Clinical Quality

Background

Person-centred structured medication review (SMR) is associated with reduced polypharmacy, adverse drug reactions (ADRs), admission to hospital and mortality. Our service development aimed to explore the cost-efficacy of a multi-disciplinary team (MDT) providing SMR as part of a comprehensive geriatric assessment for care home (CH) residents.

Method

We established an MDT consisting of a consultant geriatrician, specialist clinical pharmacist, two general practitioners, clinical fellow, physician associate and frailty paramedic practitioner. Training on SMR was given by the pharmacist to other team members, with further support offered through the pilot.

Results

A total of 785 residents were reviewed across 20 CH sites during the initial 6-month pilot. Overall, polypharmacy was reduced by an average of 1.33 medicines per resident (8.32 to 6.99). The drug classes most commonly deprescribed were laxatives, antidepressants, lipid lowering drugs, opioids, and nutritional supplements. Medicines altered included three classes known to cause 40% of avoidable hospital admissions due to ADRs(1): diuretics (stopped/changed for 42 residents), antiplatelets (stopped for 34 residents) and anticoagulants (stopped/changed for 26 residents). Annual projected medication savings totalled £131,462(net), with an average saving of £169 per resident (range £63- £367). Drug classes with the largest cost impact were nutritional supplements (40% total savings), laxatives (12%), opioids (12%) and anticoagulants (11%). Carbon footprint savings from the 12 inhalers stopped during this phase totalled 1,323,098 gCO2e per annum: equivalent to 4562 car miles.

Conclusion(s)

A multi-disciplinary approach to medication review was shown to reduce inappropriate polypharmacy in care home residents. This intervention was associated with significant projected cost savings. Future work should aim to target SMR to patients with the highest rates of inappropriate polypharmacy.

References: 1. Howard, R. L. et al. Which drugs cause preventable admissions to hospital? A systematic review. British Journal of Clinical Pharmacology vol. 63 Preprint at https://doi.org/10.1111/j.1365-2125.2006.02698.x (2007).

Background Acutely unwell hospitalised older people have better outcomes including mortality and functional status when CGA (Comprehensive Geriatric Assessment) is performed. A previous complaint, escalated to the Scottish Public Services Ombudsman, highlighted issues with CGA documentation and recording MDT discussion. This pilot project’s aim was to create a method for documenting CGA MDT plans and to embed this as routine practice for all inpatients on a Geriatrics ward. Method Following consultation with staff on this ward, a sticker was developed detailing status of medical and therapy input, planned discharge date and likely required support on discharge to evidence MDT discussion. This was completed weekly at the boardround for each patient. The stickers were implemented over a 2-week roll-out phase, and use (and completion) of stickers were compared to a 2-week period approximately 1 month later. Feedback from ward staff was also collected via questionnaires. Results Initially, 98% of patients had a sticker completed (n=49/50) and 86% of all required information was documented (n=43/50). For the second round of data collection this fell to an 18% completion rate (n=7/38). Ward staff interviewed were aware of the stickers and felt they improved CGA communication (n=100%, n=8/8). Suggestions for improvement included an option to record whether families were updated, clearer options for discharge status and reasons why a patient may not have received occupational or physiotherapy. Conclusion The CGA board round sticker was a positively received, simple and effective intervention to improve documentation. It addressed an area which had been highlighted as requiring improvement. As expected, initial completion rates were high but rotation of staff impacted on subsequent completion rates. Establishing this as routine practice will be challenging but permanent staff present at the boardround will facilitate allocation of this task and a poster highlighting this process has been displayed on the ward.

Background:  

Delirium is common and experienced by 20% of all admissions to hospital1. Studies have shown a link between delirium and development of dementia2 but there are not many services to follow such patients up post-discharge. A new service has been developed at New Cross Hospital run by Care of the Elderly Consultants with an interest in Cognition.

Methods:

A delirium follow up clinic was designed to assess these patients after 6 to 8 weeks from discharge following hospital admission or reviews in Frailty. We set up a referral criteria for prolonged or recurrent delirium follow up. The clinic is run by a consultant and a registrar. A thorough history is taken and memory is assessed using the Addenbrooke's Cognitive Examination III or RUDAS. Data was collected and analysed from the clinic and the outcome was fed into an Excel sheet.

Results:

31 patients reviewed post admission with delirium, with 8 of those having a suspected cognitive impairment. 12 patients were diagnosed with dementia and 6 with Mild Cognitive impairment (MCI). The subtypes were as follows: Alzheimer's (2), Mixed Dementia (2), Vascular Dementia (6), Lewy Body Dementia (1), Fronto-temporal dementia (1) Only one patient had fully resolved delirium with no cognitive impairment. The rest of the patients had a diagnosis of BPSD (Korsakoff's) (1), ongoing reviews (4), cognitive impairment not quantified (6) and pseudodementia/depression (1).

Conclusion:

This service has ensured follow up for patients with delirium and has shown a significant relationship between complex delirium and MCI or dementia. It has provided a medium to diagnose, treat and signpost patients and carers for support with community services. Very few regions have such pathways in place and the services to follow up patients with delirium discharged from health care settings. This service offers quick and comprehensive follow-up for patients with concerns regarding cognition. 

Introduction: One in three hospitalised patients die within 12 months of admission, rising to 45.6% in individuals aged 85 and older. Resuscitation is rarely successful in this patient group. Most older persons are happy to engage in discussions regarding resuscitation and patients' and relatives' involvement is recommended by the General Medical Council and Royal College of Physicians.

We aimed to increase the number of resuscitation and escalation of care discussions across our Ageing and Complex Medicine department to 90% by November 2022.

Method: Retrospective review of randomly selected electronic case notes for patients discharged in August 2021, November 2021, March 2022, August 2022 and November 2022, to determine when resuscitation was discussed and, if not discussed, the reasons why. Interventions included: 1. face-to-face presentation of findings with discussion at departmental teaching, 2. distribution of posters on each ward, 3. discussion between each ward team, to review individual wards results.

Results: 388 patient cases were reviewed over 5 data collection cycles. At baseline, in August 2021, 49% patients had discussion surrounding resuscitation, increasing to 69% following intervention 1 (November 2021) and 79% following intervention 2 (March 2022). Follow up in August 2022 showed this increase was not sustained, falling to 64%. After intervention 3 (November 2022) this rose again to 72%. August 2022 data was evaluated to identify reasons behind no discussion. The main reason was 'good baseline' (31.1%) with no documented reason in 48.3% cases.

Conclusion: Percentage of resuscitation discussions has fluctuated over time, improving following targeted intervention but has not reached 90%. The main barriers to success identified included junior doctor change-over, fast patient flow, competing ward priorities and patients'/relatives' lack of understanding. We hope to integrate teaching regarding resuscitation into our departmental induction, to sustain knowledge and understanding within the workforce.

Improving the quality of teaching for junior Doctors within the Ageing and Complex Medicine Department; introducing a novel teaching and training programme. 

Introduction 

Feedback from the National Training Survey (NTS) in 2018 showed suboptimal satisfaction levels within our department, particularly for local teaching and clinical supervision. A novel dedicated teaching and training programme was designed and implemented. National and local feedback from trainees highlights significant improvement in satisfaction levels across all domains.   

Method 

The new programme includes scheduled weekly teaching using a defined geriatrics curriculum; simulation sessions, improved opportunities for bedside teaching and workplace-based assessment, opportunities to present patients/interesting topics at weekly teaching, overhaul of our induction programme, support and supervision with QIPs/research including formal end of placement QIP presentation sessions. We reviewed national feedback alongside our own locally sourced feedback to quantify improvements in satisfaction levels and address further areas for improvement.  

Results 

Feedback from the NTS shows satisfaction within all domains has improved between 2018 and 2022. In particular, satisfaction with clinical supervision improved from 80.1 (below national average) to 88.33, satisfaction with our induction process improved from 75.19 to 88.89 (above national average) and satisfaction with local teaching improved from 70.83 to 81 (above national average). Local feedback showed that trainees are satisfied with the quantity and quality of teaching and training during their placement; 92.5% rated the quality of clinical supervision as very high or high quality, 95% felt the formal teaching was useful to their learning, and 90% would recommend an ACM placement at RAEI to their colleagues.  

Conclusion(s). 

Our teaching and training programme has improved the quality and quantity of learning experiences for junior doctors within our department. There are domains in which satisfaction remains suboptimal including “rota design” and “workload” however there are factors affecting these areas which are out of the control of our department and therefore may present challenges when trying to implement change.  

Introduction The pathway for referral to elective perioperative clinic involves frailty screening patients at the point of referral1. This is adequate If waiting times are short. At Swansea Bay 6,458 patients>65 years are awaiting surgery with up to 5 year waits for cholecystectomies. Opportunity to medically optimise patients prior to surgery are lost using a traditional approach. We aimed to develop a screening tool to identify frailty in patients awaiting surgery. Method The cholecystectomy list (750 patients) of which 258 were> 65years. Older people were sent a postal questionnaire gaining 96 responses. 58.3% felt their health deteriorated since being referred for surgery. 50% stating they had unmet healthcare needs and 17.5% stating unmet social care needs. Frailty was identified using this questionnaire, telephone interview or electronically by the Hospital Frailty Risk Score (HFRS). 193 patients were successfully contacted utilising an expanded CRANE questionnaire. All patients triggering on HFRS, CFS>4 or any concern on the CRANE questionnaire were offered a clinic appointment. Each interaction was then classified into change or no change in medical management of patients. 92 patients had no interventions, 35 had an intervention following the initial CRANE telephone questionnaire that did not require further input, 31 had an intervention following clinic. CFS>4 identifies 56% of the patients that under go any form of intervention. HFRS identifies 34% and the CRANE questionnaire identifies 42%. In patients who need a clinic review HFRS identifies 19%, CFS>4 identifies 59% and CRANE identifies 87%. Conclusion The CRANE questionnaire is a useful screen for patients on a waiting list who will benefit from an elective perioperative clinic. References 1 Guidelines of perioperative care CPOC.

Introduction:

Perioperative medicine for the Older Patient undergoing Surgery (POPS) is an established, evidence based medically led service across many Trusts. However, with consultant workforce constraints, the aim was to determine if an alternative ACP led model of care, with consultant geriatrician oversight, delivered the same benefits.

Method:

• A senior nurse, with POPS expertise, was seconded for one year to oversee the project. NHS Elect network supported, from February to October 2022, with monthly meetings, data analysis and facilitated shared learning from other sites

• An ACP from the medical frailty service worked alongside to develop perioperative expertise and allow future sustainability.

• Geriatrician with interest in perioperative care was appointed in May 2022 and contributed to service development and delivery.

• Patients with frailty were identified proactively through the daily board round and surgical handover. Those identified were reviewed using a comprehensive geriatric assessment. Medical advice was sought as required.

• Prospective data collected on all patients seen

Results:

Patient data analysed (n=404) from January to August 2022. Length of Stay (LOS) reduced for patients over 65 years of age living and with frailty by 4 days (17 to 13 days). Variation in LOS reduced from 46 to 26 days. Readmission rate was 6% (26/404). Average Trust rate of 11%. Introduction of POPS improved the National Emergency Laparotomy Audit geriatric specialist input from 10% in Q1 2020/2021 to 91% of patients in Q4 2021/22.

Unmeasured benefits include upskilling of nursing staff on the wards identifying frailty and discharge planning. Shared decision making influencing non-surgical treatment for patients for better outcomes. Reduction in calls to medical registrar post POPS introduction.

Conclusion:

This pilot successfully demonstrated the role of ACP in service design, care coordination and timely medical review to deliver a reduction in length of stay and readmission rate.

Introduction: Scotland's National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method: Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals including education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results: In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis assessment of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion Appointment of a Dementia ANP and integration with H@H  services improves time to assessment and diagnosis of dementia. 

Background

West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction

Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods

Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drug Tariff(1). Qualitative feedback was sought from all members of the MDT.

Results

43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion

Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.

Reference

1.            Public Health Scotland, Scottish Drug Tariff,

Introduction

It is well recognized frailty is increasing amongst the population and can impact on outcomes for patients when admitted to hospital.  Frail older adults are more vulnerable to developing complications form continued hospital admissions. National recommendations by GIRFT indicate CFS scores ought to be documented in the Emergency Department (ED) to facilitate early recognition of frailty and stream patient to the appropriate pathway and clinician. The aim of this is to ensure the correct Clinician reviews the frailer adult in the most appropriate setting and thereby reduce risk of deterioration and patient harm.  In October 2022. Bolton NHS Trust created a dedicated frailty unit staffed by Geriatricians for older frail adults.  Therefore, a method of identifying and streaming frailer older adults is crucial to effectiveness of the unit. This was embedded into Electronic Patient Record (EPR) system.

Methods

PDSA cycles were implemented. A retrospective audit was performed prior to the implementation of the CFS documentation.

A robust education programme was introduced to all clinical staff in the Emergency Department. Online modules were also available. A second audit as part of PDSA cycle was then performed to assess the intervention.

Results

Pre-intervention and EPR documentation tool only 11% of patients had CFS score. Following the intervention, 88% of medical staff included the CFS score in their assessment prior to a Frailty team referral and review. The frailty team have observed an increase in referrals.

Conclusions

Early recognition and documentation has enabled improved streaming and review of the correct patients to the frailty unit.  This has enabled Gold Standard of Comprehensive Geriatric Assessment for frailer adults to be completed.  Further PDSA cycles to the effectiveness of the unit are ongoing. Initial data indicates with correct identification and recognition of frailty; the average length of stay has reduced.