Clinical Quality

Background  

University Hospital Southampton (UHS) partnered with Saints Foundation (SF), to test the feasibility and acceptability of a non-registered Exercise Practitioner (EP) to work alongside the therapy team to promote physical activity (PA) of hospitalised older people. Our aim was to collect trust level data to review the impact the EP had on outcomes such as length of stay (LOS) and discharge destination (DD) and identify and address any additional challenges that arose. 

Methods  

The EP delivered twice weekly gym-based group interventions as well as regular 1:1 rehabilitation and education sessions to hospitalised older patients. Interventions were ward based or within the acute therapy gym.  

Results  

Between June and August 2023 the EP reviewed 82 patients, mean age of 88 years. 15 (18%) patients underwent 1:1 rehabilitation whereas 67 (82%) patients underwent gym-based rehabilitation sessions. Median LOS for patients reviewed by the EP was 15 days compared with average departmental LOS of 8 days. 53 (65%) patients were able to either maintain or improve their predicted to actual discharge destination, compared with 10 (12%) patients whose physical capability declined. Of those remaining, 1 patient died and 18 others had not yet been discharged. High patient satisfaction levels continued to be reported.  

Conclusion  

Intervention by a non-registered EP appears to have an impact on patients’ ability to maintain or improve level of function and physical dependency during acute hospital stay.  Factors such as outbreaks of infectious illness and staffing challenges prevented more frequent EP led intervention. Next steps include introducing daily class-based interventions. Participants will be encouraged to attend at least three classes. Anticipated benefits include improvement in patients’ functional levels and reductions in physical dependency on discharge.  Additional data will be collected on fear of falling and confidence in function as well as uptake of post discharge activity and readmission. 

Introduction:

Traumatic Brain Injury (TBI) is the most common fall-related injury among adults 65 and older, despite the high incidence there is a paucity of research to guide management of older adult TBI . Simple passive remote home monitoring systems can be used to unobtrusively track markers of health and function in older adults and enhance clinical decision making in community-based care models, such as ‘hospital at home’. There are few studies to-date examining healthcare practitioners (HCPs) views on this technology. We aimed to explore HCPs insights on how to best develop the technology and examined barriers and facilitators to the adoption of passive remote monitoring in the community to track health and function in older adults following TBI.

Method:

This was a multi-center mixed methodology qualitative study. HCPs opinions were explored during and online focus group and individual interviews. Purposive sampling was used to provide balanced representation of healthcare professionals (physicians, nurses and therapists) from both community and acute multidisciplinary teams. Data were analysed using the framework approach.

Results:

The perspectives of 6 HCPs were analysed. Potential barriers to adoption were HCPs lack of familiarity with technology, skepticism over the reliability of technology, the potential for nefarious use of patient’s data and concerns over how data will be managed and interpreted for clinical use. Facilitators were the promotion of safety and independence at home, reduced workload for HCPS, the potential to target appropriate healthcare interventions and flag issues early in cognitively impaired older adults.

Conclusion(s):

HCPs felt that passive remote monitoring holds potential to improve care for older adults following TBI. However, its implementation demands thoughtful planning and clear guidelines for its use and interpretation of data. Iterative development of these systems, incorporating HCPs insights will be key to successful and sustained use in research and clinical practice.

Introduction

Surgical intervention may not be appropriate in frail patients with new or recurrent bladder cancer. To ensure that their care is aligned to the principles of ‘Realistic Medicine’, we developed a structured programme of joint management between our Peri-Operative care of Older People undergoing Surgery (POPS), Anaesthetic and Urology teams. This analysis examines our experience.

Method

Patients listed for surgery and deemed to be frail at initial screening, underwent Comprehensive Geriatric Assessment, an anaesthetic review (if indicated) and surgical evaluations. Validated measures of frailty, cognition and function were used. Each patient had a joint consultation with a bladder cancer and POPS specialist. Patient details, clinical metrics were recorded prospectively on a POPS database, with clinical follow-up records maintained electronically.

Results

From a total of (approximately) 460 suspected or confirmed bladder cancer patients, 100 were reviewed in the joint POPS-bladder cancer specialist clinic between January 2017 and early January 2024. Moderate/severe frailty was noted in 55%. Only 23% of patients proceeded with their intended surgery (GA cystoscopy/TURBT/cystectomy). Most patients opted for no operative intervention instead choosing best supportive care (45%), repeat flexible cystoscopy (17%) or repeat diagnostics (14%). Over the follow up period (median 4 years), of those who opted for no operative intervention, most did not need to change from the recommended plan; 5% of patients required an emergency admission (bladder washouts only).

Conclusions

This novel joint working with POPS and bladder cancer specialists appears to be a safe, comprehensive, and patient-centred approach to the effective and efficient management of frail patients with bladder cancer. It allows various important factors to be carefully considered and balanced including frailty, patient priorities, symptom burden and tumour size/grade/number. This model of care means selected patients could avoid the burden of unnecessary procedures and surveillance.

INTRODUCTION:

University Hospital Southampton (UHS) and Saints Foundation (SF) have partnered to test and deliver rehabilitation to hospitalised older adults via a non-registered Exercise Practitioner (EP) to promote physical activity (PA) and address hospital associated deconditioning. Now in its third phase, the project has evolved in response to patient and staff feedback. It delivers regular gym-based exercise classes and additional interventions, which have maintained or improved patients’ dependency levels on discharge.

METHODOLOGY:

From September 2023, the EP has delivered daily gym-based group interventions as well as 1:1 rehabilitation to hospitalised older adults. In addition, exercise prescription education for staff and signposting to community-based interventions is provided. Interventions take place in the acute therapy gym or wards.

RESULTS:

Between October 2023 and February 2024, the EP reviewed 115 patients, with a mean age of 86yrs. 90 (78%) underwent group-based intervention whereas 25 (22%) received 1:1 input. 100 (87%) patients maintained or improved their predicted to actual discharge destination, compared to 13 (11%) whose physical capability declined and 2 (2%) who died. 20 (17%) were readmitted within 30 days of discharge. Elderly Mobility Scores (EMS) improved from a mean of 13.42 to 13.97. Most patients were reviewed twice or more. Most patients (79% after 2 interventions) maintained a 4m gait speed score of >0.8m/s. Patient satisfaction and confidence in function rated high.

CONCLUSION:

Intervention via a non-registered EP continues to have a positive impact on older adults’ ability to maintain or improve function during an acute hospital stay. Factors such as outbreaks of infectious illness, staff absence and vacancies and high patient acuity prevent more frequent EP led intervention. Although overall strength and functional gains are limited, patient confidence in function remains high. Our future aim is to expand the project across UHS and bridge the gap to community rehabilitation services.

Introduction

There are multiple national drivers promoting person-centered healthcare. In the face of competing pressures, patient experience is often compromised. 

Aim: To increase the percentage of service users in our orthogeriatric rehabilitation ward rating experience as more than 6/10 to 90% by June 2024.

Methods

A multidisciplinary project using quality improvement methodology.  Patients and carers were involved throughout. Patient, staff and carer interviews shaped improvement themes and change ideas. Broad themes identified:

•             Communication

•             Provision, and facilitation of, ward activities 

•             Environment

Several, cost neutral, tests of change were studied: weekly exercise class, mobile library, ‘activities trolley’, music concerts, volunteer recruitment, improved signposting and coordinating weekly relative update.

Run and SPC charts were used to study impact. Measures used:

•             Outcome: Patient and carer satisfaction using 10-point Likert scale (1=poor, 10=excellent) in weekly, random cohort (P-chart). Mapping themes over time.

•             Process: Minutes of physiotherapy delivered/week. Number of patients participating in activity other than PT/OT (C-chart). Percentage of relatives updated by MDT/week

•             Balancing: Length of Stay (LOS). Readmission within 1-month. Staff Feedback. Inpatient falls.

Results

•             The % of patients scoring experience >6/10 increased over the project but did not meet ‘special cause’                criteria. Feedback themes shifted positively.

•             The median percentage of relatives receiving a weekly update increased (45% to 78%).

•             Participation in activities improved, with special cause variation observed. The amount of physiotherapy delivered each week increased by 3 hours due to exercise classes.

•             There was no significant change to falls, readmissions or LOS.

•             Staffing, covid outbreaks and workload impacted negatively during the project. 

Conclusions

‘Experience’ is individually unique and cannot be improved with a unilateral approach.

Using continuous feedback from patients and carers, we tested multiple interventions across several areas, demonstrating positive changes.

Patient experience is challenging to measure quantitatively but should not deter improvement work in this area

Introduction

There has been a recent shift in guidelines regarding HbA1c targets in the frail population. NICE (June 2022) advocate individualised HbA1c targets for frail patients with diabetes in circumstances where the long-term benefit is uncertain or when a tight glycaemic control would increase the risk of poor clinical outcomes. This is backed up by randomised control trials that have showed that Hba1c levels < 53 mmol/mol (7%) because of anti-hyperglycaemic therapy are associated with increased morbidity and mortality in frail patients with diabetes.

This led us to explore the current standards with regards to HbA1c review and consequent anti-hyperglycaemic deprescribing in frail patients in Hereford County Hospital.

Methods

Two audit cycles have been completed from March - June 2024 with a total sample size of 28 patients. Inclusion criteria were patients aged over 65 with a history of diabetes and a Rockwood Frailty score of 5 or more.

Results

The results of the first cycle showed that only 20% of the study group had their HbA1c reviewed. Only one had evidence of de-prescribing considerations. After the first cycle, a poster was created highlighting the importance of considering deprescribing for frail patients. The results of the second cycle indicated improvements following the poster display with 22% of the study population having had their HbA1c reviewed with subsequent considerations to de-prescribe. Furthermore, the poster generated positive informal feedback and stimulated conversations with colleagues about deprescribing.

Discussion and conclusion

For frail diabetic patients presenting to the Emergency department, deprescribing their diabetic medications is often not considered. They may be on medications that could be potentially causing more harm than benefit. Staff education appears to have a positive benefit, but more work needs to be done to ensure that deprescribing is considered for these patients.

Introduction

As the prevalence of dementia continues to increase across the UK, understanding the lived experience of patients and carers affected by dementia becomes paramount. There is an established dementia pathway in Sussex for people living with dementia (PLWD) and their carers. To improve care and inform future commissioning priorities, the Brighton and Hove Health Watch (BHHW- a community interest company) surveyed the opinions of a group of PLWD and their carers around initial diagnosis and subsequent support.

Methods

PLWD and their carers receiving social support and willing to provide feedback were included in this survey. Using a topic guide, BHHW volunteers conducted a telephone interview with this group exploring their experience with their general practitioner (GP), and the memory assessment service (MAS) in relation to diagnosis, and post-diagnosis support. Transcribed interviews were analysed using qualitative thematic analysis (inductively and deductively) using Braun and Clarke’s method.

Results

Forty-five participants were interviewed, 37 carers and 6 PLWD (average age 78.2 range 64-95 years) between December 2022 and May 2023. Thirty-nine participants (86%) were of white-British ethnicity. Participants reported a range of different experiences with no consistent pattern by age, gender or location. Participants were generally satisfied with the initial GP care they received. The waiting time to access MAS was six weeks on average, an acceptable timeframe for the group. Some participants reported waiting as long as two years since the initial GP consultation before a dementia diagnosis was eventually made. Participants were generally satisfied by the thorough MAS review. Most participants felt that the information material they immediately received after dementia diagnosis was complex and overwhelming. Social support offered post-diagnosis was commendable.

Conclusion

The lived experience of PLWD and their carers in Sussex was generally positive. However, a tailored approach to post-diagnosis information provision is required.

Introduction:

CGA is the gold-standard intervention for older adults living with frailty. A challenge is providing person-centred, time-efficient CGA. The CGA-questionnaire (CGA-Q) aims to facilitate person-centred CGA, allowing patients/carers to highlight concerns. We describe a two-site multi-cycle QIP implementing the CGA-Q.

Methods:

CGA-Q is a 19-item questionnaire covering seven CGA domains. It was adapted from the validated CGA-GOLD questionnaire. Between March 2023-June 2024, CGA-Q was established in a London and Scottish NHS Trust using ‘Plan-Do-Study-Act’ methodology. Cycle 1-3 involved designing and establishing CGA-Q at one London geriatric clinic. Cycle 4 assessed feasibility in multiple London geriatric clinics. Cycle 5 examined implementation of CGA-Q in a Scottish day-hospital. Person-centredness refers to inclusion of person-selected concerns in clinic letters, and not including person-excluded concerns.

Results:

Across cycles, cohorts were comparable in age, sex, frailty and cognitive status. In cycles 1-3 (n=174), CGA-Q completion rates improved from 39% to 83%. More CGA-Q questions were addressed especially cognition, mood, continence and falls. Inclusion of person-selected concerns increased from 60% to 70%; exclusion of person-excluded concerns remained ~70%. In cycle 4, completion rates varied by clinic: renal-CGA 100% (12/12); CGA 42% (13/31); bone-health 14% (10/60). >50% of questionnaires were completed by patients, except in bone-health where two-thirds were completed by staff. Staff feedback highlights CGA-Q is a useful discussion prompt. In cycle 5 (n=41), a similar breadth of CGA-Q questions were addressed among respondents compared to baseline. With CGA-Q, continence and pain were addressed more frequently. Inclusion of person-selected concerns was 62%; exclusion of person-excluded concerns was 71%.

Conclusion:

CGA-Q has been successfully implemented across multiple sites and clinics. It can improve person-centeredness and breadth of CGA, but early results vary across subspecialty geriatric medicine clinics with their unique processes. Ongoing work will determine the experience of patients and carers of this approach.

Introduction: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.

Introduction
The Assessment and Rehabilitation Centre (ARC) in Edinburgh sees around 600 new patients a year who are beginning to demonstrate signs of frailty, principally around mobility and balance. When taking a comprehensive geriatric assessment, we commonly identify concerns around cognition. We noted in some cases people were already waiting to be seen by the Memory Clinic Services, the current wait for which is approximately 10 months. We decided to see what ARC could do to help.
Method
From within existing resources, alongside the Psychiatry of Older Age (POA) Team, the ARC multi-disciplinary team coproduced a pathway that involved an initial assessment comprising identification of potentially cognitively frail patients, taking a corroborative history, performing cognitive and imaging investigations. Each step was added to a shared spreadsheet enabling us to chart progress of diagnostic information steps.
Then once assessment complete, a POA colleague reviewed the evidence and made a diagnosis with treatment recommendations.  The ARC team then discusses the outcome with the patient and their family, arranges a medication tolerance follow-up in ARC, then refers onward for ongoing community support.
Results
Between March 2023 and 2024, 52 patients completed the Memory MDT process, 34 (65%) of which were diagnosed with a dementia, 20 (33%) of which were started on dementia medication. 16 were removed from the Memory service waiting list (2.5%) and a further 18 avoided the need to be referred.
Conclusion
We identified a group of patients with a common underlying pathology that had resulted in them being referred to multiple specialities.  By arranging our services around this vulnerable patient group rather than the other way around, we reduced their need for multiple hospital attendances and freed up resource in the memory service. Work is underway to spread and scale up.