Clinical Quality

Background: A QIP conducted within the geriatrics department at University Hospital Coventry & Warwickshire, led by a team of resident doctors under consultant supervision. 

Introduction: Efficient handovers are an essential part of safe care and geriatric medicine has unique challenges due to complex patient needs, nuanced decision making and requiring continuity of care. The Royal College of Physicians (RCP) recommends standardised, dynamic handovers with digital and face-to-face components. Our departmental out of hours handover process was perceived as inefficient by resident doctors. This QIP aimed to formally evaluate and improve handover processes, to enhance service efficiency and patient outcomes.

Methods: Two PDSA cycles were conducted. Resident doctors were surveyed regarding handover practices which identified flaws including inefficiency, high error potential and limited scope for communication. Key measures included time expenditure, ease of use and user satisfaction. The data was reviewed alongside RCP recommendations to help devise and implement interventions, and staff were re-surveyed 10 weeks later. The first cycle integrated the handover process directly into the trust’s Electronic Patient Record (EPR). Following successful implementation, the second cycle expanded this intervention to a second ward and added an in-person handover. 

Results: Transitioning to an EPR-integrated handover system improved user satisfaction, perceived efficiency, and accessibility. Doctors reported an average time saving of 15 minutes per individual per shift. The addition of an in-person handover enhanced the handover experience. 

Conclusion: This QIP demonstrated an improvement in the geriatric departmental handover process, aligning it with RCP recommendations through digital integration and the addition of a face-to-face component. Improved handover efficiency, functionality, and communication are expected to have positive effects on the care of our frail older patients. Future steps include extension to the full department and potentially adoption across the Trust.

Introduction:

Vitamin D is essential for blood calcium and phosphate homeostasis. In addition, it has anti-inflammatory, anti-oxidant and neuroprotective effects. The geriatric population is vulnerable to Vitamin D deficiency (VD) due to poor dietary intake, reduced exposure to sunlight, reduced skin thickness, drug interactions, and impaired absorption and metabolism. VD is associated with osteomalacia, high bone turnover, an increased risk of hip fractures, infection, cardiovascular and metabolic disorders and cancer risk. Clinical diagnosis of VD  is difficult due to vague symptoms. It is recommended to check serum 25-hydroxyvitamin D (25[OH]D) as it indicates the best Vitamin D status in the body with both skin-synthesised and dietary sources. According to “ Vitamin D in the older population-consensus statement”, the primary treatment strategies are exposure to sunlight, food fortification and supplementation. Early detection of VD is crucial because effective and safe treatment options are available. This study aims to determine VD prevalence among patients in an acute elderly care ward.

Methods:

This study was conducted retrospectively among patients admitted to an acute elderly care ward who required a Vitamin D level investigation. The serum 25[OH]D was measured using the recommended Vitamin D threshold for the UK: a level of less than 25 nmol/L is considered a deficiency,  25-50 nmol/L is deemed insufficient, and greater than 50 nmol/L is considered sufficient.

Results:

Out of 102 patients, 64 (62.7%) were male. The mean age of the population was 85.2 years (minimum 69, Maximum 97). The prevalence of VD was 19.6%, while the prevalence of Vitamin D insufficiency was 28.45%. Only 52% of our population had sufficient Vitamin D levels.

Conclusions:

The prevalence of VD and insufficiency in our study sample is very high. Early detection and starting treatment are vital to prevent harmful complications in the elderly.

Introduction: Venous thromboembolism (VE) prophylaxis is commonly administered to patients across many hospital settings, however it can be more challenging to address in frailty patients. These patients are more likely to have contraindications to anticoagulation and be "delayed discharges" (medically fit for discharge and at baseline mobility), at which point VTE prophylaxis may not be indicated. 

Method: This quality improvement project was carried out in the acute geriatric ward at St John's Hospital. With the aim to improve VTE prophylaxis (appropriately prescribed and deprescribed when delayed discharge) in frailty inpatients by December 2024, through education of medical staff and by creating a Trak proforma. Teaching was provided to ward medical staff and a new delayed discharge Trak proforma was created. This prompted a review of VTE prophylaxis deprescribing when patients were medically fit for discharge. A simultaneous QI project created an admissions proforma which prompted a review of VTE prophylaxis prescribing when a patient was first admitted to the ward. 

Results: Before the intervention, only 58% of patients in Ward 8 had VTE prophylaxis correctly prescribed on admission. Many patients (40%) remained on VTE prophylaxis despite being delayed discharges. A staff survey revealed a higher confidence level around prescribing VTE prophylaxis than deprescribing. Only 44% of staff regularly considered stopping VTE prophylaxis once a patient was a delayed discharge. After intervention, an increased number of patients (74%) had correct VTE prescriptions on Ward 8 admission (28% improvement). Only 16% of delayed discharge patients remained on VTE prophylaxis (60% improvement). 

Conclusion: This project improved rates of VTE prescribing in patients admitted to an acute frailty ward and deprescription rates in patients where VTE prophylaxis was no longer indicated by prompting regular reviews of these prescriptions. This intervention could be used in other departments.

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

Delirium is a common acute neuropsychiatric disorder, affecting approximately 23% of older adults admitted to hospitals in the UK. It is often triggered by acute illness and is associated with a high in-hospital mortality rate of around 30%. While delirium typically resolves, many patients experience prolonged cognitive and functional decline. Despite its prevalence, structured post-hospital follow-up services remain limited, leading to increased emergency department (ED) reattendance, hospital readmissions, and delayed recognition of cognitive impairment.

Method

To address this gap, we established a geriatrician-led outpatient delirium follow-up service at East Surrey Hospital. This service targets patients aged 65 and over, discharged within the last eight weeks with a new delirium diagnosis and no prior formal dementia diagnosis. Our consultant-led multidisciplinary clinic conducts comprehensive geriatric and cognitive assessments to improve patient outcomes, enable early referral to memory services, support advance care planning, and assist families and carers. Cognitive testing includes the Addenbrooke’s Cognitive Examination III (ACE-III) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

Results

Over four months, 13 patients with new-onset delirium were assessed. Of these, eight (62%) showed probable cognitive impairment, while five (38%) had no significant impairment. Those with suspected impairment were referred to Specialist Memory Clinics for further evaluation.

Conclusion

Our delirium follow-up service enables early detection of cognitive impairment, facilitating timely dementia diagnoses and better access to community support. Given that few centres currently offer this service, expanding this model across the healthcare system could improve outcomes for patients recovering from delirium.

Background

Eastbourne, on the East Sussex coast, has a population older than the national average. Older people make up a significant proportion of the hospital inpatient cohort, so services should be adapted to their needs. Language plays an important role in inclusion, but evidence is limited about preferred language in caring for older people. Anecdotally, "Elderly Care" did not resonate with patients. To find out more, surveys were conducted.

Methods

Surveys were used to find out patients' views on the name "Elderly Care" and identify other names they might prefer. Inpatients over 65 were asked how satisfied they were with the current name of the department (Elderly Care) and to rank their top 3 choices from a list of alternatives. 

Results

Data was collected from 53 inpatients on medical wards. The mean age of participants was 80.3 years, with a range of 65-99 years. There were 24 women and 29 men. All but one participant reported their ethnicity as white, white British or British. Socioeconomic factors were not evaluated. 74% of participants were somewhat satisfied or very satisfied with the name "Elderly Care."  

"Senior Healthcare," "Department of Medicine for Older People (DMOP)/Medicine for Older People (MOP)" and "Care of Older People (COP)" were popular. Whilst Senior Healthcare was most popular as a first choice, Care of Older People appeared as a top 3 choice more times overall.   

Conclusions

Locally we felt that a name change would not improve satisfaction, given 74% of survey participants were satisfied with the current name. There was not a clear consensus among participants as to which options were preferred and disliked, which may reflect the wide age range and differing lived experiences of participants. It is not known how generalisable these results are, but they add to the limited evidence in this area. 

Introduction 

Fragility Fractures can lead to immediate complications, decline in health status, increase in hospital stay, increased care needs and reduction in the quality of life (Court-Brown C Clement N, Duckworth A, The Bone and Joint Journal, 2014 96-B(3) 366-372). However, the National Osteoporosis Society (2017) reported 80% of non-hip fractures were not offered strength or balance exercises It is estimated that fragility fractures cost the UK £4.4 billion which includes £1.1 billion for social care (Office for Health Improvement & Disparities, 2022). At Sussex Community NHS Foundation Trust, non-weight bearing (NWB) patients have prolonged bed based stays. Complex patients cannot be discharged home when NWB as there is no commissioned social care pathway. These patients are seen as low priority for rehabilitation. The aim of the project was to reduce the length of stay for NWB orthopaedic patients. 

Method: 

Baseline data of 10 inpatients from the Sussex Community NHS Foundation Trust ICU, discharged in April 24 was scrutinised. The team articulated the issues for NWB in a fishbone diagram, and a tailored programme of resistance strengthening and balance exercises was introduced for 8 NWB patients in May and June 2024, as a PDSA cycle. This included leg ankle weights and dumbbells to carry out chair and standing exercises (when appropriate), in addition to routine group physiotherapy sessions. All patients were seen 2-3 times a week. Results: The average length of stay for NWB patients reduced by 14 days. The number of therapy contact sessions reduced to 2.1 post orthopaedic review and patients were weight bearing again. 

Conclusion: 

Providing a tailored strengthening exercise programme that focuses on the non-weight bearing phase of the patient's orthopaedic rehabilitation journey reduced the length of stay on the intermediate care unit, and the physiotherapy interventions once weight bearing.
 

Introduction: In Scotland, more than 18,000 older people are admitted to hospital after a fall each year. One in three people over the age of 65 experience a fall at least once each year (1). Neurological examination is an essential part of the initial assessment of these patients in hospital and can determine the cause of falls such as stroke, peripheral neuropathies and Parkinson’s disease. Local anecdotal evidence suggested that this was often not carried out, with the potential for delayed diagnosis and treatment.

Method: Baseline data was collected from clinical notes of admissions to the care of the elderly (COTE) wards at University Hospital Hairmyres (UHH) over a 1-month period. Multiple departmental education sessions were arranged to highlight to medical staff the importance of neurological examination in patients presenting to hospital following a fall. Following these sessions the data collection cycle was repeated. A poster has now been designed highlighting common causes of falls and in particular emphasising the importance of performing a neurological examination, with a further cycle of data collection planned.

Results: 36.8% of patients admitted to COTE wards in August 2022 were admitted with falls, with only 23% of patients having a neurological exam documented on admission. Following the initial intervention, 30 patients’ notes were reviewed in January 2023. 56.7% of patients were admitted with falls and frequency of documented neurological examination had increased to 58.8%.

Conclusion: Educational sessions resulted in a 156% increase in documented neurological examinations for patients admitted with falls. We hope this improvement will lead to earlier identification of causes of patients’ falls, allowing prompt management. Our project is ongoing, with planned implementation of posters as a secondary intervention, with further data collection in due course.

References: 1. NHS Inform. Why Falls Matter. Available from: https://www.nhsinform.scot/healthyliving/preventing-falls/why-falls-mat… (accessed 27 November 2022)

INTRODUCTION: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Introduction 

Older people living with frailty are often prescribed many medications exposing them to potential medicine-related harm. Pharmacists are a new addition to the East Kent Community Frailty Team, which otherwise consists of doctors and advanced clinical practitioners at various levels of training. Pharmacists are ideally placed to develop medication review processes and support fellow clinicians with deprescribing efforts in frailty. This audit set out to determine current levels of medication review and associated cost-savings through deprescribing. 

Method 

All patients admitted to the frailty team caseloads in the month of May 2023 had their notes manually reviewed for evidence of medication reconciliation, review, and deprescribing. Medicines were assigned a cost price based on the NHSBSA Drug Tariff (May 2023). 

Results 

192 patients were seen in total, 170 of whom were acutely unwell. 62% of patients had their medication documented, taking an average of 8.2 medicines. The majority of omissions were patients with a zero length-of-stay, which include advice calls. 29% of patients had at least one medication stopped, representing an average 0.7 medicines stopped per patient seen. The monthly cost of medications stopped was £690. There were greater levels of deprescribing in the caseloads with MDT board rounds. 

Conclusion 

Rates of deprescribing are low compared to published studies (Ibrahim et al, BMC Geriatr 21, 258 (2021)), although still represent a rolling saving of approximately £8,000 per month on cost of medicines alone, assuming a twelve-month average life expectancy. Lack of standardisation of clinical notes and documentation made data collection difficult and has the potential to lead to transfer-of-care errors. Further work needs to be undertaken to optimise the medication review process and address inappropriate polypharmacy and will be the focus of efforts over the coming year.