Clinical Quality

Background

Time critical intervention delays contribute to increased waiting times, length of stay, worsening morbidity, and mortality for the already frail patient. Evidence suggests some clinicians decide to admit whenever test results are not yet available; mistakenly believing this decreases patient risk. Within one day, this project reduced waiting times for decision makers by upgrading the blood sample processing priority so results are available sooner.

Method

Our Quality Improvement (QI) team leader spent one shift observing practices in the Emergency Department, noting ED blood samples are processed as ‘urgent’. The QI team leader discussed with the laboratory manager if capacity existed to process the frailty unit’s bloods as ‘urgent’ rather than ‘routine’. This had zero impact on laboratory resources due to limited numbers attending the frailty service daily; they supplied different colour coded blood sample bags: purple. This immediately visually indicates to staff the sample is ‘urgent’. (Previous bags: red - haematology, yellow - biochemistry, green - microbiology). A start date was arranged for the following day. Red, yellow and green bags were removed from the frailty services’ unit and replaced with purple. Staff were informed the change would start that morning.

Results

Our main outcome measure was average waiting time for a decision to admit or alternative pathway. From day one, staff achieved 100% compliance with ‘urgent’ sampling and waiting times for a decision reduced by up to 80% (from up to eight hours to less than one hour).

Conclusion

QI identified a reason for delayed decision making contributing to increased waiting times for frail patients. This sustainable change reduced risk and improved quality of care.

Introduction: Anti-psychotics and benzodiazepines are commonly prescribed for older people. They are usually indicated in the short term for delirium and agitation. There are known risks associated with these drugs in the older population including functional decline, increased falls risk and overall mortality. Moreover, chemical sedation is a form of restraint and deprives patients of their liberty. Sedative prescribing should be protocol driven and preceded by non-pharmacological intervention. However, these prescriptions are often initiated prematurely and evade review, continuing in the long-term.

Method: Our QI team aimed to reduce prescribing of new sedating drugs by 60% in patients using an MDT approach. Our strategies focused on increasing awareness and utilisation of existing protocols, to improve non-pharmacological management of delirium. This was achieved through the strategic delivery of teaching sessions for nursing, pharmacy and medical staff. Further, we utilised force function techniques and management charts to encourage review of these prescriptions. We gathered our data on a weekly basis over a five-month period by reviewing all prescribed medicines for patients on an older people’s ward.

Results: We exceeded our initial aim achieving a reduction of 82% in the prescribing of new lorazepam and haloperidol. We also attained a significant and sustained uptake of over 95% in the use of the delirium protocol. Where a review sticker was used, 80% led to discontinuation of the target prescription. Although these improvements were focused on one ward, the wider changes and improvements were observed throughout the hospital.

Conclusion: The significant reduction in sedative prescribing demonstrates the need and potential for improving the quality and safety of this aspect of patient care. The wider success of this project highlights the importance of addressing human factors to drive and sustain change. Improving the understanding of MDT members is integral to changing behaviours and improving patient safety.

Introduction: Acute pain is a common presentation of elderly and tends to be under-recognised and under-treated. Consequently, delayed and inadequate treatment of acute pain is known to lengthen in-hospital stay whilst reducing quality of life. Using local hospital guidelines for acute pain management in adults as gold standard, anecdotally we felt patients were not received medication as per guidance. A quality improvement project was undertaken with an aim to increase the number of patients >65 years old that received appropriate analgesia within the first 24-48 hours of presenting to the front door with acute pain by 15% within 8 months.

Methods: The study cohort composed of randomly selected patients > 65 years of age presenting to the front door with acute pain in the form of soft tissue injury, suspected/confirmed fracture. Parameters for data collection included cognitive background, pain assessment done on admission, analgesia prescribed in the first 24-48 hours and whether prescribed appropriately as directed by hospital guidelines. During the project period, the first intervention was aimed at sensitising medical staff of timely initiation and appropriate analgesia in elderly with an info graphic poster put up in the acute assessment unit and highlighted during Acute Medicine safety brief. A second intervention was directed at nursing staff regarding pain assessment on admission using a poster and emphasizing its importance during nursing handover.

Results: The percentage of patients who had pain assessment done increased from 27.8% to 75.0% during the project period. Similarly, of those prescribed analgesia, the percentage of patients prescribed appropriately rose from 66.0% to 86.8%.

Conclusion: This project has positively impacted the number of patients who received appropriate analgesia. Accurate pain assessment helped to determine choice of analgesia. Limitations include using age cut-off for elderly instead of frailty reflecting a role and need for frailty-based guidance.

Introduction

AFU aims to provide Comprehensive Geriatric Assessment to frail, older service users.  A key component is Medication Review.

Patients living with frailty are more susceptible to medication side-effects and are often on Falls Risk Increasing Drugs (FRIDs¹) and medications with Anticholinergic Burden (ACB²) effects, which can cause falls/confusion/delirium/hallucinations. Aiming to reduce inappropriate polypharmacy, ACB and FRIDs scores, and optimise bone health is therefore essential.

Data highlighted only 17% of patients received Medication Review by a Pharmacist, which needed addressed without additional resources.

Method 

Medication Review usually involves a Pharmacist working alone and can be a lengthy process. We suggested a team approach with preparation and clinical details brought to a focused meeting with decisions made collectively.

After identifying key stakeholders, we introduced a focused Medication Review meeting twice weekly. 

Aims of review: reduce ACB and FRIDs scores, discontinue medications no longer indicated, improve bone health with a patient-centred approach throughout.

We produced a data collection form for audit purposes, and agreed how to communicate suggested changes to patients and other staff. 

Results

109 patients audited from October 2022-March 2023.

Medication Reviews increased from 17%-69%.

Improvements noted: average number of medications reduced from 9.5-9.0 (reduction diminished by addition of bone optimising medications³), number of patients with ACB ≥3 reduced from 32-11, average ACB score reduced from 1.9-0.9 and FRIDs score from 5.5-3.4.

ScHARR⁴ potential cost avoidance for 557 interventions was £37,501 - £86,218 with an average of 5 interventions/patient.

Conclusion 

A focused multidisciplinary Medication Review led to a reduced ACB and FRIDs score, with a potential saving from interventions. It also increased the number of patients receiving a Medication Review.

This innovative way of providing Medication Review makes best use of our time and skills, encourages education, and promotes conversations with patients/families about medications to see what matters to them.

References

1.  FRIDs (Falls Risk Increasing Drugs)

Northern Ireland Medicines Optimisation in Older People (MOOP)

2.  ACB Calculator

Available at: https://www.acbcalc.com/

3.  FRAX® Fracture Risk Assessment Tool

Available at: Frax.shef.ac.uk. (2023)

4.  ScHARR Potential Cost Avoidance

Karnon, J.; McIntosh, A.; Dean, J. et al. Modelling the expected net benefits of interventions to reduce the burden of medication errors. J. Health Serv. Res. Policy 2008, 13, 85–91.

 Introduction:

Intracerebral haemorrhage (ICH) accounts for 10-20% of strokes worldwide. Mortality is high at 40% and survivors might suffer from severe disabilities that massively impact quality of life and independence. Diagnosis and treatment are straight forward. A non-contrast CT head scan is diagnostic. Treatment is focused on prompt anticoagulation reversal and blood pressure control, with consideration of surgery in appropriate cases and admission to an acute stroke unit or an intensive care unit.

Methods:

Two PDSA cycles of 28 and 29 patients were completed in the acute stroke Unit between 2020-2022 (8 months apart), Data gathered included blood pressure readings on admission and intervention to control it. The percentage of anticoagulation reversal was noted. We recorded if each patient was admitted to the stroke unit and if the patient was discussed with neurosurgery. Interventions post-first PDSA cycle included implementing a formal bundle of care, reflecting ABC-ICH practice, formalisation of the departmental guideline on blood pressure control, anticoagulation reversal and neurosurgical referrals. Teaching sessions were delivered to junior doctors and stroke assessor nurses.

Results:

Anticoagulation was reversed in 30% patients on anticoagulant (1% improvement). BP medication was given in 62% compared to 52% yet control within 1 hour was achieved in only 12.5 %. All patients were admitted to ASU (97 % previously). There was an evident improvement in decreasing over-referral to the neurosurgeons, 50% compared to 76% previously, and also in terms of selecting the proper patient to refer where 100% of hydrocephalus patient was referred.

Conclusion:

Although the re-audit has shown consistency in admitting all patients to HASU and decreased numbers of referrals to neurosurgery, it showed an unacceptable shortage in the key management of intracerebral haemorrhage, specifically in two major areas, reversal of anti-coagulation treatment and prompt blood pressure management. Further quality improvement work is being undertaken.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to frailty at the front door or a community based service and has access to rapid diagnostic and intervention services.

Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers.

Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls.

Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services.

Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

Introduction:

Faecal-immunochemical test is employed as a screening tool for colorectal cancer. Our observational study examined the FIT in primary care as a risk stratification tool in frail patients.

Method:

The records of 217 frail patients over a 24-month period were analysed. Patients with haematological indices of anaemia were offered FIT to detect GI haemorrhage as part of assessment for selection for lower GI investigations. Patients were risk stratified based on FIT results based on the presence or absence of red flags. Patients who were FIT positive were referred for urgent lower GI endoscopy versus those who were FIT negative were managed without bowel investigations unless there were red flags such as abdominal mass, changed bowel habits or family history of bowel cancer.

Results:

Of 217 patients over a 24-month period of these 42 patients (19.4%) were FIT positive. All of these (n = 42) underwent colonoscopy of which 9 (normal )18 ( colonic polyps ) 12 ( diverticulosis ) 3 ( colorectal cancer ). Of the 42 FIT positive patients 16 were on direct oral anticoagulant (DOAC). Patients on DOACs and those on dual anti platelet agents were more likely to be FIT positive. We also found a positive correlation between higher frailty indices, HAS BLED scores and chronic kidney disease and low creatinine clearance r=0.68, p=0.001. Despite the small numbers in this study the correlation is statistically significant.

Conclusion

There is a statistically significant positive correlation of FIT positive and frailty indices with DOACs, Dual anti platelet agents, CKD, low creatinine clearance ( r=0.68 and p=0.001 ). Following this the HASBLED scores increased, hence our practices implemented an enhanced surveillance of monitoring these patients quarterly due to the increased risk. We advocate frailty indices should be incorporated in the HAS BLED scores for improved patient safety.

Between 2016 and 2021, HSC Trust reported 1,383 choking-related adverse incidents, highlighting a pressing concern for patient safety. This Quality Improvement (QI) Initiative was developed within a Nursing Home specializing in caring for residents with learning disabilities who faced an elevated risk of eating and drinking difficulties. The primary objective was to enhance safety during meal times by integrating a structured safety pause, aligned with the "7 Rights" framework. The initiative leveraged various QI tools, including process mapping, PDSA (Plan-Do-Study-Act) cycles, structured observations, and interviews.

Results of the initiative demonstrated a notable increase in patient satisfaction, a boost in staff confidence, and a reduction in near-miss incidents. The success of the program prompted its expansion to other nursing homes, involving families in the process. To further support patient safety, each staff member and family member now possesses a small card outlining the "7 Rights," which can be readily utilized before assisting patients with eating and drinking difficulties. This initiative represents a valuable step forward in safeguarding vulnerable individuals and has the potential to positively impact patient care across various healthcare settings.

Introduction: Falls are a leading cause of mortality and morbidity in older people and the risk of falling is exacerbated by underlying mental health conditions and associated treatments. NICE recommends that people who fall should undergo multifactorial assessment including a post-fall protocol with assessment for injury before being safely moved, a timely medical examination (within a maximum of 12 hours or 30 minutes if fast-tracked), neurological observations (if there is suspicion of head injury or unwitnessed fall) and a medication review. Aim: We aimed to assess the quality of post-falls assessment and documentation in order to identify areas for improvement to reduce potential harm from injuries and implement strategies to reduce further falls. Methods: We identified ten falls over a 3-month period on two old age psychiatric inpatient wards. Data collected from e-notes was analysed for assessment for injuries, medical review, neurological observations and medication review. We also looked whether patients had OT/Physio input post-falls and MDT discussion to determine the likely cause for fall. Results: Only 40% of patients had a medical assessment completed within 12 hours. There was suspicion of head injury in 40% of patients but none of them had neurological observations completed. In 20% of falls, an MDT discussion took place to determine likely cause of fall and patients had their medications reviewed post-falls. Almost 90% had OT/physio input post-falls. Conclusion: We have since conducted a survey among healthcare professionals to identify common knowledge gaps that can be targeted to improve quality of care post-falls and conducted teaching sessions on relevant themes. Feedback has showed participants confidence has significantly improved in post-falls assessment. We have also created a weekly falls review meeting and designed and displayed a post-falls board with all necessary information. We aim to re-audit our practice now that changes have been implemented.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to community based service and has access to rapid diagnostic and intervention services. Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers. Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls. Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services. Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.