Clinical Quality

Title

Evaluation of a new regional pathway for Medicines Optimisation in Older People (MOOP) medicines adherence pharmacist optimising medicines in older people referred by Northern Ireland Ambulance Service (NIAS)

Authors & Provenance

PCrawford1; SJohnston1; PGalbraith1; PTennyson1; CDarcy2; CMcGuigan2; KMiller3; JPatterson3; JAgnew4; JMcGennity4; HMcKee5; ACunningham5; CStevenson5; KBloomer6.

1. MOOP Pharmacy Medicines Adherence Service, Belfast Health and Social Care Trust
2. MOOP Pharmacy Medicines Adherence Service, Western Health and Social Care Trust
3. MOOP Pharmacy Medicines Adherence Service, South Eastern Health and Social Care Trust
4. MOOP Pharmacy Medicines Adherence Service, Southern Health and Social Care Trust
5. MOOP Pharmacy Medicines Adherence Service, Northern Health and Social Care Trust
6. Consultant Paramedic Urgent Care, Northern Ireland Ambulance Service

Introduction

The Regional Medicines Optimisation in Older People (MOOP) Medicines Adherence Pharmacy team review medicines for older people at home across Northern Ireland (NI). Northern Ireland Ambulance Service (NIAS) are often the 1st responders to older people at home requiring medical attention, & identify medicines adherence issues, which may lead to Emergency Department presentation and hospitalisation if not addressed. 

In July 2023 a new pathway to enable NIAS first responders to refer people ≥65 years for a medicines adherence review was piloted.

• Age ≥65 years
• Medicines adherence issues
• Patient consents to referral

Pharmacist Interventions were graded using the Eadon grading scale¹ & ScHARR cost avoidance estimates^2,3, which defines costs related to Adverse Drug Events (ADEs) were applied (Table 1).

Results n=12

Reason for referrals by NIAS included older people with multiple unused medicine compliance aids, suboptimal pain management, or confused about their medicines.

Time spent by the pharmacist reviewing patients ranged from 60 to 400 minutes (average 170 minutes per patient). Clinical interventions included blood pressure measurement, deprescribing of inappropriate medicines, optimising pain management, & supply of adherence aids.

Table 1: Cost avoidance^2,3 of medicines adherence pharmacist optimising medicines

Invest to save: £6.40- £14.52 for every £1 invested.

Conclusion

A collaborative pathway between medicines optimisation in older people pharmacy service and the Northern Ireland Ambulance Service, let to cost effective improvements in medicines optimisation for older people.

References

1.Eadon, H. Assessing the quality of ward pharmacists’ interventions. Int J Pharm Pract. 1992; 1(3): 145-147.

2.Karnon J, Mcintosh A, Dean J et al. 2008. Modelling the expected net benefits of interventions to reduce the burden of medication errors. J Health Serv Res Policy2008; 13: 85-91.

3.Mair A, Scott M, Kirke C. iSimpathy Evaluation Report Edinburgh 2023 ISBN978-1-3999-6298-8.

Background 

Specialist, hyperacute management of a transient ischemic attack (TIA) is necessary to decrease subsequent stroke. As part of a local Quality Improvement (QI) initiative, we implemented a new TIA pathway in our hospital to maximise efficiency, encourage an ambulatory approach, and improve global TIA management in line with the 2023 UK and Ireland Clinical Guidelines for Stroke. 

Method 

We completed a retrospective cohort study of patients who attended our hospital between April 1, 2024, and June 30, 2024. Patients with a primary diagnosis of TIA were identified through the Hospital In-Patient Enquiry (HIPE). Each diagnosis was verified with electronic records review, with exploration of key investigations and management parameters. 

Result 

28 patients were coded as TIA. 28.5% were seen directly via Acute Medical Unit (AMU), increased from 10.1% pre-TIA pathway, with the rest attending ED initially. The median length of Stay (LoS) in hospital was 0.65 days, down from 1.08 days pre-TIA pathway for those managed directly in AMU. 35.7% were managed within 24 hours, vs 28.2% prior to new pathway initiation. Most patients were admitted under the AMU (35% vs 33% pre-pathway) or Stroke service (42.9% vs 26% pre-pathway), with a shorter LoS if the patient was admitted under these services. 27 (96.4%) patients underwent neuroimaging; 89.3% underwent CT Brain vs 94.8% pre-pathway, 7% underwent MRI Brain without preceding CT in keeping with National Clinical Guideline for Stroke for the UK and Ireland recommendations. 96.4% were reviewed by a stroke specialist vs 82.1% pre-pathway. Utilisation of inpatient echocardiograms and 24-hour holter monitors were reduced to 35.7% and 21.4% respectively, down from 42.9% pre-pathway. 

Conclusion 

This re-audit has shown improved neuroimaging utilisation, increased numbers of patients being reviewed by stroke specialist clinicians, increased use of ambulatory services, and reduced length of stay.

Introduction: Anticholinergic medications are associated with cognitive decline and increased risk of falls. This link is dose dependent and has been shown to decrease with medication discontinuation, therefore reducing the anticholinergic burden of patients represents an opportunity to prevent patient harm and improve quality of life. This project aims to improve patients’ anticholinergic burden (ACB) scores following admission to Meadowlands Care of the Elderly Unit and presentation to the Frailty Assessment Unit. 

Methods: We began by conducting two simultaneous audits in the inpatient and outpatient setting. We audited ACB scores on presentation and on discharge from the inpatient ward or following clinic review as appropriate. We then completed two PDSA cycles. Our first intervention involved a teaching session for doctors on the risks associated with anticholinergic medication and the benefits of reducing ACB scores. Our second intervention was a poster directing staff to the ACB calculator and raising awareness of the risks of anticholinergic medications for our patients. 

Results: In both the inpatient and outpatient setting, and regardless of intervention, the average ACB score improved following admission or outpatient review. In the inpatient setting the average reduction was 0.57, and in the outpatient setting the average reduction was 0.35. However, there was no clear improvement in the reduction of ACB scores associated with any of our interventions. 

Conclusion: While it was encouraging to see that following admission under the Care of the Elderly Team or after review at the Frailty Assessment Unit there was a reduction in patients’ anticholinergic burden, this reduction is small and could potentially be improved. Unfortunately our interventions did not bring about this improvement. There are multiple possible reasons for this, including the rotational nature of trainee medical staff and the lack of pharmacist involvement.

Introduction: The Irish Hip Fracture Database (IHFD) is a national clinical audit that measures standards of care for hip fracture patients across trauma sites in Ireland. Early mobilisation is considered to be one of the most influential modifiable factors for improving outcomes post hip fracture in older adults. The development of a mobility standard within the IHFD has provided a framework for physiotherapists to provide early mobilisation for hip fracture patients nationally. 

Method: Each of the sixteen trauma sites in Ireland enter data into the IHFD. The data is analysed by NOCA and published in annual reports. 2018 saw the commencement of reporting mobilisation post-operatively as part of the IHFD. In 2022, a formal clinical standard for mobilisation, titled Irish Hip Fracture Standard seven (IHFS 7) was introduced. The standard requires patients to complete a stand on the day of or day after surgery by a physiotherapist. Functional measures including the Cumulative Ambulatory Score (CAS) and the New Mobility Score (NMS), are also recorded to guide goal-orientated rehabilitation and quality care for this cohort. IHFS 7 has also led to the formation of a physiotherapy network, designed to encourage shared learning and knowledge for therapists. 

Results: Mobility rates have increased from 7% in 2018 to 87% in 2023 on day one post surgery. Weekend physiotherapy service provision have also increased based on organisational surveys completed nationally. The majority of Irish hip fracture patients demonstrate low functional ability pre-fracture (52%), as graded by the NMS, with only 24% achieving independent mobility by day of discharge. 

Conclusion: The introduction of IHFS 7 has been successful in supporting early mobilisation. Work needs to continue in enhancing completion rates for our functional outcome measures and evaluating barriers to mobility in the early post-operative phase.

Introduction: Ireland's population aged 65 and older increased by 40% in the last decade. ALONE is a national organisation that enables older people at age at home. The ALONE model is being delivered within the Enhanced Community Care (ECC) programme, which aims to ensure health services work in an integrated way to meet population needs. This presentation, designed using the RE-AIM Framework, presents preliminary effectiveness results from ALONE's national service evaluation. 

Methods: Phone-based surveys using validated measures (Shortened Warwick-Edinburgh Mental Wellbeing Scale, EQ-5D-3L, UCLA Loneliness Scale-3) were conducted with participants at baseline and three months into service. These measures were selected and piloted by the project team, which includes older people and volunteers. 

Results: 272 participants completed the first survey (62.5% were female, 51.5% aged 75-85). Almost all (97%) had at least one chronic illness, 98% identified as white and 95% were not working. Participants had higher levels of loneliness (M= 5.7; SD = 2.2), lower wellbeing (M= 23.81; SD = 4.3), and lower health-related quality of life (M = 59.6, SD =23.6) compared to national studies. Preliminary analysis of data from 212 older people who participated in Time 2 indicated incremental improvements in loneliness (M T1=5.7; M T2=5.5) and self-reported health (M T1= 59.6; M T2 = 64.7). There were some changes in the percentage of people reporting no pain (T1=19.3%; T2 =21.2%) and not feeling anxious or depressed (T1=38.7%; T2=40.1%). Moreover, the average number of GP consultations (T1M = 2.32; T2M=1.93), A&E calls/attendance (T1M=.24; T2M=.09/T1M=.43; T2M=.17), planned (T1M=.30; T2M=.12) and unplanned (T1M=.58; T2M=.24) hospital stays per participant decreased. 

Discussion: These early findings demonstrate modest improvements across several areas within three months of ALONE support. This provides important evidence supporting the effectiveness of community-centred care coordination as part of the wider system.

Introduction:

Despite clear national guidelines and government support for Fracture Liaison Services, the osteoporosis treatment gap remains significant.  The Fracture Liaison Service Database (FLS-DB), a national audit run by the Royal College of Physicians (RCP), has recently expanded its reporting to highlight this issue.

Method:

Previously the FLS-DB benchmarked data from those trusts submitting data to the audit.  From January 2025, an extra column has been added to show ‘Missed Opportunities’ that includes data from sites not participating in the FLS-DB.  Using local hip fracture data for 2022 from the National Hip Fracture Database (NHFD) figures, the predicted local FLS caseload was determined by multiplying the number of hip fractures by 5.  Expecting 80% of the predicted caseload to be identified, at least 50% of those to be recommended treatment (accounting for mortality, severe comorbidities etc.) and 80% of those initiating and staying on treatment up to 12 months gives the expected on treatment population. This was compared with the data from the FLS-DB and NHFD KPI set to generate the number with a missed opportunity.

Results:

77 FLS are participating with the FLS-DB with 82 NHFD sites not covered by an FLS. While 80,767 records were submitted in 2022, the missed opportunity count was estimated to be 56,550 patients (48,214 in England and 6,180 in Wales) per annum. When the missed opportunity estimate was analysed in 36 ICSs, there was an over 10 fold difference in the estimate.

Conclusions:

Despite clear guidelines and prioritisation of FLSs, over 50,000 patients are not on osteoporosis treatment when they should be. By making this data visible at the local hospital and ICS / Health board level, care providers can better judge the level of resources required for FLS locally, and the data provides support for ICSs in FLS implementation. 

Venous thromboembolism (VTE) prophylaxis is commonly administered to patients across many hospital settings; however, it can be more challenging to address in frailty patients. These patients are more likely to have contraindications to anticoagulation and be “delayed discharges” (medically fit for discharge and at baseline mobility), at which point VTE prophylaxis may not be indicated. 

Method: This quality improvement project was carried out in the acute geriatric ward at St John’s Hospital. With the aim to improve VTE prophylaxis (appropriately prescribed and deprescribed when delayed discharge) in frailty inpatients by December 2024, through education of medical staff and by creating a Trak proforma. Teaching was provided to ward medical staff and a new delayed discharge Trak proforma was created. This prompted a review of VTE prophylaxis deprescribing when patients were medically fit for discharge. A simultaneous QI project created an admissions proforma which prompted a review of VTE prophylaxis prescribing when a patient was first admitted to the ward. 

Results: Before the intervention, only 58% of patients in Ward 8 had VTE prophylaxis correctly prescribed on admission. Many patients (40%) remained on VTE prophylaxis despite being delayed discharges. A staff survey revealed a higher confidence level around prescribing VTE prophylaxis than deprescribing. Only 44% of staff regularly considered stopping VTE prophylaxis once a patient was a delayed discharge. After the intervention, an increased number of patients (74%) had correct VTE prescriptions on Ward 8 admission (28% improvement). Only 16% of delayed discharge patients remained on VTE prophylaxis (60% improvement). 

Conclusion: This project improved rates of VTE prescribing in patients admitted to an acute frailty ward and deprescription rates in patients where VTE prophylaxis was no longer indicated by prompting regular reviews of these prescriptions. This intervention could be utilised in other departments

Introduction
Observations of the acute medical take suggested that patients who sustained a fall were affected by long delays and wait times to see both A+E and medical doctors. We felt that analgesia prescribing in these patients, many of whom sustained injury, was done poorly and some were being left without any analgesia leading to a negatively perceived patient journey. Our aim was to assess analgesia prescribing practices for patients following a fall with a view to improving experience.
Method
We completed three rounds of data collection, with 20 patients in each. We included patients coded as having a fall on admission and excluded patients under 70. We manually reviewed the case notes to see if patients had a pain assessment on admission and whether they were prescribed analgesia by the A+E team, the medical admissions team or on the post-take ward round. Our intervention was a presentation and education session to the acute medicine and geriatrics departments following each cycle, with the aim of involving both junior and senior decision makers with prescribing privileges.
Results
We reviewed 68 patients across all three data cycles and found that 40% of patients were not prescribed any analgesia by the A+E team. We found that the number of patients with regular or PRN analgesia prescribed rose to 70% once the medical and post-take had seen them. The proportion of patients that had no regular/PRN/stat analgesia prescribed throughout their entire acute patient journey fell from 28% to 16%.
Conclusion
Despite intervention, prescribing practices remained static. 1/3rd of patients did not receive regular or PRN analgesia following their admission injury despite seeing multiple clinicians. There was a modest reduction in patients who never received any analgesia at all following intervention.

Introduction

The timely administration of Parkinson’s Disease (PD) medications is essential for better motor symptom control, leading to improved patient outcomes. The NICE Guidelines and Parkinson’s UK recommend all hospital in-patients with PD should get their PD medications on time – within 30 minutes of their prescribed administration time. This audit aimed to assess the adherence of timely administration of PD medications amongst in-patients at South Tyneside and Sunderland NHS Foundation Trust, and to compare this pre- and post-interventions. 

Methods 

A two-cycle retrospective audit was conducted on November 2023 (pre-intervention) and July 2024 data (post-intervention). Data on all doses of PD medications administered in the trust, and whether they were given on time, was collected via our trust’s data warehouse application. On analysis, the percentage of PD medication doses given on time was calculated according to location. From this, six lower-performing wards were identified, and interventions for them (surveys, education and training) were carried out in April-May 2024. 

Results 

In November 2023, the trustwide percentage of PD medications given on time was 83.46% (n=2920), increasing to 88.32% (n=4024) in July 2024. Pre-intervention, the percentage of PD medications given on time across in-patient locations within the trust was varied, ranging from 0-100%. Post-intervention, there was more consistency – ranging from 50-100%, this evidenced improved performance achieved trustwide. All wards where interventions took place showed improved results, seeing 7.5-95.4% increases from their previous rates. New lower-performing wards which would benefit from interventions in future cycles of this audit were also identified. 

Conclusion

Over the two cycles, South Tyneside and Sunderland NHS Foundation Trust showed improvement in the percentage of in-patients receiving their PD medications on time. The post-intervention data also illustrates the positive impact of our interventions. Our work has been recognised as a best practice case study by Parkinson’s UK.

Introduction 

Delirium is a common presentation in geriatric medicine. Improvement in delirium assessment and management should improve identification of these patients and improve their outcomes. This Quality Improvement Project, completed by a group of Health Care for Older People (HCOP) resident doctors, aimed to improve delirium assessment and management for patients admitted to the five HCOP wards at Good Hope Hospital, Sutton Coldfield. 

Methods 

Patients with documented confusion were selected and delirium assessment/management was compared to current NICE Guidance. This included whether delirium screening was done, which screening tool was used, and how delirium was managed. Data was collected retrospectively from electronic patient records, anonymised, and recorded using an online form. Data from 85 randomly-selected patients admitted to HCOP wards in Good Hope Hospital during September 2024 was collected. Interventions of departmental teaching for all HCOP doctors and informative posters in common areas were implemented. Data collection was then repeated with 77 patients admitted during November 2024. 

Results 

Screening for delirium increased from 55.3% to 71.4% (+16.1%). Use of the NICE recommended 4AT tool increased from 30% to 43.9% (+13.9%). Implementation of non-pharmacological techniques (such as re-orientation) rose from 2.4% to 16.9% (+14.5%), and treating an identified cause rose from 75.6% to 94.8% (+19.2%). 

Conclusion 

Departmental teaching and educational posters were successful in improving delirium assessment and management. The largest improvements were in using a screening tool and treating an identified cause, which are largely undertaken by doctors. To improve further, educational efforts could be extended to the entire multi-disciplinary team. This may have resulted in more frequent use of non-pharmacological interventions. To implement long-lasting change, the posters have been provided to the department and delirium will continue to be taught in departmental teaching for future rotations of resident doctors.