Clinical Quality

Introduction. Older people with frailty are at risk of adverse outcomes from hospital admission. Early identification of frailty at can help reduce these. The Clinical Frailty Scale (CFS) identifies frailty, is quick to perform and can be done in acute settings. We have a well-established a Frailty Assessment Unit (FAU) which supports comprehensive geriatric assessment (CGA) for older adults with frailty in hospital. We developed direct admission pathway for frail patients direct from our emergency department (ED) to FAU and we needed to ensure that CFS was performed in the ED. Methods. A training and education programme in CFS was delivered to ED via Frailty nurse practitioners. CFS was embedded in the ED safety briefs and daily handovers. A Frailty link nurse was identified in ED . We implemented an electronic CFS Frailty Alert (eFA) to our electronic Patient Management System. Results. A direct admission pathway was established in March 2021 and eFA began in September 2021 (delayed due to Covid-19) The number of patients presenting to ED who have eFA added at admission has increased from 4/ month to 100/month ( fig1) . This has allowed us to maintain 80% of patients being admitted to FAU ( and therefore to GCA) < 24 hours of attendance at hospital (fig 2). The number of patients who have a eFA recorded in the overall service has also increased (fig3) Fig 1. Fig 2. Fig 3. Conclusion We improved the number of patients with an eFA in ED and can better identify who needs CGA. We can use eFA as a visual tool for site awareness of frailty which helps to support flow. Capability of ED /hospital teams to add eFA was increased and extended to Hospital@Home/ community teams. Finally, this has been shared across our NHSL sites

Background

North Central London Integrated Care System has invested in a pre-hospital programme where geriatricians and emergency physicians support London Ambulance Service via a telephone ‘Silver Triage’ in their clinical decision making on whether to convey an older person living with frailty to hospital. The results of the scheme are described elsewhere.

Methods

452 cases were discussed with Silver Triage between November 2021 and January 2023. Paramedics using the service were sent a survey including a free text question on how the scheme could be improved which was analysed using thematic analysis.

Results

We received 103 comments on how we could improve which fell into three key themes each with subsequent subthemes:

1. Improving access to the service – this included expanding into a 24-hour service, accessible in other areas of London, available to emergency medicine technicians and for people not living in care or nursing homes.

2. Improving information about the service – this included education for paramedics on who to refer but also increasing awareness of the scheme in local emergency departments.

3. Improving delivery of the service – this included requests for video conferencing, reported technology issues and frustrations with pathway breakdown following triage. For example if the agreed plan was not to convey and to support through rapid response or district nurse services, lack of availability led to conveyance to hospital contrary to outcome of triage.

Conclusion

Whilst the Silver Triage scheme has been well received by paramedics there are clear areas for improvement to ensure sustainable and equitable pre-hospital care for older people living with frailty.

Introduction:

NICE guidelines state that assessment of osteoporosis risk is a part of multifactorial fall assessment in older people who present with a fall (NICE clinical guidelines: fall in older people, June 2013). This audit was conducted to examine and improve our practice in assessing osteoporosis risk in patients admitted with fall to Care of Elderly department.

Method:

FRAX or QFracture are the recommended tools to evaluate the risk of osteoporosis and future fragility fracture. We have checked if any of these assessment tools has been used in patients who were admitted with a diagnosis of fall.

Results:

Baseline data was collected for 30 random patients admitted between 1st January 2022 – 31st March 2022, it showed only in 3.3% the assessment tool (FRAX/QFracture) was used. Following attempts to improve the practice by increasing the awareness of the importance of using FRAX/QFracture tools (lecture presentation and email reminders), a significant improvement has been achieved in cycle 2 which checked 21 random patients between 1st June 2022 and 15th August 2022. This showed 48% of patients have documented risk of osteoporosis and future fragility fracture checked with an assessment tool (FRAX was the tool used in all patients). As a result, osteoporosis treatment was started in 9.8%, DXA scan was requested in 4.8% and only life style advice was given to 33.6% of all fall patients included in cycle 2.

Conclusion:

A significant improvement in using the assessment tools (FRAX/Qfracture) in fall patients has been achieved. With continuing to implement the same measures (educating doctors and sending reminders), we are expecting a better result in the future.

Introduction: The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents ​(1)​. Documented ACP discussions guide decision-making in acute situations and may facilitate avoidance of inappropriate hospital admissions. Methods: We established a multidisciplinary care home service which aimed to provide comprehensive geriatric assessment (CGA) based ACP to all residents within three pilot care homes. We evaluated the effect of proactive, systematic CGA and ACP. Ambulance call-out and conveyance data for the pilot care homes were compared for three months before and after our intervention. Results: 122 residents were reviewed during the pilot period and 61 new ACPs were completed. Amongst the 61 new ACPs, 41 new decisions were made during the pilot to avoid future hospital admission and to prioritise comfort in the community. Total ambulance callouts to the 3 pilot care homes were observed to fall from 55 to 33 in the 3 months following our intervention: a reduction of 40%. Additionally, when an ambulance attended the scene, conveyance to an acute hospital was observed to fall by 50% (pre-n =40 vs post-n=19), in favour of discharging into the community. Conclusion: The provision of systematic CGA-based advance care planning in care homes may be associated with a lower frequency of ambulance call-outs and lower rates of conveyance of care home residents to hospital. Proactive advance care planning may influence GP, care home, and paramedic decision-making.

​​1. NHS England and NHS Improvement. The Framework for Enhanced Health in Care Homes. 2020 Mar.

Background: Geriatrician assessment is associated with improved clinical outcomes for seriously injured older adults. In 2021, the Queen Elizabeth University Hospital opened a dedicated Major Trauma (MT) ward for adults with significant polytrauma. Four Geriatrician sessions were introduced per week, establishing the ‘Frail-T' service. Our aim was to provide specialist review to frail trauma patients within 72 hours of admission. Methods: All patients reviewed were prospectively added to a secure database. Patients >65 years on the MT ward were screened for frailty and reviewed if Clinical Frailty Score (CFS) >4. If medical issues arose in patients CFS ≤4, input was provided upon request. Reviews on Critical Care and surgical wards were provided on referral. Qualitative data collected after service implementation assessed staff satisfaction and service improvements. Our database was compared to analysis from 2019 and cross-referenced with the Scottish Trauma Audit Group (STAG) figures to estimate unmet needs. Results: 220 patients were reviewed between September 2021 and August 2022. Median age was 81. 33.2% of patients were frail. 45% received delirium management intervention. Compared to 2019, median time to Geriatrician input improved in polytrauma patients (5 to 3 days), but head and isolated chest injuries (usually on surgical/medical wards) experienced delays (6 and 5 days respectively). 332 additional patients aged >65 on the STAG database were identified; Geriatrician review was recorded in 38% (n=126). Qualitative feedback deemed the service highly accessible (88%, n=15) with themes of improvement: greater service promotion and educational input. Conclusions: Only a third of patients reviewed by the team were frail, reflecting requirement for medical expertise in trauma care. Cohorting polytrauma in a dedicated ward with proactive screening has improved time to Geriatrician review. Delays remain for isolated head and chest wall injuries. Improvement work will focus on greater identification of patients beyond the MT ward.

Background

NICE and SIGN guidelines recommend screening of inpatients at risk of delirium using the 4AT (www.the4at.com) and communication of delirium to patients’ General Practitioners (GP). The aim of this audit was to establish whether delirium is currently being screened and documented, as recommended, in our Orthopaedic Trauma unit.

Methods

Data was collected by two junior doctors across four days (14/11/2022, 29/11/2022, 08/12/2022, 05/02/2023). Trauma and orthopaedic inpatients over the age of 65, who were more than four days post-surgery were included. Each patients’ medical notes, nursing notes, and drug Kardex was reviewed. Subsequently, all discharge letters available up until 8/2/23 were reviewed and documentation of delirium recorded.

Results

Forty patients were included in the study, of which, 29 (72.5%) were screened using the 4AT on both day-one and day-four post-operation. Of these 29 patients, 13 had delirium documented. Nine had a positive 4AT score and four had a negative 4AT score. One patient had documented delirium without a 4AT assessment. Of the 14 patients who had delirium documented, eight had delirium recorded on their discharge letter and four were yet to be discharged at the time of final data collection. Potential reasons for not using the 4AT included expressive dysphasia, review completed by a senior doctor using continuation rather than the proforma pages used by junior doctors, and documented confusion (unclear whether acute or chronic).

Conclusion

As per NICE and SIGN guidelines all patients with indicators for delirium (i.e. older trauma patients) should be screened for delirium using the 4AT. This audit identified a delirium screening rate of 72.5% in our unit. The majority of patients with delirium (8/10) had it documented on their discharge letter and thus was communicated to their GP. Further work to raise delirium awareness and confidence in delirium management in our unit is planned.

Introduction:

Sleep is an essential requirement for good health. The hospital environment is often not compatible with adequate, restorative sleep. Disruption is multifactorial and affecting parameters can be environmental, physical, or psychological.

Aims:

To observe the difference in sleep quality in patients on medical wards compared with their baseline and highlight areas where sleep quality can be improved.

Methods:

This observational study analysed patients on four medical wards at Chelsea and Westminster Hospital. Inclusion criteria: Patients with good cognition who had been in hospital for over a week. We used a modified Jenkins sleep questionnaire in which patients’ sleep before and during their hospital stay was compared, assigning a score to each. Questions assessed how often in a week patients had difficulty sleeping, waking up too often or early, and feeling exhausted. The higher the score the worse the sleep quality. Patients were also invited to report factors contributing to sleep disturbances and make suggestions.

Results:

Overall, sleep quality was reduced in hospital. Across all patients, the cumulative modified Jenkins score increased by 70% from 144 to 245 (n =25). The mean sleep satisfaction score was 6.08/10, the range was 10, and the median was 7. The median score amongst both side rooms (n=10/25) and open bay patients (n=15/25) was equal (6.6). Amongst the qualitative data, common themes were identified: noise, light and overnight observations. Of the two patients who used eye masks/sleeping aids, both were very satisfied with their sleep. Similar findings are echoed in existing literature.

Conclusion:

Hospital admission is associated with worse sleep. The introduction of eye-masks and earplugs more routinely may improve sleep quality and prevent overuse of hypnotics, which can lead to potential complications. Additionally, optimising frequency of overnight observations, guided by patients’ National Early Warning Score may reduce interruptions amongst medically fit patients overnight.

Delirium is common especially in the older adult (≥65 years) and is characterised by disturbed consciousness, cognitive function or perception. It develops acutely, often has a fluctuant course and is associated with several adverse outcomes including increased length of hospital stay, increased mortality and increased incidence of developing dementia. Delirium is under-recognised, however assessment tools such as 4AT and abbreviated mental test score (AMTS) have been developed to help clinicians assess for the presence of delirium. The “TIME” bundle developed by Healthcare Improvement Scotland helps clinicians to think about underlying triggers for delirium. Baseline data collected from a care of the elderly ward showed that 26% (5/19) of patients aged ≥65 years had a delirium assessment tool used on admission. 42% (8/19) of patients were given a diagnosis of delirium on admission. Out of the 8 patients diagnosed with delirium, only 13% (1/8) of patients was assessed for urinary retention, 50% (4/8) for pain and constipation and 25% (2/8) had blood glucose measured. Several PDSA cycles were implemented including an educational session to promote early detection and management of delirium, poster detailing 4AT assessment and “TIME” bundle and use of a 4AT sticker in the medical admission booklet. The sticker was the most successful intervention as results showed 50% (13/26) of patients aged ≥65 years had a delirium assessment tool filled in on admission. For those diagnosed with delirium, assessment for urinary retention and blood glucose measurement improved to 78% (7/9), pain assessment improved to 67% (6/9) and 100% (9/9) of patients were assessed for constipation. In conclusion, this project has improved use of delirium assessment tools at the front door and when delirium is recognised, there is greater awareness of common underlying causes. Planned future cycles include a ward “delirium champion” to help with recognition and management of delirium.

Introduction
As part of a planned care initiative undertaken with the Bevan Commission to improve surgical waiting lists in Swansea Bay we contacted patients on the waiting list for a cholecystectomy, undertook frailty screening and invited those with frailty markers to undergo clinic based geriatric assessment . Clinical governance requires patient input into the setup of any service (1). A patient satisfaction survey following clinic, along with a patient focus group were conducted. Methods 27 patients completed an online survey regarding their experience at clinic. 8 patients attended the focus group, all had attended clinic. Those we hadn't seen face to face declined or were unable to attend. The group was run by a team who were independent of the project, recorded on teams and transcribed. Results Post clinic survey 100% (27/27 patients) knew why they were invited to clinic, >80% found it useful and 92% felt their health needs were covered. The focus group highlighted a number of issues regarding frustration with administration of the list, feeling ‘forgotten about’ and as though they ‘didn’t matter’. They attended multiple pre-op assessments but had no communication, they felt our clinic was their first meaningful clinical contact.

Conclusions

Patient reported experience is a key part of service development however bias is often evident. (2) It was clear that patients valued the face to face aspect of clinic and the focus group. One clear theme from our focus group highlights administration and communication which are potentially modifiable within our resources. A theme of desiring patient choice and continuity of care between specialities was evident, which we hope to address with a unified pathway for perioperative care. 1) Clinical governance - GOV.UK (www.gov.uk) 2) The use of focus group discussion methodology: Insights from two decades of application in conservation, T O Nyumba. 2018

Introduction: With the anticipated rise in the annual number of dementia cases in Cardiff and the Vale of Glamorgan (C&V), improvements in dementia diagnosis rates are essential. However, barriers to accessing support still exist, precipitating delays in diagnosis and establishing appropriate interventions. This article aims to highlight potential barriers patients attending the C&V Memory Assessment Service (MAS) may face, as well as ascertain possible delays within diagnostic pathways of cognitively impaired patients.

Methodology: Demographic and primary data analysis was undertaken using a questionnaire. Data was collected in an outpatient setting at two hospitals in C&V. WCP supplemented additional information on patient referrals and memory appointments. Subsequent findings were reviewed.

Results: The C&V MAS received satisfactory feedback from 87.2% of patients, with negative comments surrounding the lack of awareness of support available in the community. 34.5% (n=19)of participants faced difficulties in accessing support. Barriers included stigma, the Covid-19 pandemic, language, delayed GP referrals to the MAS, transport, and parking. The survey discovered an underrepresentation of ethnic minority dementia patients attending the C&V MAS. 94.5% (n=52) of patients were of Caucasian ethnicity. The remaining patients (5.5%) who were from ethnic minority backgrounds reported facing language and/or stigma barriers in obtaining support. The average duration for patients to present to primary care where applicable was 6-12 months from cognitive symptom recognition.

Conclusion: It is evident that the data obtained is not an accurate representation of the overall C&V dementia population, due to sample bias. Educational and strategic interventions need to be implemented to target this issue as well as barriers identified to accessing care.