Clinical Quality

Introduction

There are approximately 600 patients in the Pembrokeshire Movement disorder service, of whom, around 10% are either housebound or live in placements.   There is concern these patients struggle to access follow up due to difficulties in attending face to face clinics.  NICE and Parkinson’s UK recommend that people with Parkinson’s should be seen by a specialist healthcare professional every 6 to 12 months.

Method

A retrospective case note analysis was carried out for 55 patients that were identified as being either housebound or living in residential or nursing homes.  Data were collected on time since last clinic visit and last letter, hospital admissions in the past 2 years, number of prescribed medications and DNACPR status on Welsh Clinical Portal.

Results

The mean time since last clinic visit was 15.3 months, with the longest 81 months.  Housebound patients had a mean time since last clinic visit of 15.5 months and those in placements had a mean time of 15.3 months.   The time since last letter was lower, however those patients still in their own homes had a longer interval than those in placement.   53% of patients had a DNACPR decision recorded on Welsh Clinical Portal.  When isolating   housebound patients this dropped to 29%.  72% of those in placements had a DNACPR decision.

Conclusions

The requirement to see patients with Parkinson’s every 6 to 12 months is not being met.  This is likely due to practical difficulties of attending face to face clinics.   It is proposed to create a regular virtual clinic to discuss these patients, in combination with their relatives or carers and patient reported outcome measure questionnaires.  This will be brought to the health board Parkinson’s meeting in order to facilitate change.  Once the change has been implemented data can be recollected to establish the effect of the change.

Introduction: There are approximately 549,000 new fragility fractures each year in the UK and the prevalence of both osteoporosis and risk of falling increases with age. Care home residents are three times more likely to fall and have a 3- to 4-fold higher incidence of fractures than people of the same age living in the community. These older, frailer and multimorbid patients often have the highest fracture risk and therefore the most to gain from anti-osteoporosis treatments to reduce this risk. 

Method: Retrospective audit of residents who were reviewed by the newly started Enhanced Health in Care Homes (EHCH) team within the 5 residential homes for an initial comprehensive geriatric assessment (CGA) between March 2022-June 2024. These initial CGAs were reviewed to determine if a FRAX assessment had been completed and subsequent sub-analysis of those with high/very high FRAX scores to determine whether they were on appropriate bone protection. 

Results: 100% of residents (183) had a bone health assessment including a FRAX score (age-adjusted if appropriate). Prior to CGA, 37% patients with a high/very high FRAX score were on appropriate bone protection, having excluded patients who were not suitable for any treatment for reasons including poor renal function or not clinically appropriate. Following EHCH initial CGA and management plan, this average improved to 85% across the residential homes. The most significant improvement in one residential home was from 0% to 83% post bone health assessment. 

Conclusion: There has been a considerable improvement from 37% to 85% in the number of residents at high and very high risk of fractures who are on appropriate bone health protection following an initial bone health assessment and subsequent management plan initiated by the Enhanced Health in Care Home team. 

Background: The National Clinical Guideline for Stroke recommends bone health assessment for patients at higher risk of falls. Following stroke, patients have reduced bone mineral density, correlated with functional deficit. Stroke can result in reduced mobility, asymmetric weight bearing, poor nutrition and impaired Vitamin D stores. This results in higher risk of fragility fracture. However, bone health is often overlooked. An initial review on a stroke rehabilitation unit in March 2024 found no bone health assessment process. 

Objectives: Patients with stroke and high risk of fragility fracture should undergo bone health assessment and timely treatment or onward referral if indicated. 

Methodology: Patients undergoing stroke rehabilitation were identified as high-risk for fragility fracture based on age, gender, falls history, cognition, visual impairment and post-stroke seizures. Patients with life expectancy 1 year or predicted to be bedbound longer term were excluded. Data was collected over two cycles for 1 month (September 2024, November 2024). If high-risk, records were reviewed for serum calcium and Vitamin D measurement, FRAX score and treatment initiation and/or onward referral. 

Results: Local guidelines were developed with input from orthogeriatric and stroke physicians. Following initial analysis, 3/32 eligible inpatients (11.1%) had recorded FRAX scores with none initiated on therapy. Prompts were added to patient records and departmental teaching delivered. Significant improvement was seen in the following cycle: 43.8% (n=14) of eligible patients had bone health assessment. Serum Vitamin D measurement increased from 41% to 56% and all below threshold started replacement. Five patients were referred for bone densitometry and a further five were prescribed bisphosphonate therapy. 

Conclusion: Patients with stroke are at higher risk of fragility fractures. Increased awareness and assessment in the rehabilitation setting are required. Further improvements include displaying posters of the treatment flowchart, induction education for rotating doctors and additional electronic record prompts to increase engagement.

Introduction Delirium is a common, reversible condition with significant morbidity. Guidelines facilitate diagnosis and management (NICE Delirium Guidelines [CG103]). Previous audits in an acute frailty ward identified areas for improvement in assessment of delirium. In this cycle, a novel admission proforma was implemented to promote adherence to current guidelines. Methods This is a continuation of a previous quality improvement project representing cycles three and four. An admission proforma was co-developed with patients and the multidisciplinary team (MDT), primarily to prompt staff to complete delirium assessments. Adherence was audited and the proforma was modified based on feedback. An equivalent audit was then conducted on the updated proforma. The audit period occurred over several resident doctor changeovers. Primary outcomes; completion of delirium assessments, positive diagnosis of delirium and use of the new proforma. Secondary outcomes; completion of resuscitation and clinical frailty score (CFS) forms and the relationship between length of stay (LOS) and delirium or CFS. Results  The initial admission proforma was used in 86% of admissions. After its introduction, 53% of patients had completed delirium assessments and the prevalence of delirium was 25%. Resuscitation forms were completed in 86% of patients, 60% of patients had completed CFS. Diagnoses of delirium were associated with increased LOS. CFS of 6/7 was associated with an increased LOS and a diagnosis of delirium. The modified proforma was used in 94% of admissions. Completion of delirium assessments improved to 79% and diagnoses of delirium to 43%. Completion of resuscitation forms and CFS improved to 93% and 79% respectively. The difference in LOS between patients with and without delirium was statistically significant. Conclusion This study shows the efficacy of an admission proforma, as low-cost MDT-based intervention, improving and sustaining adherence to guidelines and improving documentation and assessment of other elements of a comprehensive geriatric assessment. 

Introduction 

Delirium complicates 10% of admissions. A delay in diagnosis can lead to permanent cognitive decline, care home placement and death. Watford General Hospital’s (WGH) delirium liaison service receives fewer referrals than expected from areas with vulnerable patients such as ITU. This audit sought to understand why and what effect this might have on outcomes. 

Method The audit team reviewed notes for all >75-years-old in WGH on a single day, looking for delirium risk factors, evidence of delirium and, if present, a diagnosis and management plan. Outcomes were reviewed at 90 days. 

Results Of 216 patients, 44% had evidence of delirium. 40% were missed, with only half of those diagnosed having a delirium-centred plan. Pareto analysis revealed 50% of >75-yr-olds on only four of twenty wards and 50% of delirium present on those same four wards. 90-day outcomes revealed: - Delirium is associated with higher mortality (OR 2.28) - Longer length of stay (LOS) (+3 days). - LOS was longer if delirium was missed (average 28.5 days) - Frailty is a predictor of delirium (OR 3.26) and mortality (OR 2.5) Subgroup analysis showed that, even when compared to other geriatrician led CGA based care, orthogeriatric patients with delirium had significantly higher rates of diagnosis (100% vs 53%), management (100% vs 35%), lower mortality (OR 0.55), comparable LOS, and fewer than half as many readmissions. 

Conclusions Delirium is concentrated on a small number of medical and orthopaedic wards. Orthogeriatric patients have significantly higher rates of diagnosis, delirium-focused plans, lower mortality and readmission rates. This data suggests that a best practice pathway, akin to that for hip fractures, mandating delirium screening for at-risk, especially frail, patients on high-risk medical wards may improve outcomes. This data has allowed us to develop a focused improvement plan based on a time-critical pathway. 

Parkinson’s disease (PD) is a progressive neurological condition which affects approximately 153,000 people in the United Kingdom (1). It classically involves a triad of bradykinesia, rigidity and tremor alongside other significant motor and non-motor features (2). Delayed or missed medications can result in unpleasant motor and non-motor fluctuations (3). Inappropriate management of patient medication has been shown to result in longer length of stay, delayed recovery, and worse overall outcomes (4). Patients with PD have a high risk of complications peri-operatively with evidence showing they are best managed via a multidisciplinary approach (5).​​The PD team at Aintree University Hospital, part of NHS University Hospitals of Liverpool Group (UHLG), noted that referrals for patients undergoing surgery were low. An initial review of data confirmed that patients undergoing surgery at the site were not having the PD team involved in their care. ​The acute management of Parkinson’s disease for inpatients guidelines were updated to include more detailed advice around the management of patients with PD undergoing surgery. The second cycle reviewed patients cared for after the intervention had occurred.​After the guideline was implemented the number of patients reviewed either pre- or post-operatively by the PD team increased from 4 to 47%.​In the initial review there were 640 missed or late doses of PD medications, with only 17% of patients consistently receiving their medications on time. This improved to 56% in the second cohort. ​Cognitive testing via the 4AT was completed for 38% of patients compared to 18% in the initial cohort. ​In the second cohort data was collected to review the number of patients with PD who were put first on the operating list, this occurred in 26% of patients.​ The results show an improvement in all aspects of care that were reviewed. The number of patients seen by the PD team, medications given on time, and cognitive tests performed all improved. Despite this there is still room for improvement; medications are still not being given on time, every time. UHLG has undertaken a trust wide time critical medication quality improvement project which we hope will have a positive impact. Further improvement through education of the surgical and anaesthetic teams and a guideline awareness campaign are planned.

Background: The NHS Long Term plan calls for change to deliver proactive community frailty care1. Proactive frailty case-finding outside traditional healthcare settings should be explored2. 

Aims: To pilot test proactive frailty screening at a community event. Methods: GSTT Musculoskeletal Physiotherapy department hosted a community day in a deprived area of Lambeth, London. Waiting list residents were invited for a café-style assessment. Stalls were available to meet wider needs including finances, wellbeing, Ageing Well and others. Ageing Well (Consultant Geriatrician & Geriatrics trainee) completed frailty screening using a 1-page screening tool with follow on assessment/interventions. Accessibility evaluated by characteristics of attendees. Feasibility and acceptability evaluated by participation and assessment completion. Appropriateness by prevalence of frailty needs, number of interventions arranged. 

Results: 137 residents accepted, 26 (19%) were 65+ years old. 14 residents were reviewed by Ageing Well. Mean age 67 years (57-80), mean 4 comorbidities, 72% from ethnic minority groups, mean Clinical Frailty Scale (CFS) 4 (range 2-5). 43% were digitally excluded (unable to use internet or phone). All 14 residents participated freely in an open setting suggesting acceptability including sensitive topics e.g. continence/mental health. The Frailty screening tool identified significant needs: pain (93%), fatigue (64%), falls (50%), mental health concerns (64%), medication management (50%), bladder concerns (50%), difficulties with activities of daily living (57%), financial concerns (43%). 43% attended ED in the last year. Only 1 was known to social services but 43% had informal help from friends/family. Personalised care plans included bone health interventions, medication changes, continence management, strength/balance exercises programme access, equipment provision, social services access, self-management advice/information . 

Conclusions: Ageing Well screening & assessments appeared feasible, acceptable, accessible and appropriate to managing frailty needs proactively in ambulant vulnerable-mildly frail residents. This proactive outreach approach should be explored at alternative outreach events.

Introduction

Frail older patients with hearing impairments face significant communication challenges in acute care settings such as the Emergency Department (ED) and Same Day Emergency Care (SDEC). These challenges often lead to misdiagnoses, increased anxiety, and diminished patient satisfaction. Improving communication for such patients is critical to enhancing their care experience, maintaining dignity, and improving overall satisfaction and outcomes.

Method

A Quality Improvement Project (QIP) was conducted involving ten participants over 75 years who were identified with hearing impairments and admitted to the SDEC frailty unit from the ED. Baseline communication difficulties were assessed using a pre-designed questionnaire. The AudiMed Communicator 2, a lightweight and ergonomic device with a high-quality amplifier and built-in microphone, was introduced to enhance hearing without requiring traditional hearing aids. Participants provided feedback post-intervention via a follow-up questionnaire, evaluating the device's impact on hearing and communication.

Results

All participants initially relied on alternative communication methods and reported frustration due to impaired hearing. Most did not have functioning hearing aids. Following the implementation of AudiMed, participants' hearing ability scores improved dramatically. All reported a score of 5 on a 1-5 scale, indicating high satisfaction. 100% of participants preferred using AudiMed and highlighted its positive impact on their communication and care experience.

Conclusion

The AudiMed Communicator has significantly enhanced communication, hearing ability, and patient satisfaction among frail older patients in acute care settings. By addressing communication barriers, the device has empowered patients, promoted dignity, and streamlined care delivery, ultimately improving outcomes and quality of life. Recommendations include expanding the use of AudiMed in similar settings, providing staff education for seamless integration, and ensuring ongoing feedback for continued evaluation and improvement.

Pneumococcal pneumonia in a confused older person – is it enough for diagnosis of delirium?

Objective: To discuss the high suspicion of meningitis in an immunocompromised patient presenting with pneumococcal bacteraemia as Streptococcus pneumoniae (SP) exhibits a notable tropism for the meninges. With the recent rise in non-PCV13 serotypes, it is important to remain vigilant about the possibility of pneumococcal meningitis in susceptible individuals despite the widespread use of pneumococcal vaccines. Health promotion through vaccination should be encouraged to prevent an increase in invasive pneumococcal disease (IPD) incidence.

Case Presentation: The patient is an 82-year-old gentleman with low-grade lymphoproliferative disorder who presented with confusion. CXR reported diffuse bilateral shadow suggestive of possible acute infection. Intravenous antibiotics were commenced for delirium related to community-acquired pneumonia. Blood culture confirmed the presence of SP. Given this organism’s predilection for meninges, he was re-assessed clinically, which identified neck stiffness and positive Kernig and Brudzinski’s sign. CSF sample showed raised protein, LDH and white cells with low glucose. CSF PCR confirmed the presence of SP. Intravenous antibiotics were adjusted, and the patient recovered fully. After discharge, conjugated pneumococcal vaccine and monthly immunoglobulin replacement were recommended due to the high risks and life-threatening nature of IPD.

Discussion: Despite vaccination efforts, Streptococcus pneumoniae remains the leading cause of bacterial meningitis. It is associated with long-term neurological complications and high mortality rates, even with antibiotic treatment. Despite only a brief neurological presentation, a high index of suspicion for meningitis is warranted, especially where SP appears in blood culture as it denotes invasiveness.

Conclusion: This case report emphasises the significance of early diagnosis and treatment of pneumococcal meningitis in the older to reduce morbidity/mortality, and the need for vaccination to safeguard against serious infections caused by SP. It also highlights diagnostical problems of meningitis in the older who frequently present with delirium in the context of less sinister infections such as chest infection.