Clinical Quality

Introduction

NICE Clinical Guideline CG103 states that adults aged 65 and older should be screened for delirium within 48 hours of emergency hospital admission. The Geriatric Medicine Research Collaborative (GeMRC)'s World Delirium Day data from 2019 showed an average screening rate of 27% nationally. After an inpatient fall on the Medical Assessment Unit resulted in hip fracture for a patient who had not been screened for delirium with the recommended 4 A's Test (4AT), we decided to collect data on screening rates and devised a way of improving these.

Method

Baseline data was collected examining patient notes of adults over 65 years currently on the Medical Assessment Unit who had been seen by a doctor. The intervention was a teaching session on delirium for the junior doctors on the ward, focusing on the adverse prognostic features of delirium and importance of clear diagnosis with onward communication to the patient's GP. Repeat data collection was done following this.

Results

55% of all patients on the ward throughout data collection were over 65 years of age. A total of 79 patient notes were examined. The baseline rate of delirium screening with a completed 4AT pre-intervention was 25%. Post-intervention this increased to 41.3%. Without further education this fell to 26.9%. Most of the unscreened patients showed incomplete 4ATs or only the Abbreviated Mental Test (AMT) section completed.

Conclusion

Integrating delirium teaching into departmental teaching on Acute Medical Units can increase the rates at which delirium is diagnosed, which is important for the patient's clinical trajectory and prognosis, both for their inpatient stay and long term. After this data was presented at a clinical governance meeting, the Emergency Department purchased an electronic patient record including mandatory delirium screening in those over 65 presenting to hospital. Future work may include assessing the rate of documented diagnosis out of those who clinically fit the criteria.

Introduction: 

Primary care-based frailty identification and proactive comprehensive geriatric assessment (CGA) remains challenging. Our Devon-based Primary Care Network has developed and introduced an innovative, community-based IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We wished to see if this process could improve effectiveness of ACP in residential care home (CH) residents.

Methods/Intervention:

1) GPs clinically assessed all CH residents for frailty.

2) Proactive i-CGAs completed using our IT-assisted CGA tool, which prompts to review/consider/address:

• Previous i-CGA-related entries
• Traditional CGA-domains/risks
• High-risk drugs/deprescribing
• ACP discussions (hospitalisation/resuscitation/place of death preferences)

3) ACPs shared with relevant healthcare services/Out-Of-Hours.

Interim analysis focused on adherence to ACP-documentation in severely frail residents, comparing groups:

• i-CGA (1-year post-i-CGA completion)
• Control (1-year post-frailty diagnosis, no i-CGA, usual care)

Results:

i-CGA group: 196 residents(16 mild, 69 moderate,111 severe frailty)

Control group: 100(13 mild,31 moderate,56 severefrailty ).

No significant baseline differences.

Advance care planning:

• i-CGA: 100% residents had documented resuscitation decisions. 97% (191/196) preferred to "allow a natural death. Patients with severe frailty: 85%(94/111) preferred not to be hospitalised. 55%(52/94) died, 90%(47/52) in their CH.
• Control:  72%(72/100) had documented resuscitation decisions or which 97% in this group (70/72) preferred to "allow a natural death". Patients with severe frailty: 29%(16/56) had no hospitalisation preferences documented and in this group 25%(4/16) died in hospital.

Hospitalisation in residents with severe frailty:

• i-CGA: compared to the preceding year, unplanned hospitalisation rates fell:0.86 to 0.68/person years alive.
• Control: Unplanned hospitalisations increased:0.87 to 2.05/person years alive.

Survival: significant group mortality difference was seen at one year: 55%(62/111) severely frail i-CGA residents died compared to 77%(43/56) controls, p=0.0013.

Conclusions:

Proactive primary care-led i-CGA in severely frail CH residents promotes up-to-date discussions regarding preferred place of care and death. Most prefer not to be hospitalised, despite traditionally high rates of unplanned admissions. Our i-CGA/ACP process improves adherence to preferences, reduces unplanned hospitalisations and mortality rates. Progressive i-CGA completion and annual/opportunistic reviews should confer progressive benefits.

Introduction: Frailty is a long term condition with potentially significant associated healthcare costs and resource usage. The gold standard evidence based intervention is a comprehensive geriatric assessment. The NHS Long Term Plan highlights the importance of ageing well and developing proactive services in the community. Care home residents often have unmet health and social care needs, and are frequently frail. Methods: 59 patients with severe or very severe frailty (Rockwood clinical frailty score 7 or 8) across three care homes with both residential and nursing provision were reviewed in person. They were then discussed in an MDT comprised of geriatricians, GPs, community matrons, district nurses, community therapists and care home staff in order to complete a virtual CGA resulting in a personalised care plan. Results: In the 8 weeks after MDT, compared to the 8 weeks before, there was a 49% reduction in GP contacts (28 vs 55) and a 17% reduction in ED attendances (5 vs 6). There was a 133% increase in proactive referrals (7 vs 3) and 20 advanced care plans were completed. 74 medications were reduced or stopped whilst 4 medications were started, with a cost saving of £812.58 over the 8 week follow up. Conclusions: Despite a small sample size and a short follow up period, these results suggest that intervention with a proactive CGA provides benefits to frail care home residents, particularly with regards to reductions in polypharmacy and improved access to advanced care planning. These results also suggest potential benefits to the wider system, with reductions in GP contacts and unplanned hospital attendance. We suggest that in future a CGA should be completed for each new resident to a care home as the basis of a personalised care plan.

INTRODUCTION

The National End of Life Care (EOLC) Strategy highlighted the need for individualised, accessible, multi-disciplinary care plans for people nearing the end of life. Proformas provide a systematic approach to recording end of life discussions. Our Trust uses an electronic patient record (Cerner), which includes an “End of life care agreement” for people in the last days of life.

An initial staff survey on a Medicine for the Elderly (MFE) ward highlighted a lack of familiarity with required documentation. The aim of this project was to improve end of life care documentation.

METHODS

A Driver Diagram was used to examine the principles underlying excellent EOLC and aided development of change ideas. The Model for Improvement allowed identification of measurable aims. Cerner records of 20 patients were reviewed fortnightly, including patients who had died since the previous intervention.

RESULTS

Three PDSA cycles were completed. The first PDSA cycle involved training for nursing colleagues. Step-by-step teaching on accessing and using Cerner end of life care documentation demonstrated a 15% increase in completed care plans. The second cycle (placing posters around the ward) - detailing how to access and document care plans resulted in a further 5% increase. The third cycle involved education sessions for ward doctors, with a further 25% improvement.

CONCLUSIONS

Comprehensive documentation is key to ensuring good end of life care, as it enables continuity of care and improves MDT communication. Active interventions including face-to-face teaching were more effective than passive (posters) in improving documentation.

Our findings demonstrated consistent improvement in completion of our EOLC agreement. We aim to extend our training interventions to other MFE wards and to integrate documentation training into junior doctor induction. We also plan to use similar methodologies to improve our existing end of life care agreement.

Introduction

Falls are a major cause of morbidity and mortality in patients over 65. Unrecognised postural hypotension is a significant and treatable contributor. Training nurses and health-care assistants (HCAs) in correct measurement technique can be challenging, as these groups are rarely able to fully attend single sessions due to urgent clinical commitments, night duties and staff-shortages.

We aimed to improve the frequency and quality of lying-standing blood pressure (LSBP) measurement in a Geriatric inpatient cohort.

Methods

3 PDSA cycles were performed over a 10-month period on a single Care of the Elderly ward, including an initial audit in March 2021. The outcome measures were 1. the percentage of non-bedbound patients having LSBP correctly measured (5-min recumbent, 1 and 3 min standing readings), assessed by chart review and 2. the understanding and confidence of measurers in correct technique, as assessed by a questionnaire.

The intervention was developed into three separate days of ad-hoc mobile teaching sessions to allow reinforcement of knowledge. Trainers moved from bay-to-bay delivering a 5-minute pre-prepared presentation/demonstration on the indications and correct technique of LSBP measurement. This was repeated throughout each day until all measurers had participated.

Results

On initial assessment, only 21% (6/28) of non-bedbound patients had LSBP correctly measured. This improved to 44% (8/18) by July and 62% (8/13) by December 2021.

When sampled, measurers had sustained improvements from July (n=8) to December (n=7), in terms of self-rated confidence (mean 4.4/5 vs 4.9/5), correct technique (25% vs 100%), interpretation of results (25% vs 43%) and knowledge of contraindications to measurement (88% vs 100%).

Conclusions

We describe a strategy using ad-hoc mobile teaching sessions to train nurses and HCAs to measure LSBP in a Geriatric inpatient cohort, which resulted in sustained improvements. We believe this technique is readily applicable to other units and areas of practice.

Introduction

Care home residents can have variable access to eye care services & treatments. We developed a collaborative approach between optometrists, care homes, and primary & secondary care to enable personalised patient-centred care. Objective To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback & hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility & acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity & pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated & are more efficient for residents, health & care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

Introduction

An Acute Medical Unit at Morriston Hospital became geriatrician-led in July 2021. From January 2022 the unit received patients on frailty criteria for Comprehensive Geriatric Assessment (CGA). Clinical Nurse Specialists actively manage patients until discharge.

Methodology

The first phase (November 2020 -January 2021) was acute physician-led. Phase 2(September-November 2021) and Phase 3 (March-July 2022) were geriatrician-led. Phase 3 evaluates a frailty specific intake. Patient age, LOS (length of stay), number of referrals to other medical specialities and overall hospital LOS for patients admitted through the unit were analysed.

Result

The number of patients for the three phases were 496, 566 & 503 respectively. Median unit LOS increased by one day between phase 1 and 3 (p<0.01). Meanwhile, median overall hospital LOS showed a reduction from 7 to 5 days between phase 1 and phase 2 (p<0.01) and between phase 1 and 3 (p<0.05). For patients >80 years old, the median LOS overall has reduced from 12 days in phase 1 to 7 days in phase 3 (p<0.01). There was an observed reduction in number of referrals to other specialities per bed between geriatricans (mean 0.41) and acute care physicians (mean 0.57). 50.1% of the patients who are admitted do not meet the frailty criteria set for the unit.

Conclusion

The unit has shown a LOS benefit for patients >70 years, those >80 years experience a 5-day overall LOS reduction. Identifying frail patients who may benefit from CGA is essential for individuals and overall system efficiency. However, patient selection is difficult to achieve with usual bed management processes. Morriston Hospital has developed a modified electronic screening tool based on the Hospital Frailty Risk Score (HFRS). This is embedded into the digital patient management system. It is hoped that this can be utilised to improve access to CGA for older patients

Introduction

Gorseinon Hospital (GH) is a community rehabilitation facility which offers reablement following an acute admission to hospital. Patients are accepted from both medical and surgical specialty wards. Between 2015-2019 GH had median length of stay (LOS) 32 days. In 2018, 81% of patients returned to their own homes.

Methodology

A retrospective review of all admissions to GH from January to December 2021 (n= 256) to identify opportunities for service improvement.

Results

Median GH LOS was 53 days. Patients transferred from acute frailty and stroke services who received early Comprehensive Geriatric Assessment (CGA) were considered as a separate subgroup; this group (r-CGA) was compared to patients who did not receive early CGA (nr-CGA). The median overall LOS for group nr-CGA is 56 days vs r-CGA median of 51.5 days (Z = -2.591, p < 0.05). 18% of patients returned to the acute hospital. A detailed analysis showed 32.26% patients from general surgical wards returned to hospital. While the proportion of patients in the r-CGA group who returned to hospital was 16.33% and group nr-CGA 18.6%. Median LOS for COVID-19 positive patients was 79 days vs 52 days (p < 0.01). 66% of patients returned home; 13% were discharged to institutional care.

Conclusion

Patients were observed to have a longer length of stay at GH and an increased risk of being discharged to institutional care. Deconditioning associated with hospitalisation, Covid-19 infection and the lockdown periods enforced by the pandemic are potential factors. Early implementation of CGA is likely to reduce acute hospital returns and overall LOS.

1. Introduction

Delirium is a very common and treatable condition, and approximately 20-30% of older patients in medical wards in hospitals presented with delirium. Hence it is important to do timely assessment and correct management of delirium. This QIP was carried out to improve adherence to the trust’s clinical guideline for delirium and to improve the communication with patients, relatives, and primary care doctors.

2. Method

40 patients’ notes were randomly reviewed in the geriatric wards of the Addenbrooke’s hospital as baseline, then 20 patients’ notes were reviewed again after PDSA intervention. As an intervention, we introduced new discharge template to ensure better communication with the GP and we did departmental teaching session to promote awareness of delirium assessment and management. Patients on End-of-Life care were excluded.

3. Results

Compliance of delirium screening tests (4AT or CAM) markedly increased from 37.5% to 80% and documentation of delirium diagnosis in the discharge letter was improved from 70% to 100%. Doing cognitive assessment increased from 32.5% to 40% while performing confusion screening bloods raised from 57.5% to 75% and CXR from 85% to 90%. Taking collateral history was noted to be less complied with 75% after intervention from 85%. Performing urine culture/analysis dropped from 55% to 20%. Assessing delirium screening tool within 24 hours of admission, documenting delirium trigger factors and updating delirium in the problem lists were also analysed.

4. Conclusion

This QIP has shown improvement in delirium assessment and management, but some areas were identified for further progress. It is recommended to continue promoting awareness of delirium (diagnosis, assessment, investigations, and discharge letter template) within department.

Introduction

Ambulance offload delays at the Emergency Department (ED) are linked to adverse outcomes. By 2030, 25% of patients attending the ED are projected to be over 80 years old. Geriatric frailty syndromes can be difficult for triage systems to assess, leading to older people being allocated lower priority status and a higher chance of a 4-hour target breach vs a younger patient(1). We assessed whether ambulance offload time is associated with frailty, death or re‐attendance at an emergency department at a large regional centre. Methods Retrospective analysis of adult ambulance offload data from February to June 2022 looking at age, frailty (CFS), inpatient length of stay (LOS), ED re-attendance within 6 months and death.

Results:

We included 1000 people transported by ambulance to ED February to June 2022. >65 years old– 622 patients (47% Male). Mean 406.3 minutes’ offload, CFS 5.4, LOS 11.75 days, Age 80.21 (IQR 73-87), 193 re-presented (32.76%), 135 deaths (22.9%). <65 - 378 patients (52.9% Male). Mean 189 minutes’ offload, LOS 5.1 days, Age 43.81 (IQR 33-56), 116 re-presented (31.86%), 24 deaths (6.34%). Significant associations (P<0.05) for CFS vs LOS, CFS vs Average offload, Average offload vs Age and LOS vs Average Offload. There is a significant link with Death vs CFS (P<0.05) but not re-presentation vs CFS.

Conclusions:

Longer ambulance offload times are associated with greater 6-month mortality and re‐attendance for people presenting to ED who are older and have increased frailty. Those directly offloaded to OPAS had decreased LOS (5.1 days) and offload time (121 minutes’) despite a mean CFS 6.41, indicating a need to increase OPAS capacity including for direct offloads into OPAS.