Clinical Quality

Introduction:

Falls in older people are associated with multifactorial risks which are often preventable. Last year there were over 220,000 emergency admissions for falls in people aged 65 years and over in the UK. Improving how we assess such patients on admission may help to ameliorate these risks and prevent future admissions.

Method:

The aim of this quality improvement project was to identify weaknesses in our acute risk assessment of multifactorial falls and to improve on these. We completed a retrospective case note review for 68 patients in their first 48 hours of admission. As an analytical framework, we adopted the NICE guideline: ‘Falls in older people: assessing risk and prevention’ which details twelve key parameters of risk assessment. For each patient we sought to determine whether these parameters were assessed or missed. After the first audit cycle, we found four guideline parameters which were commonly missed during the acute admission phase. An educational intervention was subsequently organised for medical staff at a departmental level and corroborating posters were placed around the acute areas of the hospital. Two months later a second audit cycle was undertaken which assessed the same parameters and looked for improvement.

Results:

There were notable improvements in four areas. The assessment of visual impairment increased from 32.4% to 42%. The documentation of patients’ perceived risk of falling improved from 37.3% to 60.9%. Osteoporosis risk assessment rose from 32.4% to 63.8%. The completion of Lying/Standing BP demonstrated the most significant increase, from 14.7% to 44.9%.

Conclusions:

The results suggest that a tailored educational session and a poster campaign have increased overall awareness and improved the risk assessment of multifactorial falls at a central Birmingham Hospital.

Introduction:

A scoping exercise in a residential dementia care home identified high numbers of falls occurring in residents’ bedrooms at night. Assessment and reduction of risk was often difficult since many falls were unwitnessed, and residents had poor recall. Collaborative working between Lewisham Community Falls Service (CFS); and Lewisham Linkline Service; involved the use of the ‘Just Checking’ monitoring system to enhance multifactorial falls assessment.

Method:

The Occupational Therapist (OT) in the CFS completed an initial multifactorial falls assessment. This helped to determine if data on night-time activity would be beneficial. This was discussed with care home staff and patient’s family prior to installation by the Telecare Specialist. The system was left insitu for four weeks with regular analysis of data by the OT and Telecare Specialist.

Results:

Resident A was a new admission with a recent dementia diagnosis and an injurious fall at home. 'Just Checking' was installed to monitor night time orientation and if he used his walking aid. He was refusing to keep a light on and was resistant to staff entering his room for checks. 'Just Checking' data guided intervention which included installation of motion centred lights. The resident started to use his walking aid at night without staff involvement. Resident B who had moderate to severe dementia, had demonstrated some challenging behaviours at night which increased his falls risk. 'Just Checking' data showed that he was restless throughout the night. This lack of quality sleep was identified as a key falls risk factor. Further exploration of his life story found that he had been a night worker for many years. Care home staff changed his day/sleep patterns. He experienced no further falls.

Conclusion:

Used as an adjunct to multifactorial falls assessment; ‘Just Checking’ can provide valuable data to understand falls risk and improve resident safety.

Introduction:

Orthostatic hypotension (OH) is common in both community dwelling and hospitalised older adults. It is associated with significant morbidity, falls and all cause mortality. A spot audit of inpatients across all care of the elderly wards in Gloucester Royal Hospital and Cheltenham General Hospital revealed only 67% of appropriate patients where having documented lying and standing blood pressure measurements. Of those with documented orthostatic hypotension 44% had no documented action plan.

Methods:

Using quality improvement methodology this project aimed to achieve 100% of appropriate patients having a documented lying and standing blood pressure when admitted to a care of the elderly ward. Patients identified to have orthostatic hypotension should have this recorded in their working diagnosis with a documented action plan. Change ideas were implemented using the plan, do, study, act (PDSA) framework initially looking at recognition of OH and subsequently management of patients identified to have OH. Outcome measures included prevalence of OH in the inpatient population and inpatient falls rates. Process measures included percentage of patients with documented lying and standing blood pressure, percentage of patients with confirmed OH documented in their working diagnosis and percentage of patients with confirmed OH having a documented management strategy.

Results:

Following the first PDSA cycle the project demonstrated increased number of patients having a recorded lying and standing blood pressure, however following the second cycle a sustained increase was not seen. A third PDSA cycle is underway involving MDT education.

Conclusion:

Baseline data confirmed that in the elderly inpatient population orthostatic hypotension was both under diagnosed and under treated. Ensuring sustained change remains a challenge due to staff turnover and rotational working. Further work is ongoing to increase recognition and treatment of OH.

Introduction: Discharging patients from hospital is a complex process which requires multiple professions and processes. Late afternoon discharges can lead to admission bottlenecks and contribute to emergency department overcrowding. Focusing on discharging patients earlier in the day, can contribute to greater flow through the hospital and greater patient satisfaction. Leeds Teaching Hospital Trust (LTHT) aims to achieve 70% of discharges before 3pm. The Specialist and Integrated Medicine (SIM) department care for frail elderly patients who are at increased risk of harm following prolonged stays in the emergency department and were discharging 30% of patients before 3pm.

Method: To gain greater understanding, a survey was conducted amongst various staff members to understand their perceptions of why delays occur in patient discharge. A deep dive into discharges after 3pm was also conducted to identify avoidable delays. This enabled multicomponent interventions to be developed with the team and enacted across SIM. These included:

- Education about the importance of timely discharge

- Community discharges prioritised in pharmacy the day before

- 'Golden patient' identified on wards for morning discharge.

- Promoting utilisation of the discharge lounge

- Recognition of achievement for wards

- Recruiting of junior doctors to lead individualised ward QI projects to improve earlier discharge

- Involvement of senior leaders to have buy in from consultants and senior managers

- Discharge boards being utilised.

Results: SIM achieved a 12% improvement in number of discharges before 3pm which has been sustained despite increasing pressures on the department. This is the highest median ever achieved by the department.

Conclusion: Achieving patient discharges earlier in the day is complex and requires a multifocal approach from multidisciplinary professionals. The interventions used were based on an in depth look at data and developing an understanding of the perceived and actual barriers from the team themselves.

Aim: Several patient selection scores have been developed to identify patients suitable for ambulatory care from triage in the Emergency Department (ED) and from the acute medical intake. These scores are designed to improve system efficiency, overcrowding and patient experience. Studies have been conducted that compare the ability of several scoring systems; none specifically in frail older adults (1-4). This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Ambs). Methods: The Older Person’s Assessment service is ED based, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years. The service achieves same day discharge for >75% of patients. The service databank was retrospectively analysed for people assessed between January-December 2021. Interactions between clinical outcomes with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside a comparison of each ambulatory score. Emergency department documentation was used to gain triage data. Results: 502 attendances were analysed of which 112 (22.3%) were admissions, 374 (74.5%) presented with falls. 185 (37.2%) were male, mean age 82.8 years, CFS 5.1 and CCI 6.6. There was a significant link between those admitted and those discharged when comparing CFS (p<.001). ambs: sensitivity 0.42, specificity 0.75, positive predictive value (ppv) 0.80, negative (npv) 0.23, area under curve (auc) 0.70. gaps: 0.15, 0.87, ppv npv auc 0.62. start: 0.09, 0.97, 0.92, 0.64. conclusion: frailty is an important determinant in identifying whether ambulatory care appropriate. however, was low for all scores and none could be reliably used as a screen suitable patients same day emergency services although the ambs score most accurate our population.

Introduction: Frailty is under-recognised in hospital leading to unwarranted variation in care. National guidance recommends that all healthcare professionals can identify frailty and offer interventions to reduce risk factors for frailty. Previously, physiotherapists working in Older People’s Medicine (OPM) did not record frailty status in their clinical assessment. This quality improvement project seeks to translate and implement best practice, supporting physiotherapists to record the Clinical Frailty Scale (CFS) score within routine patient assessment, so interventions can be initiated to optimise outcomes.

Project aim: Within 3 months, to achieve a 50% increase in the number of patients with a Clinical Frailty Scale (CFS) score recorded within their physiotherapy assessment.

Methods: Plan-Do-Study-Act cycles with interventions of bespoke teaching and assessment proforma re-design were employed targeting the OPM physiotherapy team on ward 31, RVI.

Measures: The weekly number of patients with a CFS score recorded within physiotherapy assessment was collected over 13 weeks and evaluated on a run chart. Staff knowledge and skills self-assessment scores and cohort data were also recorded and described using descriptive statistics.

Results: At baseline – 0/114 (0%) physiotherapy patients had a CFS score recorded, this improved to 95/192 (49%), suggestive of effective change post interventions. Staff confidence scores also improved.

Conclusions: This project has led to improved frailty awareness and identification amongst OPM physiotherapy staff. This work supports a collaborative approach to improving frailty care; better identification of frailty can reduce harm by informing healthcare needs, supporting patient flow, and resulting in better, safer, and more equitable care.

The 2020-21 Chief Medical Officer report described Treatment Escalation Plans (TEPs) as ‘Realistic Medicine in action.’ Our aim is to increase TEP completion on the Medicine of the Elderly (MOE) wards at the Royal Infirmary of Edinburgh to >90% by July 2023.

Since August 2022, we collected weekly data from a single MOE ward. In October, we upscaled to include four MOE and one stroke ward. The notes of five randomly selected patients were reviewed weekly to see whether they have a TEP, and if so, which parts were completed. To further understand behaviours around TEP completion, we collected qualitative data asking doctors what the triggers and barriers were to TEP completion. 40% found the conversations challenging whereas 30% cited time and environment as barriers. We used this data to generate change ideas. For PDSA cycle 1, we developed a teaching session around TEP conversations. This is delivered regularly to all junior doctors and ANPs in the department. For PDSA 2, we allocated a weekly ward ‘TEP champion’ to highlight patients without a TEP and encourage completion.

Median for TEP completion was 75% on the initial ward, 42% over the four MOE wards and 20% for the stroke ward. All patients with a TEP had their resuscitation status documented. One third of patients did not have a TEP at all. Of the two thirds of patients with a TEP, a quarter were incomplete. Sections on goals of care, communication and interventions were completed in around half.

This project is ongoing with future PDSAs planned to address the barriers of time and environment. PDSA 3 will test the introduction of a mobile TEP phone to enable discussions in a quieter environment. The variation in practice in MOE versus stroke is important and requires further understanding of the barriers specific to stroke.

Introduction
Mittens are used to facilitate necessary interventions safely in patients who lack the mental capacity adhere to them. A serious incident (SI) occurred at our Trust when a patient, with delirium, developed pressure ulcers to their wrists as a result of prolonged use of mittens. A subsequent investigation revealed that there had been inadequate skin checks and insufficient documentation, from the medical team, directing the use of mittens.

Method
A multidisciplinary QIP was initiated: • For the Medical team: An electronic “Mittens Request Form” was created. This included fields to document a mental capacity assessment, the best interest decision and a link to apply for Depravation of Liberty Safeguards. There was also a prompt to prescribe mittens on the electronic drug chart. • For the Nursing team: A pre-existing electronic mittens checklist form was updated to confirm that a daily skin check had been completed. The outcomes of the SI report and changes above were communicated to the department. After the QIP, a notes review was completed for all patients over the age of 65 years who had a mittens checklist completed before and after the interventions. Notes were assessed for documentation of a mental capacity assessment, communication of a best interest decision, prescription of mittens and completion of a daily skin assessment.

Results
Documentation of a capacity assessment improved from 9% to 47%. Communication with relatives improved from 0% to 35%. Prescription of mittens, on the drug chart, improved from 0% to 24%. Documentation of a daily skin assessment Increased from 0% to 94%

Conclusions
This QIP brought about improved documentation of best interest decisions related to mittens and ensured regular skin checks. The next stages will involve expanding the QIP to other departments within the hospital and reinforcing messaging about communication with relatives and prescription of mittens.

INTRODUCTION   

Postural hypotension (PH) is an identifiable and potentially reversible cause of falls in elderly patients. The National Audit of Inpatient Falls recommends lying and standing blood pressure (LSBP) measurement for patients aged over 65. Our project aims to review current clinical practice and to develop a standardised approach to correctly investigate and manage PH in patients admitted following a fall to the geriatric department.  

METHOD:   

We performed two cycles of retrospective data collection across three geriatric wards, looking at percentage of patients investigated for PH and the use of correct technique for LSBP measurements as recommended by the Royal College of Physicians (RCP) guidelines. Between cycles, formal and informal educational strategies were implemented and the RCP LSBP measurement guidelines were displayed on doctors’ noticeboards and blood pressure monitoring devices. A PH sticker was designed to ensure correct technique was used and documented.  

RESULTS:    

Following the interventions, the percentage of patients who had LSBP measurements performed improved from 28% to 96% [p<.00001(x2 test)]. Introduction of the PH stickers improved use of correct technique from 12% to 37.5%. Performance and documentation of medication reviews for patients diagnosed with postural hypotension improved from 0% to 87.5% and lifestyle advice given and documented improved from 0 to 37.5%. 

CONCLUSIONS: 

Our study highlighted the need for further training on investigation and management of PH. Our results demonstrate that educational interventions and a standardised sticker to ensure clear documentation can significantly improve diagnosis of PH. The local Falls Prevention team are keen to promote use of the sticker across the Trust and we have produced patient information leaflets to ensure all patients receive lifestyle advice.

Background

The Ageing Well programme within the NHS Long Term Plan promotes person-centred care aligning  with the goals of Integrated Care Systems (ICSs) in unifying health and social care aiming to increase the proportion of care to older people delivered in the community (NHS England, 2019). As most older people admitted to hospital are conveyed by ambulance services this presents a focus to reduce hospitalisation (Maynou L, Street A, Burton C, et al. Emergency Medicine Journal 2023).

North Central London ICS has invested in ‘Silver Triage’ a pre-hospital telephone support scheme which sees geriatricians and emergency physicians supporting the London Ambulance Service in their clinical decision making relating to older people at the point of assessment.

Methods

Data from the first fourteen months of the scheme was analysed.

Results

Between November 2021 and January 2023 there have been 452 Silver Triage cases with 80% resulting in a decision to not convey an older person to hospital. The mode clinical frailty scale (CFS) score was 6 with no difference in conveyance rates based on CFS. Prior to triage paramedics thought hospitalisation was not needed in 44% of cases (n=72/165). Most paramedics (93%, n=154/165) found it easy to contact the team with all 176 who responded to a post triage survey answering they would use it again. Many (66%, n=108/164) felt they learnt something from the discussion, with 16% (n=27/164) reporting it changed their decision-making process.

Conclusion

Silver Triage has the potential to improve the care of older people by preventing unnecessary hospitalisation and has been well received by paramedics.