Clinical Quality

Introduction Alcohol excess is a risk factor for falls in all ages. However, it is important to establish the relationship in older patients, who are at a greater risk of falling, to allow for appropriate risk management. Methods The Older Persons Assessment Service (OPAS) is an Emergency Department service which, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years (falls, confusion, care dependence, polypharmacy and poor mobility).The OPAS databank was retrospectively analysed for people with alcohol excess admitted with a fall between June 2020-December 2022. We examined clinical outcomes relating to medication, age, Charlson Co-morbidity index (CCI) and clinical frailty score (CFS). Alcohol Excess was defined by regularly exceeding government guidelines (>14 units a week). We applied the POSAMINO (Potentially Serious Alcohol–Medication Interactions in Older adults) criteria to our database to identify potentially inappropriate medications (PIMS). Results 1067 consecutive patients presenting with falls with 55 (0.05%) having a history of chronic alcohol excess; 3 with acute intoxication at the time of presentation on a background of chronic misuse. Those who presented with alcohol excess were younger (76.5 years (±9.5) vs 84.5 (±7.5) p<0.001) and less frail as per CFS (4.9 (±1.1) vs 5.3 (±1.3) p<0.05). There was a trend towards greater CCI (5.9 (±2.4) vs 5.6 (±1.9) p=0.13) in those who drink more alcohol. There was no significant difference in gender or mortality between the groups. When applying the POSAMINO criteria, the overall number of PIMS identified was 1.7 (±1.4), with those PIMS contributing to increased falls of 1.2 (±1.2). Conclusion Alcohol consumption is associated with an increased risk of falls in older adults. Increased awareness of the POSAMINO criteria can aid clinician de-prescribing decisions, especially in this cohort who are more vulnerable for recurrent falls.

Introduction
The NHS backlog in Elective Surgery are a subject of societal concern and political pressure. Over 6,400 patients >65 yrs are currently awaiting surgery at Swansea Bay. What role, if any, can geriatricians play in improving patient and organisational outcomes? Intervention We wrote to all 258 patients on the Cholecystectomy waiting list > 65 yrs with a letter explaining the project and a patient experience questionnaire. An attempt to contact all patients by telephone was made with an intention to ask questions about their health, activities of daily living and frailty and complete a CRANE questionnaire. Patients who were identified as frail either by the CFS or HFRS, with complex co-morbidities and any concerns raised by the CRANE questionnaire were offered a clinic appointment. Clinic outcomes were prospectively recorded. Patients who attended clinic were asked about their experience through another questionnaire and focus groups. Results from phase A (January 2023) The waiting list had 258 patients, 193 (75%) patients spoken to on telephone. 32 of these have been seen clinic to date with another 11 due to attend. These clinics have identified spinal wedge fractures, abdominal aortic aneurysm requiring surveillance, potential malignancy (referred for imaging), possible new diagnosis of RA, optimisation of cardiac drugs (5 patients), polypharmacy management, hyponatraemia; amongst others with several patients referred to other frailty or specialist services. This process was able to reduce the waiting list by 36 patients or 14% of those >65yrs on the waiting list. The focus groups and questionnaires showed patients valued the service.

Conclusion
This project demonstrates that proactive management can yield a substantial benefit, both in optimising patients experience and health outcomes and by producing an organisational benefit by reducing the overall waiting list size and allowing anaesthetic led perioperative clinics to function more efficiently.

Introduction

The UK Parkinson's audit assesses whether patients with Parkinson's Disease (PD) are managed according to standards. Referring patients to physiotherapy (PT) and advising those with daytime sleepiness not to drive are two of these. In our clinic, patients identified as drivers are advised to inform the DVLA and will undergo a MOCA, sleep questionnaire and driving assessment. 

Project Aim

Are we making early physiotherapy referrals and documenting driving status in newly diagnosed outpatients? 

Methods

Online notes of newly diagnosed patients over a 12 month period were reviewed. A clinic checklist was created and displayed in the clinic as a poster with the mnemonic:

Lasting Power of attorney

Driving

Osteoporosis

Physiotherapy

Anticipatory care planning

Following introduction of the checklist a further cycle has taken place. 

Results

In the initial cycle, 34 newly diagnosed patients were identified. 4 were nursing home residents and excluded from results. Of those remaining, 83% had documentation of driving status. 2 patients were drivers and one had evidence of completed driving assessments. 20 patients were referred to physiotherapy and a further 3 patients were offered (76%). 50% of referrals were within the first month of diagnosis. Following checklist introduction, 21 new PD patients were identified over 6 months. The clinic team were sent updated data throughout to encourage ongoing improvements. 95% had documentation of driving status. 9 were drivers. 6 had full driving assessment completed. 16 (76%) patients were referred to physiotherapy. 75% of these were referred within the first month.

Conclusions

Repeat data collection has shown improvement in both driving status documentation and early physiotherapy referral. The checklist reminds us of important aspects of outpatient care in PD that may otherwise get forgotten. Ongoing data collection will hopefully continue to improve. 

Introduction
Timely administration of medication for people living with Parkinson’s Disease (PwP) is critical. Missed or delayed Parkinson’s Disease (PD) medication can lead to motor complications, swallow impairment, and in some cases a neuroleptic malignant type syndrome. This can lead to morbidity and mortality and longer hospital stays. Our local policy on the nil by mouth (NBM) guidance for PwP is available on the intranet. We wanted to audit knowledge of, and adherence to this policy.

Method
An audit tool was used to collect responses from nursing and medical staff in the Clyde sector, including Royal Alexandra Hospital, Inverclyde Royal Hospital and Vale of Leven Hospital. Paper copies and QR code linking to the questionnaire were distributed across the wards between November 2022 to January 2023.

Results
A total of 124 responses were obtained, where 84 were prescribers. The responses showed some pre-existing understanding on the NBM policy for PwP, with 77% agreeing that Rotigotine patches should be considered if the oral or enteral feeding route is unavailable. 67% also knew the frequency for Rotigotine patches to be changed. Of the responses, only 52 (50%) have seen the trust’s NBM policy. Prescribers were also asked on how to calculate the dose for Rotigotine patches, 37 (52%) knew of the online calculator or referring to a guideline, with the remaining unsure or leaving the question unanswered. 41 (33%) knew the location of the emergency stock for PD meds.

Conclusion
Our study has shown a gap in the awareness of the NBM trust policy for PwP and highlights the need for more staff education. Educating medical staff at their weekly teaching and signposting them to the local guidance will be a starting point for our intervention. For the wider hospital staff, further training will be provided during PD awareness week.
 

INTRODUCTION

The aim of this quality improvement project was to assess the medical discharge letters written by medical colleagues at this trust against the guidelines set by the Royal College of Physicians. The target was to achieve at least 90% compliance across the components evaluated at the end of this project.

METHOD

This quality improvement project evaluated medical discharge letters from three medical wards. Following the application of filtering criteria, a sample size of approximately 20 patients was randomly selected for data collection. Sections that were evaluated in the discharge letter included areas of clinical summary information, investigative results, medication changes, follow-ups and GP actions. Information obtained from the letters were reported as 'yes', 'no' or 'non-applicable' on an Excel spreadsheet. Data collected was analysed and areas of strengths and weaknesses were identified. They were used to form action plans, following which the cycle of evaluation was repeated.

RESULTS

Two cycles were carried out in this project. Issues were identified in the sections of clinical summary, documentation of blood results, medication changes and their indication, and follow-ups. Action plans such as education (leaflet, emails and education session), introduction of a discharge letter checklist and acronym expansion were used. By the end of the third round of data collection, all components achieved at least 90% compliance, with the exception of changes in regular medications and differentiation of follow-ups into booked and those which needed booking.

CONCLUSION

This project has resulted in an increase in adherence to the standards set by the College when completing medical discharge letters. Periodic evaluation will be beneficial to ensure that a high standard of compliance is consistently achieved. Sample size could be increased to improve the significance of evaluation. This study can be expanded to other specialties to increase coverage.

Introduction: Procollagen-N-terminal-peptide(P1NP) is a bone formation marker. Bisphosphonates lead to a reduction in P1NP levels and levels are significantly elevated shortly after fracture. In older patients taking bisphosphonates who have had a further osteoporotic fracture there is a lack of evidence to guide ongoing osteoporotic management.

Objectives: To assess if measuring P1NP in patients receiving Bisphosphonates treatment who develop neck of femur fractures helps guide further management in regards to long term bone protection treatment.

Methodology: Retrospective descriptive cohort study of P1NP levels for the patients who presented with NOF# (>60yrs) and who were taking anti-resorptive medications. Cases were discussed in our complex bone health MDM and patient specific plans made accordingly.

Results: 60 patients were identified between March 2017 and Sept 2021 had P1NP tested(2.6 % of the 2,303 total fractures in this time). Mean age 83 years(F:M – 54:6 / # type - IC:EC – 34:26).

Overall: 17(28%) patients had significantly elevated PINP with identifiable reasons. 39(65%) patients had supressed P1NP levels(< 35mcg/L) and 5(7 %) between 36-39 mcg/L.

Of those with supressed P1NP: Patients taking treatment >5 years(n=9) – Treatment stopped for 6 patients, 2 changed treatment following DXA and 1 continued. On treatment 3-5 years(n=8) – 5 continued with treatment, 1 had further ix and 2 treatments changed On treatment 1-3 years(n=17) – 14 continued treatment, 2 treatments stopped, 1 treatment changed On treatment <1 year(n=16) – all continued the same treatment

Conclusion: The measurement of P1NP has been helpful in making patient centred decisions in this cohort. It has added to the detailed discussions in the hip fracture bone health MDM and for 23% of patients with supressed bone turnover contributed to a change in management. Most changes occurred in those patients taking treatment for more than 5 years where the evidence of bone turnover suppression gives confidence to stop or change treatment.

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions: 1. What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? 2. Does the provision of these interventions or services improve outcomes?

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

Introduction

The Norman Power Centre (NPC) is an Intermediate Care Unit, in Birmingham, UK, providing enhanced assessment beds (EAB) where patients undergo functional assessment after an acute admission. There is little published data regarding the outcomes for patients admitted to EAB, so we set out to analyse outcomes in our unit.

Method

Data was collected from 50 patients who were discharged from EAB between September 2021 and March 2022.

Results

The mean length of stay was 36 days, median was 29 days. Of the 50 patients: 4 went home with no services, 9 went home with Early Intervention Community Team (EICT) support, 5 went home with package of care (not EICT), 13 went to new residential home placements, 6 went to new nursing home placements, 11 were re-admitted to hospital, 1 died and 1 received palliative care. 28 patients went to the destination that was originally intended on admission, 9 went to a less restrictive option and 12 required a higher dependency destination (predominantly re-admission to hospital.) The change in Elderly Mobility Scale from admission to discharge ranged from -1 to +15. Mode and median were both 0 and mean change was +2. 49 patients had Barthel scores on admission and discharge. Change in score ranged between -1 and +9. Mode and median change was 0, and mean was +1.7.

Conclusions

This data shows positive outcomes in terms of discharging most patients to their intended, or better, destinations. It also gives us an objective measure of the change in functional status that patients are achieving during their stay. There is a high rate of hospital re-admissions, indicating the unstable nature of the health of frail people. We are now ready to move onto a PDSA cycle to see if we can improve outcomes for our patients.

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021 (Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit)

Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data).

A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit)

1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data).

A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7.

Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas.

The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007).

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Introduction:

Large numbers of geriatric inpatients within acute settings are deemed medically safe for discharge (MSFD) but stranded within the hospital due to a lack of community services and social care packages, leading to increasing length of patient stay and reduced hospital flow. These patients do not require inpatient care and would otherwise be discharged to their home or residential care. This project aimed to identify these patients and rationalise their medical input to mirror a community setting (without routine daily medical reviews).

Methods:

MSFD patient were identified by the multi-disciplinary team (MDT). Patients identified received standard nursing and therapy input, alongside daily MDT discussion at a board round to progress discharge planning. If the MDT expressed concern about a MSFD patient, they would receive a medical review. A sticker placed in the notes identified patients deemed MSFD.

Results:

A 3-week trial on a 19-bedded geriatric ward showed 46% of bed days were occupied by MSFD patients. On average, 8 MSFD patients did not require daily review. 0.6 unplanned reviews/day were needed due to MDT concern, saving an average of 7.4 patient reviews/day, equating to 3.3 hours/day doctor time saved.

Conclusions:

Doctor time saved allowed redistribution of staff to busier wards with more unwell patients, with no detriment to patient care noted. The trust formalised a SOP and the MSFD pathway was introduced across the geriatric medicine department. A MSFD ward has now been opened, to cohort patients awaiting discharge to community pathways. This ward should require minimal doctor input to allow continued redistribution of medical staff across the hospital, as well as facilitating patient flow by admitting patients who reside on the acute frailty unit who require increased community care.