Clinical Quality

Introduction

The term ‘frailty’ is increasingly being used in clinical practice. NHS services established to assess frail older people are described using various names including ‘Frailty Unit’ (FU). Little is known about patient’s self-perception on being frail and their views on the use of these terms and nomenclatures. Following the development of a new FU in the Emergency Quadrant of our DGH, this study was undertaken to assess how elderly in-patients in the unit perceive ‘frailty’ as a concept. Their views on the nomenclature of the unit and the service were also evaluated.

Methods

A semi-structured qualitative interview was conducted on in-patients in the FU after medical optimisation of their condition and prior to discharge. Those with communication barriers and lacking mental capacity to participate were excluded. Frailty severity was assessed using the Edmonton Frail Scale (EFS).

Results

20 patients were interviewed (mean age 84 years; range 75-98; 65% females). EFS classified patients (n) as ‘not frail’ (2), ‘vulnerable’ (7), ‘mild frailty’ (4), ‘moderate frailty’ (4) and ‘severe frailty’ (3). There was no correlation between age and presence of frailty on EFS. Only 5 (25%) considered themselves as frail compared to 55% deemed to be frail on EFS. Only 28.6% with moderate to severe frailty on EFS considered themselves as frail. 40% disapproved the nomenclature ‘Frailty Unit’ due to its negative connotation despite overall satisfaction with the service. Majority (85%) were happy to discuss the concept of frailty and strategies to manage it.

Conclusion

Identification of frailty on EFS may not necessarily correlate with the patient’s self-perception of being frail. Though the term frailty and frailty unit may be perceived as negative by some patients, this did not correlate with their service experience. Clinicians must take the opportunity to discuss the concept of frailty openly with patients including management strategies.

Introduction:

East Lothian Community Hospital (ELCH) comprises of 95 medical beds for older patients undergoing rehabilitation following acute admission or discharge planning. Ideally, transfers from acute hospitals should have Treatment Escalation Plans (TEPs) in place, however only 67% of patients had a TEP documented electronically within three days of ELCH admission. Overnight and weekend cover is provided through nurse practitioners or Hospital at Night (off-site), therefore documented individualised plans by senior decision makers in the event of clinical deterioration is vital.

Objective:

95% of patients admitted to ELCH would have a provisional TEP documented electronically within 72 hours of admission by February 2023.

Methods:

Using quality improvement methodology, two Plan-Do-Study-Act cycles were completed. Firstly, a questionnaire was sent to junior doctors and nurse practitioners responsible for admitting patients to understand barriers to completing TEPs. Data was collected from electronic records on admission date, first documentation of provisional TEP (by a junior doctor or nurse practitioner) and admitting ward. The first cycle of change focused on increased awareness through posters reminding clinicians to consider TEP on admission. The second cycle of change involved two education sessions, highlighting the importance of TEP and how to approach difficult conversations.

Results:

28.5% of junior clinicians did not feel comfortable discussing TEPs on admission, with barriers being time constraints, level of responsibility and concern about making incorrect decisions. The first cycle (increased awareness) showed an improvement in documented provisional TEPs within 72 hours of admission from 67% to 79%. The second cycle (two education sessions) saw a further improvement to 94%.

Conclusions:

Basic interventions to increase awareness and education to address concerns surrounding TEP discussions were very effective. Future cycles are planned with new junior doctors to sustain the improvement. Next steps are to clarify the role of other medical practitioners in completing provisional TEPs.

Introduction: Following COP26, the NHS pledged a ‘Net Zero’ health service by 2040. Incineration of clinical waste has a negative impact on the environment whilst also being extremely costly. NHS Grampian spends over £1m annually on disposal of clinical waste, whilst 20% of the waste incinerated is unsuitable for that waste stream. An excess of clean plastic packaging from visors, used when managing respiratory viruses, was a particular contributor in our unit. To improve sustainability, the aim of this quality improvement project was to reduce unnecessary disposal of plastic packaging in clinical waste streams by 80% in our Geriatric Assessment Unit.

Method: Using PDSA methodology, data was collected regarding the number and location of clinical waste bins and how many contained plastic visor packaging or any form of ‘non-clinical’ waste. Qualitative data highlighted that staff were aware of disposing waste in the wrong stream, however, struggled to find alternative waste bins located nearby. Selected orange bins were removed and black bins introduced at convenient points. Further PDSA cycles focused on staff engagement and education.

Results: Following PDSA Cycle 1, a baseline median of 57% of orange bins contained clean plastic packaging and 64% contained any form of non-clinical waste. Following staff education, clinical waste bins containing single use plastic dropped to 0%, whilst the percentage containing any form of non-clinical waste remained averaging 35%.

Conclusion: Making clinical waste bins less readily available reduces the amount of unnecessary clean plastic packaging entering clinical waste. We must counteract this through increasing access to general and recyclable waste bins to ensure waste is disposed of correctly. This may be achieved through the creation of “waste stations” in preparation areas, to facilitate readily available access to all waste streams at a single point if required.

Introduction

During the COVID-19 pandemic, restricted hospital visitation policies were implemented to reduce the spread of the viral infection. As a result, telephone has become the main communication method despite the complexity of the elderly patients' medical and psychosocial issues. This has heightened anxiety and reduced satisfaction among patients and their families. This quality improvement project aimed at improving communication with patients' families. We introduced several strategies with the aim to update patients' families within 48 hours of admission and then at least once a week during patient's journey from admission to discharge.

Method

Retrospectively, all patients who were admitted to the ACM ward during the study period were included. Multiple Plan-Do-Study-Act (PDSA) cycles were implemented. As the first intervention, we added a new section on "Update patients' families" in our weekly harm free care document to identify patients' families who were not updated. Also, reminder emails were sent to all medical doctors to ensure that we record all discussions with families using "Discussions with patients and families' document". As the second intervention, a poster on "Harm Free Thursday and Update Friday" was displayed in the doctor's office. Face-to-face education was provided to new trainees to emphasise the importance of good communication with patients' families. Data was collected from electronic patient record (EPR) and Microsoft Excel was used for data collection and analysis.

Results

189 patients were included in the baseline audit which showed that only 49% of patients' families were updated weekly throughout the admission. Compliance in communication with families after the first and second cycle was 62% and 69% respectively. Following the second PDSA cycle, the percentage of patients' families who were updated within 48 hours of admission increased from 50% to 56%.

Conclusion

The project showed significant improvement in communication with patients' families with each cycle.

 Introduction: Indwelling urinary catheters (IUC) are well-known to cause serious adverse outcomes in older adults; such as catheter associated urinary tract infections (CAUTI), direct trauma, delirium, deconditioning, falls, restrain, prolonged length of stay etc. (Lee E., Malatt C, 2011). Removal of IUCs as soon as the indication is resolved, results in better outcomes (Dawson et al, 2017). We identified high rates of inappropriate catheterisations as a regular practice or part of sepsis protocol in our hospital. This QIP was designed to compare our practice against the standards set by NICE and Royal College of Nursing.

Methods: Two PDSA cycles of 30 patients each, were completed between 2021-2022 (4 months apart), in Acute Frailty Unit and two Elderly Care wards. New IUCs in patients above 65 years were included. Data were collected on, documentation of IUCs, indications, plans for Trial without catheters (TWOC), appropriate management plans and CAUTI. Interventions post first PDSA cycle were; organised teaching to the nurses and doctors, discussing catheters at by-daily board rounds (BR), displaying flowcharts and reviewing IUCs during ward rounds.

Results: Documentation of IUCs improved significantly from 17/30 to 24/30. There was a small reduction in inappropriate indications from 16/30 to 12/30. Documentation of TWOC plans improved from 4/30 to 11/30. Collection of urine samples for CAUTI’s improved from 11 to 18. Our interventions were shown to produce positive outcomes.

Conclusion: Despite continuous education and BR discussions, there’s still room for improvement. Better understanding of catheter associated harm by frailty teams resulted in positive outcomes. Next steps prior to the 3rd PDSA cycle include educating Emergency and medical teams through wider teaching platforms and integrating changes to hospital electronic systems on appropriate documentation and TWOC plans. Our study would be applicable in similar settings nationally and globally to achieve better catheter care in older adults.

Introduction

Increased frailty is associated with increased post-operative morbidity and mortality in older patients undergoing emergency laparotomy. NELA recommend documentation of frailty in surgical patients over 65.

Using QI methodology, we introduced a ‘CARE tool’ for surgical doctors aiming to improve their documentation of an older person’s medical history (including CFS and delirium).

Method

A collaborative team representing geriatric medicine, anaesthetics and surgery devised the acronym CARE (Cognition, Assistance at home, Record the CFS, Exercise tolerance).

The tool was tested using QI methodology over 2 PDSA cycles. Cycle one introduced the tool into electronic patient records (EPR) and presented it at the surgical faculty meeting. Cycle two introduced the tool specifically to surgical FY1 doctors during induction.

The EPR surgical clerkings of patients over 65 years old admitted to general surgery were sampled weekly over seven weeks to assess CARE tool completion.

Post-intervention, we surveyed the surgical doctors assessing their understanding of frailty and perceived value of the CARE tool.

Results

At baseline: 12% of confusion, 92% dementia status, 0% CFS, 30% assistance at home, 8% exercise tolerance were documented.

Following PDSA cycle one, use of the CARE tool was 40%. There was an increase in the documentation of confusion (40%) and CFS (40%). Dementia status and assistance at home were documented in similar frequency pre and post-cycle.

During cycle two, CFS documentation increased to 55% but identification of confusion dropped to 25%. The survey demonstrated that frailty, CFS scoring and delirium screening were better understood by junior doctors than Consultants and registrars.

Conclusions

Our project showed mixed success in improving documentation using the CARE tool. The survey demonstrated a good understanding and knowledge of frailty in surgical FY1s. Ongoing frailty teaching is planned for the surgical department.

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.