Clinical Quality

Introduction

Causeway Hospital’s frailty service consists of an Acute Elder Medicine/Stroke unit of 30 inpatient beds and a Frailty Direct Assessment Unit (DAU) for GP referrals and EmergenIntroductioncy Department (ED) patients suitable for same-day turnaround with comprehensive geriatric assessment (CGA) from our multidisciplinary team. 

We have devised a new Frailty Model to enhance our service, maximise integration between primary and secondary care services and facilitate more effective short-stay care and early supported discharge. 

Method

To initiate this model, we plan to: 

1. Strengthen our DAU admission pathways – by identifying ED patients more quickly, promoting anticipatory care pathways, and ensuring all GP’s in the Causeway locality are made aware of the direct referral pathway. 

2. Explore new ways of working within DAU – by collaborating with the NI Ambulance Service to develop a direct access pathway to DAU for patients meeting specific criteria (e.g. non-injurious falls), and setting up pathways for residential homes (offering CGA in DAU for new permanent admissions into residential homes). 

3. Open an Acute Frailty Unit – by developing a 6-bedded Acute Elderly Area, and testing a model in the coming months to assess the long-term viability of this project. 

Results

We expect early results for the impact of this model in the coming months, and hope our enhanced service will provide comprehensive short-stay care and support timely discharge back to the community with a safe wrap-around service. 

Conclusion

To meet the increasing needs of today’s ageing population, we need pathways that decrease reliance on acute secondary care services, promote independent living for frail, older people where possible and strengthen our relationship with primary care colleagues. 

Our Frailty Model aims to streamline services and create new ways of ensuring our older population are given the best chance to have a healthy, fulfilling and well-supported later life.

Introduction; Patients living with frailty admitted under Emergency Surgery are vulnerable to complications, longer lengths of stay and readmission. Perioperative Care of the Older Person in Surgery (POPS) services are well evidenced and recommended by many national reports. Whilst they are well established in the other home nations, our POPS pilot in Craigavon Area Hospital is the first in N.Ireland.

Method; Our POPS Pilot in the Emergency Surgical Unit aimed to identify all patients over 65 living with frailty and deliver high quality comprehensive geriatric assessment (CGA). This consists of 4 sessions/week provided by 2 Consultant Geriatricians.

Results; Since our pilot began in January 2022 we have performed CGA on 285 patients, delivered education sessions, increased Frailty awareness, supported junior staff, championed our allied-health professionals and participated in multi-disciplinary team meetings. Typical interventions include delirium prevention and management, medication review, shared decision making and discharge planning. 87.5% of patients seen receive a medication review with discontinuation of several medications. This is vital for prevention of drug adverse events and financially accounts to an approximate saving of £21,545/year in 2022. Both patient and medical staff feedback have been positive and in periods of more intense activity, there has been a promising trend towards lower lengths-of-stay. 30-day readmission rates in the over-65s have also improved, falling from 22% in May-July 2021 to 14% for the same period in 2022. This was evident despite the increased total admissions.

Conclusion; Restrictions and obstacles remain, however with a limited team we have already shown a reduction in readmission rates and made meaningful changes to patient care. With adequate resources, we hope to provide a more consistent service and meet the national CPOC/BGS guidelines to provide good quality perioperative care for people living with frailty undergoing elective and emergency surgery.

Rationale: 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 a frailty at the front door or a community based service, and has access to rapid diagnostic and intervention services. As this is a novel service a qualitative study was undertaken to assess patient satisfaction and guide the direction and development of future quality improvements initiatives.

Objective: To evaluate the satisfaction of service users with the implementation of an out - patient Frailty Intervention Team in a Model 2 Hospital setting.

Implementation: A mixed methods study was carried out in the form of a patient satisfaction survey which included quantitative questions as well as Likert Scale closed ended questions and open ended questions. This qualitative data was analysed by collating common words, creating word clouds to organize the ideas and suggestions made.

Outcome: Of the 150 surveys disseminated there was a 46.7% response rate. 66% of responders rated the services ability to meet their expectations as “excellent”. The main qualitative outcome of the survey was that service users felt they needed ‘a report sent to myself so I can remember’. Thus the Patient Action Plan Leaflet was developed where each discipline writes a summary of the intervention and advice provided during their assessment. A copy of this is then provided to the patient after each appointment.

Conclusion: This mixed method study resulted in service user feedback guiding a positive change to the provision of the service for the direct benefit of service users. Future research will aim to evaluate the effect of the Patient Action Plan Leaflet.

Background

Hip fracture in the elderly is associated with significant morbidity and mortality. These patients often have serious co-morbidities, including cardiac conditions, and are at risk of developing perioperative decompensation. Heart failure represents a common and serious perioperative condition in hip fracture patients1. We conducted a quality improvement project to identify incidence of perioperative pulmonary oedema and the possible risk factors.

Method

Retrospective analysis of patients aged 60 years and older admitted with hip fracture over a one month period. Perioperative period was taken as time from admission to day 5 post surgery. Intravenous fluids administered pre-op, intra-op and for 5 days post-op were reviewed. Pulmonary oedema was diagnosed on clinical and radiological findings.

Results

50 patients admitted: 14 (28%) male; 36 (72%) female. Mean age: 82 years, 94% (47) admitted via emergency department. Comorbidities: 48% hypertension, 30% atrial fibrillation/flutter, 18% cardiac failure, 14% dementia. Pre-operative clinical review identified 14 (28%) patients as high risk for developing cardiac decompensation perioperatively. 57% (27/47) of patients admitted via accident and emergency received intravenous fluids pre-operatively. None of these patients had vital signs suggestive of hypovolaemia. Rate of fluid administration: 10/27 (37%) 1 litre over 4 hours, 5/27 (22%) 1 litre over 2 hours, 2/27 (7%) 1 litre over 1 hour. Intra-operatively 43 patients (86%) received intravenous fluids, 18 patients (36%) received ≥ 2 litres of fluid. 6 (12%) patients developed pulmonary oedema in the perioperative period

Conclusion

Fluid overload in our cohort may be an underestimate as many patients were anticipated to be at high risk of developing pulmonary oedema with consequent very careful fluid management and diuretic administration. Intravenous fluid administration requires careful assessment and monitoring in elderly hip fracture patients.

References

1. Michael W Cullen 1 , Rachel E Gullerud, Dirk R Larson et al J Hosp Med 2011 Nov;6(9):507-12.

Introduction:

The use of the ROX index in COVID-19 patients allows evaluating those with a high risk of ventilatory failure, however, it has not been openly validated in patients who use a mask with a Hudson-type reservoir.

Materials and Methods:

retrospective study of 306 adults infected with SARSCOV2 by antigenic or molecular test. The main objective was to evaluate the role of the ROX index as a predictor of respiratory failure and mortality. In the inferential statistical analysis, the odds ratios OR with their confidence intervals greater than 95% will be used as association measures. Qualitative variables were evaluated using the Chi-square test or Fisher's exact test, and in the case of numerical or quantitative variables, the Student's t-test or Mann-Whitney test was used.

Results:

The highest frequency in male gender 78% and female 22%, the ROX values were higher in survivors at 2 h 5.8 (4.7 - 6.9), in relation to the deceased 4.5 (3.6 - 5 ,6). Similarly, at 12 h the values were higher in the group of survivors 7.8 (5.2 - 8.7) in relation to the deceased 4.9 (3.8 - 6.0). The age- and gender-adjusted odds ratio of the ROX index was 8.5, CI (2.0 - 91.4) at 2 h and 17.6, CI (2.8 - 93.6) at 12 h.

Discussion: The present study showed a correlation between the ROX index and older age groups, showing higher mortality in those older than 70 years and a higher rate of comorbidities and lower ROX. Conclusions: The ROX index in this study has proven to be a reliable evaluator of mortality in COVID-19, studies with larger groups of patients are required to validate the results found here.

Aims

This closed loop audit aims to primarily assess and improve the number of geriatric patients who fell on elderly wards in a District General Hospital using cost effective methods. The secondary aim is to improve documentation of falls and assess for contributing factors. Hypothesis The primary hypothesis is that number of falls can be reduced through better nursing training and co-locating high risk patients. The secondary hypothesis is that improvements in documentation can be made with nursing training specified to falls and to corroborate risk factors with existing literature.

Methods

The first cycle was conducted between February 2021 to May 2021. Patients who were deemed high risk of falls, defined as over 80 years with at least 1 previous fall, were co-located. Nursing staff were provided with falls related training and how to report falls. The audit was repeated between the months of February 2022 and May 2022 to prevent seasonal bias. Results collected using the computerised internal patient records and paper documents. The number of falls, in addition to demographics, comorbidities, medications and complications were collected and compared.

Results

It was shown that cost- effective measures implemented in this audit significantly reduced the number of falls- down from 50 to 29 total falls across the same time period. We showed polypharmacy is a contributing factor to increased falls, with anti- hypertensive medications recurring as a repeated offender. 90% of those who fell were recurrent fallers, highlighting the importance of early identification of those at high risk.

Conclusion and further studies

This audit has highlighted the importance of simple, clinically effective and cost- effective measures in falls prevention. Further improvements, such as falls alarm for patients and refurbishing of ward layouts have been suggested by nursing feedback. Once implemented, the wards can be re- audited for further falls prevention.

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.