Clinical Quality

Introduction

There are approximately 600 patients in the Pembrokeshire Movement disorder service, of whom, around 10% are either housebound or live in placements.   There is concern these patients struggle to access follow up due to difficulties in attending face to face clinics.  NICE and Parkinson’s UK recommend that people with Parkinson’s should be seen by a specialist healthcare professional every 6 to 12 months.

Method

A retrospective case note analysis was carried out for 55 patients that were identified as being either housebound or living in residential or nursing homes.  Data were collected on time since last clinic visit and last letter, hospital admissions in the past 2 years, number of prescribed medications and DNACPR status on Welsh Clinical Portal.

Results

The mean time since last clinic visit was 15.3 months, with the longest 81 months.  Housebound patients had a mean time since last clinic visit of 15.5 months and those in placements had a mean time of 15.3 months.   The time since last letter was lower, however those patients still in their own homes had a longer interval than those in placement.   53% of patients had a DNACPR decision recorded on Welsh Clinical Portal.  When isolating   housebound patients this dropped to 29%.  72% of those in placements had a DNACPR decision.

Conclusions

The requirement to see patients with Parkinson’s every 6 to 12 months is not being met.  This is likely due to practical difficulties of attending face to face clinics.   It is proposed to create a regular virtual clinic to discuss these patients, in combination with their relatives or carers and patient reported outcome measure questionnaires.  This will be brought to the health board Parkinson’s meeting in order to facilitate change.  Once the change has been implemented data can be recollected to establish the effect of the change.

Introduction: There are approximately 549,000 new fragility fractures each year in the UK and the prevalence of both osteoporosis and risk of falling increases with age. Care home residents are three times more likely to fall and have a 3- to 4-fold higher incidence of fractures than people of the same age living in the community. These older, frailer and multimorbid patients often have the highest fracture risk and therefore the most to gain from anti-osteoporosis treatments to reduce this risk. 

Method: Retrospective audit of residents who were reviewed by the newly started Enhanced Health in Care Homes (EHCH) team within the 5 residential homes for an initial comprehensive geriatric assessment (CGA) between March 2022-June 2024. These initial CGAs were reviewed to determine if a FRAX assessment had been completed and subsequent sub-analysis of those with high/very high FRAX scores to determine whether they were on appropriate bone protection. 

Results: 100% of residents (183) had a bone health assessment including a FRAX score (age-adjusted if appropriate). Prior to CGA, 37% patients with a high/very high FRAX score were on appropriate bone protection, having excluded patients who were not suitable for any treatment for reasons including poor renal function or not clinically appropriate. Following EHCH initial CGA and management plan, this average improved to 85% across the residential homes. The most significant improvement in one residential home was from 0% to 83% post bone health assessment. 

Conclusion: There has been a considerable improvement from 37% to 85% in the number of residents at high and very high risk of fractures who are on appropriate bone health protection following an initial bone health assessment and subsequent management plan initiated by the Enhanced Health in Care Home team. 

Background: The National Clinical Guideline for Stroke recommends bone health assessment for patients at higher risk of falls. Following stroke, patients have reduced bone mineral density, correlated with functional deficit. Stroke can result in reduced mobility, asymmetric weight bearing, poor nutrition and impaired Vitamin D stores. This results in higher risk of fragility fracture. However, bone health is often overlooked. An initial review on a stroke rehabilitation unit in March 2024 found no bone health assessment process. 

Objectives: Patients with stroke and high risk of fragility fracture should undergo bone health assessment and timely treatment or onward referral if indicated. 

Methodology: Patients undergoing stroke rehabilitation were identified as high-risk for fragility fracture based on age, gender, falls history, cognition, visual impairment and post-stroke seizures. Patients with life expectancy 1 year or predicted to be bedbound longer term were excluded. Data was collected over two cycles for 1 month (September 2024, November 2024). If high-risk, records were reviewed for serum calcium and Vitamin D measurement, FRAX score and treatment initiation and/or onward referral. 

Results: Local guidelines were developed with input from orthogeriatric and stroke physicians. Following initial analysis, 3/32 eligible inpatients (11.1%) had recorded FRAX scores with none initiated on therapy. Prompts were added to patient records and departmental teaching delivered. Significant improvement was seen in the following cycle: 43.8% (n=14) of eligible patients had bone health assessment. Serum Vitamin D measurement increased from 41% to 56% and all below threshold started replacement. Five patients were referred for bone densitometry and a further five were prescribed bisphosphonate therapy. 

Conclusion: Patients with stroke are at higher risk of fragility fractures. Increased awareness and assessment in the rehabilitation setting are required. Further improvements include displaying posters of the treatment flowchart, induction education for rotating doctors and additional electronic record prompts to increase engagement.

Introduction Delirium is a common, reversible condition with significant morbidity. Guidelines facilitate diagnosis and management (NICE Delirium Guidelines [CG103]). Previous audits in an acute frailty ward identified areas for improvement in assessment of delirium. In this cycle, a novel admission proforma was implemented to promote adherence to current guidelines. Methods This is a continuation of a previous quality improvement project representing cycles three and four. An admission proforma was co-developed with patients and the multidisciplinary team (MDT), primarily to prompt staff to complete delirium assessments. Adherence was audited and the proforma was modified based on feedback. An equivalent audit was then conducted on the updated proforma. The audit period occurred over several resident doctor changeovers. Primary outcomes; completion of delirium assessments, positive diagnosis of delirium and use of the new proforma. Secondary outcomes; completion of resuscitation and clinical frailty score (CFS) forms and the relationship between length of stay (LOS) and delirium or CFS. Results  The initial admission proforma was used in 86% of admissions. After its introduction, 53% of patients had completed delirium assessments and the prevalence of delirium was 25%. Resuscitation forms were completed in 86% of patients, 60% of patients had completed CFS. Diagnoses of delirium were associated with increased LOS. CFS of 6/7 was associated with an increased LOS and a diagnosis of delirium. The modified proforma was used in 94% of admissions. Completion of delirium assessments improved to 79% and diagnoses of delirium to 43%. Completion of resuscitation forms and CFS improved to 93% and 79% respectively. The difference in LOS between patients with and without delirium was statistically significant. Conclusion This study shows the efficacy of an admission proforma, as low-cost MDT-based intervention, improving and sustaining adherence to guidelines and improving documentation and assessment of other elements of a comprehensive geriatric assessment. 

Introduction 

Delirium complicates 10% of admissions. A delay in diagnosis can lead to permanent cognitive decline, care home placement and death. Watford General Hospital’s (WGH) delirium liaison service receives fewer referrals than expected from areas with vulnerable patients such as ITU. This audit sought to understand why and what effect this might have on outcomes. 

Method The audit team reviewed notes for all >75-years-old in WGH on a single day, looking for delirium risk factors, evidence of delirium and, if present, a diagnosis and management plan. Outcomes were reviewed at 90 days. 

Results Of 216 patients, 44% had evidence of delirium. 40% were missed, with only half of those diagnosed having a delirium-centred plan. Pareto analysis revealed 50% of >75-yr-olds on only four of twenty wards and 50% of delirium present on those same four wards. 90-day outcomes revealed: - Delirium is associated with higher mortality (OR 2.28) - Longer length of stay (LOS) (+3 days). - LOS was longer if delirium was missed (average 28.5 days) - Frailty is a predictor of delirium (OR 3.26) and mortality (OR 2.5) Subgroup analysis showed that, even when compared to other geriatrician led CGA based care, orthogeriatric patients with delirium had significantly higher rates of diagnosis (100% vs 53%), management (100% vs 35%), lower mortality (OR 0.55), comparable LOS, and fewer than half as many readmissions. 

Conclusions Delirium is concentrated on a small number of medical and orthopaedic wards. Orthogeriatric patients have significantly higher rates of diagnosis, delirium-focused plans, lower mortality and readmission rates. This data suggests that a best practice pathway, akin to that for hip fractures, mandating delirium screening for at-risk, especially frail, patients on high-risk medical wards may improve outcomes. This data has allowed us to develop a focused improvement plan based on a time-critical pathway. 

Care of the elderly simulation-based teaching for the multidisciplinary team

Introduction

Geriatric medicine is inherently complex and requires multi-disciplinary integration. Simulation-based training has been recognised by the Joint Royal Colleges of Physicians’ Training Board and the Royal College of Nursing as a method to enhance learning and improve patient outcomes. This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional clinical practice that takes place on geriatric hospital wards.

Methods

A total of ten half-day simulation sessions have been run across two sites in two years. The scenarios cover frailty, orthogeriatric post-operative complications, acute delirium, Parkinson’s disease, thrombolysis and end of life care.

The sessions were attended by 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates. Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation as a learning tool.

Results

Both pre- and post- simulation, candidates had the most confidence in managing end of life situations, and least confidence in managing acutely unwell patients with Parkinson’s disease. Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the simulation session. Thematic analysis highlighted the importance of collaboration within a team to enhance a sense of belonging, and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.

Conclusions

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the multi-disciplinary team looking after geriatric patients through exposing candidates to complex situations and increasing awareness of the roles within the team.

The simulation sessions have highlighted clinical areas that require further education within the Trust, such as thrombolysis.

Future development of the simulation will aim to adapt the scenarios for use of the wider multidisciplinary team, incorporating therapists and pharmacists.

Introduction: Polypharmacy, multimorbidity, and frailty are closely interlinked. The STOPPFrail (Screening Tool of Older Person’s Prescriptions) criteria offer a structured approach to identifying potentially inappropriate medications (PIMs) in very frail older adults with limited life expectancy. This study evaluates the application of these criteria before and after admission to a specialist geriatric ward in a tertiary care hospital. 

Methodology: Medications were assessed against the STOPPFrail (Version 2) criteria before and after admission. Patients aged ≥65 years were included if they met all three STOPPFrail criteria: dependency in activities of daily living and/or severe chronic disease or terminal illness, severe irreversible frailty, and a clinical expectation of survival of less than 12 months. Data, including demographics, Clinical Frailty Scale (CFS) scores, medical history, and medication lists, were collected prospectively over three months. 

Results : Of 120 patients admitted, 30 met the STOPPFrail criteria (57% female, median age 89.5 years, median CFS 6, median Charlson Comorbidity Index 7). All patients were prescribed one or more PIMs before admission, and 96.7% remained on at least one PIM after admission. Lipid-lowering medications decreased from 36.7% to 16.7%, while antihypertensives were fully discontinued (23.3% to 0%). Vitamin D and calcium supplements decreased from 60% to 43.3%, antipsychotic use increased slightly (10% to 13.3%), and proton pump inhibitor (PPI) use remained unchanged at 30%. Despite deprescribing efforts, the median number of medications increased from 8.5 to 9.5. 

Conclusion: PIMs are prevalent in frail older adults. While deprescribing was focused on lipid-lowering and antihypertensive medications, gaps remain for PPIs and antipsychotics. Structured medication reviews, clinician education, improved documentation, and greater pharmacy involvement are essential to optimize prescribing. Identifying very frail older adults for whom STOPPFrail criteria are appropriate is vital to ensure a person-centred approach to medication management, enhancing safety and appropriateness for this vulnerable population.

Introduction: Treatment Escalation Planning (TEP) ensures timely clinical decision-making and appropriate responses to patient deterioration. This project aims to assess compliance with TEP documentation in the acute respiratory ward, identify gaps, and implement strategies for effective documentation. 

Methods: 3 PDSA cycles were completed using a quality improvement strategy, each for 5 days. Data was collected retrospectively using the patient’s electronic records, assessing key metrics such as TEP presence in patient’s notes and TEP TAB, DNACPR documentation, and time from admission to TEP completion. An intervention followed each cycle. The first cycle focused on awareness to consider TEP completion on admission, second cycle focused on educational sessions highlighting the importance of TEP discussion and documentation in a timely manner. 

Results: The results show steady improvement in TEP documentation across all cycles. TEP in patient's note completion increased by 11.5% in Cycle 2 and 15.3% in Cycle 3, reaching 61.5%. However, TEP in TEP TAB completion drops by 10.1% in Cycle 2 but recovers with a 24.7% increase in Cycle 3, reaching 26.1%. DNACPR documentation improves by 14.4% in Cycle 2 but decreases slightly by 1.6% in Cycle 3. The average time to TEP completion decreases by 2.6 days in Cycle 2 and 0.7 days in Cycle 3, reaching 1.5 days. These findings indicate significant progress but highlight areas needing attention. 

Conclusions & Recommendations: Ensuring the completion of both TEP in notes and TEP TAB is crucial for effective patient management. To improve compliance, the implementation of a ward-round documentation template is recommended to prompt TEP status when seeing new patients with the Consultant on-call. Additionally, TEP status should be considered during patient clerking to ensure early documentation and prompt discussions should take place if a patient’s clinical condition deteriorates. Sustained improvements can be achieved through structured documentation workflows and ongoing clinician training.

Over a 6 month period, all 92 residents were offered the opportunity to have a ReSPECT conversation and 86 accepted the opportunity. In addition to families/legal representatives, advocacy services were used to enable equitable participation. Digitally-facilitated communication tools were also offered.

The vast majority responded positively, and a mutually agreed ReSPECT form was completed. These were stored electronically on NHS systems and shared with the care home in paper format.

However, even when offered all available information some residents chose not to have a ReSPECT placing limitations on their care. Some family members objected strongly to what was being suggested. Case-by-case analysis is ongoing on the impact on unscheduled care use.

Conclusions

Our experiences highlight both the benefits of structured FCP, but also reflect the practical challenges and concerns among the population and those who support them. Empowering staff and family members to advocate in the event of a health deterioration was a powerful consequence. Equally, respecting individual preferences necessitates avoiding blanket approaches. ReSPECT discussions often enabled more timely hospital discharge when an admission occurred. Practical challenges, including the lack of care home access to NHS digital systems can be overcome, but reflect structural barriers to information sharing which integrated systems should avoid.