Clinical Quality

Introduction

16% of adults over the age of 75 years old have a diabetes diagnosis¹ and 1 in 6 hospital beds in the UK is occupied by someone with diabetes². Keeping diabetic patients safe during hospital stays is a priority, and in 2023 the Joint British Diabetes Societies (JBDS-IP) published guidance on managing Diabetes in Frail inpatients³. An audit at our hospital later that year found that 70% of Capillary Blood Glucose (CBG) testing was non-compliant with guidelines resulting in unnecessary patient intervention, use of staff time and consumption of non-recyclable resources. The main aim of our project was to improve compliance with these guidelines and establish potential time and cost saving resulting from this.

Method

Focus on medical education with teaching sessions, information cards for lanyards and prompt posters around the inpatient ward areas. Worked with electronic prescribing team to establish use of an order-set for CBG testing to allow medical team to accurately communicate with nursing colleagues.  In addition, engaged nursing staff via ward bulletins and observed CBG testing on ward.  

Results

There was a reduction in CBG frequency for all diabetic patients of 27.9%. We identified that those patients with diet-controlled diabetes were commonly over tested, and in this sub-group the number of CBG tests performed was reduced by 51.9%. Average time for CBG testing was 147 seconds with anticipated cost savings from staff time and equipment use.

Conclusions

The use of default four times a day CBG testing results in unnecessary intervention in our frail inpatients. Through education and use of electronic systems we can reduce these interventions based on national guidelines, but more work needs to be done. Reducing CBG testing reduces use of healthcare assistant time, costly non-recyclable materials and overall reduces unnecessary patient intervention.

References

1. NHS England (2023) Health Survey for England, 2021 Part 2 < https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-diabetes#:~:text=Prevalence%20of%20doctor%2Ddiagnosed%20diabetes%2C%20by%20age%20and%20sex&text=Prevalence%20increased%20with%20age%2C%20from,adults%20aged%2075%20and%20over.> Accessed 8/11/24
2. Watts.E, Rayman. G (2018) Diabetes UK: Making Hospitals safe for people with diabetes. Available at < https://www.diabetes.org.uk/resources-s3/2018-12/Making%20Hospitals%20safe%20for%20people%20with%20diabetes_FINAL%20%28002%29.pd> Accessed 24/07/2024
3. JPDS-IP 2023: Inpatient care of the Frail Older Adult with Diabetes. Available at <JBDS_15_Inpatient_Care_of_the Frail_Older_Adult_with_Diabetes_with_QR_code_February_2023.pdf (abcd.care)>

Introduction

End-of-life (EOL) care in care homes includes patients experiencing "ordinary dying" from dementia or frailty, alongside those with chronic diseases and cancer. Recognizing non-specific decline is complex. The One Weston Care Home Hub (CHH) implements comprehensive EOL care, achieving 95% of deaths in the preferred place and prioritising a "good death". Whilst "Just in Case" (JIC) injectable medications are commonly prescribed, a broader understanding of prescribing patterns is useful for learning about medicines waste and recognition of dying. This study investigates the prevalence of common prescriptions and explores the need to re-evaluate anticipatory medications for care home residents.

Method

A qualitative audit evaluated EOL care prescribing practices in 100 care home deaths by examining medication management in patient notes. Data were collected retrospectively on parameters including the completion of palliative drug charts, issuing JIC medications, and the timeline from prescribing JIC medications to death. Information on medications administered within the last two weeks of life and the cause of death was also recorded.

Results

34% received no additional medications. Antibiotics were the most commonly issued medications; 31% patients received them, half in liquid form. Other prescriptions included oral or topical analgesia (21%), laxatives (9%), benzodiazepines (8%), and oral steroids (5%). Liquid preparations comprised half of the issued medications. 74% of patients had JIC medications issued a median of 23 days before death (range: 1-1244 days).

Discussion

The use of antibiotics in this cohort is complex: are they prescribed for successful treatment, or could braver decisions be made not to prescribe when recovery chances are limited? Injectable JIC medications are a timely proxy for recognizing the terminal phase, but 26% of patients who died did not have these in place. Further study is required to determine if they were indeed not needed and how many of those prescribed were used.

Introduction:

Clinical frailty scale (CFS) is used to generate a score ranging from 1 (very fit) to 9 (terminally ill) for people aged ≥65 years. A CFS of ≥7 correlates with a one-year mortality rate of ~50%, making it useful for identifying individuals potentially approaching last year of life. NICE recommend this patient group are offered Advance care planning (ACP). ACP is paramount to ensuring individuals receive high-quality, personalised end of life care. We aimed to investigate CFS documentation and frequency of ACP discussions following educational interventions.  

Methods:

We performed a retrospective analysis of all inpatients admitted to an Elderly Medicine department on a given day. Data for demographics, documented CFS score, and ACP discussions was collected. CFS scores were recalculated to assess accuracy. Following formal education sessions on CFS documentation and ACP delivered to the MDT, data was recollected. Subsequently, CFS scores were recorded within electronic “flowsheets” to ensure scores could automatically populate future clinical notes and be extracted for research purposes. 

Results: 

The initial sample included 61 patients with 52 in the repeat sample. 36% of patients had CFS recorded in the initial sample compared to 77% in the repeat. In the initial sample, there was an 18.1% difference in documented and recalculated CFS for patients with a CFS≥7 compared to 7.7% in the repeat, showing improved identification of advanced frailty. In the initial cohort, 18% had pre-existing ACP and 16.4% had inpatient ACP discussion, compared to 21.2% in the repeat with pre-existing ACP and 15.4% having inpatient ACP discussion; demonstrating minimal difference. 

Conclusions: 

CFS documentation improved highlighting effectiveness of education involving the whole MDT to better identify frailty within the inpatient setting. Despite this, ACP discussion rates remained low. Potential barriers include time-pressure and lack of confidence approaching ACP demonstrating a need for further awareness and training.  

Introduction:

The local issue tackled was the suboptimal compliance with the Patient Fall Management Assessment (PFMA) on the Electronic Patient Record (EPR) due to assessments being completed on alternative electronic documents.The goal was to emphasize on this to improve patient safety.

Methods:

Audit data was collected by reviewing incident reports of inpatient falls across various complex care wards over a 12-month period each, with 109 notes reviewed in the first cycle and 204 in the second.

Interventions:

The approach involved conducting repeated training sessions for all grades of training doctors within the trust.

Results:

The first audit cycle revealed fair compliance with the PFMA document (87%), documenting events (94%), examinations (87-96%), further investigations and management (80-86%). However, these were lacking for past medical history (61%), medications, especially anticoagulation/antiplatelets (58%), although antihypertensives/sedative reviews were better (75%).

The interventions led to a small (2%) increase in the use of the PFMA document but a 100% compliance in recording fall events and a 13% improvement in documenting histories. Review of blood thinners and other medications improved by 17% and 8% respectively. Significant improvements were also seen in examinations and developing management plans. Despite these advancements, 14% of patients experienced recurrent falls, indicating a need for ongoing efforts.

Conclusions:

The audit highlighted the effectiveness of continuous training to ensure regular understanding of the importance of completing the PFMA. Given the frequent rotation of junior doctors as well as the increasing variety of allied health care professionals reviewing patients, especially out of hours, this presents a particular challenge. Future efforts will focus on more sustainable methods of increasing awareness of the PFMA such as discussion at multi-disciplinary staff inductions and welcome packs. Sustaining these improvements will involve regular audits and feedback loops as well as feedback on the document itself to assess for future improvements.

Introduction:

Malnutrition is a significant problem in the hospitalised population, particularly in those with cognitive impairment. Malnutrition has been shown to increase rates of infection, pressure sores, length of stay, readmission and morbidity. Malnutrition Universal Screening Tool (MUST) scoring identifies adults at risk of malnutrition and prompts dietetic referrals where appropriate. MUST score recordings across four Complex Medicine Units in the John Radcliffe Hospital were often inaccurate or incomplete, impacting on the identification of malnutrition and timely referral to dietetics. Multi-disciplinary teaching on MUST scores improved identification of malnutrition in this patient population. Further interventions are planned.

Methods:

Electronic patient records for patients >/=75 years of age admitted to the Complex Medical Units at the John Radcliffe Hospital with a diagnosis of cognitive impairment were analysed. The percentage of patients who had either an incomplete or incorrect MUST score were identified. The percentage of patients that did not receive a referral to dietetics due to an underestimated MUST score and the reasons for the underestimation, were determined. Multi-disciplinary teaching interventions focussing on the identification of malnutrition in inpatients were implemented. MUST score recording was re-analysed following intervention.

Results:

71% of MUST scores underestimated risk of malnutrition. 67% of this cohort met criteria for referral to dietetics based on a corrected score, with only 33% of this group receiving the appropriate referral. Failure to identify weight loss in the preceding 3-6 months accounted for 88% of inaccurate scores. Multi-disciplinary teaching interventions improved MUST score accuracy by 14%, indicating improved identification of malnutrition risk.

Conclusion:

Identification of malnutrition is important to improve patient outcomes. Changes to practise will include multi-disciplinary education, improved use of technology to generate accurate MUST scores and the utilisation of transfer boards with integrated weighing scales to ensure all new admissions have an accurate weight.

Introduction The Chandlers Ford, Eastleigh and Southern Parishes Frailty Support Team (FST) identified pockets of high referral rates within independent living facilities. It was hypothesised that this may be because independent living facilities do not have a contractual arrangement for proactive intervention, unlike care homes and nursing homes. This leaves individuals and carers unsure how, when, and where to seek support. In turn, this potentially has a high healthcare burden through unplanned access to GP’s, 999, 111 or admissions to hospital.

Methods: An independent living facility was identified, and participants were invited to have a proactive, holistic review. Medical notes were reviewed for 12 calendar months prior the project and all unplanned contacts recorded. Each participant then received a face-to-face review which identified, addressed and rectified any findings/ concerns. A follow-up review of medical notes and a telephone call to participants was completed 3 months later; 3 months after telephone review medical notes were reviewed to identify incidents of unplanned care.  

Results: This project has decreased unplanned medical contacts by an average of 52% in all participants which equates to an average 6-month gross saving of £431 per person and a 6-month net saving of £383 *Net savings allowed for 3 hours of Agenda for Change 23/24 mid band 7 pay. Trend shows face to face contact has the best impact at reducing unplanned care incidents, however this does not affect the emergency needs secondary to trauma.

Conclusions: The project suggests that in independent living facilities switching from a reactive to a proactive model may allow for better holistic care, in turn reducing the burden on the local health services. It is acknowledged that this is a small sample and therefore may not be representative or generalisable and a larger study is recommended.

Abstract Content - Introduction

We wished to improve the knowledge of care home staff in Leeds in identifying frailty and managing frailty related problems

Method

We developed a frailty education course (www.leedsfrailtyeducation.co.uk) which was then refined and modified to target care home staff. We engaged key stakeholders at the council and the ICB to help develop and promote the course. The course was delivered across 4 venues in Leeds by geriatricians, a pharmacist and a community nurse.

Results

We had 128 attendees across the four days. From the feedback taken immediately after the study day (n=69): -100% of attendees found that the content was useful and well delivered. -97% of attendees improved their knowledge of frailty and 100% improved knowledge of CGA. -CGA, assessing delirium and positive approaches to managing dementia were the 3 most common things attendees intended to take away for their future practice. From the follow-up feedback (n=19): - 95% (18/19) ‘extremely agree’ with the statements “Attending the training day has improved my understanding of frailty” and “I would recommend my colleagues attend this course” -42% (8/19) have implemented frailty assessments as part of standard care in some form Attendees also valued the multi-sector, multi-professional expert presenters alongside the opportunity to meet and interact in-person.

Conclusion(s)

A dedicated study day for care home staff was well received by attendees and feedback received demonstrated self-reported lasting change to practice. Key enablers to the success of the course were: the reputation of the course locally which had been piloted and delivered in different formats previously, tailoring the material to the audience, and delivering the course in several different locations. More regular frailty teaching days can be implemented to capture more care home staff and ultimately improve care for residents.

Introduction: Hospital-Associated Deconditioning Syndrome (HADS) can lead to prolonged length of stay (LOS). Evidence indicates that early intervention may reduce HADS and LOS. (British Geriatrics Society, Deconditioning, Healthy Ageing, 11 May 2017, Dr Amit Arora, NHS England, 24 January 2017, Time to Move). The Acute Frailty Team (AFT) at Eastbourne District General Hospital piloted a Frailty Early Discharge Scheme (FEDS) in the Frailty Unit for 8 weeks between May-June 2023 with the aim of providing early mobilisation and discharge planning to reduce LOS.

Methods: Patients were admitted to either FEDS or Non-FEDS (NFEDS) beds depending on the bed availability. FEDS patients were provided with additional early assessments and interventions including discharge plans from day 1 after admission, offering early, continuous and active mobilisation by a trained FEDS team of a registered Nurse and Health Care Assistant. The FEDS team worked in conjunction with the medical team to actively promote discharge planning while patients were still receiving acute medical treatment, before patients becoming medically fit for discharge (MFFD). NFEDS followed the standard care plan, usually initiated after patients were declared MFFD. Data was collected for all patients, comparing FEDS 12 beds with NFEDS 12 beds.

Results: 83 patients were enrolled 45 FEDS, 38 NFEDS Discharged within 48hrs FEDS 11.11%, NFEDS 2.63% Discharged within 7 days FEDS 44.44%, NFEDS 28.94% LOS 8.07 days FEDS, 11.36 days NFEDS (30 day trim point).

Conclusions: 1. Increased rate of discharge within 48 hrs and 7 days. 2. Reduced LOS within 30 days. 3. The benefit is mostly noticed within the first 7 days indicating the need to apply the intervention early 4. The adoption of a FEDS-project in all frailty wards could be beneficial for elderly patients.

Introduction:

Neck of femur (NOF) fractures can cause significant morbidity in elderly patients. Adequate pain control is essential for early mobilisation and improved outcomes. Health board prescription protocols exist offering a multi-modal analgesia approach as well as laxatives on the electronic platform (HEPMA). The aim of this quality improvement (QI) project was to assess adherence to these protocols.

Methods:

Patients over 65 with isolated NOF fractures admitted to trauma wards from ED at a single district general hospital were included. Baseline data was collected from patients admitted between October to December 2023. Post-intervention data collected from April to June 2024. Prescriptions for regular and breakthrough opioids, regular paracetamol and laxatives on admission to the trauma wards were audited. Day 3 and day 5 review of pain and bowel status were also audited.

Intervention:

An information session was delivered at the time of staff change over to senior house officers and junior clinical fellows to ensure they were aware of the NOF fracture analgesia and bowel protocol and available electronic prescribing bundles.

Results:

A total of 169 patients were included. 84 prior to the intervention and 85 post intervention. Prior to the intervention accuracy for regular opioid prescription was 72.6%, PRN 83.3%, laxatives 81.8%, Paracetamol 88.1%. Post intervention respectively 87.1%, 94.1%, 92.9% and 91.9%. We demonstrated statistically significant change (p< 0.05) in regular, PRN opioid and laxative prescribing. No change in paracetamol, Day 3 and 5 pain and bowel reviews was found.

Conclusion:

A positive change in prescribing accuracy was demonstrated. Potential barriers to appropriate analgesia prescribing may be lack of awareness of protocols and hesitancy in prescribing opioids in elderly frail patients. Information sessions will continue to run to ensure appropriate prescribing for NOF patients on admission. Further data will be available following further educational and poster interventions.

Background: Language is a social determinant of health, as constituted by the World Health Organisation (WHO) back in 1948. UK migration rates have risen exponentially recently, and with it the inability for patients to speak functional English is a growing concern. Poorer health information and avoidance of service use creates fundamental health inequity within this demographic. The UK’s ever-changing sociodemographic landscape necessitates a growing focus on health outcomes within non-English speaking patients.

Aim: To explore the barriers towards interpreter service use within South Yorkshire and how to improve communication with non-English speaking patients.

Method: Data was collected in a mixed quantitative-qualitative approach. A yes/no approach was adopted to answer the study objectives (ie., whether family members had translated on behalf of relatives or if interpreter service use was documented). Observational comments from the notes were used to contextualise the data for further discussion. This was compared to available UK guidelines.

Findings: There was a widespread reliance on family members to interpret on patients’ behalf, seen in 75% of non-English speaking patients on the sampled wards. Only 50% of these patients had documented use of interpreter phone lines across the wards, significantly below the audit’s standards.

Discussion: Barriers to interpreter services may be attributed to inefficiencies within its online nature, including queues and connectivity issues. This discourages its uptake, especially in the face of increasing hospital pressures. The high reliance on family members requires ethical considerations. These include issues with confidentiality, poor safety netting and disjointed communication of diagnoses when family members are used to translate. Ultimately, reliance on family members should be actively discouraged. This project recommends a language assessment tool and identification charts to guide NHS staff to appropriate interpreter services, preventing care delays.