Clinical Quality

Introduction

At Epsom and St Helier, a dedicated Frailty service exists during daytime hours, and not weekends, nights or Bank Holidays. During these hours, patients are reviewed primarily by a cohort of “frailty-naïve” medical junior doctors. We aimed to compare the management plans, patient outcomes, rates of discharge, documentation and care delivered by medical junior doctors to that of an established frailty service.

Methodology

Data on presenting complaint, demographics, degree of frailty, postcode was collected on all patients over the age of 65, presenting to A&E at Epsom and St Helier Hospitals with a Frailty Syndrome. Patients who presented with symptoms or signs outside of the frailty syndrome criteria were excluded. The Medical Service was compared to the Frailty Service on rates of discharged and whether or not a resuscitation status, an escalation plan, baseline functional assessment, vision and hearing assessment, home set-up assessment, cognitive status, the elicitation of patient preferences and a medication assessment were performed.

Results

In 202 patients, average age was 85.2 years and consisted of 85 men and 117 women. Unwitnessed falls were responsible for 143 presentations. 127 patients were Caucasian and from the least deprived deciles. 109 patients (54%%) were seen directly by Frailty, and another 93 (46%) seen as referrals to the Medical Doctors. 33(16%) of patients were discharged by Frailty within 24 hours of admission, compared to 15(7.4%) by the Medical Team. The Frailty Service was more proficient in assessing patient baseline status (OR1.71), property (OR1.64), cognition (OR1.43), medications (OR1.28) and patient preferences (OR21.95).

Conclusion

Frailty reviews at an early stage in patient presentation to hospital was twice as likely to result in discharge within 24 hours of admission. Additionally, patients were more likely to have a thorough, comprehensive frailty assessment, and were significantly more likely to be empowered in their decision-making process.

Introduction

Hip fracture is the most common fracture in adults over 60 years, affecting approximately 70,000 people in the UK in 2019. Mortality after hip fracture continues to be high and the cost of hip fracture is estimated at £1.1 billion per year for the NHS. It has been shown that there are key clinical indicators which can improve patient outcomes. These are monitored annually in the UK by the national hip fracture database (NHFD).

Methods

Our aim was to look at the demographics and clinical codes for patients admitted with hip fracture, codes when they are readmitted and cause of death. Information analysts at both hospitals provided authors with these data from hip fracture admissions in 2020. Inclusion criteria reflected the inclusion criteria for the NHFD. Cause of death was identified from records in the medical examiner's offices for inpatient deaths. Data were viewed and analysed in Microsoft Excel.

Results

In total, there were 878 admissions for hip fracture in 2020, 312 at Barnsley Hospital (BH) and 566 Sheffield Teaching Hospitals (STH). Average age was 80.9 at BH and 82.6 at STH. The most frequent codes on admission were 'fall' and the most common complication was pneumonia, coded in 23% of patients. 174 (56%) individuals at BH had at least one readmission in the first year and 318 (57%) at STH. The codes for readmission were varied, most commonly for musculoskeletal or orthopaedic conditions, including fracture. 85 died within one year (27.2%) and 26 died within 30 days (8.3%) at BH. 186 died within one year (32.7%) and 69 within 30 days (12.1%) at STH. The commonest cause of death was pneumonia, in 26 of 66 inpatient deaths.

Conclusions

This analysis of coding data confirms known complications following hip fracture. Morbidity and mortality following hip fracture remains extremely high.

Hip fractures tend to affect older, frailer people and are associated with high morbidity and mortality. The Best Practice Tariff (B PT) was introduced to recognise gold standard care. Features of the BPT include prompt surgical and orthogeriatric input, with multidisciplinary working throughout. Subsequent service changes have led to the creation of specialist hip fracture wards. However, it is not always possible to admit patients with a fractured neck of femur to a specialist hip fracture ward.

We reviewed data for 691 patients admitted with a primary neck of femur fracture to a district general hospital in Sussex between 01/02/2023 and 29/02/2024. We compared the demographics and outcomes of patients admitted to a specialist hip fracture ward (SHFW) and a general surgical ward (GSW) using data available from the National Hip Fracture Database. 570 patients were admitted to the SHFW, 121 to the GSW.

BPT achievement was significantly higher on the SHFW (74% SHFW, 53% GSW, p<0.00001). 30-day mortality was lower on the SHFW, although this was not statistically significant (2.98% SHFW, 5.79% GSW, p=0.126). We found no significant difference in patient age, time to surgery, time to orthogeriatrician review, or length of stay.

This analysis highlights the importance of a specialist multidisciplinary team approach in the management of patients presenting with fractured neck of femur. While not a perfect metric, non-achievement of the BPT is likely to result in worse patient care, with higher mortality and poorer longer term functional outcomes. BPT non-achievement is also associated with significant loss of income to NHS trusts. We suggest that, wherever possible, beds on specialist hip fracture wards should be ring fenced for patients with primary neck of femur fracture.

AimsTo reduce the burden of inappropriate CPR with surgical specialties and to improve the conversations we are having with patient’s and their relatives around CPR.

Methods Data collection was done one one day in March, June and September 2024 across three surgical wards. Patients were included over the age of 65 and with a Rockwood Clinical frailty score over 5. A retrospective review of whether discussions with patient and/or next of kin was done. Below is the table demographics.

Results Following teaching intervention to junior doctors and discussion with geriatric medicine surgical liaison services there was an improvement in the number of patients who had resuscitation decisions (wither FOR or DNACPR) on their medical records.This is reflected in the number of patients having no DNACPR recommendation on the patient notes going from 47% to 8%.

Summary Through education and improving awareness around the importance of DNACPR discussions we have seen am improvement in the number of surgical patients who are living with frailty having a recommendation around CPR in their medical notes

Introduction:

Chronic limb-threatening ischemia (CLTI) is defined by presence of peripheral artery disease, rest pain, and/or gangrene or ulceration.1 Management of CLTI often involves a major amputation which has a 30-day in-hospital mortality of 6.6%. Despite improvements in secondary risk management, 5-year mortality remains high.1 Understanding how comorbidity affects amputation survival may help support patient optimisation and shared decision-making.

Methods:

This audit assessed the outcomes of patients who were reviewed by the POPS team using a comprehensive geriatric assessment (CGA) before undergoing a major lower limb amputation. We retrospectively analysed electronic records from 60 patients with CLTI who were admitted in an emergency setting, reviewed by the POPS team, and underwent a major lower limb amputation during 2022. The primary outcome measure was death following surgery. Data was collected from the patient records and analysed using the Chi square test.

Results:

In this group of 60 patients the 30-day mortality was 5% (3 patients) and 1-year mortality 43% (26 patients), with the average age at time of death being 77 years. Age (p=0.022) and co-morbidity (p = 0.021) were the strongest prognostic factors for mortality. Other factors like clinical frailty score (CFS), albumin concentration and length of hospital stay showed non-significant correlations with mortality in patients who underwent lower limb amputation.

Conclusion:

This study highlighted prognostic factors that could enable doctors to identify high-risk patients who may benefit from optimisation and detailed shared decision-making prior to undergoing a major lower limb amputation. As mortality is not necessarily modifiable, even in the context of a CGA in this group, it also highlights the need for advanced care planning before discharge.

References 1. Waton S, Johal A, Birmpili P, et al. National Vascular Registry: 2022 Annual Report. London: The Royal College of Surgeons of England.

Introduction Hospital-at-Home (HaH) is an innovative care model delivering hospital-level care to community patients. A key priority for Bromley HaH has been to streamline strategies, providing integrated, individualised care for patients with heart failure (HF). Our study revealed that our length of stay (LOS) exceeded the 7-day target, and readmission rates surpassed the 0-10% target. Recognising the complexities of managing HF in the community, we evaluated the impact of a new HF bundle to enhance clinician confidence, reduce LOS, and improve outcomes and service capacity. Method An adapted HF bundle was developed in collaboration with local cardiologists to integrate services. The bundle included standardised assessment/management tools, technology-enabled care (point-of-care and remote monitoring), and clear discharge criteria. It was implemented alongside departmental teaching, HF clinic/MDT attendance for experiential learning, and weekly consultant-led MDMs to build confidence. Retrospective data was collected before and after the bundle's introduction to assess impact on LOS and readmission rates. Results Between February 2023 and May 2024, 48 unique patients were seen (mean age 81, 28 hospital step-downs, 20 community step-ups). Initial clinician surveys showed 83% lacked confidence, 75% struggled with diuretic titration, and 60% unsure about optimising prognostics. Baseline data from February 2023 to January 2024 showed an average LOS of 13 days and a readmission rate of 15.7%. Post-bundle implementation, average LOS reduced to 10.95 days, and readmission rates dropped to 7%. Clinician surveys reported increased confidence, and over 90% of service users rated their care as excellent. Conclusion The implementation of our HF bundle significantly improved clinician confidence, halved readmission rates, and reduced LOS, thereby increasing patient throughput and service capacity, and achieving a 41% reduction in cost per bed-day. The study also contributed to the development of a dashboard to continuously monitor the effectiveness of these interventions and highlight areas of further development.

Introduction: Prevalence of aortic stenosis and comorbidity burden correlates with advancing age. The Charlson Comorbidity Index (CCI) is a widely validated tool that predicts outcomes in a range of conditions and settings.

Methods: We analysed 38 eligible patients referred for CT TAVI at our institution between August 21 - December 22 and calculated their CCI score to study its impact on symptoms, procedural complications and mortality at 30-days, 6-months and 1-year post TAVI. Evidence of frailty screening was determined using retrospective case note review.

Results: Thirty-eight patients were referred for TAVI with mean age 77.9 and mean CCI 4.5. Twenty-seven (71%) underwent TAVI with mean age 77.5 and mean CCI 5.2. The commonest comorbidities were myocardial infarction (47%), congestive heart failure (21%) and COPD (34%). At 30-days, 41% of patients (mean CCI 4.3) had objective improvement in exercise tolerance, 33% (mean CCI 5) reported subjective improvement and 7% (mean CCI 7) experienced no change in symptoms. Complications occurred in 2 (mean CCI 4.5). The benefit persisted in 15 out of 18 at 6 months. At 1-year, 3 out of 6 reported sustained benefit (mean CCI 4.6) and 3 reported worsening symptoms (mean CCI 5.6) due to progression of mitral valve disease (1), new diagnosis of possible cancer (1) and worsening ankle swelling (1). Frailty screening was not routinely done.

Conclusion: The CCI tool is reliable in predicting TAVI outcomes. Good 30-day outcomes were seen with CCI ≤5 but benefit decreased at 6-months and 1-year when CCI >5.6, reflecting European Society of Cardiology guidance of CCI >5 conferring poorer prognosis. Futility was predicted by CCI >7 in our group. The Rockwood Clinical Frailty scale identifies mild-moderate frailty (CFS 5/6), in whom comprehensive geriatric assessment can help. These rapid web-based tools can be performed in clinic to identify potential barriers to recovery.

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Introduction

It is estimated that by 2030, 1 in 5 people undergoing surgery will be over the age of 75. These patients are often frail with a higher risk of post-operative complications including delirium. They are also more likely to have multiple co-morbidities and an increased anticholinergic burden due to polypharmacy. Anticholinergics are often linked with an increased risk of dementia, delirium, and falls.

Methods

This retrospective cohort study analysed anonymised data from 50 emergency general surgery patients the POPS team reviewed between December 2023 and February 2024 at the University Hospital of Wales. Objectives included measuring ACB (anticholinergic burden) scores on admission and discharge and evaluating subgroup analysis such as the relationship between CFS (clinical frailty score), known or new cognitive impairment and ACB score.

Results

66% of patients were female, the median age was 82 and median CFS was 6. 32% had delirium on admission, 40% had a Charlson comorbidity score of 5 or 6 and the median length of stay was 17 days. 74% of patients had no known cognitive impairment while 8% had dementia on admission. Small bowel obstruction (34%) was the commonest diagnosis and emergency laparotomy was the most common surgery type (56%). The median number of medications on admission and discharge was 9. Median ACB score on discharge reduced from 1.5 to 1 and 86% showed a stable or reduced ACB score. There was a positive correlation between frailty and delirium as well as frailty and ACB score. The correlation between delirium and ACB score was unclear. 

Conclusion

CGA by the POPS team reduces the anticholinergic burden of this patient cohort. Increasing frailty appears to be associated with an increased risk of delirium and ACB score on admission, however the relationship between anticholinergic burden and delirium is unclear in this small patient cohort.