Clinical Quality

Introduction:

Atrial Fibrillation (AF) causes 15% of ischaemic strokes. The National Clinical Guideline for Stroke recommends at least 24 hours of cardiac monitoring and a longer duration if cardio-embolic stroke is suspected. The British Heart Rhythm Society suggests up to 72 hours of cardiac monitoring. Currently, there is little data on the use of telemetry in detecting AF in acute strokes.

Aims:

Our study aims to evaluate the detection rate of new onset AF in acute stroke with telemetry and to determine if there was any correlation between the duration of telemetry and the detection rate of AF.

Methods:

All patients with ischaemic stroke who were admitted to stroke ward over a 3-month period were retrospectively analysed. Exclusion criteria were patients who were known to have AF, had new AF on admission electrocardiogram, patients receiving palliative care, patients who were discharged home early without having a telemetry and patients with missing records.

Results:

61 patients met the inclusion criteria and 5 (8.2%) had AF on telemetry. Two patients had AF on day 1, one on day 2 and two on day 3. All of these patients were anticoagulated. The duration of telemetry ranged between 1- 19 days however no AF was detected beyond the third day of this study.

Conclusions:

AF was detected in 8% of patients with ischaemic stroke within the first 72 hours of admission. Among the patients in whom AF was detected, 5% were detected between 24 hours and 72 hours of admission. Studies (EMBRACE and CRYSTAL trials) have shown that prolonged cardiac monitoring (30 days and 6 months to a year respectively) resulted in higher detection rates of AF. This study suggests that patients with ischaemic stroke should be monitored for at least 72 hours due to a higher detection rate of AF.

Background End-of-life (EOL) care aims to anticipate, prevent and treat symptoms experienced by the dying patient. An EOL care strategy described by King’s Health Partners (KHP) outlines the ‘ICARE’ framework, created from the five priorities for the dying patient, giving generalist hospital teams a memorable prompt to consider holistic needs of patients. We aim to reconcile performance of Acute Medical Unit (AMU) in providing EOL care, against KHP's framework, to reduce patient suffering and improve care. Methods A prospective review was performed of all AMU deaths from March-September 2021, reviewing resuscitation status and EOL medications. Sudden deaths for full resuscitation were excluded. Following review, teaching to AMU was delivered and a wall poster of the ‘ICARE’ framework was displayed. A second prospective cycle was performed reviewing deaths from March-September 2022. Results 50 deaths were recorded in cycle one. 21% (12/58) of dying patients were not prescribed EOL medications. Medication omission for 50% (6/12) of patients were due to lack of recognition of EOL. Other reasons included no consultant review, undecided resuscitation status and a missing prescription. In cycle two, 11% of dying patients (6/48 patients) were not prescribed EOL medications, all of which were due to lack of recognition of EOL. 12 deaths had EOL medications prescribed but had an inappropriate resuscitation status. Conclusion The second cycle showed a 50% reduction in deaths with EOL medication omissions, when compared to the first cycle. Reasons for medication omissions were less varied in cycle two, highlighting reduction in avoidable causes. Although not affecting patient care, a notable number of patient records had incorrect resuscitation statuses. Overall, improvement in delivery of EOL care within AMU can be seen. Future considerations involve emphasis on keeping electronic patient record up to date to avoid errors and continual provision of education to new and rolling staff.

Aim:  Several patient selection scores have been developed to identify patients suitable for SDEC from triage in Emergency Departments (ED) and the acute medical intake. Scores are designed to improve system efficiency, overcrowding and patient experience.  Studies have been conducted that compare these; none in frail older adults. This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Amb). 

Methods: The Older Person’s Assessment service (OPAS) is ED based, accepting patients with frailty syndromes aged >70 years with same-day discharge for >75% of patients. The OPAS databank was retrospectively analysed and interactions with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside each ambulatory score. ED documentation was used to gain triage data.   

Results: 748 attendances, 274(36.6%) Male with mean age 82.8(±8.5) years, CFS 5.2(±1.4) and CCI 6.7(±2.6) with 584(78.1%) discharged same day.  Mean Amb 4.2(±1.7), GAPS 21.4(±5.8), START 23.5(±4.7) scores all within admission range with 29.1% Mortality within 12 months. There was a significant difference between those admitted and discharged with CFS (p<0.001) and mortality (p<0.001).

Conclusion:  Frailty is an important determinant in identifying whether ambulatory care is appropriate. No score could be reliably used as a screen for suitable patients for SDEC services although the Amb score was the most accurate when assessing each individual variable. We are developing our own SDEC score for older, frailer adults which is currently being validated in the OPAS and SDEC settings. 

Introduction Factors contributing to frailty result in increased hospitalisations, with 5- 10% of patients attending Accident and Emergency department living with frailty, and 30% of those patients admitted to acute medical units (Conroy, 2013). Hospital admissions result in functional decline and deconditioning (Get It Right First Time, 2021). The number of people in the UK over the age of 85 is set to double in the next 20 years and treble in the next 30 (Office of National Statistics, 2013). Their needs are best met in the community with a multi-disciplinary approach. Method Patients, residing in Benfleet and Leigh-on-sea, discharged from Geriatric wards at Southend Hospital were identified during ward MDT meetings. Inclusion criteria: • Recurrent admissions • Prolonged hospital stay • Clinical Frailty Score > 5 • Social support Using this criteria, 216 patients were included. 7 day readmission and 30 day readmission data was collected and compared to readmission rate prior to intervention. Intervention On discharge patients were linked with Frailty Nurses within their Primary Care Network and were reviewed within 48- 72 hours of discharge. Community support was provided via MDT, with involvement from consultant geriatrician. Concerns that could result in readmission were highlighted during these meeting, with patients being seen in Day Assessment Unit for review of sub-acute frailty syndrome if appropriate. Results Following intervention of utilising community MDT there was a reduction in rate of readmission. 9 patients (4.1%) were readmitted within 7 days of discharge and 14 patients (6.4%) were readmitted within 30 days, in comparison to 7.6% and 19.3%, respectively, prior to commencement of MDT. Conclusion This concludes that utilising community MDT with review following discharge has positive impact in reducing readmission rates. Highlighting potential risks of readmissions allows the MDT to address issues within the community and use bridging services appropriately.

Introduction

Weight loss is common during acute hospital admissions, and can be devastating to the older patient where weight loss is associated with an increase in mortality over a 12 month period. Patients who lack the ability to communicate their food preferences are at risk of receiving food they do not like, especially as food orders are often taken when family/carers are not present.

Methods

While working on a Department of Medicine for Older People and Stroke (DMOPS) ward, we worked with the Multidisciplinary team (MDT) with the aim of reducing weight loss. We implemented two interventions. The first being ‘MUST Mondays’, where patients were weighed and had a Malnutrition universal screening tool (MUST) completed on admission to the ward, and then weekly. We also implemented A3 Laminated menus - where patients and their families/carers were given food choices for the week in advance, and could use a marker to identify foods they did/did not like. These were then displayed above the bedspace. All patients were over the age of 65. We excluded patients who were actively dying, patients who were aiming for weight loss (Such as in fluid overload) and patients who were admitted for fewer than 8 days.

Results

Prior to putting the interventions in place, we audited 23 patients admitted over a 3 month period. 70% of patients lost weight over the course of their admission, and 48% had MUST assessments completed weekly. We re-audited 5 months after the interventions were implemented, we audited 20 patients over a 5 month period and found 55% lost weight over the course of their admission, and 80% had weekly MUST assessments.

Conclusion

Working as an MDT to put in place small interventions can have a meaningful impact on reducing weight loss in older patients during acute hospital admission.

Introduction

In the United Kingdom an average of 65,000 patients attend hospital with hip fractures each year, with 87% of these patients over the age of 70. Effective pain management is associated with significantly improved outcomes. Pain is known to be a significant trigger for delirium which itself greatly increases 1 year mortality and morbidity. Given the magnitude of the issue, this audit aimed to assess the effectiveness of an intervention in relation to the NICE National Standards for Neck of Femur (NOF) fractures at Weston General Hospital.

Methods

Data sets were collected from NOF fracture patients attending Weston General Hospital (WGH) Emergency Department (ED). The first data was from 29 patients between 4/4/2022-13/5/2022 and the second from 48 patients between 12/9/2022-22/2/2023. The red phone proforma in ED was amended in-between these data collections to include pain scoring and X-ray. Basic analysis allowed comparison between data sets.

Results

11.11% of patients had pain assessed within 15 minutes of arrival compared to 13.79% previously. For standard 2&3, 8.82% of patients had analgesia within 60 minutes, thus not meeting NICE targets. 93.18% of patients had an x-ray requested within 120 minutes compared to 62.07% previously.

Conclusion

Our results were very positive regarding X-ray time. However, the intervention did not improve pain assessment and analgesia time. Going forward, block training should be increased and more widely available in the ED given that only 33% of patients received one on admission. Additional consideration would be to edit the proforma to include pain re-assessment to closer meet NICE targets and improve patient care.

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.