Clinical Quality

Abstract: Ageing is a complex biological process that is progressive in nature. There is a decline observed in the muscle mass and the sensorimotor systems which may contribute to decreased balance and stability while walking.Balance is one of the most crucial intrinsic risk factor for the occurrence of falls. Falls are the leading cause of fatal and non fatal injuries among the elderly.Multiple studies indicate that a structured exercise program helps in improving balance and reducing risk of falls.Exercises can be performed on land as well as in water.Thereby the need of the study to evaluate the effect of land vs aquatic exercises on balance in the elderly.

Method :A Randomised Control Trial with 40 elderly’s selected based on the inclusion criteria; randomly divided in 2 groups. Balance was assessed using Tinetti POMA scale. Exercises were done 3 times a week on alternate days. Below are the walking activities: Walking forward 11 feet. Marching forward 11 feet. Sidestepping without crossing legs 11 feet. Tandem walking 11 feet. Below are the exercise activities. Marching in place. Hip flexion/extension .Hip abduction/adduction. Toe raises/heel raises. Shallow knee bends. Sit to stand from chair in land group. Sit to stand from pool shelf in aquatic group.

Results :Wilcoxin pair signed rank test was used for within group pre and post analysis, for land exercise the two tailed p value <0.0001, which is extremely significant; for aquatic exercises the two tailed p values < 0.0001, which is extremely significant.For between group analysis Mann Whitney Test was used, the two tailed p value < 0.0001, which is extremely significant.

Conclusion:The results show that there is an improvement in balance post both land and aquatic exercises individually, but when compared between the two mediums aquatic exercises showed a better result.

Index terms : Land exercises, Aquatic exercises, Balance in elderly, reduce risk of fall

Introduction:

The benefits of early frailty scoring for patients over 65 presenting to emergency settings are well established. A scoping exercise in the Emergency Department (ED) at the University Hospital of Wales (UHW) identified lack of familiarity with the Clinical Frailty Scale (CFS) and time pressures as barriers to achieving frailty screening at triage. In response, the Frailty Intervention Team (FIT) at UHW developed the Self-Assessment of Frailty in the Emergency Settings Tool (SAFE-T).

Methods:

A PDSA cycle was performed to assess SAFE-T validity and the feasibility of implementation in ED and in a community intermediate care clinic. A 5-day pilot was conducted in April 2023 where all patients >65 years were asked to complete and return a SAFE-T. In parallel, blinded to the result of the SAFE-T, the FIT team completed a CFS score and the results were compared. Process feedback was collected from the FIT team, ED staff and hospital volunteers to identify implementation barriers.

Results:

Data were analysed from 58 questionnaires (50 from ED, 8 from Community Clinic). 42 participants completed SAFE-T alone, 16 completed it with support (e.g. family advocate/hospital volunteer). 7 were excluded from final analysis due to insufficient data to enable comparison. Initial results indicate that the SAFE-T is a sensitive screening tool for frailty and that sensitivity maybe improved where the patient is supported by a collateral informant. Process feedback identified problems with SAFE-T layout, resource implications and the perceived labour intensiveness of the tool.

Conclusions:

SAFE-T is a sensitive tool for the identification of frailty in different clinical settings. Process feedback suggests that further development of the tool will improve ease of use for patients and healthcare professionals. A further PDSA cycle is now underway to assess how the tool may assist in improving compliance with frailty scoring in ED

Introduction

The World Health organisation states that polypharmacy is a major global challenge. Older people in care homes are at risk of harm with 91% taking 5 or more medications. Pharmacists play an essential role in conducting medication reviews, identifying potential drug related problems, and implementing appropriate interventions to optimise treatment.

Method

As part of a pilot project for The Welsh Government Six Goals For Urgent and Emergency Care Pharmacists in Swansea Bay University Health Board’s Medicines Management team worked in collaboration with Consultant Geriatricians at Morriston hospital to review and optimise care home residents medication. Polypharmacy reviews were conducted assessing falls risk medication, anticholinergic burden and appropriateness of medication. Pharmacists engaged with the care homes to complete holistic clinical reviews and collaborated with consultant geriatricians to review recommendations. Pharmacists then actioned interventions and supported ongoing monitoring, working closely with the care homes. A total of five care homes have been chosen for the project with an estimated 200 residents. The team are still undertaking these reviews and conducting education.

Results

Thus far 79 residents totalling 855 medications have been reviewed. 288 interventions have been identified averaging 3.6 interventions per resident. Of the 288 interventions 132 (15.4%) medications have been stopped that were identified as inappropriate or no longer required, 16.7% of the medication stopped were classed as medications that may increase the risk of falls. In addition to safety measures results from medication reviews have shown financial benefit through cost savings.

Conclusion

Problematic polypharmacy continues to be a challenge that needs to be addressed and with nearly a quarter of medications prescribed in this cohort being stopped the benefit of specialist older people polypharmacy review for care home residents is apparent.

Introduction

The Cardiff and Vale Memory Team is comprised of a range of healthcare professionals who provide direct and indirect contact to coordinate the care of dementia patients. Memory link workers (MLWs) are a single point of contact for patients; they contact patient’s post-diagnosis and at 6-month intervals. Clinical Nurse Specialists (CNSs) assist patients with medical aspects of their care, including diagnostic home assessments with the support of the medical team. This evaluation aimed to establish the impact of these roles on people living with dementia and their carers.

Methods

This study is a retrospective service evaluation of 200 patients, who contacted the MLWs and CNSs between early April and mid-May (289 contacts). PARIS, Welsh Clinical Portal and written notes were used to collate information on patient demographics and each contact.

Results

The majority of patients were female (70%), the median age was 83 and Alzheimer’s was the predominant diagnosis. The greatest need identified in both MLW and CNS contacts was social care provision (39%). MLWs predominantly addressed wellbeing (n=55), CNSs had discussions surrounding medication (n=39) and physical health (n=44). The most common subjective outcome in the MLW group, was improvement in quality of life (75%); in the CNS cohort it was addressing acute medical problems (37%). Overall, the contacts were divided as follows, quality of life (50%), admission prevention (24%) and acute medical (24%).

Conclusion

The service is proactive and addresses a variety of needs; it has the potential to improve patients' quality of life and prevent admission. Both professionals were able to identify deteriorating patients and increased carer burden; additionally, patients were able to receive a diagnosis in a home setting. The service could be improved with more frequent contact, streamlined links with social services and increased liaison with mental health services to improve speed of access.

Introduction  

People with Parkinson’s (PWP) are twice as likely to fracture and over twice as likely to develop osteoporosis (1. Henderson et al, Parkinsonism & Related Disorders, 2019, Vol.64, pp.181-187). This is associated with significant morbidity (1). Assessment of bone health is often overlooked in clinic (2. UK Parkinson’s Excellence Network, 2019, pp.4-56), deeming it a priority area for improvement. Our project focuses on implementing routine bone health assessment for PWP in clinic, to achieve better standards of care.  

Methods  

This was a 12-week medical student led project, supported by the specialist multi-disciplinary Parkinson’s team (MDT) in Cardiff and Vale. To establish baseline current practice, a retrospective fracture risk assessment was completed for 141 patients using the Bone-Park algorithm (1). To screen bone health, we developed a bone health proforma, incorporating the FRAX tool. We trialled proforma integration in clinic, by gaining patient feedback and analysing logistics. Administration was done in a patient, healthcare assistant (HCA) and clinician led format.  

Results  

The retrospective analysis showed that 61.7% (n=87/141) of patients required bone health intervention. Of these patients, 41.4% required vitamin D supplementation. 40.2% required bone density measurement. 18.4% required bone strengthening treatment. This was subsequently initiated. Issues identified with self-administered forms (n=8/30) were physical difficulty in completing forms and confusion around medical terminologies, which clinician led administration (n=14/30) could support. HCA’s (n= 8/30) required MDT support to complete forms. 

Conclusion  

As PWP have an increased fracture risk (1), our results provide compelling evidence that routine bone health assessment should be better integrated into Parkinson’s management. Clinician led administration of our proforma was the best model of integration. This was based on patient preference, a reduction in duplication and improved accuracy. Further bone health education is needed within our MDT, which we aim to incorporate through our Parkinson’s web application.   

Introduction

Old age psychiatry wards facilitate patients who have physical health needs alongside mental health needs, deeming them high risk for falls. Following a fall, best practice suggests a doctor should perform a medical review. An audit of this was performed within the Harplands Hospital in-patient elderly care psychiatric ward, which revealed incomplete documentation or the absence of a review. Subsequently, a post-falls proforma was implemented and a re-audit was performed.

Method

Audit cycle one gathered data on post-falls documentation between August and September 2020. A falls proforma was then introduced and cascaded to ward staff. Audit cycle two then gathered data on post-falls documentation between November and December 2021. Information collected included if falls occurred within normal working hours (Monday-Friday, 09:00-17:00), whether witnessed or unwitnessed, if an assessment was documented, whether a head injury occurred, whether anticoagulation status was documented, and whether neurological observations were completed.

Results

The first cycle showed a total of 31 falls. Insufficient documentation was recorded in 5 falls (16.1%), including 2 falls (6.5%) with no documentation of a physical assessment. A head injury was recorded following 25% of falls, with anticoagulation status documented in 100% of cases. The re-audit showed a total of 10 falls. All falls (100%) were reviewed by a doctor with documentation recorded, including a brief history and assessment. A head injury was recorded in 4 cases (40%), with anticoagulant status only being documented in one case (25%).

Conclusion

This audit demonstrated the implementation of a falls proforma improved post fall documentation. It was noted that the falls proforma was not always utilised, which was thought to be due to junior doctor rotational changes alongside lack of communication regarding this tool. Moving forward, this second cycle identified the need for proforma digitalisation and junior doctor education at induction. 

Introduction: One of the key action areas of the World Health Organization (WHO) third Global Patient Safety Challenge ‘Medication Without Harm’ (WHO, 2017) is to reduce severe avoidable medication-related harm and address polypharmacy. NICE guidance on falls risk assessment and prevention also includes medication review as part of its recommended multifactorial risk assessment (NICE, 2013). Use of Falls Risk Increasing Drugs (FRIDs), along with polypharmacy and anticholinergic burden (ACB) are known to increase the risk of falls, particularly in older people.

Method:

This research quantitatively evaluates the impact of the intervention of a novel community falls pharmacist role on medicines optimisation, in relation to FRIDs in older people who have had a fall. We will present data on admission and discharge from the service in relation to:

• Number and type of FRIDs prescribed
• Calculation of Anticholinergic Burden score using the ACBcalc® (King and Rabino, 2022)
• Polypharmacy- number of medications prescribed
• The appropriateness of medicines prescribed
• Undertake measurement of lying/ standing manual blood pressure to identify potential postural drop in blood pressure, and hypertension.
• Undertake a Bone health review using an approved tool (FRAX)
• Outcome of pharmacist referral of appropriate patients for DEXA scan using a new direct referral system
• Measure the significance of clinical interventions (EADON graded)
• Calculate the cost avoidance of pharmacist interventions (ScHARR Tool) Results

Results:

Data was collected on 92 patients over 14 months. Results indicate a medicines review by the community falls pharmacist leads to a statistically significant reduction in polypharmacy (¯8%; p<0.05) and ACB (¯33%; p<0.05), an increased appropriateness of prescribing (MAI ¯56%; p<0.05), 317 clinically significant interventions, identification of blood pressure issues (22%) eg orthostatic hypotension, and identification of osteopenia (n=13) or osteoporosis (n=4) using a new pharmacist DEXA referral pathway. Amitriptyline was the most common FRID deprescribed (22%). Annual cost avoidance due to pharmacist interventions were in the range of £28160 – £62358 along with drug cost savings of £6041, amounting to total savings of £34201-£68400, and invest to save return of one to two pounds for every £1 invested. Benefit to the environment of reduced inappropriate prescribing amounted to almost 1 tonne of avoidable CO₂ emissions per year.

Conclusion:

Introduction of a community falls pharmacist role is an effective and cost efficient means to optimise medicines in older people who experience falls, as well as having a positive impact on the environment.

Introduction:

Urinary incontinence, one of the original geriatric giants, is frequently overlooked despite its potential for reversibility and profound impact on older adults. The purpose of this audit was to evaluate the prevalence of continence and utilisation of incontinence wear among inpatients in a rehabilitation facility.

Methods:

Continence care quality in a medical gerontology ward was evaluated using the Royal College of Physicians (RCP) National Audit of Continence Care (NACC) standard. A prospective audit was conducted over a five-day period, documenting continence wear and urinary continence. Two interventions were implemented before re-auditing: incorporating continence as a teaching topic in the non-consultant hospital doctor (NCHD) teaching schedule and adapting the multi-disciplinary team (MDT) proforma to include patient-specific continence records. A snapshot re-audit was then conducted to assess any improvements resulting from these interventions.

Results:

The initial audit included 31 patients, with 26 (83.9%) wearing incontinence wear, of whom 21 (80.8%) opted for it voluntarily. Urinary incontinence was documented in 13 patients (41.9%).

In the re-audit, 40 patients were included, with 27 (67.5%) wearing incontinence wear, of whom 19 (70%) made the choice. Urinary incontinence was documented in 18 patients (45.7%).

Conclusion:

The re-audit revealed a slight decrease in incontinence wear usage (67.5% compared to the initial rate of 83.9%). Many patients wearing incontinence wear expressed a consistent preference for it in both audit cycles. The prevalence of urinary incontinence remained relatively consistent between the initial audit (41.9%) and the re-audit (45.7%).

The persistent prevalence of urinary incontinence calls for effective strategies to address this issue. Furthermore, the patients' preference for incontinence wear underscores the significance of engaging both the MDT and the patients themselves in future interventions. Future projects should focus on gaining a deeper understanding of patients' perspectives on continence care and evaluating the impact of incontinence on patient outcomes.

Introduction:

Delirium is a common presentation in older people and associated with falls risk, longer inpatient stay, post-discharge institutionalisation, accelerated cognitive decline and higher mortality. While median duration of delirium is reported as 1 week but for one third patients, symptoms may persist 3 months or more, even a proportion of patients will never fully recover to their pre-delirium cognitive baseline.  It is essential we are sharing the diagnosis with people and their relatives in order to provide information, facilitate discussions around the risks of hospital versus home, reduce distress and highlight the role that carers play in delirium management. Physicians should be aware that delirium sufferers often have an awareness of their experience and for affected person and their family, delirium can be a cause of significant distress. Identification of risk factors, education, and a systematic approach to management can improve the outcome and experience of the syndrome [1].

Aim: To provide delirium education and Improve documentation up to 95 % in GAU.

Methodology:

• Prospective data collection.
• Jan 2023 to March 2023.
• Monthly data analysis of 20 patients in GAU with the confirmed diagnosis of delirium.

• PDSA 1 Departmental teaching and SIGN delirium leaflet awareness and availability .
• PDSA 2 Poster as Visual prompt.

Results:

 After 2 PDSA cycles, we noticed significant improvement in delirium education and documentation up to 95%.  A further Qi project is ongoing to embed the TIME bundle within our daily practices which will hopefully ensure that this improvement is sustained by giving another prompt to discuss and document diagnosis. 

Conclusion:

 Along with prompt diagnosis and management, good educational approach and clear documentation will lead to improve understanding about delirium, reduce distress and facilitate safe early discharge.

Reference

Healthcare Improvement Scotland SIGN

Risk reduction and management of delirium

March 2019

Around 40% elderly patients need urinary catheters during hospital stay.

Most common indications are acute urinary retention(due to constipation), AKI and sepsis. According to NHS and trust guidelines, the review should be performed by the medical team to establish whether catheter is still required,when to remove and plan following TWOC of the catheter during every ward round. For example if catheter was inserted due to acute retention due to constipation,catheter should be removed after adequate bowel movement.The aim of audit was to gauge whether elderly patients with catheter are managed with standard guidelines or not.

Retrospective data was collected using quisionnaire(5 questions? documented indication of the catheter,?plan when to TWOC during every ward round,?documented plan after failed TWOC,? Patient is medicaly stable with catheter,?medically stable patient had catheter-associated UTI) , looking into 80 patient records admitted on geriatric wards from 15/4/23 to 16/5/23.

The result after data collection from 80 admitted patient with catheter revealed that 78% patients had documented indication of catheterization,24% patients had review of catheter and TWOC plan everyday.3%patients had documented management plan following failed TWOC,33% medically stable platients had catheter with no documented plan when to remove catheter,14% medically stable patients were treated for catheter associated UTI.In summery,the initial stage of audit revealed that the catheter management standard was not met as there is discrepancies beetween guidelines and clinical practise.The audit has shown the need for standardization of urinary catheter management in admitted elderly patients.Therefore,audit report was presented during geatric doctors meeting ,education and teaching was provided to improve standard of care.The audit will be repeated after 3 months following implimentation of requested changes(catheter management guideline flowchart printed on doctors room, including catheter management guideline flowchart during doctors induction,regular teaching and re audit).