Clinical Quality

Introduction : 

The delayed discharge is defined as patient is deemed medically fit to leave hospital but is unable to do so for non-medical reasons. Delayed discharges are associated with mortality, infection, depression, reduction in patients' mobility and their daily activities. 

Aim and Objectives:

1.Recognition of different causes of discharge delays will allow health professionals, hospital administrators to propose potential strategies for minimising delays. 2.To identify causes of prolong delays in discharge among elderly patients.3. To propose strategies for eliminating advisable delays and improving healthcare delivery as well as patient flow process.

Methods:

Total 29 patients' data were collected at the same time. The average length of admission was 32 days. The data were collected to assessed likely presence of delayed discharges and reason for delayed discharges.

Results:

Total 19/29 ( 65% ) were medically fit for discharge (MFFD) and 10/29 ( 35% ) were not MFFD. The average length of time since being declared MFFD was 16days. The reasons for delayed discharges are awaiting POC (32%), awaiting placement (26%), awaiting furniture arrangement at home (10%), awaiting mental capacity assessment from social worker (10%), awaiting equipment delivery (5%), awaiting safeguarding outcomes (5%), awaiting family to find a property to be discharged (5%), family refused equipment (5%).

Recommendations

The recommendations are 1.completing early assessment of onward care needs and recognising the potential needs for either rehabilitation, home assessment for safety and need equipment or residential/nursing home. 2. Early discussion with patients and/or families to reduce the disagreement 3. Early communication with community teams like social worker and CCG by discharge team.

Conclusion

It is important to achieve the correct balance between minimising delays and not discharging patients from hospital before they are clinically ready.

Aims:

i) Develop and test a theory-based diagnostic instrument to assess barriers and facilitators accurately and prospectively; and ii) survey barriers and facilitators to the delivery of skin hygiene care in care homes.    

Background:

There is an ageing population and an increasing number of people residing in care homes. As skin ages it become vulnerable to dryness, itching, cracks, and tears. These are experienced by many older people and cause discomfort, compromised quality of life, skin breakdown, increased dependency, longer hospital stays, and greater financial and human costs. These problems can be prevented through adequate skin hygiene care, however despite best practice guidance, concordance may be sub-optimal.  

Methods:

Barriers and facilitators identified from a literature review and pilot study were categorised in a Delphi survey of experts (psychology or skin health) (n=8) to the Theoretical Domains Framework. This model was tested in three rounds for face validity (n=38), construct validity (n=235), and test-retest reliability (n=11).  Barriers and facilitators were surveyed in round two. 

Results:

A 29-item valid and reliable instrument resulted (χ2/df=1.539, RMSEA=0.047, CFA=0.872).  Key barriers were delivering skin hygiene care to agitated or confused residents, pressure to rush or engage in other tasks from colleagues, high workload, and difficulties meeting often unrealistic expectations of relatives. A key facilitator was knowledge of how to perform effective skin hygiene care. 

Conclusions:

This study identified a comprehensive list of barriers and facilitators to skin hygiene care including barriers previously unreported.  

Relevance to clinical practice:

Efforts to improve care tend to be based on information giving. However, our work illustrates that barriers other than knowledge need to be addressed.  Use of the SHELL-CH Index will allow identification of barriers and facilitators in local contexts and this understanding will support the development of interventions tailored according to need. 

Introduction

Across inpatient HSC settings ward based medicines management pharmacy technicians support ward based multi-disciplinary teams.  The aim of this study was to explore the potential role and impact of a medicines management pharmacy technician and ‘stock solution’ in a Care Home facility.

Method

A 30 bedded private Care Home was identified for the pilot.  A medicines management pharmacy technician liaised with senior nursing staff to review and understand the monthly medication ordering process.  The technician audited the Care Home’s medication destruction records for 4 months and reviewed all the medication documentation i.e. T-MARs, kardexes and MAR charts.  A ‘PRN medication stock solution’ with standard operating procedure (SOP) for use was devised and trialled for 2 months. 

Results

The monthly medication ordering process took a minimum of 12 hours, if no discrepancies/queries.  This process could be completed by a medicines management pharmacy technician. 

From destruction records the combined wastage of medications, controlled drugs and topical medications extrapolated to £11163.66 per year. 

An average of 2.33 discrepancies per resident were identified between kardex and MAR.  87.7% were classed as Eadon grade 4 i.e. intervention is significant and results in an improvement in the standard of care.  The remainder were Eadon graded 3.  An average of 0.2 discrepancies per resident were found between the T-MAR and MAR/Kardex.  These discrepancies were classed as Eadon grade 3 - Intervention is significant but does not lead to an improvement in patient care.

Following stock solution trial nursing staff completed questionnaires.   Questionnaire response rate was 71%.   The majority of responses were positive about the trial.

Conclusion

Use of a Medicine Management pharmacy technician, together with a ‘PRN medication stock solution’, similar to medicines management in a hospital ward would lead to a reduction of waste, cost savings and an improved standard of care.

Introduction
SDH is a community hospital within Cardiff and Vale University Health Board. There are 60 -70 beds, over three geriatric wards. The primary focus is for patients requiring rehabilitation and complex discharge planning. All admissions are transfers from the acute setting. There is a high level of frailty. There are ward doctors and a consultant geriatrician within working hours (Monday-Friday), OOH cover is provided by primary care. The concern of ‘blanket’ DNACPR orders, during the COVID-19 pandemic has featured in national news reports. In part, this led to our question and audit. Method 30 sets of notes for 3 time periods: - September – November 2019 – “pre-COVID” - April – July 2020 – “COVID” - May – July 2022 – “post-COVID” Each set of notes were independently audited by two doctors – a Geriatrician and ED physician

Factors assessed:

• DNACPR Appropriateness
• Where the DNACPR decision made?
• Quality of DNACPR documentation

Results

• Sept – Nov 2019 – 22 patients. 1 for resus, 3 did not specify. 18 audited.
• Apr-July 2020 – 31 patients. 1 for resus, 3 no DNACPR form. 27 audited.
• May -July 2022 – 43 patients. 4 for resus, 1 no DNACPR form. 38 audited.

Time period Number of patients DNACPR (%) 2019 18/22 81 2020 27/31 87 2022 38/43 88

• Comparable % of DNACPR forms across time periods.
• Every DNACPR decision was felt appropriate by 2 independent auditors. 10 sets of notes outstanding for 2019 period

Conclusions

1. Appropriate decision-making and no significant change in practice during COVID period
2.  Relatively high DNACPR rates are appropriate for the patient group in this setting- reflecting frailty levels and comorbidity in this cohort
3. Audit illuminates the need for a clear escalation plan prior to patient leaving the referring hospital.

Introduction
Person-centred care is recognised as best practice for the care of people with delirium or dementia. In Cardiff and Vale University Health Board (CAVUHB), “Read About Me” (RAM) documents are used to support person-centred care in these patient groups. However, there are significant barriers to their routine use in clinical practice (Clark, E, Wood, F, Wood, S. Health Expect. 2022; 25: 1215- 1231). We conducted a two-cycle audit investigating the use of these documents on geriatric wards in two acute hospital sites, and trialled two interventions to increase their usage.
Methods 

Both rounds evaluated patients on 9 acute geriatric wards at CAVUHB. Patients with a diagnosis of dementia or delirium were identified by ward staff and medical notes, which we also used to see if a RAM had been completed. Intervention one was the installation of noticeboards on geriatric wards encouraging RAM usage. Intervention two was the implementation of a ward admission checklist as well as engagement with CAVUHB “dementia champions” to advocate for their usage.
Results 

Taking the 9 wards surveyed individually, in round one, the median usage of RAMs was 25% (range of 0% to 55%), which improved to 33% (range of 15.2% to 66.6%) after our intervention. Re-evaluation 3 months later, prior to intervention two, showed that RAM usage had regressed (median 27.2%, range 0% to 50%). We will re-evaluate after intervention two.

Conclusions

Long-term improvement in RAM usage was not achieved after installation of noticeboards. This loss of drive may be due to the wearing off of the novelty of the noticeboards, leading to prioritisation of other clinical tasks. We believe a better approach could be to combine a checklist to reduce cognitive workload with engagement of dementia champions in order to improve RAM usage and therefore improve person-centred care.

Introduction

Frailty is defined as “a condition characterised by loss of biological reserves, failure of physiological mechanisms and consequent increased risk of experiencing a range of adverse outcomes, including hospitalisation, longer length of inpatient stay, and delirium” [1-4]. We aim to investigate the association between baseline frailty and functional recovery amongst hospitalized older adults and its association with inpatient delirium.

Method

Retrospective analysis of patients admitted to a Geriatrics ward from August to November 2022. Interactions between clinical outcomes with age, length of stay (LOS), discharge destination, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated plus incidence of inpatient delirium.

Results

In total, 58 patients reviewed, mean age 78.8 (±15.1) years, 43 (74%) woman. 79% were admitted from their own home with 56% same discharge destination and 9% inpatient mortality. Median LOS in hospital was 13 days with 8 days on the Geriatrics ward. Mean CFS on admission compared to discharge was (4.9 vs 5.7 (p<0.001)), with no significant difference in CCI. There was a significant association between CFS and LOS, both overall and on the Geriatrics ward (P<0.001). 17 patients (29%) developed delirium, with increased LOS (45 days vs 9 (P<0.001)), increased CFS both on admission (5.9 vs 4.4 (p=0.002)) and discharge (7.4 vs 5.0 (p<0.001)) and were less likely to be discharged to their own home (33.3% vs 84.8% (p<0.001)).

Conclusion

Frailty is a powerful predictor for possible risk of deconditioning and is associated with longer acute hospital stay in our more vulnerable patients. The coexistence of frailty and delirium significantly increased the risk of a prolonged hospital stay. This indicates that a multidisciplinary approach to provide a comprehensive geriatric assessment, is necessary to decrease LOSand the incidence of adverse outcomes as during this time period we had limited specialist therapy staff on the ward

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.