Clinical Quality

Background

The Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary tool, designed to promote holistic care of elderly patients and provide a framework for intervention. There is evidence that the CGA reduces mortality and slows progression of frailty. Performing such interventions in the acute setting can be complex and time-consuming.

Introduction

The Older Person’s Assessment Unit (OPAU) at Weston General Hospital allows early identification of frailty and prompt intervention. We aimed to promote elements of the CGA by providing a tool for utilisation throughout the patient’s admission to coordinate patient care.

Methods

This was a prospective pre-post intervention study on OPAU. We reviewed medical records in a 5-day period analysing documentation of elements of the CGA. The primary intervention was introduction of a ward-round proforma prompting delirium screening. Following analysis and re-evaluation, a an updated proforma with an additional bone-health prompt was circulated. The completion of proformas was re-assessed.

Results

Baseline data of 20 patients showed that common presenting complaints were falls and confusion. Only 14% of those who presented with a fall had a documented bone-health screen. 0% of patients with confusion had a delirium screen. After cycle 1, 0% had bone-health screening and 20% had delirium screening. Following cycle 2, 89% of patients who had a fall had completed bone-health screening.

Conclusion

Implementation of a CGA-orientated ward-round proforma encourages consistent documentation. It demonstrated successful increased uptake of delirium and bone-health screening. The future aim is to introduce a full CGA proforma that encourages opportunistic assessment by all members of the multi-disciplinary team.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Introduction:

Frailty significantly affects outcomes like length of stay and readmissions in elderly patients. At Queen Alexandra Hospital, inpatients under 85 are under the care of General Internal Medicine (GIM) wards and they lack regular access to frailty services. This baseline audit evaluated frailty assessment, management practices and patient outcomes, implementing staff education, ward posters, and a frailty Multidisciplinary Team (MDT) between cycles.

Methods:

Data were retrospectively collected from three GIM wards over two cycles—January and August 2024. Eligibility criteria: Patients aged 65-85, admitted to GIM were included. The audit measured frailty assessment using the Clinical Frailty Scale (CFS), Comprehensive Geriatric Assessment (CGA) practices, frailty prevalence (CFS ≥ 5), advance care planning (ACP), and readmission rates.

Results:

Frailty assessment compliance rose from 76.6% to 94.4%. Frailty detection (CFS ≥ 5) increased from 36% to 75%. CFS documentation improved to 34.5%, with better CGA documentation. However, ACP rates remained low at 3.03%, and 56.6% of frail patients were readmitted within the year, indicating ongoing challenges. Conclusion: Improvements were seen in frailty assessments and detection, yet ACP remains underutilized, and readmission rates are high. Continued efforts are needed to enhance ACP documentation and frailty management strategies.

Recommendations:

1. Implement robust policies for ACP and implement a straightforward pathway for ACP documentation by all doctors.
2. Educate all doctors to practice comprehensive geriatric assessment and participate in frailty MDT meetings.
3. Further audits to specifically investigate the proportion of patients admitted with frailty syndrome and assess their prognosis.
4. Prioritize triage based on CFS scores/frailty over age to enhance targeted care and resource allocation.

Introduction: Delirium is a common and reversible neurobehavioral condition with significant morbidity and mortality ramifications. Consequentially, clear guidelines exist pertaining to its swift identification and management. However, studies suggest adherence to these guidelines is poor. This audit evaluates compliance to the National Institute for Health and Care Excellence’s (NICE) delirium guidelines in an Acute Senior Health Unit (ASHU) and presents a single centre experience of low-cost ward-based interventions for improving guideline adherence.

Methods: A retrospective observational audit was conducted on patients admitted to ASHU between 01/07/2023 and 30/07/2023. Data on delirium assessments, diagnoses and causes of delirium were obtained through retrospective database searches. Posters and education based multidisciplinary team (MDT) interventions were designed and initiated following grounded thematic literature analysis and ward discussion. A methodically equivalent audit was then conducted between 01/09/2023 and 30/09/23. Data was anonymised and blinded and analysis was performed on SPSS V12.0.

Results: A total of 128 patients were included in the study. Initial audit revealed suboptimal compliance with NICE recommendations. Chi-square test of independence found that patients were statistically more likely to receive a full delirium assessment (1.9% vs. 56.6%, p=0.001) and formal diagnosis (5.8% vs. 27.6%, p=0.002) after the ward-based intervention.

Conclusion: This study provides limited evidence in favour of low-cost MDT based interventions for improving adherence to NICE delirium guidelines and provides a 5-step framework for future studies. This study also explores the potential patient implications of these interventions. A repeat audit should be conducted to ensure lasting and sustainable change is achieved. Trial registration/clinical trial number: AUDI003614

Introduction

High-dose corticosteroids have significant benefits for infective exacerbations of COPD, reducing risk of relapse, length of hospital stay and earlier symptom improvement. However, recurrent use has been shown to increase risk of comorbidities including osteoporosis, type two diabetes mellitus (T2DM), cardiovascular disease, hypertension, and elevated body mass index (BMI). 

This audit assessed how many patients at Anchor Mill Medical Practice in Paisley, who had been prescribed two or more courses of prednisolone in the six months prior to the start of data collection, had been assessed for T2DM, renal impairment, elevated BMI, hypertension and osteoporosis within the previous year. 

Methodology 

An EMIS search was performed for patients over eighteen who were coded as having COPD and who had received two or more acute prescriptions of prednisolone from 03/04/2023 to 03/10/2023. 

Data was then collected from the patient's medical summaries and investigations, looking at if they had had HbA1c, urea and electrolytes, lipids, BMI and blood pressure checked within the preceding year. The audit also looked at how many patients had had a QFracture score calculated over the past year, or if they had been referred for or had had a DXA scan within the previous five years. 

Results 

Over 50% had had their lipid profile and HbA1c checked, with over 75% having had their U+Es, BMI and BP checked. The major outlier was OP risk assessment, for which only 31.25% of patients had been screened. 

Conclusions 

Within this primary care setting, improvements could be made on screening for associated comorbidities with COPD. The patients were referred for these investigations, with the biggest improvement being a 140% increase in patients referred for a DXA scan, and annual follow up with the practice nurse was changed to include these investigations as appropriate.

Introduction

Older people living with frailty are core users of health and social care. Services attuned to the needs of people with frailty afford better outcomes, help avoid harm and improve the experience for people and those who care for them. Such services can also help with flow and capacity. The Glasgow Royal Infirmary (GRI) Team aimed to advance services in order to enhance the quality and provision of care for older people with frailty.

Methods

As part of the Health Improvement Scotland Focus on Frailty Programme, the GRI Team developed processes for early identification of people living with frailty, using an electronic Frailty Assessment Tool. Processes were designed to streamline patients with frailty to specialist areas of care in order to initiate early Comprehensive Geriatric Assessment (CGA). A Frailty Assessment Proforma was created to swiftly identify the priorities, concerns and goals of patients and carers and to gather key collateral information promptly. Daily CGA Huddles were commenced which include participants from various different health and social care services. Work is now being done towards the development of a dedicated Frailty Assessment Area and a trial of Rapid Access appointments at the Assessment and Rehabilitation Centres is being undertaken.

Results

There has been an improvement in frailty identification. 79% patients over the age of 75 years, who are admitted through the Acute Medical Receiving Unit, are being screened for frailty. There has been improvement noted in terms of access and time to a specialty bed. Further, there has been a reduction in length of stay for people with frailty, coupled with a reduction in readmissions at 7 and 30 days.

Conclusion

Frailty attuned acute services help patients receive timely, specialist care. They help reduce time spent in hospital and readmissions which, in turn, can contribute to improved flow and capacity.

Introduction

At Epsom and St Helier, a dedicated Frailty service exists during daytime hours, and not weekends, nights or Bank Holidays. During these hours, patients are reviewed primarily by a cohort of “frailty-naïve” medical junior doctors. We aimed to compare the management plans, patient outcomes, rates of discharge, documentation and care delivered by medical junior doctors to that of an established frailty service.

Methodology

Data on presenting complaint, demographics, degree of frailty, postcode was collected on all patients over the age of 65, presenting to A&E at Epsom and St Helier Hospitals with a Frailty Syndrome. Patients who presented with symptoms or signs outside of the frailty syndrome criteria were excluded. The Medical Service was compared to the Frailty Service on rates of discharged and whether or not a resuscitation status, an escalation plan, baseline functional assessment, vision and hearing assessment, home set-up assessment, cognitive status, the elicitation of patient preferences and a medication assessment were performed.

Results

In 202 patients, average age was 85.2 years and consisted of 85 men and 117 women. Unwitnessed falls were responsible for 143 presentations. 127 patients were Caucasian and from the least deprived deciles. 109 patients (54%%) were seen directly by Frailty, and another 93 (46%) seen as referrals to the Medical Doctors. 33(16%) of patients were discharged by Frailty within 24 hours of admission, compared to 15(7.4%) by the Medical Team. The Frailty Service was more proficient in assessing patient baseline status (OR1.71), property (OR1.64), cognition (OR1.43), medications (OR1.28) and patient preferences (OR21.95).

Conclusion

Frailty reviews at an early stage in patient presentation to hospital was twice as likely to result in discharge within 24 hours of admission. Additionally, patients were more likely to have a thorough, comprehensive frailty assessment, and were significantly more likely to be empowered in their decision-making process.

Introduction

Hip fracture is the most common fracture in adults over 60 years, affecting approximately 70,000 people in the UK in 2019. Mortality after hip fracture continues to be high and the cost of hip fracture is estimated at £1.1 billion per year for the NHS. It has been shown that there are key clinical indicators which can improve patient outcomes. These are monitored annually in the UK by the national hip fracture database (NHFD).

Methods

Our aim was to look at the demographics and clinical codes for patients admitted with hip fracture, codes when they are readmitted and cause of death. Information analysts at both hospitals provided authors with these data from hip fracture admissions in 2020. Inclusion criteria reflected the inclusion criteria for the NHFD. Cause of death was identified from records in the medical examiner's offices for inpatient deaths. Data were viewed and analysed in Microsoft Excel.

Results

In total, there were 878 admissions for hip fracture in 2020, 312 at Barnsley Hospital (BH) and 566 Sheffield Teaching Hospitals (STH). Average age was 80.9 at BH and 82.6 at STH. The most frequent codes on admission were 'fall' and the most common complication was pneumonia, coded in 23% of patients. 174 (56%) individuals at BH had at least one readmission in the first year and 318 (57%) at STH. The codes for readmission were varied, most commonly for musculoskeletal or orthopaedic conditions, including fracture. 85 died within one year (27.2%) and 26 died within 30 days (8.3%) at BH. 186 died within one year (32.7%) and 69 within 30 days (12.1%) at STH. The commonest cause of death was pneumonia, in 26 of 66 inpatient deaths.

Conclusions

This analysis of coding data confirms known complications following hip fracture. Morbidity and mortality following hip fracture remains extremely high.

Hip fractures tend to affect older, frailer people and are associated with high morbidity and mortality. The Best Practice Tariff (B PT) was introduced to recognise gold standard care. Features of the BPT include prompt surgical and orthogeriatric input, with multidisciplinary working throughout. Subsequent service changes have led to the creation of specialist hip fracture wards. However, it is not always possible to admit patients with a fractured neck of femur to a specialist hip fracture ward.

We reviewed data for 691 patients admitted with a primary neck of femur fracture to a district general hospital in Sussex between 01/02/2023 and 29/02/2024. We compared the demographics and outcomes of patients admitted to a specialist hip fracture ward (SHFW) and a general surgical ward (GSW) using data available from the National Hip Fracture Database. 570 patients were admitted to the SHFW, 121 to the GSW.

BPT achievement was significantly higher on the SHFW (74% SHFW, 53% GSW, p<0.00001). 30-day mortality was lower on the SHFW, although this was not statistically significant (2.98% SHFW, 5.79% GSW, p=0.126). We found no significant difference in patient age, time to surgery, time to orthogeriatrician review, or length of stay.

This analysis highlights the importance of a specialist multidisciplinary team approach in the management of patients presenting with fractured neck of femur. While not a perfect metric, non-achievement of the BPT is likely to result in worse patient care, with higher mortality and poorer longer term functional outcomes. BPT non-achievement is also associated with significant loss of income to NHS trusts. We suggest that, wherever possible, beds on specialist hip fracture wards should be ring fenced for patients with primary neck of femur fracture.

AimsTo reduce the burden of inappropriate CPR with surgical specialties and to improve the conversations we are having with patient’s and their relatives around CPR.

Methods Data collection was done one one day in March, June and September 2024 across three surgical wards. Patients were included over the age of 65 and with a Rockwood Clinical frailty score over 5. A retrospective review of whether discussions with patient and/or next of kin was done. Below is the table demographics.

Results Following teaching intervention to junior doctors and discussion with geriatric medicine surgical liaison services there was an improvement in the number of patients who had resuscitation decisions (wither FOR or DNACPR) on their medical records.This is reflected in the number of patients having no DNACPR recommendation on the patient notes going from 47% to 8%.

Summary Through education and improving awareness around the importance of DNACPR discussions we have seen am improvement in the number of surgical patients who are living with frailty having a recommendation around CPR in their medical notes