Clinical Quality

Can use of sensor technology prevent hospitalisations in frail older people at high risk of hospital admissions?

Background

There has been significant developments, investment and ambition to use modern technology in admission avoidance in hospitals. Sensor technology has been one area of development. We used My Sense to improve outcomes for a cohort of High Intensity Users (HIU) frail older patients, and compared hospitalisation rates before and after employing Sensor technology. HIU patient consent criteria is 3 Admissions with 40 days Length of Stay.

Introduction

MySENSE

• 8 Sensors placed around the home
• Chargeable wrist device
• Monitors - activity, heart rate, environment temperature

Aim

• To detect change in health and routine
• Reduce deterioration in physical and mental health well-being
• Promote independence
• Unnecessary Admissions

Methods

 Fifty randomly selected HIU patients consented to use My Sense from November 2021 to June 2022.  HIU monitors usage via a dashboard with the aim to intervene and reduce the likelihood of deterioration caused by inactivity or illness.  HIU contacts the key responders, include liaising with family members, GP, other health/care professionals if unusual patterns or no activity is recorded. For example - bed/chair/toilet/kettle/tap sensor not being activated for some time. Indicators for potential UTI’s, constipation, dehydration, reduced mobility and other conditions if not addressed may result in admission.

Results

• Admissions prior to installation 84 post 54
• Length of Stay prior to installation 909 post 724
• Cost saving = £64,750.00
• Cost of equipment £399 with a monthly subscription fees £39.99 per month

Conclusion

• Useful to detect any changes to normal pattern improving patient safety
• Early identification of deterioration and early deployment of help for earlier intervention
• Raised patient, family and staff satisfaction/reassurance
• Reduced reliance on acute care
• Reduced level of physical social care support / greater independence
• Useful tool but more detailed studies are needed.

Introduction

Older adults with diabetes are at increased risk of hypoglycaemia during inpatient hospital stays. It was noted that a large proportion of diabetic patients on the care of the elderly wards at North Middlesex University Hospital were experiencing hypoglycaemia so a quality improvement project was devised to address this issue and improve patient safety.

Method

Baseline data was collected in October 2021 by monitoring the glucose levels of 21 diabetic inpatients across three care of the elderly wards over a 72-hour period. The project consisted of 3 interventions introduced on one of these wards. The initial intervention was a poster reminding doctors to check the HbA1c results of diabetic patients. The second was the introduction of a bedtime snack for diabetic patients. The final intervention was the inclusion of a hypoglycaemia report in the nursing handover.

Results

In the baseline data collection 3/21 (14.2%) patients had a recorded episode of hypoglycaemia. Following the introduction of the poster, 0/7 (0%) and 1/9 (11%) patients experienced episodes of hypoglycaemia at 2- and 4-weeks post-intervention respectively. Following the introduction of a bedtime snack, 1/5 (20%) patients experienced an episode of hypoglycaemia at 2-weeks post intervention. Following the introduction of the nursing handover report, 1/8 (12.5%) and 0/5 (0%) patients experienced an episode of hypoglycaemia at 4- and 5-weeks post-intervention respectively.

Conclusions

The high rate of hypoglycaemia in elderly diabetic inpatients is likely to be multifactorial and therefore a multidisciplinary approach is essential. The sample size was too small to draw clear conclusions, but suggests that a simple nursing intervention could be effective at reducing the frequency of hypoglycaemia. The next steps will be to formally introduce the nursing handover intervention to the other care of the elderly wards and monitor its impact.

 Introduction In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes ( 1, 2). Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time. Method An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention. Results There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were > 64 with high CFS and 70% over 80. A 3 month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention. Conclusion Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement. (3

Background

Up to 17.5% of admissions for older adults with frailty may be Preventable Emergency Admissions (PEAs). PEAs are costly and expose patients to complications including deconditioning, delirium, malnutrition and nosocomial infections. Royal Derby Hospital (RDH) has 1159 beds and cares for a population of around one million. The Frailty Emergency Assessment Team (FEAT) operates within the Emergency Department (ED) and Medical Assessment Unit. FEAT is multi-disciplinary, comprising nurses, physiotherapists and occupational therapists.

Aim

To reduce the number of PEAs for older adults presenting to RDH.

Design

We integrated a Geriatrician into FEAT with the aim of reducing PEAs through early medical reviews. Suitable patients were identified through referral from ED and routine screening of the patient information system. To support consistent medical reviews and automate data collection we created an e-form embedded within the Electronic Patient Record. This captured details and outcome of medical reviews including Clinical Frailty Score (CFS), problem list, medication review and ‘Medically Stable for Discharge’ (MSFD) status.

Results

Between 7th February 2022 and 20th February 2022 68 medical reviews were collected on the e-form. 72% were assessed first by an ED clinician. 81% had a CFS of 5-7 and 7% had a CFS of 8. The most common presenting complaint was ‘fall(s)’ (25%) followed by ‘clouded consciousness’ (13%). 66% of FEAT physician reviews resulted in planned discharge from ED, 13% of which avoided an admission planned by ED. Of 68 patients reviewed 42 (62%) were MSFD. Of these 29 (69%) were discharged home, 11 (26%) were admitted to a ward to await interim beds or new care package, one (2%) patient was discharged to a care home and one (2%) to another health care facility.

Conclusion

Our intervention reduced PEAs for older adults presenting to RDH. The e-form automated data collection successfully.

Introduction

Our perioperative service for older people undergoing surgery (POPS) commenced preoperative assessment of co-morbid and frail patients undergoing elective orthopaedic surgery in 2021. As part of the comprehensive geriatric assessment (CGA) and shared-decision-making process (SDM), we wanted to analyse the decisions our patients made around surgery and how many regretted having surgery.  

Methods

• Review of all orthopaedic patients seen by POPS between September 2021-December 2022

Intervention

• CGA and SDM on all patients
• Data collected: comorbidities, Clinical Frailty Scale (CFS), SDM outcome.
• Decision regret scale was sent out 6 months post op from August 2022.

Results

• 111 patients assessed. Median age 89 (range 60-97). Median CFS 4 (range 1-7)
• Median comorbidities 12 (range 2-22).
• Surgery considered: knee 43%, hip 33%, shoulder 10%, spine 6%, revision hip 5%, and revision knee 3%.
• 77% wanted to proceed with surgery and 13% did not after SDM. 5% were deemed not fit enough and 5% are still awaiting final decision outcomes.
• Decision regret data has been returned by 10/14 (71%) of patients who proceeded. None regretted their decision. 

Conclusion

The majority of patients seen by POPS wish to proceed with orthopaedic surgery. However, 13% did not wish to proceed following SDM which is similar to the 14% of patients who regretted undergoing surgery in other settings¹. Of those that have returned the 6-month post op questionnaires, none have regretted their decision. Understanding how optimisation and appropriate SDM impacts on the patient experience is important as frailty impacts adversely on patient reported outcomes in elective hip and knee surgery. Frail patients are also less likely to report their postoperative outcomes in national data sets compared to less frail patients².

1. CPOC website
2. Cook et al (2022). The impact of frailty on patient reported outcomes following hip and knee arthroplasty. Age and Ageing.

Introduction:

Nationally, there have been increased attendances to hospital for older frailer adults. Recommendations from GIRFT and NHS England acknowledge the importance of identifying frailty, and the role that dedicated specialist services play. Best practice indicates when frailer adults receive a Comprehensive Geriatric Assessment (CGA), this reduces patient harm and improves outcomes.

Locally in October 2022, Bolton NHS Trust converted an Acute Medical Assessment Unit (AMU) to a 22 bedded frailty unit, the Older Person’s Assessment Unit (OPAU) to provide older frailer adults with early specialist input and review from a dedicated multi-disciplinary team (MDT). The unit is run by three Consultant Geriatricians and a dedicated wider MDT, with links to community partners and when needed preferential admission to Geriatric base wards.

Methods:

Data was collated and analysed with set metrics by the Trust’s Business Intelligence Department. Data was compared for the 3 months pre and post inception of the frailty unit. Regular service reviews occur and utilise PDSA cycles to assess interventional change.

Results:

The average age of patients pre-intervention was 69, and post intervention was 79.6.

Pre-intervention, the average length of stay for patients admitted from AMU to Geriatric base wards was 25.93 days. This reduced to 18.79 days post-intervention.

The average length of stay for patients admitted to non-Geriatric base wards was 10.77 days, this reduced to 8.62 days post intervention.

Conclusion:

Specialist Consultant Geriatrician and MDT input on a dedicated frailty unit has reduced the average length of stay of patients to all base medical wards assessed, especially base Geriatric wards. This has clear implications on patient flow, and benefits patients and the Trust. We expect this will have a compound and positive effect on patients by reducing the risk of deconditioning and potential development of inpatient harms.

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.