Clinical Quality

Older people with severe frailty are 5 times more likely to die in the next 12 months than older non-frail people however prognosis and disease trajectory in frailty remains difficult to predict. Advance care planning (ACP) is often not fully discussed or documented due to these prognostic uncertainties, plus time/workload constraints. This can result in multiple admissions for people with frailty in the last 12 months of life and can lead to care and death in a non-preferred place. Electronic Advance Care Plans (eACP) can be useful in reducing unwanted admissions and promoting care and death in preferred location. This project aimed to improve proportion of patients receiving care in their preferred location and reduce readmission rates. Identified patients who wished to avoid hospital readmission with clinical frailty score of 6 or more and at least 2 unplanned admissions in the preceding 12 months over a 4 month period at a district general hospital in south London. ACP was discussed with patients and families and an eACP was generated. Patients were then followed up at 3 and 6 months to assess readmission rate and rate of end of life care in preferred location. 24 patients consented - 17 women, 7 men. Mean age of 88.3 Mean pre-admission frailty score of 6.1. High level of pre-admission co-morbidity with 80% having 3 or more major comorbidities. Readmission rate was 8%. One third of patients alive at 3 months all without readmission. 23 patients had died at 6 months. 13% died in hospital versus a national average of 44%. 70% died in preferred place of death versus national average of 53%. Use of electronic Advance Care plans resulted in a low readmission rate and a higher proportion of people receiving end of life care in their preferred place of death.

Introduction

Commonly, discharge letters employ a chronological “narrative” style (NS). These unstructured letters often do not clearly communicate rationale for diagnoses and management – a problem exacerbated in letters compiled by multiple staff. This project trialled an alternative format.

Methods

An itemised letter (IL) was designed, each diagnosis a separate numbered point; guidance was provided for relevant investigations and management to include for core geriatric conditions. Four “Plan Do Study Act” (PDSA) cycles were completed. Mixed-methods feedback informed subsequent cycles. PDSA cycle 1 piloted the IL. Responding to concerns ILs took longer, cycle 2 measured writing times on a second ward. Cycle 3 monitored spontaneous IL uptake and feedback throughout geriatric medicine, continued in Cycle 4 after 12 months when the department formally adopted ILs.

Results

We collected 17 email responses, 9 semi-structured interviews, 1 tweet, writing times, and uptake statistics. Framework analysis synthesised qualitative and quantitative results. The key finding was that ILs improved information clarity. The standardised structure made it easier to update letters, and teach letter writing to new staff. Some staff reported challenges changing letter format, and noted electronic templates were not optimised for ILs. Mean completion times were 23 minutes for IL (range 6.5–38, N=15) and 20 minutes for NS (15–26, N=5). Sample size imbalance reflected exclusion of letters, predominantly NS, started on other wards. Uptake data evidenced continued IL use despite staff rotations. When cycle 4 commenced a mean of 35% (range 0–91%) of letters were in IL, increasing after seven months to 64% (40.6–90%). Qualitative feedback mirrored on-going usage, with many doctors continuing IL use after rotation. PDSA cycle 5 has begun, discussing using ILs in other specialties.

Conclusions

The IL format was well received by hospital staff, and will be improved by feedback from GPs, relatives, and patients.

Promoting Bone Health by ensuring in-patient Ortho-geriatrician Bone Health plan in patient notes following Neck of Femur Fracture (NOF).

1. Introduction & Aims

Osteoporosis affects 3 million people in the UK with more than 500,000 hospital presentations annually due to fragility fractures costing in excess of £4.4 billion to the NHS. Bone protective medications are a cost-effective way of reducing fracture and admission following a fall.

The Royal College of Physicians National Hip Fracture Database targets that patients are: “given suitable bone strengthening treatment and followed up to ensure that they are still receiving this protection 120 days after fracture”. Lewisham Hospital achieves this in only 22% of suitable patients against a national average of 35%.

This project aimed to increase the number of eligible NOF patients on bone protective medication.

2. Method

Data was collected for patients over the age of 65 admitted with NOF. 22 eligible patients were admitted from 01/01/23 to 28/02/23 and 16 from 01/03/23 to 31/05/23. It was identified whether an appropriate bone health plan, including FRAX and calcium/vitamin D supplementation, was recorded in the medical notes and electronic departure note (EDN). Interventions included an advice sheet for rotating doctors, additional education at induction and a bone health proforma for medical notes and EDNs.

3. Results

86% of patients in cohort one had bone health plans in their notes and 59% in their EDN.  64% commenced on bisphosphonates with 1 eligible patient (4.5%) not receiving medication. After the interventions 100% patients had a bone health plan in their notes and 80% on their EDN. 46.7% of this cohort commenced bisphosphonates which equated to 100% of patients appropriate for bone protective medication.

Conclusion(s)

Providing guidance and education to rotating doctors to ensure Geriatrician-led bone health planning resulted in all eligible patients commencing bone protective medication and total numbers above the national average.

Introduction:

 It is recognised that there are pressures on the NHS particularly the emergency services.  Therefore, a focus of the 21/22 Priorities and Operational Guidance was to develop community services to prevent emergency department (ED) attendance and avoidable hospital admissions.  This informed the funding of urgent community response services (UCR).  An urgent response is defined as a presentation that would likely result in hospital admission if a response were not made within 2 hours.  Quality Improvement methodology was applied to evaluate the potential impact an advance clinical practitioner (ACP) could have in providing alternatives to hospital conveyance by redirecting appropriate calls to the UCR. 

Method:

Small scale tests of change with iterations of Plan Do Study Act cycles were conducted to enable comparison and recommendation for the use of the funding.  PDSA 1.  ACP based in an ambulance station. PDSA 2 and 4 ACP based in 2 different hospital EDs at the point of triage.  PDSA 3.  ACP based in the clinical hub where 111 calls are triaged.  

Results:

These PDSA cycles enabled process mapping of the patient journey to be made and a gap analysis showed the possible interventions an ACP to make to prevent an inappropriate admission.  It was apparent that a call stack pull model where the ACP can directly respond to calls from the ambulance list, and often redirect to the UCR service, was the most effective method.  Cross organisational information governance issues were found to be a barrier to implementation.

Conclusion:

Small-scale tests of change were implemented to seek the most effective use of an ACP to support alternatives to hospital admission. To introduce this pathway, a whole systems approach is needed to collaboratively provide a seamless service and an overall better experience for all.

Introduction:

Recent studies show the use of comprehensive geriatric assessment (CGA) in older patients with cancer can result in better quality of life, improved treatment tolerance and reduced hospital admissions, leading to international consensus that CGA should be routinely included in care. We have piloted an onco-geriatric MDT, consisting of oncologists, geriatricians and therapy input, alongside a rapid-access geriatrician-led onco-geriatric clinic

Method:

Referrals were invited from oncologists for older patients (>70) with a new diagnosis of cancer, with expected prognosis of more than 1 year, about whom they had concerns regarding their ability to undergo radical treatment due to co-morbidities, falls, cognitive impairment or social isolation. A CGA was completed prior to starting radical treatment in most cases. Performance status, Rockwood frailty score(RFS) and G8 score were calculated for all patients.

Results:

During the 24 week trial period, an MDT and clinic has run every week. A total of 32 patients have been discussed at MDT, with 22 seen in clinic, from cancer sites including colorectal, breast, urological and ovarian. Patient seen in clinic had an average RFS of 4.5 and G8 score of 13. All patients have seen a geriatrician, with most also seeing our physiotherapist. Interventions included medication review and rationalisation, anaemia review and treatment, referral to specialist memory and continence services, blood pressure optimisation and completion of a treatment escalation plan.

Conclusions:

Feedback from patients attending the clinic has been resoundingly positive, with 100% of patients rating their service experience as “good” or “very good” and praising the time to talk about their health as a whole. Follow up of clinic patients is in progress, identifying emergency admissions alongside treatment toxicities and complications within this group, as well as whether G8 is an appropriate screening tool for clinic review, to secure the long-term future of the service.

Background:

Nutrition is one of the cornerstones of healthy aging. As we age there are many changes in our bodies, including decreased appetite and poor dentition, that contribute to increasing malnutrition. The MUST (Malnutrition Universal Screening Tool) score is a quick and effective tool to assess this.

Aim:

In this project, we aimed to review MUST score and food chart completion on the frailty wards at EDGH to attempt to improve the nutrition of elderly patients.

Methods:

The charts of 75 patients were reviewed over a period of one month. Following this, a training program for all the nursing staff was put in place. The initial results were discussed and the importance of nutrition in the elderly was highlighted. The staff were shown how to fill in the MUST score and follow management guidelines. Also, a reminder was set up on Nervecentre (electronic patient record) for all staff.

Results:

Of the initial 75 patients;

1 – a MUST score was completed for only 64% on admission.

2 – 41.3% of patients were eating 50% or less of their meals.

3 – In only 27% the reasons why they were not eating were documented.

In the second cycle, 80 patients were included and the results were markedly improved.

1 – The percentage of MUST score completion on admission increased to 91.3%.

2 – Management guidelines were followed in 92.5% of the cases.

3 – 18.8% with a MUST score of two or more, were referred to dietitians at an early stage.

Conclusion:

- Our quality improvement project significantly increased MUST score completion and prompted action at an early stage. 

- The next step is to improve the documentation of patient’s food charts and encourage staff to look for and document the reasons why patients are not eating.

Introduction

The Mental Capacity Act is designed to protect patients who may lack the mental capacity to make decisions about treatment. At the Nuffield Orthopedic Centre (NOC) in Oxford, nurses obtain a baseline AMTS during the pre-operative assessment clinic. Following on from this, any patient over 64 years old that is seen by the orthogeriatrics team will have a post-op AMTS done to assess for cognitive impairment. If the AMTS is less than 8, or the patient is clinically believed to be delirious, then an MCA form will be completed for the decision to accept treatment. The aim of this QI project was to widen this practice to all the junior doctors at the NOC.

Method

AMTS and MCA data were collected from one month of inpatients >64 years old at the NOC. The AMTS were analysed and the patients with post-op AMTS of <8 were identified and checked for MCA form completions. The data was presented to junior doctors at the NOC, and a repeat cycle was performed to assess if the practice was being implemented.

Results

Data collected from 10/01/23 – 10/02/23 (n=125) showed that out of 10 patients meeting the AMTS criteria, only 4 had MCA forms completed. Once the QI projected was presented on 25/05/23, data collected from 12/06/23 – 15/07/23 showed that out of 5 eligible patients, 4 of them had MCA forms completed.

Conclusion

Prior to this QI project, only 40% of eligible patients from the collected data were having MCA forms completed by junior doctors at the NOC. Following the presentation to raise awareness, the data collected shows that this figure had increased to 80%. In conclusion, this QI project has been a success and should be repeated every 4 months to account for each new rotation of junior doctors.

Introduction -The use of anti-psychotics is higher in older people than their younger adult counterparts due to high prevalence of dementia/delirium. Anti-psychotic drugs cause side effects which include cardio vascular, metabolic, extra pyramidal and high risk of falls. So, we set out to do a QIP on antipsychotic medication prescription on our Geriatric wards and compared it with NICE guidelines.

Method- We had 2 approaches to use. Firstly, we prepared a check list for anti-psychotic medication monitoring according to NICE guidelines 2021 and we applied this retrospectively to 17 patients who had been initiated on anti-psychotics within last 12 months, the aim being to compare our practice with best practice. Secondly, we prepared a questionnaire for doctors to assess their knowledge about antipsychotic NICE guidelines and we distributed it to 14 junior doctors in RGH.

Results- • Main Indication for prescribing antipsychotics was Behavioural and psychological symptoms of dementia (BPSD) - 94% of the time • Risperidone was the most commonly prescribed (64%) antipsychotic for our patients • 83% of them had non pharmacological methods tried before considering antipsychotic medications. • 82% had their baseline ECGs checked • 35% had their lipids checked and 47% had their HbA1c checked • 52% of the doctors were aware about NICE guidelines on prescribing anti-psychotic medications • 70% of the doctors had knowledge about the side effects.

Conclusions- Our study showed the most commonly used antipsychotic drug was risperidone. We were good at documenting the indication, trying non pharmacological methods and discussing side effects with patients/family. Hba1c, lipids and prolactin were not often checked, showing room to develop best practice. We therefore are in the process of finalising a sticker so that we can follow the guidance set by NICE for prescription of antipsychotics. To improve knowledge of antipsychotics in doctors, we have presented the findings and aim to put up posters on all medical wards and to teach at our local level during doctor change overs

Introduction: The Community Geriatrician team based at the Countess of Chester Hospital is a multidisciplinary team offering comprehensive assessments at home to older patients with frailty. The team review frail patients identified as being at risk of hospital admission. Cognitive impairment and dementia are increasingly common concerns in our patient group and significant risk factors for admission. Frail patients often struggle to access traditional memory clinics for a variety of reasons and can therefore remain undiagnosed. They often require a more holistic approach in their home environment. We therefore identified a need to offer a dedicated frailty memory pathway within our community geriatrician team enabling better access to dementia assessment and diagnosis in complex frail patients.

Method: A frailty memory assessment pathway was proposed and commenced in 2022. Following identification of a cognitive concern during the initial comprehensive geriatric assessment a further home visit is arranged to assess memory in more depth. Patients are then discussed, and a diagnosis reached via a monthly Frailty memory MDT attended by Consultant psychiatrist, Consultant geriatrician, and Specialist Occupational therapist. Following delivery of a diagnosis our AGE UK well-being coordinator within the team provides post diagnostic support and sign posting to patient and family. A retrospective audit was undertaken reviewing the 44 patients diagnosed since pathway commenced. The number of hospital admissions and number of inpatient bed days was compared in the 3 months pre and post initial assessment.

Results: In the 3 months following assessment 82% of patients had a reduction or unchanged number of admissions, there was a total reduction of 71 inpatient bed days.

Conclusion: We believe our pathway offers a unique multidisciplinary approach to dementia diagnosis in the frail population, improving frail patients access to dementia assessment with a reduction in hospital admissions.

Introduction

The patients most often admitted with a hip fracture are older adults, many of whom are frail. The Scottish Hip Fracture Standards recommend that all patients have fluid assessment and are mobilised by the end of day 1 post operatively. We set out to look to see which patients are most at risk of acute kidney injury (AKI) and orthostatic hypotension (OH) post operatively and whether this was linked to the prescription of iv fluids (IVF).

Method

All online notes of patients admitted with a hip fracture in the months of July and November 2022 were reviewed. Notes were reviewed for type of anaesthesia (General Anaesthetic or spinal), frailty score (using Rockwood), presence of AKI on days 1-3 post operatively (as determined by looking at lab results), and presence of orthostatic hypotension on days 1-3 post operatively (as documented in physiotherapy notes).

Results

There were 120 patients audited (July: 59; November: 61). 39 patients had IVF prescribed post operatively, 15 developed orthostatic hypotension and 20 developed an AKI. The frailest patients (Rockwood 6/7) were most likely to be prescribed fluids post-operatively (25/52) however had the highest rate of AKI (12/52). Moderately frail patients (Rockwood 4/5) were less likely to be prescribed IVF (8/42) and most likely to develop orthostatic hypotension (9/42) even compared with the frailest patients (3/52). This did not differ by operation type as the same proportion received IV fluids with a spinal (11/30) or general anaesthetic (28/86). Antihypertensives were not linked to AKI but were to OH.

Conclusion

Moderately frail patients are the group that appear most likely to develop post operative orthostatic hypotension but are not prescribed post operative fluids as frequently as the most frail. This may be leading to increased risk of orthostatic hypotension and thereby delay rehabilitation in a vulnerable group.