Clinical Quality

1. Introduction

Parkinson’s Disease (PD) is a complex neurodegenerative disorder which impacts nearly all aspects of quality of life. Given the known challenges and risks of complications with PD, it is crucial to improve management prior to admission for surgery, in particular accurate medication timing and dose. Therefore a quality improvement project on this subject was initiated.

2. Method

A retrospective analysis was conducted of Surgical attendances to Worthing hospital with the aim to identify patients with Parkinson’s disease (PD) admitted under their care. Each patient’s hospital records were manually screened using Evolve Live software and WellSky EPMA to extract the information pertaining to PD medications for the audit. Statistical analysis was conducted using Microsoft Excel. The cycle was repeated following interventions of posters and education of surgical teams.

3. Results

In both cycles there were patients attending for elective surgery or admitted into hospital. The following is regarding patients who were admitted to hospital and were on PD medications. For the first cycle, 27 admissions were identified and 20 in the second cycle. In the first cycle, 5/27 (18.5%) had their medications accurately documented, which improved to 9/20 (45%) in the second cycle. First cycle, 16/27 (59%) patients had their medications prescribed correctly, which was similar to 12/20 (60%) patients in the second. 17/27 (62.7%) patients missed doses in the 1st cycle, and 9/20 (45%) patients in the 2nd cycle.

4. Conclusion(s)

From the first cycle, it was identified that PD in patients was not recognised as promptly as it should. It was reflected in the high proportion of incorrect prescribing and issues due to delay in medications. In the second cycle, following our interventions, there was improved awareness of PD with fewer prescribing issues and complications during admission.

Parkinson's Disease (PD) is a progressive neurological disorder for which there is currently no cure.  Palliative care should be discussed as part of PD management, both to empower patient understanding and expectations of their condition and to avoid unnecessary hospital admissions

Results from the 2022 Parkinson’s UK national audit,  found that the elderly care PD service in York was underperforming in having advance care planning (ACP) discussions with PD patients. The aim of this quality improvement project is to further review ACP discussions on a larger sample size and improve practice in this area.

Our sample included 100 people with idiopathic PD within the Vale of York who had been seen by a PD specialist in the month of November. Clinic letters from all PD specialist involvement were read, alongside any letters from other specialities, discharge letters from hospital and general practice encounters to look for any documentation of ACP discussions.

Results showed that 82 patients had no documentation of any discussions on ACP. This population included patients in nursing homes, needing package of care, patients with Rockwood frailty scores >6 and patients showing signs of deterioration in their condition.

It is clear from the data that these discussions are not occurring as often as they should.  Simply doing this QIP has raised awareness within the team and anecdotally, improvement in performance has already been noted.  Further discussion and presentation of the QIP findings are to be presented at clinical governance meetings to provide further education.  Data will then be reaudited. 

Further change options following discussion and education could include clear documentation strategies for ACP helping to link between primary and secondary care. It should be noted that our service does not provide a Parkinson’s nurse who would often instigate ACP discussions.

This Quality Improvement Project (QIP) addresses the pressing need for increased awareness of delirium among patients' relatives. With a 26% rise in the elderly population in Cambridgeshire, surpassing the 18.6% national average, the project aimed to provide crucial information to enhance understanding and support for patients grappling with delirium, a condition affecting up to 50% of elderly hospital patients. This prospective study was conducted across seven geriatric wards at Cambridge University Hospital (CUH). Baseline measurements utilized existing data on CUH Delirium website views and involved collecting surveys to explore delirium awareness among total of 26 randomly selected subjects who were relatives of patients. To establish a baseline for comparison between pre- and post-intervention data, specific durations were selected in different calendar years (5/4/2022 - 18/7/2022 and 4/4/2023 - 17/7/2023). Interventions included strategically placing redesigned CUH Delirium Posters with QR codes across wards, along with awareness campaigns targeting healthcare professionals, including Dementia and Delirium Champion Training. Pre- and post-intervention questionnaires showed up to 10 -20% increment in respondents' awareness, understanding, and interest in delirium. Post-intervention, website views surged by 132%, indicating the effectiveness of the multifaceted approach. Key findings highlighted the importance of laminated posters, strategic placement based on staff feedback, and the necessity for detailed data on website visits. Future recommendations include continuous monitoring, content evaluation, and strategies to address poster removal. Suggested actions involve sustained monitoring, collecting qualitative feedback, and ongoing efforts to enhance understanding of delirium care. In conclusion, this QIP serves as a successful model for increasing delirium awareness, addressing challenges through adaptability and sustained engagement. The positive impact on awareness and website engagement sets a precedent for future healthcare quality improvement initiatives, fostering continued progress in delirium care and understanding among elderly patients and their relatives

Introduction Many patients admitted with fragility femoral fractures have established cognitive impairment but no formal diagnosis of dementia. This lack of pre-existing diagnosis impacts care, counselling and discharge planning. This audit assessed how many people aged >65 admitted with a fragility fracture had information, at the time of admission, suggesting a likely but unconfirmed diagnosis of dementia and how their length of stay (LOS) and discharge destination compared to patients with confirmed dementia.

Methods 47 consecutive patients aged >65, admitted with a fragility femoral fracture had their electronic care records reviewed to identify information suggesting the presence of cognitive impairment/dementia. 30-day mortality, LOS and discharge destination was compared for three groups, 1) dementia, 2) informal dementia diagnosis and 3) no evidence of cognitive impairment.

Results Of 47 patients reviewed, 35(74%) were female, mean age 80.6 years (range, 68-94). Of these, 7/47(15%) had an established dementia diagnosis (mean age 82.4 years), 9/47 (19%) had unconfirmed cognitive impairment/dementia but without a formal diagnosis (mean age 82.2years) and 31/47 (66%) had no evidence of cognitive impairment(mean age 79.7 years). In cases of confirmed dementia diagnosis, the mean LOS was 54.7 days (range, 16-114). One patient died 1/7 (14.3%) and 3/7 (42.9%) were discharged home. For patients with an informal dementia diagnosis, the mean LOS was 35 days (range, 7-74). Two patients (2/9) died (22.2%), and 3/9 (33.3%) were discharged home. For those with no cognitive impairment, the mean LOS was 36 days (range, 7-92). Three patients 3/31 (9.7%) died, and 22/31 (71.0%) were discharged home.

Conclusion A significant minority of patients had likely undiagnosed dementia, with mortality and discharge destinations similar to patients with recognised dementia. Services need to consider how best to identify and diagnose cognitive impairment/dementia at the time of admission for fragility fractures.

Introduction: Vitamin B12 and folate are essential for normal red blood cell production, tissue and cell repair, and DNA synthesis. B12 stores last for 3-5 years, while folate lasts for about four months. B12 or folate deficiency indicates a chronic shortage of one or both vitamins. Geriatric patients are more susceptible to Vitamin B12 and folate deficiency due to inadequate oral intake, malabsorption caused by pernicious anaemia, achlorhydria, and poor bioavailability. The clinical diagnosis is difficult in the elderly because of subtle, nonspecific, and highly variable clinical manifestations. Vitamin B12 and folate deficiency are associated with neuro-cognitive, psychotic, and mood symptoms. Because safe treatments are available, early diagnosis and treatment are crucial to prevent irreversible structural brain damage. Methods: A clinical audit was conducted among patients admitted to an elderly care ward who required Vitamin B12 and folate level investigation. A serum vitamin B12 level of less than 200ng/l (148pmol/l) is considered B12 deficiency, and a serum folate level of less than three microgram/l (7nmol/l) is considered folate deficiency. 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 Vitamin B12 deficiency was 8.8%, while the prevalence of Folate deficiency was 31.3%. Four per cent of the population had both Vitamin B12 and folate deficiency. Conclusions: The prevalence of Vitamin B12 and folate deficiency is high among elderly patients. Early detection and treatment are vital to prevent irreversible neuropsychiatric sequelae.

Same Day Emergency Care (SDEC) at St James’ Hospital, Leeds provides urgent care at the interface between primary and secondary care, offering comprehensive geriatric assessment (CGA) to those living with frailty, aiming to prevent hospitalisation and delay frailty progression. Advance care planning (ACP) is a vital component of prioritising care preferences including at end-of-life, but timing often falls short in practice. This quality improvement (QI) initiative aims to proactively open ACP discussions, allowing patients to consider their care goals, ensuring our care is aligned with their priorities.

Between July 2022 and April 2023, the project involved 1039 patients. Led by Advanced Clinical Practitioners with support from consultant geriatricians and a palliative care specialist nurse, ACP discussions were encouraged through prompts in daily staff huddles and drop-in teaching sessions. ACP uptake increased from 7.8 % to 19.3%. Insights from a perception survey involving 83 healthcare professionals revealed key barriers including clinical workload, limited space, lack of experience and confidence as well as prognostic uncertainty and patient factors. Education and training, clinical supervision, patient information leaflets and a conducive environment were positively associated with ACP.

There has been a cultural shift in the department as the practitioners now routinely prompt staff to undertake ACP in safety huddles. Key catalysts for ACP initiation were found to be progression of frailty, terminal diagnoses, dementia, and recurrent hospital admissions. As a new SDEC unit is scheduled to open in the coming months, with provision of space and privacy, our aim is to improve the quality and quantity of ACP discussions with the patient at the centre of all decision-making. In line with these endeavours, parallel support within the community through our home (virtual) ward will further enhance proactive care planning in older people living with frailty.

Introduction: Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness. This has serious consequences including the increased risk of dementia, death, length of hospital stay and increased chance of new admission to long term care. Therefore, prompt identification and management is essential. NICE recommends the use of the 4AT score in identification of delirium to improve subsequent management.

Methodology: A retrospective descriptive study was done identifying all patients admitted to Wigan infirmary who received a 4AT during the 1/4/22- 30/9/22. Patients were excluded if aged 64 4AT score of 1-3 (a score over 4 is positive for delirium) and had multiple admissions. This reduced the sample size to 275 from 8648 patients, of these data was collected from the individual electronic records from the first 110 patients.

Results: The average age of patients within the sample is 81, average 4 AT score of 6 and the average CSF was 5. There was a diagnosis of delirium in 32 (29%), and 'confusion' in 10 (15%), a past medical history of dementia in 49 (45%) and cognitive impairment/ suspected dementia in a further 10 (9%), PD was found in 9 (8%) of patients. A basic blood test screen to identify a cause for delirium was done in 50 (45%) of patients. DNA CPR was present in 59 (54%) of patients, and a DOLS in 43 (39%) during the admission reviewed. Patients were on a significant number of medication (mean of 10 on discharge) and had an average of 3 ward moves. Length of stay was 20.3 days and 51 (46%) were deceased within a year of admission.

Conclusion: Embedding 4AT in electronic records improves recognition of delirium. Further work will be undertaken to improve management of this condition once it is recognised.

Background

NICE (2023) Shared Decisions Making (SDM) Guidelines ensure Health Care professionals work together with a person to reach a decision about care based on their individual preferences, beliefs, and values.

Local Problem

We conducted an Audit across our community services to assess NICE SDM, achieving 71% compliance. Results informed the project problem statement “Clinical Teams are not fully compliant to NICE SDM guidelines therefore a shared decision-making approach is not guaranteed”.

Methods A fishbone diagram was applied to understand why SDM wasn’t routinely occurring in clinical practice. Our aim is to achieve organisation wide adherence to SDM. We propose a multi modal approach to increasing awareness of SDM across the organisation. We used a driver diagram working backwards from the goal, identifying the drivers and determining the project activities. Interventions Due to the enormity of rolling out a pan-organisational programme we decided to use the Frailty NHS@Home virtual ward to test and learn before greater adoption. We firstly processed mapped how the “What Matters to you?” question is embedded into our Comprehensive Geriatric Assessments. A decision support grid for treatment option decision making was created for dehydration or high risk of dehydration within the NHS@Home service, adapted from Marrin et al (2014). Three options are described underpinned by five questions. Feedback from Patient and public involvement ensured the language was appropriate. After the first PDSA cycle, the tool was reviewed by the project team and two further questions were added, “Did you understand the options which were explained to you?” and “What matters most to you as we decide together how best to treat your dehydration?”.

Conclusion

A re audit and colleague survey will reveal increased knowledge and understanding of the SDM concept. We continually seek Feedback from individuals who use our services for their experience of SDM processes.

Introduction:

Between 5-10% of patients attending the emergency department (ED) are elderly patients living with frailty. NHS England now recommends that all patents aged >65 presenting to acute care should have a Clinical Frailty Score documented within 30 minutes of arrival. We audited the CFS documentation from the Electronic Patient Record (EPR) for patients aged >65 presenting to our local E.D.

Methods:

Our baseline audit looked at patients aged >65 presenting to our ED from 01/09/23-07/09/2023 (n=430). We extracted data for rate and timeliness of documentation from EPR. To calculate accuracy, we compared the documented scores from ED triage staff, with that of our therapist led Frailty Intervention Team (FIT). We excluded patients not assessed by the FIT.

We then re-audited the data for 3 separate weeks after delivering a tailored teaching session for band 6 and 7 nurses, and introduction of an educational poster.

Results:

We found exceptional baseline compliance and timeliness of CFS scoring with a 97% documentation rate with a median time of 31 mins from presentation. When assessing accuracy of triage nurse CFS documentation, we found that 42% of patients fell into a lower category of frailty when compared to scores allocated by the FIT. Following teaching sessions and poster education, we observed no improvement in this.

Conclusion:

Our audit identified an overall excellent baseline compliance and timeliness in EPR documentation of CFS scores despite the department’s heavy workload. We noted a significant underrecognition of frailty at ED triage compared to specialist therapist scoring. Despite delivering education sessions and introduction of an educational poster there is still significant room for improvement in accurate identification of frailty with the CFS.

Introduction:

Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting.

Method:

Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22 - 28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made.

Results:

Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioiod medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six month review.

Conclusion(s):

Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.