Clinical Quality

Introduction: Within our hospital, the Surgical Acute Frailty Team (SAFT) delivers perioperative care to the older emergency surgical population. SAFT focuses on early identification of frailty using the Clinical Frailty Scale and subsequent comprehensive geriatric assessment delivery. The most common referral reason to the team is delirium therefore widespread awareness and timely management is essential. Given the challenging clinical environment, SAFT decided to implement a blended teaching programme to support with delivering frailty education to the surgical multidisciplinary team. The aim of the education programme was to improve confidence in frailty identification, delirium assessment and management.

Methods: Teaching sessions targeting all healthcare professionals were delivered by members of SAFT. Education was delivered in two formats: ‘tea trolley teaching’ and small group classroom-based lectures. ‘Tea trolley teaching’ provides focussed ward-based education with a sweet treat provided as an incentive to attend. Feedback was gathered real-time before and after sessions to identify areas of knowledge improvement.

Results: 53 healthcare professionals attended these face to face teaching sessions. Prior to receiving this education, only 26% of participants felt confident in the identification of frailty. This improved to 91% post education. There was also significant improvement in participants’ confidence with delirium assessment from 23% to 74%. A similar improvement was also recorded in confidence with use of the TIME bundle for delirium management from 13% to 60%.

Conclusions: Delivering our education programme using a blended learning approach has improved participants’ confidence with frailty identification, delirium assessment and management. Future plans include the expansion of the teaching curriculum to include other common frailty-related topics, with the goal of improving the perioperative care of older adults within the emergency surgical setting.

Introduction

Introduction of the medical examiner (ME) service has changed the process in which the Medical Certificate of Cause of Death (MCCD) is completed across South Wales. In a tertiary hospital we endeavoured to improve team ownership of medical cause of death decisions, senior involvement, and communication of this to the medical examiner service, through development of a new process and communication form.

Methods

Two PDSA cycles have been completed. With stakeholder involvement we produced a process map and developed a Proposed Cause of Death form. In 2022 medical teams on 2 wards (A&B) trialled a new process - to discuss as near as possible after death the likely cause of death and submit a Proposed Cause of Death form. We collected data on number of deaths, number of forms completed and time between death and MCCD completion. In 2023 a task and finish group developed an electronic form and piloted on a further three selected medical wards (C,D&E).

Results

Cycle 1: Mar-Aug 2022. Proportion of deaths with form completed: Ward A 0%(0/25), Ward B 71%(27/38). Time from death to MCCD completion was not increased by form implementation (3.1 days after vs 4.7 days before). Cycle 2: Aug 2023–Jan 2024. Proportion of deaths with form completed: Ward C 60.9%(14/23), Ward D 0%(0/22), Ward E 5.3%(1/19). Time from death to MCCD completion increased by only 0.6days compared to 3 control wards (5.7days vs 5.1days).

Conclusions

The process and form were successfully adopted on 2/5 wards. Facilitators of adoption were ward level consultant engagement and prompting of the medical team by the bereavement team. Barriers to adoption were a perception of extra work and being unable to perceive usefulness of the process. Ongoing work aims to improve team motivation through education and recruitment of ward 'champions', and rollout to additional wards.

Background: Idiopathic Parkinson’s disease (IPD) increases fall risk and is associated with osteoporosis and fragility fractures (FF). Despite the high risk of adverse outcomes from untreated osteoporosis in IPD patients, bone health is clinically overlooked. This study aimed to evaluate the adequacy of bone health assessment among Aneurin Bevan University Health Board (ABUHB) patients.
Methods: This observational cohort study retrospectively analysed data from IPD patients at the ABUHB movement disorder clinic, between May 2022 and January 2024. Data collected included: demographics, disease severity, FF, FRAX® score, and bone protection. Clinic letters were also reviewed for mentions of bone health.

Results: The study included 57 patients with a mean age of 78.5 years; 70.2% were male. The mean Charlson Comorbidity Index was 5.1 and the mean Hoen and Yarh score was 2.3. Of these patients, 24.6% had osteopenia/osteoporosis, 36.8% had >0 FF, and 3.5% had fractures before PD diagnosis. The mean time from IPD diagnosis to the first FF was 3 years and 7 months. The mean duration of IPD diagnosis was 5.75 years, with those having FF showing a mean duration of 7.12 years compared to 5.21 years for those without FF. 75% of fractures were major osteoporotic fractures. Bone protection was used by 14% of patients: 100% of high-risk, 21.0% of moderate-risk, and 8.10% of low-risk patients (based on FRAX® scores). Bone health was mentioned in 22.8% of all clinic letters and in 33.3% of letters for those with >0 fragility fractures.
Conclusion: There is a positive correlation between the duration of IPD and the occurrence of  FF. The study highlights a need to improve bone health management in IPD patients, especially those at moderate risk of fractures, as only 21.0% of moderate-risk patients are receiving bone protection. Increased awareness of bone health in this cohort must be promoted.

Introduction

Authoritative medical organisations including the Resuscitation Council UK, NHS and BMA all state that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions should only be relevant to CPR and should not impact other decisions about care and treatment. We set out to examine the reality of decision making in clinical practice.

Methods

We circulated a clinical scenario of a patient deteriorating with COVID-19 after hip fracture to 128 members of the consultant and trainee geriatrician WhatsApp groups in Wales. Recipients were blindly randomised to one of two versions; differing only in whether or not they included the words “She has a DNACPR in place”. Recipients were unaware of the survey’s purpose. We surveyed individuals’ management decisions using a multiple-choice Likert scale questionnaire.

Results

A total of 47 (37%) clinicians responded. Those who addressed the scenario without a DNACPR decision were more likely to consider non-invasive ventilation (91% vs 67%, P<0.05), and more likely to consider escalation to intensive care (26% vs 21%).

Decisions in respect of ward level care were also affected. In the absence of a DNACPR decision, clinicians were more active in providing naloxone for a potential opioid toxicity (57% vs 29%).

Conclusion

Patients’ concern that a DNACPR decision might reduce the intensity of care they might receive do not appear to be unfounded. We believe that this study demonstrates the reality of clinical decision making in acute patient care.

These clinicians will have been aware that DNACPR status should have no influence on other clinical decision making, but unconscious bias clearly has substantial influence despite this. We do not believe that training to reinforce such knowledge will ever fully compensate for such unconscious bias.

Clinicians need to consider how DNACPR decisions are made, recorded and communicated given this risk of unforeseen consequences for other aspects of care.

Introduction

Venous thromboembolism (VTE) risk following acute stroke is high. Current guidelines recommended intermittent pneumatic compression (IPC) stockings for up to 30 days in those who are immobile following acute stroke. The concern post-stroke is haemorrhagic complications when using low molecular weight heparin (LMWH). The CLOTS3 trial favoured IPC for safety in the first 30 days. However, in many cases, doses suitable for VTE prophylaxis can be used but with caution if IPC cannot be used.

Method

A spot audit of patients current VTE prophylaxis was undertaken in a stroke rehabilitation unit to look at IPC and LMWH usage. 10 patients were selected at random to look retrospectively at choice of VTE prophylaxis and how this changed during their admission.

Results

35 patients' full records were available. Five patients were within 30 days of admission. 12(34.3%) were anticoagulated, predominantly for atrial fibrillation. 15(42.8%) were on LMWH. VTE prophylaxis was not indicated in 3(8.6%) patients. 5(14.3%) were on no VTE prophylaxis. Of the 10 patients reviewed in depth 7(70%) had used IPCs for a time during their admission. IPCs were discontinued in 3 after starting anticoagulants and in 4 at the patients request. In 3 of the patients where IPCs were not tolerated there was a delay in starting an alternative form of VTE prophylaxis. Complex decisions were required in a patient started on LMWH post-neurosurgical intervention.

Conclusions

Decisions regarding VTE prophylaxis following acute stroke are complex. Changes are required frequently during inpatient admission and delays occur both on admission and when non-specialist team members are not confident in prescribing an alternative to IPCs. We would recommend a prompt to ensure VTE prophylaxis is considered on initial ward round and regular review during admission with anticipatory consideration of an alternative to IPCs by specialist clinicians if they are subsequently not tolerated.

Introduction 

Shared decision making (SDM) is a vital element in ensuring a more personalised approach to care.  The Peri-operative Care of Older People in Surgery (POPS) Team adopts enhanced SDM in frail patients referred for elective urological or colorectal surgery using the BRAN (benefits, risks, alternatives, nothing) approach. In frail populations, there is a complex balance between providing appropriate access to surgery and minimising exposure to potentially harmful procedures. SDM can help to negotiate this balance. This study aimed to evaluate the patient perception of the SDM process.  

Method 

Patients and/or their family proxy attending the POPS clinic between December 2023 – March 2024 were invited to participate in a follow-up telephone interview. The content of the interview was based on the CollaboRATE tool, a quick 3-question, validated questionnaire used for evaluating SDM from the patient’s perspective.  

Results 

Overall, 22 out of 29 (76%) consenting patients and/or their proxy were contactable and well enough to participate in the CollaboRATE evaluation.  

All (n=22, 100%) reported that the POPS team had made ‘a lot’ or ’every’ effort in helping them understand their health issues and listening to what mattered most to them. 86% (n=19) thought they had made ‘a lot’ or ‘every’ effort to include what mattered most to them in deciding what to do next. Patients/proxies were also able to add unstructured comments which were also positive: 

 ‘the staff were excellent - my husband transformed in front of my eyes, he was so happy with the decision.’ 

Conclusion 

The SDM process within the POPS clinic is highly rated and valued by the patients.  Considering that SDM also reduced the number who opted for surgery by 30% (April – July 2023; 9 out of 30 chose not to have surgery), it can offer added value to the individual and the wider system. 

There is unequivocal evidence to support Perioperative care for the Older Person Undergoing Surgery (POPS) services. However, POPS services are not available in all Trusts offering surgery, including Royal Surrey Foundation Trust (RSFT). The necessity for POPS services will continue to grow with increasing numbers of older people undergoing elective and emergency surgery due to: changing demographics, surgical and anaesthetic advancements, shifts in culture and patients’ expectation of healthcare (1). A RSFT POPS steering group was convened to explore the current orthopaedic elective pathway, the what-why-how of implementing a POPS service and ultimately write a business case to submit to the board to request funding for a formal POPS service. Unfortunately, ahead of submitting we were informed a business case would unlikely secure funding due to the current financial climate. To continue to evidence the need for this service, over the course of a year, Geriatricians used their Supporting Professional Activities (SPA) time to provide informal POPS Comprehensive Geriatric Assessment (CGA) reviews to patients aged ≥65 with a CFS ≥5 on the elective waiting list for knee/hip operations. The average age of patients seen was 82 years (range 67-92). The average Clinical Frailty Score calculated was 7 (range 4-7) with the average number of frailty markers identified being 4 (range 1-7). Following CGA, 75% of patients decided not to proceed with operative management. 88% either initiated or completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We now have both local and national data to support the need for a POPS service at RSFT. When financial support is not available to invest in and develop new services, alternate methods such as staff re-distribution can be considered with the aim of both providing a service as well as collating invaluable evidence to support a business case and secure funding.

Introduction:

As awareness of hospital-associated deconditioning increases, services to prevent hospital admissions and provide discharge support for older adults are expanding, aiming to reduce admissions and the risks associated with prolonged hospital stays. A Welsh Government IQS titled “Older People and People Living with Frailty” published in January 2024 identifies a need to shift our health and social care system from prioritising reactive crisis management to a ‘place-based’, community-focused approach that emphasises proactive identification and management of frailty. The CTMUHB @Home Service (AHS) was instituted in 2017 to provide domiciliary and community-based care to patients at risk of hospital admission, covering Rhondda, Cynon, Taff Ely and Merthyr Tydfil.

Methods:

A retrospective review of patients discharged from the AHS between February and May 2024 was completed (n=345). Reasons for referral, diagnostic journey details, and patient outcomes were recorded. Alongside this, the IV Antibiotics Service register for the same period was analysed (n=48) to calculate the number of Bed Days saved and its associated cost effectiveness.

Results:

57% of referrals are related to patients’ risk of or recent falls, followed by 16% of patients with increased frailty who are approaching crisis. 8% of patients have been referred for the specialised services of the AHS, such as COPD reviews, discharge support, pharmacological optimisation, or follow-up blood tests. Most referrals originate from GPs, with other sources including facilitated discharges or WAST. Bed day costs saved from the IV Antibiotics Service are estimated to be £358,000.

Conclusion:

We now have a better understanding of the AHS’ monthly patient in and outflow. Although the substantial cost savings seem positive, it is still uncertain whether this conclusively measures the AHS’ cost-effectiveness. This understanding will help pave the next steps towards increasing awareness about the functions of the AHS as a hospital avoidance team focused on frailty.

Abstract Content - Introduction: Delirium, characterized by disturbances in attention and consciousness, is common in individuals with pre-existing medical conditions, particularly the elderly, but can affect people of any age. It can lead to significant morbidity, mortality, prolonged hospital stays, increased healthcare costs, and long-term cognitive decline. Despite its impact, delirium is often underdiagnosed and undertreated, underscoring the need for better diagnostic strategies. The 4AT tool, recognized by NICE, is valued for its rapid delirium assessment, unlike the AMT-10, which is more suited for chronic cognitive disorders. Objective: This study was conducted to assess the usage of the 4-AT tool in the assessment of delirium to aid in the early detection of delirium in the elderly population. Methodology: The retrospective review of medical records over six months was conducted and divided into two cycles to evaluate delirium assessment using the 4AT. Initially, data from 59 patients 49 at FPH and 10 from WPH established a baseline of 4-AT usage across trust. Post-intervention, 60 patient records were reviewed to reassess 4AT usage. Interventions included In-person Training sessions in completing 4AT Informative posters-placed at ED and Medical wards Continuous reminders to enhance early detection. Results: Before the intervention, only 6.8% of patients were assessed using the 4AT tool, 55.9% with the AMT, and 37.2% without assessment. Post-intervention, the overall assessment rate rose to 62.7%, significantly increasing 4AT usage but Among 28 delirium-diagnosed patients, only 14.3% were screened with the 4AT, indicating room for further improvement. Discussion and Conclusion: The increased use of the 4AT tool post-intervention highlights the effectiveness of educational initiatives in improving delirium screening. Early detection through the 4AT facilitates timely interventions and better patient outcomes. However, the small sample size and underutilization among diagnosed patients suggest the need for ongoing efforts to optimize delirium assessment practices.

Introduction

In 2021, the Welsh Government launched the “All Wales Dementia Care Pathway of Standards”, which the Cardiff and Vale University Health Board (CVUHB) Memory Assessment Service (MAS) works under (1. Welsh Government, 2021). This service evaluation aims to evaluate the CVUHB MAS diagnostic pathway against these standards.

Method

This retrospective review analysed 299 referrals to the CVUHB MAS from August 2020-2023. Data was collected via referral and clinic letters, focusing on demographics, referral sources, diagnostic timelines and clinical outcomes.

Results

Patients had a mean age of 78.2 years (n=299), with 86.0% (n=257/299) referred by General Practitioners. The average Charlson Comorbidity Index (CCI) was 4.93 (n=299) and the median Clinical Frailty Scale (CFS) score was 4 (n=299). Patients were on an average of 6.5 (n=299) medications at referral, with an anticholinergic burden (ACB) score of 1.12 (n=293) and 15.0% (n=44/293) had a high ACB (≥3). The average time from referral to diagnosis was 19.3 weeks, primarily due to pending neuroimaging. Ethnic minorities experienced longer symptom onset to diagnosis, 2.56 (n=16) vs 1.94 (n=263) years average. 59.2% (n=177/299) of patients received a diagnosis of dementia and 36.5% (n=109/299) of cognitive impairment. Medication was initiated in 30.8% (n=92/299). 84.1% (n=244/290) required one clinical appointment to receive a diagnosis.

Conclusions

Results showed the average CCI score was 4.93, indicating significant health burdens. The need for targeted medication reviews in Memory Clinic was highlighted in 15.0% of patients with an ACB ≥3. Addressing ethnic disparities is crucial to the overall reduction of diagnosis times. The CVUHB MAS achieved a high diagnostic rate at first clinical contact (84.1%). 30.4% (n=91/299) received a diagnosis of mild cognitive impairment, a critical cohort for early intervention to manage disease progression. Streamlining the pre-diagnostic pathway, especially performing neuroimaging at referral, is essential to meet the 12-week diagnosis target (1).