Clinical Quality

There is unequivocal evidence to support Perioperative care for the Older Person Undergoing Surgery (POPS) services. However, POPS services are not available in all Trusts offering surgery, including Royal Surrey Foundation Trust (RSFT). The necessity for POPS services will continue to grow with increasing numbers of older people undergoing elective and emergency surgery due to: changing demographics, surgical and anaesthetic advancements, shifts in culture and patients’ expectation of healthcare (1). A RSFT POPS steering group was convened to explore the current orthopaedic elective pathway, the what-why-how of implementing a POPS service and ultimately write a business case to submit to the board to request funding for a formal POPS service. Unfortunately, ahead of submitting we were informed a business case would unlikely secure funding due to the current financial climate. To continue to evidence the need for this service, over the course of a year, Geriatricians used their Supporting Professional Activities (SPA) time to provide informal POPS Comprehensive Geriatric Assessment (CGA) reviews to patients aged ≥65 with a CFS ≥5 on the elective waiting list for knee/hip operations. The average age of patients seen was 82 years (range 67-92). The average Clinical Frailty Score calculated was 7 (range 4-7) with the average number of frailty markers identified being 4 (range 1-7). Following CGA, 75% of patients decided not to proceed with operative management. 88% either initiated or completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We now have both local and national data to support the need for a POPS service at RSFT. When financial support is not available to invest in and develop new services, alternate methods such as staff re-distribution can be considered with the aim of both providing a service as well as collating invaluable evidence to support a business case and secure funding.

 The aging population is often burdened with multiple comorbidities, leading to polypharmacy, which increases risk of adverse drug reactions .
 

Anticholinergic medications are commonly prescribed to elderly patients for various conditions, yet they are associated with a range of adverse effects, including cognitive impairment, falls, and even increased mortality.

The Anticholinergic Burden (ACB) score is a validated tool used to assess the cumulative burden of anticholinergic medications in patients. This clinical audit is aimed to evaluate the use of the Anticholinergic Burden (ACB) score as a tool to identify and manage anticholinergic burden in elderly patients within a hospital setting.

Method: A retrospective analysis was conducted on a cohort of elderly patients (> 65 years of age) admitted under orthogeri in the month of June 2023 which yielded a sample size of 33 patients using various data related patients congnition and demographics, medical history, medication

Results: Data revealed that 36% of elderly patients had impaired cognition And ACB scores were not calculated despite them being on anticholinergic drugs even though investigations of possible causes of cognitive impairment were done and ruled out as possible cause Further analysis revealed a significant correlation between ACB scores and cognition. Patients with high ACB score were nearly 3 times as likely to be confused and patients ACB score of 2 were more than twice as likely to be confused.

Data also revealed that the most common drugs contributing to anti-cholinergic burden Lansoprazole (18%) Analgesics (15%) - out of which 60% came from Codeine

Conclusion: ACB score is an efficient tool to better manage the effect of polypharmacy on the elderly .

it is important to flag high ACB scores in order to optimize medication by prescribing alternative drugs with low anti - cholinergic burden . 

Vitamin D deficiency has become commonplace, especially in older people. Given the role it plays in bone health and falls prevention, as well as the growing evidence of its extra-skeletal actions, it is important to treat vitamin D deficiency adequately. Our practice has been 2 to 3 weeks of daily treatment with 50,000IU ergocalciferol as a loading dose. However, recent guidelines recommend half this total cumulative dose given over a period of 6 to 8 weeks. Rather than promptly following the guidelines and changing our practice, we opted to conduct a quality improvement project (QIP) looking at the effectiveness of our protocol for treating Vitamin D deficiency in older patients. In the initial project patients admitted to an acute geriatric ward and found to have vitamin D deficiency were prescribed a 2 weeks course of daily ergocalciferol. In the second project, patients with severe deficiency (<20 IU/ml) received 3 weeks of treatment. In all patients pre- and post-treatment vitamin D levels were done. In total 76 patients were included. Results: all patients demonstrated significant improvement. Post-treatment serum vitamin D levels returned to normal in 66%. The median change in vitamin D level was 265%. Importantly no side effects were noted and no patient reached toxic serum vitamin D levels. Conclusion: Our results show that doses higher than the current recommendations for treating vitamin D deficiency are needed to replenish depleted vitamin D stores in older people. Compared to recommended strategies which generally span over 6 to 8 weeks, our daily protocol provides rapid replacement over 2 to 3 weeks. It is effective and safe with no side-effects. The short course of daily treatment should also increase patient compliance

Introduction

It is predicted that over 4,000,000 patients will be on an elective waiting list in England by 2030 (1) with increased demand, age and frailty following COVID (2). The importance of early assessment of frailty and geriatrician input to allow optimisation and shared decision making is key. A Geriatrician led perioperative clinic was established in Swansea Bay for patients on elective general surgical waiting lists in September 2023.

Method

Using an electronic Power Business Intelligence frailty flag, we highlighted patients and screened either electronically or via telephone using a combination of CFS and CRANE questionnaire. Covering a number of areas including continence, falls and cognition. The outcomes are reviewed by a geriatrician and directed to appropriate avenues such as face-to-face perioperative clinic, continence services or virtual wards. All patients who decide to continue on their journey to surgery are given advice r.e. operative risk, diet and fitness along with optimisation of medications and tests such as echo to minimize delays going forward.

Results

Over 250 patients >65 have been screened to date-either Digitally/Paper/Telephone. Digital responders have an average CFS of 4.48. Over 20 patients have been seen per month since initiating the service with a variety of outcomes. Over 50 (~20%) have decided against surgery following shared decision making demonstrating cost savings of approx. £200,000. There are a number of new diagnoses including dementia and incontinence. Over 20 patients have accepted referral to continence services.

Conclusion

Formalising a perioperative clinic has allowed improvements in patient care and cost savings. We have now completed an initial screen on all general surgical patients who have been on the waiting list over 1 year and have initiated ongoing screening to detect changes in frailty going forward. The next step is initiation of frailty screening at point of referral on WCCG referral.

Introduction

The importance of nutritional support has been extensively investigated in studies of people with hip and fragility fractures. Hospital nutritional assessments vary in quality, and this limits the extent to which risk assessment can be viewed as a meaningful indicator of nutritional support. Provision of supplements is an alternative measure, but only if known to have been consumed. For this reason, we developed a protocol to capture actual consumption of prescribed supplements. Methods Following nutritional risk assessment, the prescription and distribution of supplements was recorded on patients’ drug charts in the usual way. Our protocol required that when supplement cups were cleared, nurses should annotate the drug chart with the volume of supplement each patient had actually consumed. Following this protocol’s introduction, we conducted a point prevalence survey of patients’ supplement consumption in orthogeriatric rehabilitation wards in May 2024.  Results Of 25 inpatients with hip fracture, 21 (84%) had been identified as being at nutritional risk and prescribed Fortisip compact protein. Patients were recorded to have consumed between 50 and 100% of the supplement. This quantification of actual consumption allowed us to calculate that, on average, these patients with hip fracture had consumed an average of 188ml/day — which would provide an additional daily 27.4g of protein and 460 kcal of energy. Figures for 15 patients with other forms of orthopaedic injury indicated that 8 (53%) were at risk. These patients recorded similar levels of supplement consumption. Conclusion The prevalence of nutritional risk and malnutrition among patients with hip fracture would suggest that all should be considered ‘at risk’. A performance indicator might be constructed which starts with this assumption and measures whether such patients have actually consumed nutritional supplements. Our simple approach captures actual consumption, whilst reminding us of the importance of nutrition.

INTRODUCTION: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Introduction

Patients living with dementia are more likely to experience delirium and adverse outcomes when admitted to hospital (Dementia UK, 2022). The General Surgery directorate at Cardiff and Vale University Health Board secured funding for a Memory Link Worker (MLW) in the emergency stream. The aim of the MLW is to improve the hospital experience for patients living with cognitive impairment or anyone experiencing delirium. The MLW should also increase awareness and completion rates of “Read About Me” (RAM).

Method

Eligible patients are identified by ward staff or the Perioperative care of Older People undergoing Surgery (POPS) team and referred. The MLW reviews patients, offers activities, contacts families/ carers and completes the RAM. We used dementia care mapping (DCM), an observational tool to objectively measure the impact of interventions on patient wellbeing and improve care for people living with dementia. Patient, relative and staff feedback was collected via a short survey.

Results

During the first 2 years the MLW has seen 107 and 141 patients respectively. DCM demonstrated a positive impact on patient well-being, mood and engagement. Very few patients were able to self-entertain in the absence of the MLW and those that did were using tools supplied by the MLW. A small survey of patients and relatives (n=9) found MLW support to be ‘extremely helpful’ and if readmitted would want MLW support again. A larger staff survey (n=52) showed most felt their ward had benefitted from MLW input, and felt that other wards with cognitively impaired patients would benefit from similar, as well as showing good awareness of the role.

Conclusion

The DCM process aligned with survey findings of a positive impact of the MLW role on patient experiences in secondary care setting.

Introduction

A good discharge summary for a patient is an important clinical record that narrates and communicates clinical information about the patient's entire hospitalisation. Discharge communications between healthcare facilities play a pivotal role in the coordination of patient care. As geriatric patients’ physical health is intricately woven into their social circumstances, mobility, and available care facilities, the mention of these parameters becomes quite important as it informs the community medical team of the patient’s condition more comprehensively. Crafting a good summary is challenging and we noted insufficient documentation of geriatric domains.

Methods

A discharge summary QIP was run in the geriatric wards at the Royal Gwent Hospital for 5 cycles. In these 5 cycles, we introduced a poster, electronic MDT, teaching sessions, and discharge summary checklist respectively as our chosen intervention. We collected data prospectively and calculated the percentages of presenting complaints, diagnosis, comorbidities, history, examination findings, investigations, management, mobility, care needs, discharge destination, cognition, resuscitation and escalation plan, whether were documented or not in the summaries.

Results

A total of 20-30 patients’ discharges were included in each cycle. Overall, there was good documentation in general medical domains (95-100%). A remarkable rise in the documentation of care needs (65%), mobility (80%), and discharge destination (50%) amongst other parameters was noted. However, there was minimal improvement in cognition, resuscitation and escalation plans as some of them do not apply to all patients. The improvement is progressing as the physicians are now frequently referring to the checklist for writing the summaries.

Conclusion

These interventional measures showed the quality of discharge summaries has improved dramatically. Hence, we uploaded the discharge checklist to our health board intranet and included it in the induction booklet. We hope to include it in our yearly induction sessions to maintain the level of improvement.

Introduction:

Polypharmacy is commonly defined as the concomitant use of five or more medications. This is a common problem in frail elderly patients and more so on the surgical inpatients where it is not regularly reviewed by the surgical team.

Methods:

We reviewed retrospectively the data on vascular inpatients from 2015-2016 and after the set-up of the perioperative services in 2022-23. Patients above 65 years of age with a clinical frailty score of 4 or more or with two or more co-morbidities were selected from both groups. In total 130 patients were selected from each group and their notes were reviewed in terms of polypharmacy review, before and after the introduction of the perioperative service in the trust.

Results:

Average age of the patients in both groups combined was 75 years. Average polypharmacy number per patient before and after the perioperative service were 6.8 and 10.7, respectively. In 2022-23, all the 130 patients had a polypharmacy review by a Consultant Geriatrician. In 2015-16, polypharmacy was reviewed only if there was an adverse effect to the drug, for example bradycardia caused by beta blockers. There was no routine review of polypharmacy. 0.06 Medications were stopped per patient in 2015-16, in contrast to 1.7 per patient in 2022-23. Most common causes of discontinuation of medications were falls, confusion, postural hypotension, drowsiness, electrolyte imbalance or medication no longer needed.

Conclusions:

Polypharmacy optimisation should routinely be practised in frail vascular surgical patients as it leads to avoidance of undesirable side-effects, improves patient compliance to medications, and has a huge financial benefit from deprescribing.

People from ethnic minorities face additional challenges in hospital. These contribute to poorer progress and outcomes. We set out to develop an online resource to help hip fracture teams provide answers to questions commonly posed by people presenting with hip fracture, and to address inequalities in patients’ and their families’ access to information. Method In 2021 we surveyed all 167 hospitals in England, Wales, and Northern Ireland which look after people with hip fracture – to identify which provided printed or digital information, and which made this available in languages appropriate to their local population. Results Most hospitals (70%) claimed that they routinely provided printed information about injury, surgery and recovery, but only 26% could say that they provided this in languages appropriate to their local population. The equivalent figures for digital forms of information were 23% and just 10%. We produced, piloted and finalised an English language template in discussion with people attending our hospital. Initial Google translations of this were circulated to clinicians within our department who were familiar with this patient group and able to read, edit and sign off versions in other languages. We surveyed these editors and 71% described the final document as highly useful. However, nearly two-thirds had identified limitations in the Google draft and 50% reported needing to modify technical elements of the text. One-third (36%) spent more than two hours editing the text to a form they felt would be accessible to patients. Conclusion We would recommend this approach to those working with other conditions and other patient groups, as there is clearly a need for information to meet the needs of the patient. We plan to extend our portfolio of 19 languages (the first languages of >3 million people in the UK alone) in collaboration with clinicians fluent in other languages.