Clinical Quality

In hospital incontinence increases length of stay (1), in orthopaedic patients is associated with increased likelihood of discharge to an institutionalised setting (2) and can have a major negative impact, with many rating bowel and bladder incontinence as a health state the same or worse than death (3). Yet of the Geriatric Giants, it is given relatively little attention.

At a busy teaching hospital, we sought to raise awareness and improve management of incontinence across our 167 beds, by using a standardised, multi-disciplinary approach involving identification of patients and use of the components of BASICS (Bladder diary, A physical assessment, Symptom profile, Infection and Constipation check and a bladder Scan, figure 1).

Baseline data of a sample of 14 patients with new urinary incontinence with their aspects of continence assessment were added to a cumulative audit. Alongside checklists, a poster(figure 2) was designed and placed on each ward, a local teaching session about incontinence was delivered, and data shared at our local governance meetings. Following this, a further cycle of audit was performed. Reversible causes were identified and addressed appropriately. Between cycle 1 and 2 (February and June 2024), significant improvements were seen in most aspects of BASICS assessment with notable increases in use of the bladder diary (7 to 50%) and medical examination (7 to 57%). See figure 3 for breakdown.

As a consequence, there were multiple interventions aiming to improve patient symptoms. Paying consistent and sustained attention to this neglected area of practice has demonstrated a change of culture is possible. We are now incorporating continence assessment into our medical trainee audit programme to support a sustained multi- disciplinary approach and maintain improvements.

Introduction

People with Parkinson's disease are more likely to have osteoporosis and falls. They also have a higher risk of fractures, and their outcomes are poorer than in the general population. Despite this, only half of the patients seen in Parkinson's clinic have a bone health assessment. The aim of this project was to improve bone health assessments in the Parkinson's clinic at Mansfield Community Hospital.

Method

One plan - do-study-act cycle was completed with the implementation of a Parkinson's fracture risk assessment tool in the clinic. 19 clinic notes were evaluated over an 8-week period. The notes were scored on whether bone health was addressed using the assessment tool. Feedback was collected from the clinicians about utilising the assessment tool in clinic. The FRAX (Fracture risk assessment) tool was also used to calculate the risk of fractures in the patients selected.

Results

16/19 (84%) notes had used the risk assessment tool in clinic. There was an improvement in the bone health assessments in clinic from 5% (1/19) at baseline to 29% (5/17). The Parkinson's risk assessment tool's identification of individuals who were high risk of fractures, correlated with those identified as high risk using FRAX. The clinicians had positive reviews of the tool, but they highlighted the time constraints.

Conclusion

Whilst the use of the assessment tool has shown some improvement in the number of bone health assessments happening in clinic; it hasn't resulted in all patients having an assessment. This is likely due to the time constraints in clinic. This project was successful in highlighting the current problem to the clinicians and has led the development of a further separate clinic, where bone heath can be addressed. The risk assessment tool plays an important role in identifying high risk patients who would be referred into this service.

Introduction

National guidance suggests that all patients with neck of femur fractures (NOFF) should be mobilised day one post-operatively (NICE, 2023, QS16). This reduces rates of delirium, pneumonia and length of stay (Sallehuddin & Ong, Age and Ageing, 2021, 50, 356-357). Hypotension is a leading cause of immobilisation post-operatively. National guidance advises appropriate fluid resuscitation and review of polypharmacy when indicated (British Orthopaedic Association, 2007). This quality improvement project aimed to reduce post-operative hypotension and improve day one post-operative mobilisation in NOFF patients.

Method

Three months of NOFF patients were retrospectively reviewed pre-intervention. Those who did not receive surgical intervention were excluded. The proportion of NOFF patients that were unable to mobilise due to post-operative hypotension on day one was identified. We reviewed if intravenous fluids were given pre-operatively and if anti-hypertensives were held. An intervention was then implemented including educational posters and teaching sessions for doctors and nurses to encourage prescription of fluids on admission, holding of antihypertensives pre-operatively and detection and escalation of oliguria or hypotension post-operatively. Data were then re-collected in a three-month period post-intervention to ascertain if there was any change in practice.

Results

70 patients underwent NOFF repair pre-intervention compared to 54 patients post-intervention. There was a decrease in the proportion of patients unable to mobilise day one post-operatively due to hypotension from 15.7% pre-intervention to 9.3% post-intervention. There was an increase in the proportion of patients who received pre-operative intravenous fluids from 64.3% pre-intervention to 77.8% post-intervention. Of those patients who took anti-hypertensive medication, a higher proportion had this suspended pre-operatively, increasing from 82.9% pre-intervention to 88.2% post-intervention.

Conclusion

Simple educational interventions can reduce post-operative hypotension in NOFF patients. Developing local guidelines may facilitate persistent clinical change, as improvements following poster distribution and teaching sessions may be transient.

Introduction:

A Clinical Audit was recommended by the ME following identification of potential safety signal because of possible non-compliance with guidelines on Anticoagulation in AF. The audit data collection tool was developed in discussion with the Chief Pharmacist and took account of up-to-date prescribing guidance from the Integrated Commissioning Board (ICB). Aim of the audit was to identify if, as per NICE guidelines patients had: o Risk for stroke (CHA2DS2-VASc) and bleeding (ORBIT) is assessed upon new diagnosis of AF? o Made aware of their risk assessments and involved in discussion regarding risk -vs-benefit of anticoagulation o Anticoagulation prescribed as per national recommendations.

Objectives:

To ensure that patients with new diagnosis of atrial fibrillation are assessed for stroke and bleeding and involved in discussion regarding anticoagulation which is prescribed as per national recommendations. Methodology: This local audit was carried out by analysis of both electronic and paper-based patient records using an Excel spreadsheet for analysis. Data was then analyzed with the help of the Senior Clinical Effectiveness Advisor.

Results and highlighted risks:

It was observed that in most cases (82%), patients were not made aware about the condition and associated risk of stroke due to underlying AF. They were also not involved in discussion regarding commencing lifelong anticoagulation, and not explained the benefits and risks of anticoagulation. Omittance/Ignorance of anticoagulation upon new diagnosis of AF hence increasing the risk of stroke with lethal consequences of preventable death in 21% of patients.

Recommendations & Conclusion:

Formulation of “AF Anticoagulation Checklist” (based on NICE guidelines) ensuring every patient with a new diagnosis of AF has a repeat ECG for confirmation of diagnosis, CHA2DS2-VASc and ORBIT scores for risk assessment, their renal functions and coagulation profile checked, followed by discussion with patient regarding results of risk assessment and risk vs benefit of anticoagulation.

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Introduction:

The geriatric population has a high incidence of dementia, delirium and frailty meaning often these patients cannot give comprehensive histories themselves. We are left with missing pieces of the puzzle; we might not know their ‘normal’ and frequently ask: ‘Are they always like this?’.

A collateral history becomes a valuable tool, contributing to a Comprehensive Geriatric Assessment and assisting the whole MDT to make informed decisions for patient-centred care.

The primary aim of this project was to improve the quality of collateral histories taken for patients admitted to the geriatric wards, with content measured against 8 domains. A secondary aim was to encourage timely collateral histories within 48 hours of admission to the ward.

Method:

Using PDSA methodology, collateral histories were analysed before and after implementation of a poster and teaching session.

Results:

At baseline each domain was covered a mean of 40.5% of the time (range 9% - 81%). Following intervention this increased by 22% to 62.5% (range 18% - 89%), demonstrating a significant improvement (paired t-test, P<0.05).

It was already common practice to take collateral histories within 48 hours of admission to the ward (91%) which was sustained post-intervention (88%).

Conclusion:

Use of a poster as a prompt, and delivering teaching, led to more thorough collateral histories. This suggests two barriers are knowing what to ask and perceived importance; elements which could be integrated into early postgraduate education. The impact on patient care has the potential to be significant and multidimensional but further work would be needed to understand this.

Background: This project is based in the geriatric department of Wye Valley NHS trust which serves Herefordshire and mid-Powys.

Introduction : In frail, older patients, cardiopulmonary(CPR) resuscitation has low rates of success. Lack of appropriately completed ReSPECT forms leads to futile attempts of CPR, repeated readmissions and patient harm. This project aims to improve patient centred advance care planning (ACP), and the quality of their documentation in the ‘clinician recommendations’ section in ReSPECT forms through development of new educational tools.

Methods: The Supportive and Palliative Care Indicator Tool (SPICT) was used to identify patients benefitting from ACP in the department. Data was collected on how many patients had ReSPECT forms and how well they were completed against standards adapted from the Resuscitation Council guidelines. Plan-Do-Study-Act(PDSA) cycle 1 was completed developing an aide-memoire (ReSPECT tool), and an interactive workshop. PDSA cycle 2 lead to design of the project poster titled ‘Revamp your ReSPECT discussions’ which was displayed on the wards, and shared on social media. PDSA cycle 3 was conducted to measure response and aid direction. Results: PDSA 1 showed 71% patients meeting SPICT criteria had ReSPECT forms. This improved to 82% by PDSA 3. PDSA cycle 1 revealed that only 32% of ReSPECT forms were completed to audit standards, by PDSA 3 this improved to 43%. The project received engagement from the wider healthcare community on Twitter/X where the project poster garnered over 36,600 views and has been shared in the trusts latest issue of safety bites.

Conclusions: Our work led to an improvement in the quality of documentation and illustrated a novel approach to communicating the standards expected when delivering patient-centred ACP. The interest received via social media highlighted the importance of sharing this experience. We plan on building on this success through wider communication of the standards.

Introduction

The Frailty Network, initiated in November 2023, aims to enhance care for frail patients through multidisciplinary collaboration across acute and community settings. By fostering partnerships with Health and Social Care teams, GPs, district nurses, and third sector organisations, the Network strives to provide realistic and patient-centric improvements in Lanarkshire. The initiative focuses on proactive, personalised, and coordinated support to help frail older adults maintain independence and well-being.

Methods

The Frailty Network is supporting multiple teams to implement new pathways to streamline care and improve outcomes. The aim is to understand our systems and have a focus on the data impacting our older adults. Stakeholder Engagement Table was utilised to show project success so far. Quantitative methodology such as LOS, number of referrals will be used to show impact. With a progress / Driver Diagram to show Quality Improvement Journey thus far. As the Network is a large piece of work, many aims are long term.

Results

The implementation of the Frailty Network has resulted in notable improvements in communication, engagement, collaboration and innovation. There has been reduced LOS in the frailty wards, improved transfers to community hospitals and more pathways to keep people at home. There are structures now imbedded to encourage multi system working from all settings.

Conclusion

The Frailty Network's innovative design has begun to successfully improve care for frail older adults in Lanarkshire. The collaboration between acute and community teams, combined with proactive interventions and the use of digital technology, has started the journey to a more sustainable future. Continued focus on integrated leadership and shared goals will further refine and sustain these improvements, setting a gold standard for frailty care in the region. Further research is required to assess long-term impacts.

Background This quality improvement (QI) work was done at the South Edinburgh Parkinson’s clinic.

Introduction Idiopathic Parkinson’s disease (IPD) is a secondary risk factor for osteoporosis (Torsney KM et al. Journal Neurology Neurosurgery Psychiatry 2014; 85: 1159–1166). The 2022 UK Parkinson’s audit highlighted bone health as an area of QI for IPD (www.Parkinsons.org.uk).

Methods A Plan-Do-Study-Act (PDSA) structure was adopted and project charter created. Baseline data was collected from 20 patients attending the IPD clinic between June- September 2023, reviewing details of assessments in the last three years. The Parkinson’s Excellence network bone health form was used to assess osteoporosis risk (www.Parkinsons.org.uk). Patient records were prospectively assessed pre-annual clinic between June-July 2024. The assessment outcome was documented in the patient’s records to guide discussion. After clinic the form was updated and interventions actioned.

Results From baseline data, only 2 of 20 patients had a bone health assessment as part of recent annual reviews. Using the assessment form, 33 patient notes were reviewed. 22 patients were excluded based on the form’s screening criteria or lack of formal IPD diagnosis. 11 patients had a full assessment completed. Three patients were given lifestyle advice only. 7 patients (63.6%) had a FRAX score for a major osteoporotic fracture >10% and a DEXA scan was suggested for all. 3 of these patients were deemed high risk, ideally to be started on bone health treatment immediately. On average it took 3minutes and 47seconds to complete the form.

Conclusions The assessment forms were straightforward to complete and helped identify IPD patients at increased risk of osteoporosis. The Lothian Parkinson’s service is considering how best to implement this into the structure of annual reviews and will be undertaking further assessments with larger patient numbers. The impact on the service and clinical time needs to be better understood.

Background

Evidence shows that CGA based in Frailty units is better for patient care (Fox 2012, Ellis 2011). University Hospital Wishaw (UHW) is the only acute site in NHS Lanarkshire that does not have a frailty assessment unit as part of the admission/receiving pathway. Patients are currently admitted to the Medical Assessment Unit (MAU) and seen by either Geriatrician or Medical consultant depending on the time of admission. UHW is working towards a frailty unit but has been limited by space and resource. Instead we have been on a journey of step-wise improvements to establish one.

Methods

Over the course of 5 days, we developed a Rapid Access Frailty Team (RAFT) in a cohort of 10 beds within the existing MAU. Patients were over 65 and had a CFS ≥5. Patients were reviewed by a Geriatrician in morning and afternoon, and had MDT input from Physiotherapy, Occupational Therapy and a Nurse specialist.

Results

Over the 5 days 28 patients were admitted to RAFT beds. 9/28 (32%) were discharged from RAFT. Length of stay was 32 hours. Patients either went home or moved to a downstream ward if needed. Medical and AHP staff feedback was positive, but nursing staff in MAU voiced it was onerous having all frail adults in one area.

Conclusions

Development of frailty area within a medical assessment unit is possible and appears to lead to improved outcomes and discharge rates compared to non-cohorted areas. We are now looking for an area where we can apply our RAFT principles and have more staff support.