Clinical Quality

Introduction  

The weekend on-call team attends ward emergencies and front door new assessments. The extra routine ward work results in delays in the new assessments and adds further exhaustion for the on-call team, impacting junior doctor’s well-being and patient safety.  

Objective  

Aim to improve patient safety by facilitating the continuity of patient care over the weekend 

Method 

Group discussions among junior doctors, nurses, pharmacists, and ward managers were done to understand the challenges that impact communication. The average time spent on a ward by on-call team was 60 minutes. Plan-do-study-act (PDSA) cycles were introduced. The key measurement used was the time taken to complete the ward task. 

Results 

Team agreed to focus on improving communication over weekends based on the number of times nurses contacted junior doctors 

Friday morning ward round was made mandatory for every patient and a check-list sticker was introduced to test the change for 15 patients. Results were assessed and showed 3 patients did not require review and saved 6 minutes of on-call team over the weekend.  

The second PDSA included 30 patients which showed 11 minutes of time saved. But change was not sustained. Awareness sessions were introduced, and the plan was to add an A4 sheet titled Mandatory Friday Round (MFR). Next PDSA cycles showed saving on-call team but not all the on-call team and nurses reviewed MFR.  

Team reviewed the results of the 5th PDSA cycle and agreed to use the green colour MFR A4 sheet and included prompts for the team to complete all the usual tasks. This saved about 28 minutes of on-call team.  

Discussion  

28 minutes saved from one ward was used for the new assessment. Team feels extending good practice to all 5 elderly care wards will save approximately 2 hours 

Conclusion  

Effective communication using MFR has enabled on-call team to assess extra new patients and have adequate rest.  

Introduction:

The Older Person's Assessment Unit (OPAU) Physiotherapy team have been collaborating with Breathe Arts Health Research (BAHR) to provide ‘Dance for Strength and Balance’ (DSAB) classes for Older Adults as an alternative to traditional, long-established Strength and Balance Group (SABG). Previous preliminary data established DSAB to be safe and effective in falls risk reduction for participants.

The primary aim of this service evaluation was to determine if DSAB is at least as effective as SABG for improving outcomes and reducing falls risk for OPAU patients.

Methods:

46 DSAB patients were cross-matched to 46 SABG patients over a 3-year period (10^th October 2019 – 24^th November 2022). Only those with full data sets and at least 80% class adherence were included. Participants were matched by age, gender, ethnicity and functional level at class entry, including their Timed Up and Go (TUAG) scores. 

Intervention effect was measured by change in performance of outcome measures including TUAG, Gait Speed (GS), Sit to Stands in 1 minute (STS), Turn 180 and Falls Efficacy Scale (FES-I).

Data was analysed using two-tailed t-tests.

Results:

Median age of participants was 79.5 years (48-95).

DSAB and SABG were beneficial to participants, with falls risk reduction demonstrated across the range of outcome measures.

There was no significant difference between groups for changes in TUAG, Gait Speed, Turn 180 and FES-I, with p-values >0.05 for all.

There was a significant difference in STS 1min (DSAB 0.63, SD 5.17; SABG 7, SD 6.72); t=-5.1, p=0.00

Conclusion:

DSAB classes were as effective as traditional SABG in targeting outcomes known to impact falls risk. The difference in STS 1min between groups is likely due to repetition of this as an exercise in SABG, and worth incorporating into DSAB. DSAB should remain an option for older adults aiming to reduce falls risk.

Introduction

A suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Therefore, correct recognition and documentation of UTIs, as well prescribing of antibiotics, is important for optimising patient care.

Methods

We reviewed UTI antibiotic prescribing practice across the Health and Ageing Unit (HAU) wards at Kings College Hospital over a two-month period. Weekly data we collected from all patients commenced on antibiotics for a suspected UTI highlighted key areas for improvement. We designed and delivered a multifaceted educational intervention to all healthcare professionals caring for older adults across the HAU. This consisted of teaching sessions, distribution of posters, and board round reminders.

Results

A further two months of data post-intervention showed improvements in several outcomes. Correct prescribing rose from 61% to 93%. The number of prescriptions with stop dates went up from 50% to 68%. The number of patients with urine samples processed in the laboratory rose from 64% to 93%. We also saw an improvement in the management of patients with catheter associated UTIs.

Conclusions

A multidisciplinary team intervention of teaching and visual cues improved the management of UTIs. This shows the power of multifaceted educational interventions for improving the care of older adults.

In 2021, Cardiff and Vale University Health Board’s average length of stay (LOS) in Assessment Unit (AU) for over 75-year-olds was 24.2 days, due to long waits for inpatient beds. Once admitted, 23% of patients moved wards three or more times. Patient experience scores indicated poor satisfaction levels, with nearly 50% of patients feeling their needs had not been met. Staff consensus was that the environment was unsuitable for older patients.

The implementation of an enhanced frailty service began in November 2022. This was managed by a geriatrician-led team, with support from junior doctors and Physician Associates. The provision consisted of a 6-day service for the Frailty Zone, an allocated area of 12 beds in AU, an in-reach service, and input from the therapy and nurse led Frailty Intervention Team (who specialise in admission avoidance). Thus, giving the team wider reach, and ensuring frailty input from the beginning of the patients’ journey.

Between December-March 2023, there was a 36% increase in the number of patients discharged directly from AU, in patients aged 75+. This equates to an extra 21 discharges per week. The average LOS in AU reduced by 6.9 hours. Notably, the LOS for patients under 75 remained largely unaffected during this time. The number of ward transfers for this population also reduced to 13%.

The data obtained from the frailty service led to additional service development. In July 2023, the expansion of the Frailty Zone into a 19 bed Older Persons Acute Medical Unit came into effect. Staff feedback remains positive, with boosted morale. However, there is more development needed in way of communicating with all members of staff.Expansion of the Frailty Intervention Team is being developed to provide patients who are likely to need admission access to therapy and frailty nurses.

Introduction

We plan fast-track discharges when a person has limited life expectancy and is reaching end of life. When such patients are identified, we use a simple fast-track tool to minimise the delay and reduce the need for in-depth assessments and paperwork. Despite being used very widely, there is very little data in literature regarding the indications for fast-track discharges and life expectancy of patients following discharge. We conducted this observational study to answer these questions.

Methods

We collected data over a three month period from the fast-track applications focusing on indications, length of survival post discharge and what has been communicated to the families.

Results

There were 45 discharges during the three month period. The mean age was 79.6 (range 32 – 98). Most of the applications were made from the medical wards (32), especially from the care of the elderly wards, followed by surgical and the emergency quarter. 10 patients died in the hospital before their discharge could be processed. 17 patients went home, 14 went to a care home and 4 went to a community setting. 23 patients had malignancy, 11 had end organ failure, 6 had advanced dementia, 3 had stroke and 2 had fracture neck of femur. After excluding the patients who died in the hospital, the mean survival following discharge was 15.9 days (1-77 days) and 5 patients were still alive at 90 days. Evidence for good communication with families was lacking from the application forms.

Discussion

Malignancy is the most common reason for fast-track discharges. Even though many patients and families think that end of life means only days or weeks, many survive much longer. We need better documentation regarding communication with patients and families regarding diagnosis and prognosis. 

Background

This healthcare evaluation focussed on the effectiveness of an orthoptic-led inpatient vision screening service at Nottingham University Hospitals for older adults admitted with a fragility hip fracture. The service was developed in response to national guidance, which recommended a multifactorial assessment, including a vision assessment for older adults presenting following a fall.

Method

Vision screening was carried out by orthoptists on eligible patients ≥65 years of age admitted to the Trauma and Orthopaedic wards with a hip fracture. Retrospective data for patients screened between 2015-2019 were analysed, including: patient demographics, screening eligibility and outcome, ophthalmology referrals made, ophthalmology appointment attendance and outcome.

Results

Of 3321 patients admitted with hip fracture between 2015-2019, 2033 (61%) were eligible for vision screening and 1532 (75%) of these were screened. 784 (51%) patients screened had an ocular abnormality requiring ophthalmology referral via their GP, or a sight test at an optician. Only 144/383 (38%) requiring ophthalmology referral were successfully referred and only 107/186 (58%) patients given appointments attended. 98/107 had pathology and cataracts was the most common finding (51%). 61/98 (62%) patients had treatable vision impairment. 

Conclusions

We found a large proportion of hip fracture patients who had impaired vision; much of which was easily treatable and could be detected effectively with orthoptic-led bedside screening. The most common eye problem in those referred to ophthalmology was cataracts. An internal referral pathway to ophthalmology is proposed. There is a need to investigate reasons for disengagement with eye care services in this population.

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.