Clinical Quality

Hospital at Home (HaH) provides high acuity clinical care for patients in the community. HaH teams are varied and multidisciplinary. A successful HaH service depends upon streamlined communication between multidisciplinary team (MDT) members, facilitated by an integrated knowledge base. Whilst training protocols are under development, there are currently no published teaching programmes for HaH. We responded to this unique challenge by devising a teaching programme for the HaH team at St John’s Hospital, Livingston.

Methods: We identified learning needs within our team with a preliminary survey. We conducted a literature review to select four competency resources which were mapped to five domains: clinical care; pharmacy; service design and delivery; anticipatory care planning and palliative care; and ethical and legal guidance. We formalised a weekly teaching session and linked teaching topics to the core competencies. We conducted a review at 3 months and 6 months to assess the impact of the programme on staff learning and clinical confidence.

Results: A tailored teaching programme with domains linked to multidisciplinary competencies increases staff confidence in the clinical management of common HaH presentations. Our bespoke programme has successfully delivered teaching that caters for multiple clinical backgrounds.

Conclusions: HaH teams represent an opportunity to learn from MDT colleagues with diverse training backgrounds and offer a unique challenge in tailoring teaching to multiple learning needs. A formal programme with clear, identifiable domains linked to learning objectives provides an essential framework for staff to demonstrate engagement with professional development, allows staff to develop personal teaching skills and cultures a strong collaborative learning environment. Going forward, we aim to evaluate the impact on staff competence and formalise a cyclical HaH cucciculum for circulation to the NHS Lothian HaH teams with scope for wider dissemination.

Introduction

Oncogeriatrics is relatively new concept aligning geriatric services with oncology, whereby older cancer patients have a comprehensive geriatrics assessment (CGA) to support oncology decision-making and improve outcomes and quality of care. Despite the rationale, evidence for effective oncogeriatric services are largely based upon specialist centres. We initiated a feasibility study February 2021, to establish criteria and pathway implications for an Acute Trust without oncology beds.

Method

Following an iterative process, a pathway was established between the Lung MDT and the established frailty unit. Patients with lung cancer who met criteria would be seen within a week and underwent a CGA by a frailty practitioner, consultant geriatrician, physiotherapist, occupational therapist. Referrals were made as appropriate to allied services eg dietician, pharmacy, continence teams etc.

Results

We refined the referral criteria and process, identifying the presence of a geriatrician at Lung MDT as key to ensuring incorporation of CFS (Rockwood) for effective MDT case discussion. Defining the cohort and pathway was challenging given the complex interplay of cancer symptom burden and comorbidity set against COVID, workforce pressures and cancer targets. Final referral criteria was age over 70, Rockwood 4 or more, a formal lung cancer diagnosis, and a plan to undergo active treatment. Referral numbers were low during the feasibility phase. Only 38 patients were referred and we saw 23 patients over a 2 year period. Referral rates increased in the final 3 months of the pilot although only 9 of 22 who met criteria were referred.

Conclusion

Establishment of an effective oncogeriatrics service is challenging. The feasibility study has established a baseline for potential activity and job planning. Analysis of individual patient benefit is ongoing. Longer term we aim to extend the service to support patients after treatment has started, provide prehab, and include patients with all types of cancer.

Background

The East Kent Frailty Home Treatment Service (Frailty HTS) provides person-centred, hospital-level care for people living with frailty. The Frailty HTS can diagnose and treat acute medical illness at home or in care homes. The team philosophy is “we identify what you want and strive to make it happen”. This project was underpinned by advance care planning for people living in care homes, which the frailty team supports through proactive work with the primary care network care homes teams.

Frailty is associated with increased healthcare costs and poor outcomes associated with hospitalisation. The acute hospitals were under extreme pressure. The Frailty HTS serves 360 care homes.

Methods

Carers and the ambulance service discuss all acutely unwell care home residents with the Frailty HTS prior to conveyance except in the case of a long bone fracture or acute cardiac/cardiovascular event (unless care plan is not for escalation).

There were communications initiatives to care homes and Ambulance Trust explaining referral process and eligibility. A dedicated frailty HTS clinician was available to respond to calls.

Results

The pilot has seen an increase in referrals of people living in care homes from SECAMB to Frailty HTS (monthly average up from 49 up to 64) an increase in direct referral from care homes (monthly average up from 15 to 21.5). We also saw a reduction in attendance of care home residents at ED (monthly average down from 276 to 209) and reduced admissions to hospital from care homes (monthly average down from 203 to 191).

Conclusion

This project raised awareness of an alternative to acute hospital care for people living in care homes. Referrals to the Frailty HTS were increased and attendance at ED and admissions to hospital reduced.  Due to system pressures it continued to run and became business as usual.

Introduction

Although hearing loss is the foremost cause of years lived with disability in people over 70, it remains commonly underrecognised ^[1,2]. Health of the UK signing deaf community is reportedly worse than the general population, often due to resulting undertreatment of associated co-morbidities including visual impairment, falls and dementia ^[3,4].

Local Problem

There is an estimated 21% prevalence of ≥25dBHL hearing loss within the Wolverhampton adult population, this increasing with age ^[5]. A large number of inpatients admitted to the Older Adult Medicine (OAM) wards at New Cross Hospital have clinically evident sensory impairment, impacting upon interactions with healthcare staff. This project identified the current methods through which hearing and/or visual impairment is formally screened for and documented within the OAM Department of a large district general hospital, targeting interventions towards mitigating barriers faced in sensory assessment.

Methods and Intervention

Baseline and post-intervention documentation of sensory impairment was collected from admission and bedside notes of 23 inpatients during each cycle. A multidisciplinary focus group of medical, nursing and practice education facilitators identified a marked underutilisation of bedside alert signs (4%), prompting creation of a redesigned bedside poster with a greater focus on sensory aid functionality.

Results

60% of posters were utilised 10 days after introduction, with an increase from 4% to 36% in recording of known sensory impairment being observed. 100% and 25% of inpatients with correctly functioning hearing aids and spectacles were documented respectively. 100% of patients admitted through frailty intervention streams were assessed for sensory loss, compared to 0% admitted via the unselected medical take.

Conclusions

Improved bedside alert posters provided initial evidence as a sustainable improvement in supporting inpatients with sensory impairment. Incorporating positive lessons from frailty team practice will assist in developing future education sessions, highlighting intended sign usage and transferrable sensory assessment methods for involved healthcare teams.

References

1. Hearing Matters. Action on Hearing Loss. 2015. Available at: https://shorturl.at/tBEST [Accessed: 23 Nov 2023].

2. Healthy Ageing Evidence Review. 2011. Age UK, N.D. Available at: https://shorturl.at/fqAOW [Accessed: 11 Nov 2023].

3. Emond et al., 2015. The current health of the signing Deaf community in the UK compared with the general population: a cross sectional study. BMJ Open 2015.

4. Vos, T et al., 2015. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. Vol. 386 (9995) pp. 743–800.

5. Prevalence estimates provided by Professor A C Davis, using prevalence from Davis (1995) Hearing in Adults, updated with ONS (2014) National Population Projections. Available at: http://www.ons.gov.uk/ons/rel/npp/national-population-projections/2014-… [Accessed: 11 Nov 2023].

Introduction: Patients with learning disabilities (LD) often have complex medical needs resulting in onset of frailty at younger ages. This increases risk of morbidity and mortality following emergency admissions, such as acute fractured neck of femur (FNOF). This risk is further increased by communication difficulties experienced in this group. There is little information about how LD affects the quality of care of patients with FNOF as defined by the national hip fracture standards (NHFS).

Methods: This retrospective audit reviewed notes of patients with LD admitted to a teaching hospital with FNOF over 5 years. The audit examined whether the care of patients with LD complied with the NHFS and best practice tariff guidelines, regardless of age. The audit sought to explore potential disparities between patients with LD and the general population. It assessed whether steps were taken to optimise care as defined by the Royal College of Physicians toolkit for LD.

Results: 46 patients were included; 22% were under the age of 60. Operative management was in line with recommendations. However 37% did not receive appropriate bone strengthening treatment and 37% were not mobilised within the first 24 hours. This correlated with fewer patients remaining freely mobile following the admission (8.7% post-operatively vs 41.3% pre-operatively). Documentation of LD severity LD and usual behaviours was unreliable, as was documentation of key conversations, such as those regarding capacity or resuscitation.

Conclusions: This highlights the importance of addressing the increased needs of patients with LD regardless of age, to better facilitate holistic assessment and treatment of this vulnerable population. Locally we plan to minimise variation by utilizing LD nurses and providing comprehensive geriatric review of all patients with LD admitted with FNOF. We recommend that data collection, including 120-day follow-up, be incorporated into routine practice for all patients with LD admitted with FNOF.

Introduction

Identification of pain generally relies on patient self-reporting of symptoms. Patients with limited communication, advanced dementia or learning disabilities are unable to self-report pain. This results in pain being under-recognised and under-treated. Consequences of this are serious and include physical and psychological distress, longer length of stay and worse outcomes.1

Methods

Abbey Pain Score (APS) (Figure 1)was introduced on a single Healthcare of the Older Person ward.2,3 It was used as the primary means of assessing pain in non-verbal patients (NVP) in place of the usual verbal pain scale (scored 0-10). Ward-based teaching for all doctors, nurses and healthcare assistants was conducted before introduction of the APS. Data was collected for 20 consecutive NVP (Figure 2). Figure 1: Abbey Pain Score (Six items observed & Score) Vocalisation: 0-3 Facial expression: 0-3 Change in body language: 0-3 Behavioural change: 0-3 Physiological change: 0-3 Physical changes: 0-3 Scoring scale No Pain (0-2) Mild Pain (3-7) Moderate Pain (8-13) Severe (14+)

Results

At baseline we identified that pain as a symptom was missed in 54 % of NVP using the verbal pain score. With introduction of APS this dropped only slightly at 3 months but there was an increased uptake in scoring NVP on APS. With persistent engagement there was a significant decline in number of patients with un-managed pain needs. Figure 3: Abbey pain score (All patients with any pain) Baseline : Pre-intervention: 21 / 39 (54 %) Post-intervention (3 months): 10 / 20 (50 %) Post-intervention (12 months): 1 / 19 (5 %)

Conclusion

ABP is a effective means of addressing pain in NVP. It is simple to implement and can lead to significant improvements in patient care.

Introduction: Poor oral health is linked to multiple health conditions, for example pneumonia, cardiovascular and cerebrovascular disease, cancer and diabetes. Older people are particularly vulnerable to developing poor oral health due to comorbidities, medications used, and access to dental services, an effect magnified during hospital admissions. The aim of this project is to improve oral health and care received by inpatients on Healthcare for Older People (HfOP) wards.

Methods: A baseline audit of patient-response surveys on oral health access and behaviours, and care during hospital admissions was performed. HfOP inpatients aged >75 with capacity to consent were included. Plan-Do-Study-Act cycles informed interventions, focusing on education of multidisciplinary staff. First round interventions included presenting/discussing initial audit findings at a regional HfOP meeting, and working with Oral Health Practitioners to do ward-based micro-teaching and develop/distribute posters raising awareness. Second round interventions included a more in-depth certified educational session available to all HfOP staff on oral health care and promotion, and posters on how to document oral health aspects on the electronic patient record.

Results: 82% (82/100) patients reported being registered with a dentist, 50% attending a dentist in the last 12 months. Initially, only 17% (17/100) reported ward staff taking measures to ensure/help support their oral health, rising to 46% (46/50) in the second audit.

Conclusions: Though patient surveys may under-represent oral health access/issues by excluding people unable to consent, and may under-represent staff support offered/provided by recall bias, our audit did highlight gaps in staff awareness/practice. Our interventions were designed to benefit all inpatients, via opportunistic ward-based education through the audit process and formal educational sessions. Limitations included logistics of ensuring access to all staff groups. Our goal is to formalise oral health training in core MDT teaching to generate systemic lasting improvement.

Other information: Registered with local trust audit programme.

Inpatient falls remain a huge problem in hospital, causing significant injuries to patients and are an avoidable cost to the NHS. Therefore, the National Audit of Inpatient Falls (2015-2017) set out key recommendations for management of falls, including the measurement of LSBP within 3 days of hospital admission.

Our project was conducted in a major acute teaching hospital in North West London across three geriatric wards. Our aim was to improve the measurement of LSBP and correct documentation across the wards in line with the NAIF guidelines. We excluded patients unable to mobilise to standing with support, patients too unwell or unable to follow instructions and actively dying patients.

Prior to any intervention, we found that only 24% of patients had LSBP performed within three days of admission. We focused our intervention in raising education and awareness across our staff. We arranged weekly reminders during MDT meetings, created posters and organised twice monthly teaching sessions, including one to one, on how to document correctly electronically.

After one month of intervention, 73% of patients had LSBP as part of the ward round plan and almost half of patients had it correctly recorded on our system. After 4 months, we reaudited our project and found that only 32% of patients had LSBP appropriately recorded. This significant decrease can be explained by the changeover of junior doctors and emphasises the need of a more sustainable change.

Our goal is making LSBP part of a routine preadmission checklist when appropriate. We are currently working on making changes to our electronic patient record (EPR) to facilitate documentation to members of staff. This includes a new falls assessment tool and the newly incorporation of Smartzone feature on EPR. This will allow staff to put non-critical jobs in the workflow showing a less intrusive alert until completed.

Introduction

Receptive music listening has been shown to reduce depression, anxiety, and agitation in older adults. However, unfiltered and disruptive noise can increase confusion and agitation. Yet, during hospitalization older patients often have little control over when and for how long they are exposed to music, the genre which is heard, or they may have no access to music. Furthermore, older persons have reduced ability to use modern technology to counter this and their sensory and functional impairments may further isolate them. This study aimed to assess the feasibility of offering two one-hour daily sessions of patient specific music (PSM) choices on an elderly-care ward.

Methods

On an district general hospital elderly-care ward a 5-day trial of offering two one-hour daily sessions of PSM, using enhanced wireless speakers optimally positioned with daily amended music playlists based on specific patient choice. Ambient noise was minimised with regular decibel monitoring. A post-intervention staff survey was completed to assess the feasibility of continuing, the perceived impact on staff and patients and potential barriers to continuation. Thematic analyses were completed on the survey.

Results

In the post-intervention feasibility survey (n=14) the majority of staff (86%) agreed that it was possible, implementable and the procedure easy to use. In the impact assessment (n=19) 80% of staff stated it had a positive effect on patients and 89% stated it had a positive effect on staff. Thematic analyses on impact identified benefits to: work, engagement, enjoyment, physical activity and well-being. Barriers that were identified included patient choice, repetition of music, patients unable to engage with the process and staff availability for consistent delivery.

Conclusion

Playing patient specific music choice was feasible and acceptable to staff with a perceived positive influence on both staff and patients. Further studies are now required to assess the impact on patient outcomes.

Objective

To conduct a QIP to ensure that >80% of DAU patients’ vision was assessed via the VAT as per National Audit of Falls Prevention Guidance.

Background

Patients with visual impairment are twice as likely to fall than those without. The NAIF 2015 report identified <50% of elderly patients had their vision assessed in hospital; also evident at Southend Hospital.

Methods

Data collection from 56 patients over 8 weeks following weekly interventions helped us analyse their impact on VAT use. Control data (week 1) was pre-intervention.

Intervention

Six interventions were applied over 7 weeks: teaching to nurses, HCAs and doctors about VAT; email to Geriatrics team; reminder email to DAU nursing team and a feedback questionnaire.

Results and Discussion

Mean age was 82 and 38% of patients attending DAU had an ophthalmic history. Pre-intervention (week 1) identified 0% VAT use. In week 2, there was a 75% increase in VAT use after teaching nursing and HCA staff. In week 3, there was only 12.5% VAT use after the poster intervention. In week 4, there was a 25% uptake on VAT use with no intervention.

Week 5’s intervention witnessed 100% in VAT use, which remained high in week 6 (85.7%), 7 (100%) and 8 (100%). The final intervention questionnaire highlighted that 100% of staff were (i) previously unaware of VAT, (ii) agreed on its importance in assessment of elderly patients, (iii) found teaching adequate, (iv) thought there was enough awareness on VAT use via the QIP, (v) agreed that an incomplete VAT was due to inability to undertake section 4 and 5.

Conclusion

VAT use identified 3 ophthalmic problems that would have otherwise not been managed. While the QIP did not meet the target of >80% VAT use, it successfully informed DAU staff in proper conduct of VAT in falls patients.