Clinical Quality

Introduction

Delirium affects up to 50% of the elderly who are admitted to in-patient facilities. Delirium is preventable in 30-40% of geriatric in-patients. Trust guidance recommends an initial screening for all admissions >65, followed by continuous monitoring. This initial screening is documented using the 4AT delirium assessment tool and documented as a proforma. ‘’Do you think the patient is more confused than before ?’’ is the single question in delirium (SQiD) rated positive or negative by clinical staff on reviews. The concept of SQiD is to facilitate a quicker and easy-to-use approach to screening delirium prior to longer delirium assessment for confirmation as appropriate. This project aims to improve the adherence to delirium screening in accordance with local trust guidelines in a geriatric ward in a tertiary hospital and record the efficacy of SQiD usage.

Method

A baseline audit was conducted retrospectively from April to May to assess the adherence to trust guidelines. An educational poster to introduce SQiD and encourage the filling of proformas. In addition, brochures and face-to-face interviews were conducted with the nurses to promote the usage of SQiD. The SQiD question was incorporated into the nursing care rounds and usage was recorded from June through July. The percentage of adherence to guidelines was prospectively analyzed.

Results

Retrospectively, 9% of ward admissions had adhered to trust guidelines from months April to May. The introduction of SQiD significantly increased the filling of proformas to 88% from June through July. The number of SQiD documented increased from 0% to 89% after introducing the brochures and face-to-face interviews.

Conclusions

Although this project could be viewed as a success, the requirements for sustainability depend upon addressing limitations for the completion of proformas and ongoing training. Given SQiD’s ease of use and time efficiency, it serves good promise to improve recognition.

Introduction

Dysphagia affects a large proportion of patients in hospitals and the community. Poor management of dysphagia results in aspiration pneumonia, malnutrition, and poor quality of life. Management, as recommended by Speech and Language Therapists (SALT), with the strongest evidence base for reducing aspiration pneumonias, is diet modification such as thickened fluids (Rosenvinge S, Starke I. Age and Ageing. 2005;34(6):587-593). Safe management of dysphagia is important discharge, as such this study focused on patients being discharged with fluid thickeners.

Method

We assessed current rates fluid thickeners being correctly prescribed on discharge medications by analysing data sets of patients discharged by the inpatient SALT from January to February 2022; including rejected referrals, deceased patients and discharges without fluid thickeners (n=223). 26 data sets were further analysed, after applying inclusion and exclusion criteria. Data was collected on whether thickeners were prescribed as inpatient, on discharge alongside analysis of nursing notes and SALT plans.

Results

Overall, 69.2% (n=18) of patients had thickeners correctly prescribed on discharge. Of the remaining 30.7% (n=8) without thickeners prescribed on discharge, 87.5% (n=7) of these were also not prescribed as inpatient. Whereas only 9.01% (n=1) of cases had thickeners prescribed inpatient but missed on discharge. 92.31% (n=24) of nursing notes included SALT recommendations and noted that thickeners were being given.

Conclusion

Results highlighted that the burden of administrating thickeners in hospital fell upon the nursing staff who used a communal stock of fluid thickener, regardless of inpatient prescription. A recommendation put forward to doctors, and to be included in SALT plans is to prescribe thickeners on inpatient charts, to reduce chances of missed prescriptions on discharge. Similarly, including SALT recommendations in discharge summaries will aid correct prescribing for patients in their future admissions. Further education and dissemination of the importance of dysphagia management will also be beneficial

QIP topic was to improve emollient prescriptions for patients admitted to Elderly Care Unit as not all elderly care patients who are already prescribed emollients by General Practice through regular medication or current acute medication are being prescribed these when inpatient.

The aim of the QIP was: By April 2022 we will increase the number of emollient prescriptions for elderly care patients admitted to elderly care unit who are already prescribed these in general practice by 20% The QIP measures were identified which included % emollients correctly prescribed to relevant patients and number of emollient correctly prescribed to relevant patients on a run chart on LIFEQI. Use of QIP methodology demonstrated. Used EPR which is the electronic patient system to check that patient clerked into Elderly Admissions Unit were being prescribed their regular or current acute emollient. Change implantation in the first cycle included teaching doctors at handover the importance of emollient prescribing and putting up leaflets in the Elderly Admissions Unit. Data was then collected and plotted on a run chart to see if patients admitted to Elderly Admission Unit were being prescribed their regular or current acute emollients through the electronic patient system. Evaluation of change as seen by analysis data from run chart. Prior to intervention emollient prescription was at 47% then went to 76% after first intervention and hence aim of Quality Improvement Project achieved. Another cycle was done to ensure it was more sustainable and to increase emollient prescription further. This involved emailing the new doctors rotating into Elderly Care importance of emollient prescription and another teaching session. After the second intervention emollient prescription went up to 88%.

Introduction:

The number of older people living with frailty in Swansea Bay is increasing. Currently there is no dedicated rapid access multidisciplinary team (MDT) clinic for older adults living with frailty within Swansea Bay University Health Board (SBUHB). As a response to this, the team at Singleton Hospital (SBUHB) piloted a rapid access MDT clinic.

Method:

The ‘Rapid Access Clinic for the Older Person’ (RACOP) pilot ran for eight weeks across May and June 2022, delivering three clinics per week. Comprehensive Geriatric Assessment was provided via a multidisciplinary team consisting of a Consultant or Specialist Registrar in Geriatric Medicine, Advanced Nurse Practitioner, Pharmacist and Therapy Team.

Results:

41 referrals were screened and 30 patients were booked in to clinic. Of those 30, 25 were assessed. Referrals came from a variety of sources and on average, patients were seen in clinic within 5.9 days of referral. The 25 patients assessed were predominantly female (72% female and 28% male) and the ages of patients ranged from 57 to 99 years old, with the average age being 81 years old. Rockwood Clinical Frailty Scale (CFS) scores showed that 96% of patients assessed had a CFS of ≥4 and 33% had a CFS ≥6. In keeping with this pattern of frailty, all the patients were co-morbid, with 92% having more than five co-morbidities. Patients with a range of diagnoses were assessed and following assessment, only two patients required a follow up appointment. Patient experience data was collected using a validated patient experience form. All patients left positive comments and unanimously said they would recommend the service to family and friends. Staff feedback data was equally as supportive of the service.

Conclusion:

The older adult population of SBUHB would benefit from a service of this type and the patients and staff are supportive of this.

Introduction:

Older patients undergoing surgery are often living with frailty and are subsequently at increased risk of morbidity, mortality and loss of independence in the perioperative period. Accurate identification of frailty using an objective tool such as the Clinical Frailty Scale (CFS) is an imperative part of preoperative risk assessment. It also informs which patients should undergo Comprehensive Geriatric Assessment (CGA) by our Perioperative care of Older People undergoing Surgery (POPS) service.

Method:

The POPS team provided training to Surgical Assessment Unit (SAU) triage staff over a week-long period, including how to calculate and record the CFS electronically for all patients age 65 and over presenting to the unit. Once embedded, accuracy was assessed by comparing triage staff CFS scores with those calculated by the POPS team.

Results:

Fourteen SAU staff members received training. There has been a 20% initial increase in the CFS scoring compliance from 22% to 42%. Compliance has been variable and impacted by several factors including relocation of the unit and new staff members. At its peak compliance was 67% - attributed to a change in data entry procedure with the ward clerk entering the score following triage, which improved electronic capture. CFS scoring accuracy was reviewed over 7-weeks. Of the 39 CFS scores compared there were 5 matches, 8 non-matches, 19 without a CFS recorded by triage staff and 8 not recorded for other reasons. All of those not matching were underestimated by up to three CFS scoring intervals.

Conclusion:

There has been an increase in CFS scoring compliance within SAU. Further improvement work is required to increase the number being assessed and improve the accuracy of scoring. Further staff training, initiation of a ‘frailty champion’ in SAU and visual prompts including a display board are planned to increase and sustain CFS compliance and accuracy.

Introduction

In The UK around 519,000 new fragility fractures occur each year, with vertebral compression fractures among the most common1. Around 21% of vertebral fractures are incidentally found on radiological imaging2. Within Aneurin Bevan University Health Board (ABUHB) there is no formal pathway for managing incidental vertebral fractures identified on radiological imaging.

Objective

To retrospectively quantify the burden of incidental vertebral fractures and their subsequent management across a large UK Health Board. Method Patients with incidental fractures on CT scans were identified between 1st August 2020 to 1st February 2021 at ABUHB. Exclusion criteria included fractures secondary to malignancy or major trauma and death within 2 years. A pathway for management of new incidental vertebral fractures was devised and was introduced to one Care of the Elderly ward at the Royal Gwent Hospital. Results 233 patients with incidental fragility vertebral fractures were identified. 60% (139/233) were deceased and excluded. Of the patients included in the study 29% (27/94) were previously on bone protection, 19% (18/94) were commenced on bone protection, 47% (44/94) were commenced on Vitamin D, 38% (36/94) were commenced on Calcium, 12% (11/94) had a DEXA scan arranged and 17% (16/94) had orthogeriatric follow up. Care of the Elderly specialty noted the greatest burden at 40% (37/94).

Conclusion

Results indicate a significant mortality associate with osteoporotic fractures. Continuing development of the pathway for management of incidental fragility fractures and expansion throughout the health board may result in sustained improvement. 1. Borgström F, Karlsson L, Ortsäter G, et al. Fragility fractures in Europe: burden, management and opportunities. Archives of Osteoporosis 2020; 15(1): 59. 2. Bartalena, T., 2010. Incidental vertebral compression fractures in imaging studies: Lessons not learned by radiologists. World Journal of Radiology, 2(10), p.399.

Introduction

Frail adults should be offered comprehensive geriatric assessment. Falls are the most common reason for conveyance to hospital for Nursing Home (NH) residents in SBUHB and are associated with mortality, morbidity and are a significant burden on Welsh Ambulance Service (WAST) and the Emergency Department (ED). Older people are often subject to long ambulance waits and offload delays. By using a collaborative approach, we aim to reduce hospital conveyance rates and adverse patient outcomes.

Methods

Phase 1 - WAST calls analysed January 2020 – February 2022 from Swansea Bay UHB NH concerning Falls/ Potential Falls where an Emergency vehicle attended the scene. Education provided about post-fall management in Swansea NH’s in March 2022. Phase 2- Development of a referral pathway with Acute-GP unit (AGPU) and Advanced Practice Paramedic (APP) colleagues who review the WAST “live stack” allowing calls to be diverted to Older Person’s Assessment Service (OPAS). OPAS also offer same-day assessment for NH residents (and others) directly.

Results

March-July 2022, 980 calls from SBUHB NH, 195 falls (19.9%), additional 228 potential falls (22.67%). There was significant change in conveyance (p <0.05) with no change in call nature or call frequency (p >0.05). Per month, the mean conveyance reduction was 20 patients. In addition, OPAS review 8 (mean) patients from NH directly each month, bypassing WAST.

Conclusions

Falls remain a significant burden on ED and WAST and we have shown education plus collaboration between AGPU, WAST and OPAS shows significant conveyance reduction, ultimately delivering a better patient experience and system efficiency. Each call-out has a cost per hour of £101.34, with average offload for those >65 years old being 406 minutes, saving a minimum of £25000 a month. Future directions include expanding post-fall education to NH in Neath/Post Talbot and WAST first responders and piloting a rapid-response vehicle

Aim:

There been several studies validating the Hospital Frailty Risk Score (HFRS) to identify frailty. (1),(2). We proposed that it could identify patients in the Emergency Department (ED) who would benefit from the Older Persons Assessment Service (OPAS).

Methods:

OPAS is an ED service which accepts patients on frailty criteria (aged >70 years, falls, confusion, care dependence, polypharmacy and poor mobility). A retrospective analysis of the OPAS databank was conducted using HFRS to divide patients in High/Intermediate and Low Frailty Risk. We considered Age, Clinical Frailty Score (CFS), Post-code with Deprivation Index and death within a year of attendance.

Results:

700 admissions: 400 High/Intermediate HFRS and 300 Low HFRS. High/Intermediate HFRS: 170 (42.5%) male, mean age 83.69 years, CFS 5.7. Low HFRS: 102 (34%) male, mean age 81.46 years, CFS 4.5. High HFRS vs Low HFRS had similar deaths (p=0.2) but a significant difference in CFS (p<0.05). HFRS was significant at detecting frailty in those <75 years old (p<0.01) but not at >76 (p=0.08). There was no association between the Welsh index of multiple deprivation with Frailty or Death. The HFRS Sensitivity is 0.44, Specificity 0.83, Positive Predictive Value 0.66, Negative Predictive value 0.34, Area under the curve 0.39 vs CFS.

Conclusion:

The HFRS identified 57% of the retrospective OPAS cohort, with the addition of >80yrs of age, the modified score identifies >85% of service users. We found that controlling for socio-economic status, quality of discharge summaries and coding had no relationship to the efficacy of HFRS as a screening tool. We have developed an electronic, automated Frailty Flag that operates in real-time to signpost appropriate patients who would benefit from OPAS, Orthogeriatric or POPs services (this facilitates patients to be ‘flagged’ for review as stated within NELA.) The Frailty flag is currently being tested in clinical practice.

Introduction: Most stroke patients fail the swallowing assessment, hence the need to have NGT. Sometimes, it is impossible to get an aspirate from these NGTs, other times, the pH of the aspirate is quite high. As such times, to confirm NGT position, in line with the National patient safety agency an Xray is used. Recently, incidents in the trust (UHCW) have been documented regarding NGT Xray interpretation, thus the need to undertake this audit

Methods: Patients (n=15) who had NGT in the stroke ward (24th March to 20th June,2022) were reviewed against University of Coventry and Warwickshire Trust guidelines. The following were assessed: date and time Xray was requested, how it was interpreted, clear instructions regarding action, interpreter’s grade and use of NGT stickers. Data was analysed using percentages and illustrated with bar charts. These were compared with data from the first audit.

Results: The adherence to the assessed variables (date and time Xray was requested, how it was interpreted, clear instructions regarding action, interpreter’s grade and use of NGT stickers) were 77%, 46%, 73%,70% and 40% accordingly.

Conclusion: There was an improvement in documentation of date and time of requested Xray a well use of NG Tube stickers by doctors in the stroke ward, this is in contrast to documentation of the 4 point check and clear plan instructions.

Introduction:

Suprapubic catheter (SPC) insertion is recognised as an alternative to urethral catheterisation to enable urinary drainage or continence control. This audit aims to establish the 1 and 2 year mortality associated with SPC insertion and to identify factors that may be linked with mortality.

Methods:

Data were collected for demographics, medical co-morbidities, indication for procedure and mortality from 1st February 2018 to 1st February 2020 across three NHS trusts. Multivariate regression analysis was undertaken to assess correlation between mortality and collected data.

Results:

48, 12 and 8 (total 68) SPC insertions were identified at the respective trusts. Two patients were excluded owing to a lack of mortality and cognitive data. Total mortality was 10.4% (7/67 patients) at 1 year and 16.4% (11/67 patients) at 2 years. Two-year mortality for those with a clinical frailty score (CFS) ≥3 and <3 was 21% (6/28) and 13% (5/39), p>0.05. Two-year mortality in those aged over and under 71 was 21.6% and 10.3% respectively. Other collected risk factors were not associated with increased mortality.

Conclusion:

Our study has demonstrated increased mortality rates in both the moderately to severely frail population and in elderly patients. These results have triggered the entry of SPC insertion onto the Model Hospital dashboard which states a national 1 year mortality rate of 15.4%. Clinicians should continue to be judicious when considering patients for this procedure.