analysed using qualitative interview analysis. Results: Three main themes emerged: empowerment, feasibility of use, and needs unmet. The EAGLEcare ACT service provided by an acute hospital were welcomed to supplement the inavailability of resident general practitioner. It promotes capability building among partnering nursing home nurses and provides assurance to the next-of-kin of ill residents. The processes and teleconsultations were found to be convenient, and the service was responsive. Medication ordering to administration time, and laboratory investigation ordering to collection and dispatch time were identified as areas for service improvement. Conclusion: Teleconsultation service partnership between an acute hospital with nursing homes were generally well received and perceived as helpful and scalable collaboration.

Introduction

Fragility fractures are a significant cause of morbidity and mortality in the UK. An estimated 549000 fragility fractures occur each year, with a significant financial and social cost. By identifying and treating those at risk we can reduce the incidence of fragility fractures. We wished to assess how we could optimise management of bone health in those presenting to our acute frailty unit(AFU). 

Method

We conducted a retrospective review of patients admitted to AFU with falls on a background of frailty. 2 PDSA (plan, do, study and act) cycles were undertaken in 2023 and 2024 respectively. We audited if patients had a full assessment of bone health (calcium, Vitamin D levels and FRAX score) and if they had been started on appropriate treatment. Interventions included multiple educational sessions for members of the elderly medicine team, updated guidelines for primary and secondary prevention and concise poster guidelines visible on all elderly care wards. 

Results 

Over two cycles, we noted an improvement in bone health assessments amongst those admitted. By the end of our cycles, 48% had appropriate bone health bloods compared to 13% prior and 33% had a FRAX score calculated compared to 7% before. 32% of the patients had a clearly defined treatment plan for bone health compared to 0% at the start of the cycle. 

Conclusions 

1. Education proved a moderately successful tool for increasing the awareness of bone health in frail patients admitted to AFU and also in increasing appropriate assessment and management of these patients. 2. Despite this, the majority of patient’s did not receive an assessment. Possible factors limiting this included; time, clinical acuity and uncertainty about best management option. 3. This QIP has demonstrated the need for the development of a fracture liaison service to provide robust assessment and management in the frail population.

Background: Older adults with multimorbidity are prescribed medicines to manage chronic conditions. Some of these cause anticholinergic side effects which can lead to falls. Introduction: This work originated from the West Yorkshire ACB Task and Finish Group and involved pharmacists in secondary and primary care working collaboratively. The aims were: To raise awareness of ACB across all sectors. To calculate the ACB scores for patients admitted with falls on acute older patient admission wards in two hospitals and refer to primary care for review on discharge if the score is 3 or more (clinically significant). Method: On admission, the pharmacist calculated the ACB score using an online ACB calculator. Medicines contributing to ACB were reviewed throughout the hospital stay reducing doses and stopping medicines where appropriate following discussion with patients and carers. Any ACB score still ≥ 3 on discharge was documented in the discharge letter with a request to review and deprescribe anticholinergic medicines in primary care. Consent to access SystmOne was obtained so patient records could be checked in secondary care 6 weeks post discharge. Results: Over one hundred ACB scores were calculated during the 4-week data collection period. After reduction of ACB scores in secondary care, 15 patients still scored 3 or more on discharge and were referred to primary care for review. 66.67% (10/15) of patients referred received a primary care review. 70% (7/10) of primary care reviews resulted in reduced ACB scores. Conclusion: Awareness of ACB in secondary care was raised through routine calculation of ACB scores on admission. A high proportion of referrals were actioned in primary care. By reducing ACB scores patients were subjected to less side effects and a potentially reduced falls risk. This project was identified by NHSE in a national scoping exercise and analysed in a medicine safety scoping review.

Introduction: Care home residents are often multi-morbid with both physical and cognitive impairments. An average care home resident takes 7.2 medications per day. Older people are more likely to experience adverse effects from polypharmacy due to pharmacokinetic and pharmacodynamic changes associated with age. Polypharmacy and anti-cholinergic burden (ACB) not only increase the risk of adverse drug reactions but also can increase the number of falls, hospital admissions and mortality. 

Method: Retrospective analysis in October 2024 of all patients at a residential home who had an initial Comprehensive Geriatric Assessment (CGA) which included a medication review since Enhanced Health in Care Home (EHCH) team started in March 2022 up until September 2024. The number of medications a patient was on at initial CGA alongside their ACB burden was analysed pre and post CGA. 

Results: 65 residents had an initial CGA within this time period with an average of 6 medications and ACB score of 2. Post CGA, the average number of medications per resident was reduced to 5 with an ACB score of 1. 68% of patients had polypharmacy (≥5 medications) prior to initial CGA and this was reduced to 58% post. 12% had ≥10 medications (excessive polypharmacy) prior to CGA and 8% (5) post. Pre CGA, 26% of residents had a high ACB score ≥3 which reduced to 15% post. There were 59 medications prescribed with an anti-cholinergic score of ≥1 which were reduced overall by 24% following the CGAs. 

Conclusion: The overall degree of polypharmacy and anti-cholinergic burden in care home residents can be reduced through a medication review as part of a CGA

Introduction 

According to the GMC’s Good Medical Practice, medical professionals have a responsibility to be considerate and compassionate to those close to a patient through giving support and information. For those lacking capacity, clinicians can assume that patients would want those close to them to be kept up to date with their condition. NHS digital data last year showed that 17.1% of written complaints are linked with communication. The primary aim of this project was to increase the percentage of surgical patients aged 65 or over receiving a next of kin (NOK) update. The secondary aim was to decrease the time to NOK update for this patient group to under 48 hours.   

Method  

QI methodology and 2 PDSA cycle loops were used. Using the electronic patient record surgical patients aged 65 years or over on two surgical wards were identified. Medical records were checked for documentation of a NOK update. Where a NOK update was documented, time to update from surgical team decision to admit was noted. In those without a documented NOK update, time from clerking was recorded. The percentage of patients receiving an update and mean time to update was calculated. Following the implementation of posters prompting NOK updates, data was recollected. Following a teaching session a third data analysis was undertaken. 

Results  

Following the initial intervention the time to NOK update decreased by 78% from 232 hours to 50 hours. The data post second intervention saw an increase in the percentage of NOK updates from 62% pre-interventions to 70% and time to update decreased by a further 5% to 40 hours. 

 
Conclusion 

Implementation of a poster prompt and undertaking a teaching session, highlighting the importance of communication with NOKs, demonstrated improvement in percentage and mean time to NOK updates for our patient cohort on surgical wards. 

Introduction . DVT is a common complication post stroke. Clinically evident DVT can occur in 2-10% after an acute stroke. DVT can develop as early as Day 2 after acute stroke; Risk peaks between Days 2 and 7. Untreated proximal DVT has a 6-15% mortality risk. Intermittent pneumatic compression (IPC) of the legs is recommended to reduce the risk of DVT in non-ambulatory stroke patients. Methods Criteria = All new stroke admissions to Stroke ward should have IPC applied by the time they were seen by the consultant on the post-take ward round – Unless contraindicated. Initial Audit = 100 admissions from June-July 2024. Intervention = Posters placed in doctors' offices and nursing bases (three locations) to remind both nursing and medical staff to prescribe and apply IPC on time. Post-intervention Audit = 100 admissions from August-September 2024. Results Initial Audit = 21.6% of patients did not have their IPC applied on time. Post- intervention audit = 18.1% of patients did not have IPC applied on time, reflecting a 3.5% improvement. Patients not receiving IPC by Post-take ward round reduced by 3.5% post-intervention. The reduction was mainly due to more timely IPC prescriptions by medical staff (improved by 5.9%) but compliance in IPC application by nursing staff worsened (by 2.2%). Conclusion The intervention successfully improved timely IPC prescription rates but did not fully address the delay in application by nursing staff. Targeted reminders can improve compliance, but additional strategies may be necessary for sustainability. Second cycle being planned to include: More targeted posters. Larger pool of patients to be audited (150). Request for ideas for interventions from nursing staff/resident doctors. Data will be collected on incidence of VTE in affected patient group.

Introduction: Frailty is a clinically recognized condition characterized by increased vulnerability due to age-related decline across various physiological systems, leading to reduced ability to cope with daily and acute stressors . Managing frailty requires a person-centred approach, involving patients, families, and caregivers, and utilizing evidence-based practices such as Comprehensive Geriatric Assessment (CGA), delivered by specialist multidisciplinary (MDT) teams. Research indicates that older individuals receiving CGA are more likely to be alive and living independently at home six months after an acute illness. To support the development of Older People’s Services, a review of the service model was conducted to deliver a rapid access service for patients referred by general practitioners (GPs). This service aims to avoid emergency department (ED) visits while providing necessary CGA assessments. Method: The initiative involved creating a direct referral option within the GP’s electronic referral system (Clinical Commissioning Group), developing a standard operating procedure for the triage process, establishing an education process for staff to clarify roles and responsibilities including data collection, and scheduling MDT members for triage support. Results: Following the implementation of the agreed procedures, there was a notable improvement in scheduling urgent GP referrals within three days. A daily referral system with live triaging was established, along with daily post-clinic MDT meetings. The backlog of urgent GP referrals was cleared. This successful system was replicated using Plan-Do-Study-Act (PDSA) cycles to integrate ED referrals. Conclusion: Collaborating with a team whose values aligned with Health and Social Care (HSC) principles—working together, striving for excellence, openness, honesty, and compassion—was a rewarding experience. The project provided valuable learning opportunities in team-building and service development. The success of the GP referral system was also leveraged to expand the service to other areas, such as ED referrals, demonstrating effective duplication of successful strategies.

Introduction: 

Following the publication of ‘Call to action: A Five nations consensus on the use of intravenous zoledronate after hip fracture,’ Craigavon Area Hospital began offering IV Zoledronic acid (IV Zol) to patients with a fragility neck of femur (NOF) fracture. However, the administration of IV Zol is based on the bone health assessment, vitamin D level, and requires ongoing post-discharge care. An oral bisphosphonate should be started one year after IV Zol administration. This study aimed to analyse whether discharges from Craigavon Area hospital following a NOF fracture had clear instructions for post-discharge care.

Methodology: 

Discharge letters of patients with a NOF fracture from the Trauma Ward between 4/11/24 and 22/12/24 were divided into three groups:

A (Bone health, IV Zoledronic acid and post discharge instructions), B (Bone health and IV Zoledronic acid mentioned but no post discharge instructions given)

C (Bone health, IV Zoledronic acid and post discharge instructions not mentioned). 

These groups were then analysed for potential interventions to improve future discharge letters. The second stage assessed the 4 week period between 14/1/25 and 18/2/25 with the same methodology.

Discussion: 

Only 38% (16) of the 42 discharge letters were included in group A and 37.5% of these contained ambiguous instructions. There were 13 discharge letters in group B and C of which 15% and 38% were discharged during outside of normal working hours respectively. Standardised wording and poster reminders were implemented and the impact reassessed. In the second stage 96% of discharge letters contained a full bone health assessment with follow up instructions.

Conclusion:

This study has highlighted the importance of adequate post discharge care for patients who have received IV Zoledronic acid. Unfortunately, many discharges did not mention the necessary information for GPs so proposals were made to improve ongoing care. The impact has been significant with 96% of letters containing the required information and so these changes will be introduced permanently.

Introduction 

The Commissioning for Quality and Innovation (CQUIN) framework sets a 10% minimum and an ideal goal of 30% of acutely presenting patients over the age of 65 to receive frailty assessment scores. Early recognition of frailty helps mitigate risks such as deconditioning. This project aims to assess and improve the adoption of this standard in medical emergency admissions of a Birmingham district general hospital by working with medical admissions teams and frailty services and observing for associated outcome measures.

 Methodology

 PDSA methodology was used. Data was retrospectively collected for patients aged 65 and above from the electronic patient records (EPR) over a week’s interval from the acute medical take. Collected data included prevalence of CFS scoring and social history, escalation discussions and mortality. Interventions were delivered via an educational presentation to resident doctors and displayed posters in key areas. The data was examined for improvements in CFS prevalence and its relationship with onwards referral, escalation discussions or mortality. Results Pre-intervention only 3.31% (8/242 patients) had a recorded CFS score . . Post-intervention, 19.10% (34/178) patients had a CFS score documented. Post-intervention, 82.35% of those with CFS scores were referred to the frailty therapy service, as opposed to 17.36% of those without CFS scoring. Escalation discussions were had with 41.17% of those with CFS scoring and 29.17% of patients without. Mortality was 5.88% in the CFS scored patients and 9.72% in the patients with no CFS score. 

Conclusion

 After focused interventions, the CFS prevalence was above the 10% minimum requirement and closer to the 30% goal set by the CQUIN 05. Patients with a CFS score saw higher rates of onwards referrals to older person services, and higher rates of escalation discussions . In forwards application, CFS could be discussed in induction, incorporated into IT clerking systems
 

Care of the elderly simulation-based teaching for the multidisciplinary team

Introduction

Geriatric medicine is inherently complex and requires multi-disciplinary integration. Simulation-based training has been recognised by the Joint Royal Colleges of Physicians’ Training Board and the Royal College of Nursing as a method to enhance learning and improve patient outcomes. This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional clinical practice that takes place on geriatric hospital wards.

Methods

A total of ten half-day simulation sessions have been run across two sites in two years. The scenarios cover frailty, orthogeriatric post-operative complications, acute delirium, Parkinson’s disease, thrombolysis and end of life care.

The sessions were attended by 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates. Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation as a learning tool.

Results

Both pre- and post- simulation, candidates had the most confidence in managing end of life situations, and least confidence in managing acutely unwell patients with Parkinson’s disease. Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the simulation session. Thematic analysis highlighted the importance of collaboration within a team to enhance a sense of belonging, and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.

Conclusions

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the multi-disciplinary team looking after geriatric patients through exposing candidates to complex situations and increasing awareness of the roles within the team.

The simulation sessions have highlighted clinical areas that require further education within the Trust, such as thrombolysis.

Future development of the simulation will aim to adapt the scenarios for use of the wider multidisciplinary team, incorporating therapists and pharmacists.