Clinical Quality

Introduction Polypharmacy is an increasing concern in medicine which will lead to prescribing errors, serious drug interactions and potentially inappropriate prescribing. Aim To improve recognition of ‘Polypharmacy’, routine medication reviews during patient admissions and better communication and awareness of ‘Polypharmacy’ to General Practitioners (GP). Methods This audit consisted of two cycles both performed over 6 weeks. Inclusion criteria: patients aged 65 < and on 6 < medications, admitted to Elderly Care ward at Chelsea and Westminster hospital. Interventions after the first cycle included education such as encouragement of clear documentation in medical record and GP summary, introduction of medication reviews as part of ward round, collaborative work with pharmacists. In the second cycle Potentially Inappropriate Medications (PIMS) were assessed using the STOPP/ START criteria approved by NICE guideline has been used to review medication regimes and highlights PIMS. Results First cycle 30 patients were recruited with an average age of 79.2 (13males and 17 females). An average number of PIMS at the time of admission was 1.3 and 0.5 on discharge. Only 1/30 (3.3%) has ‘Polypharmacy’ documented and medication reviewed; Medications Reconciliation was 29/30 (96.7%). None of the patient has documentation for Polypharmacy. Second cycle 29 patients were recruited with and average age of 80.1. (7 males and 22 females). PIMs on admission was 1.3 and 0.3 on discharge. 25/29 (86.2%) patients had ‘Polypharmacy being documented and Medication review for 29/29(100%). Medication Reconciliation was 29/29(100%). Most Common PIMS across both cycles were statins, antihypertensive and Proton Pump Inhibitor. Conclusion The interventions complete improved significantly the awareness of Polypharmacy. There is a significant increment in number of medication review of 96.7% and 82.9% on documentation for ‘Polypharmacy’, and 20% reductions in PIMS on discharge.

BACKGROUND

Physical rehabilitation is related to better surgical and medical outcomes for patients (WHO, 2021). In hospitals, the role of the rehab team is essential to promote faster and better recovery and to prevent falls (Brett et al., 2019). We wanted to review the communication between the rehab, nursing, and medical team to aid discharge planning. Better communication can reduce repetition.

METHODS

A baseline survey was given to doctors, nurses, and rehab staff in a geriatric ward to review communication. The intervention was an A4 template highlighting the patients’ baseline and current function, which was placed by the bedside. A repeat survey was done to evaluate the effectiveness.

RESULTS

Survey 1 had 13 participants. Survey 2 had 25 participants. At least 90% of doctors and nurses strongly agree that they need to know patients’ ability to transfer, mobilise, wash, dress and falls risks. One hundred per cent of the rehab team agrees that patients’ rehab status is not clearly communicated between different members of the MDT which improved to 71.4% after the intervention. After the intervention, 20% of doctors agree that they struggle to find rehab status information, compared to 66.6% before, and 60% of doctors agree that they still find themselves asking other members of the MDT about patients’ rehab status, compared to only 37.5% of nurses.

CONCLUSION

To know patients’ rehab status is extremely important for their medical management, nursing management, and for their safety. A simple intervention had improved the awareness of patient rehab status, reducing time wasted on repetition. Another cycle to further improve communication by a teaching session will be conducted at each rotation to ensure sustainability.

INTRODUCTION Falls have significant morbidity and mortality in Nursing Home (NH) residents. By improving education to NH staff we aim to reduce 999 calls and associated adverse outcomes. . NH residents are more likely to fall than people living in the community and are more at risk of further falls as interventions and risk factor modification is more difficult.

METHODS Phase 1 - Ambulance calls, where a vehicle attended the scene, between 01/01/2020-28/02/2022 from NH in Swansea Bay University Health Board (SBUHB) concerning Falls/?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were analysed and survey was sent out to all NH. Phase 2 - Education was provided about CWTCH (hug in Welsh) and staff were surveyed post intervention Can you move them, Will it harm them? - new neck/back pain, anticoagulation, Treat them – analgesia, wound-care, Cup of Tea – can eat & drink , Help – when contact 999.

RESULTS Phase 1 – Between 01/01/2020-28/02/2022 4907 calls, 866 were falls (17.65%) and 1032 ?Falls (21.07%), 60.49% conveyed to hospital. 47% of NH do not have falls guidelines and 100% patients are Nil by Mouth and 88.24% are not moved. Emergency services were contacted 88.24%. Phase 2 - Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients with 90.98% less likely to contact 999 and 75.40% not having previous training with 96.72 % more confident in giving analgesia.

CONCLUSIONS Falls remain a significant burden and a rapid service would improve care with conveyance reduction to 53.1% post education (60.55% pre-education). Future directions include offering this education to NH in Neath/Port Talbot. From March 2022, we offer same-day assessment for NH residents (and others) from primary care and ambulances and are developing a PRN analgesia pathway e.g.PENTHROX

Introduction: A large proportion of Morriston Hospital’s acute medical take consists of elderly patients admitted with falls. Postural hypotension is a cause of syncope and fall which contributes to morbidity, disability and death in cases of injury in the frail and elderly population¹. Hence, diagnosing and treating postural hypotension is crucial. It is important that the measurement of lying-standing blood pressure (LSBP) is consistent to ensure reliability of results as this would affect patients’ management. The aim of this project is to assess how postural hypotension is diagnosed in various clinical areas and assess the quality of detection.

Methods: We designed a survey to identify baseline variation in method and accuracy in measuring postural hypotension and compared it against National Audit in-patient Falls RCP “Falls and fragility Fracture Audit Programme”¹. The survey was distributed across acute and general clinical areas involving staff nurses, healthcare assistants and junior doctors. We collected and analysed the data, implemented outcomes and re-conducted the second PDSA. Grand Round presentation and worked-based tutorial sessions based on the above was our intervention.

Results: 57 staff members (acute medical, surgical wards and emergency department) participated. PDSA2 showed improvement of >25% of participants allowing patients to rest before initial BP measurement compared to PDSA1. There is an improvement of approximately 7% in repositioning the patient. 47% measured standing BP between 1-3mins at PDSA1 and this has doubled in PDSA2.

Conclusions: This study showed the importance in ensuring consistency in measuring LSBP. There was significant variation in timing and measurements which have impacted the results and interpretation of postural hypotension. The education sessions had positive impact and is also a sustainable practice.

References: 1. Royal College of Physicians, Falls and Fragility Prevention Programme. (FFFAP)

Introduction

Heart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol.

Methods

We developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management.


Results

ACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels.


Conclusions

Through introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.

Background Polypharmacy is a recognised burden on patients with frailty. Medication reviews as part of comprehensive geriatric assessment (CGA) ensure appropriate prescribing and minimise harms. This project aimed to develop and initiate a pharmacist delivered frailty medication review tool to enhance existing CGA within our acute frailty service. Methods A structured in-patient medication review tool was developed based on the STOPIT and STOPPFRAIL tools for patients with a clinical frailty score (CFS) of >4. Initial work tested this on 20 patients in our frailty ward evaluating usability and efficacy. A sample of patients seen by the acute frailty team were audited against this tool. Data was collected on falls risk medications, Anticholinergic Burden (ACB), medications stopped, medications to review and cost savings. On identifying the potential benefits, this tool was trialled by pharmacists on all elderly care wards with similar outcomes collected. Results. Twelve acute frailty inpatients’ CGAs were audited against the tool. Five had some evidence of a polypharmacy review but no FRAX or ACB scores were completed. 58% of patients were on 3 or more 'falls medications. Overall, 19 medications should have been stopped, 5 medications could have been reduced and 14 medications highlighted for review in primary care, with a potential cost saving of £956.35/year. After initiating pharmacist reviews with the tool, 34 of 34 patients had a review, 80% of FRAX scores were documented, ACB score was completed for all patients. All patients were taking medications that increased risk of falls (average 3.5/patient) with 16 patients on ≥4. Eighty-five medications were stopped, 10 medications reduced and 33 medications highlighted for review in primary care, with a cost saving of £2755.29/year. Conclusions This project developed a pharmacist delivered acute frailty polypharmacy tool which enhanced existing frailty medication reviews with potential cost savings.

Background: Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Our aims: improve delirium detection using the 4AT screening tool as a validated approach, Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Methodology: Plan Do Study Act (PDSA) methodology was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results: Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion: Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway.Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.

A platform presentation to allow evaluation of diagnostics used in a Frailty Hospital at Home . An analysis of the data and a chance to explore the affect of diagnostics on subsequent hospital admissions or number of community team visits. Affect of diagnostics on management plans developed and whether they align with a person's documented goals. Data collected as part of an audit looking at the number of diagnostic tests taken by the Frailty Hospital at Home team. Subsequent outcomes including the number of hospital admissions, treatments started at home, subsequent number of community team visits and advance care planning were considered.

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.