Clinical Quality

Background

Dementia is a prevalent condition in an ageing population. Persons with dementia and their caregivers are often uncertain about what to expect after an initial diagnosis. Previous studies conducted on the experiences of informal caregivers show a clear demand to address these: providing adequate information, psychosocial support and access to services.

Introduction

The diagnosis of dementia is usually made by specialists in the tertiary hospital. However, resources in acute tertiary hospitals are expensive and valuable. To better allocate resources and improve the manpower situation, we have collaborated with our community partner to provide post diagnosis support (PDS) to patients newly diagnosed with dementia.

Methods

A PDS team consisting of an allied health professional and a caregiver peer is established by our community partner. They conduct home visits to provide psychoeducation to help persons with dementia and their caregivers understand more about dementia, develop personalised care plans, and coordinate support services to provide psychoemotional support.

Close communication is maintained between the PDS team and the acute hospital referral team. Multidisciplinary team meetings involving the geriatricians, nurses, case managers and community partners are also held quarterly to provide regular updates about the progress of the patients and facilitate learning.

Results

A total of 95 persons who were newly diagnosed with dementia in the previous 1.5 years were referred. 53 patients were eventually enrolled under the PDS programme, and received psychoeducation and personalised care plans. 72% were given caregiver support and 66% were linked up to community services. The average duration between date of referral to date of first home visit is 13 days.

Conclusions

In an ageing population where there is high healthcare utilisation, it is efficient to utilise existing services instead of duplicating them. By collaborating with community partners, we are empowering them to play a better role in supporting persons with dementia.

Introduction.

The National Early Warning Score (NEWS) (2017) incorporated new confusion as a category for consciousness. NEWS2 is evidenced to have high specificity but low sensitivity in detecting delirium.

Methods

Morriston Hospital 261 patients assessed. Consciousness, overall NEWS2 score and AMT4 recorded. 227 NEWS2 charts available. 208 patients recorded as alert. 44% (n=87) scored less than 4 on AMT4 ,55% (n=48) didn’t have documented past medical history (PMH) of cognitive impairment. Data missing for 14 patients. Ysbyty Gwynedd 178 patients assessed.161 recorded as alert. 58.4% patients scored less than 4 on AMT4, 77% had no PMH of cognitive impairment. Data missing for 15 patients. University Hospital Llandough. 40 patients; 38 patients were marked as Alert, 2 were excluded from observations.32.5% (n=13) had a diagnosis of possible or definite delirium. An electronic survey coupled with training delivery of 103 Health Care Workers (HCW) and 112 Registered Nurses (RN) was undertaken at Morriston. 39 HCWs ( 37.8%) and 31 RNs ( 27.6%) weren’t confident in the use of NEWS2 in regards to acute confusion. Training was offered on a 1 to 1 basis for these 215 staff members.

Results

Post intervention, 221 patients were assessed at Morriston, 209 marked as alert. 2 patients had been identified as having a new confusion and 10 patients did not have their consciousness recorded. Of the 209 marked alert 42% (88 patients) scored less than 4 on AMT4; 53 had no PMH of cognitive impairment. Training yielded little benefit.

Conclusion

The accuracy of recording consciousness has wider implications on the use of the NEWS2. NEWS2 uses routine observations and delirium assessment is variably implemented meaning routine information is not always available. The NEWS2 should be used in conjuction with other tools developed for delirium e.g 4AT and SQiD.

Key to managing frailty is to first measure it. Until recently, there was no hospital coding for frailty, which meant that it was not visible to commissioners in routine datasets, despite the wealth of studies highlight poor outcomes for older people living with frailty. AFN has created the Hospital Frailty Risk Score (HFRS), which generates a frailty risk from routine codes included in NHS datasets. This allows commissioners and providers to ‘see’ frailty across their system.

We have designed and implemented easy to use tools that allow any NHS staff to look at frailty risk profiles in any NHS organisation, to support improvement activity. The HFRS tool has been downloaded by 122 health systems in England.

Patient safety is fundamental to AFN and reducing the harm older people are exposed to in hospital is the main aim of the programme and sites participating in the network. To achieve this and spread best practice the AFN delivery team use a specific QI approach, primarily the Model for Improvement, focusing on Plan-Do-Study-Act cycles to build change in local systems.

The team deliver events each year for all participating teams to support teams and enable sharing of experience. Site visits comprise discussion about the local context, plans for change and a discussion about possible barriers, as well as a walk-though the patient pathway with patient safety as the absolute focus. Each participating hospital has an allocated QI Associate to support the team to plan, deliver and measure improvements.

AFN has linked closely with other campaigns that support the safety and improve the care of older people, such as ‘end PJ paralysis’ and ‘no decision about me without me’.

Managing ACUTE Hyperkalaemia in Frail INDIVIDUALS USING A MODERN POTASSIUM BINDER SODIUM ZIRCONIUM CYCLOSILICATE (LOKELMA®)

Background

Hyperkalemia is a common life-threatening electrolyte abnormality present in acutely admitted frail patient, often in context of Acute Kidney Injury (AKI), background of Chronic Kidney Disease (CKD) and a variety of medications such as renin-angiotensin-aldosterone system (RAAS) inhibitors.

NICE TA 599 guidance recommends the use of a modern K+ binder such as Sodium Zirconium Cyclosilicate (SZC) in the acute setting alongside standard of care. This case series was carried out with a view to gain clinical experience specifically in acutely unwell frail older individuals presenting to a District General Hospital in UK.

Methods

Eight patients presenting to ED at Medway NHS Foundation Trust over 3-week period between 7th June -11th July 2023 with Hyperkalemia were treated with SZC, data was collected retrospectively.

Results (N=8)

·        Sex: Male:4, Female 4

·        Age range: Mean age 86 years (range: 69-105 years)

·        Clinical Frailty Score:  ≥ 6 in all cases

·        Average serum K⁺ on admission: 5.75 mmol/l (range: 5.6 – 6.3 mmol/l)

·        Comorbidities: CKD: 6 / 8, T2DM 5/8, Hypertension 5/8, CCF 4/8

AKI present in 6/8, Sepsis present in 4/8

Management: SZC 10 g tds was managed to correct hyperkalemia alongside established standard of care measures for acute hyperkalemia management. Fluid resuscitation, antibiotics and discontinuation of culprit medications was carried out where indicated.

Effectiveness of SZC

·        Normokalaemia was achieved in 4/ 8 of cases within 24 hours of admission

·        In the remaining 4 patients, 3 achieved normokalemia within 48 hours and in 1 patient serum K⁺ was normalised in 72 hours after commencing treatment with SZC

Conclusions

•        Clinicians gained familiarity with prescribing SZC, in managing acute hyperkalaemia in frail older patients

•        Demonstrated effectiveness of SZC specifically in frail elderly population

•        Change in local guidelines for acute hyperkalaemia management: SZC (Lokelma®) is now available in ED, on all acute medical wards

Introduction:

Delirium, characterized by disturbances in attention and consciousness, is common in individuals with pre-existing medical conditions, particularly the elderly, but can affect people of any age. It can lead to significant morbidity, mortality, prolonged hospital stays, increased healthcare costs, and long-term cognitive decline. Despite its impact, delirium is often underdiagnosed and undertreated, underscoring the need for better diagnostic strategies. The 4AT tool, recognized by NICE, is valued for its rapid delirium assessment, unlike the AMT-10, which is more suited for chronic cognitive disorders.

Objective:

This study was conducted to assess the usage of the 4-AT tool in the assessment of delirium to aid in the early detection of delirium in the elderly population.

Methodology:

The retrospective review of medical records over six months was conducted and divided into two cycles to evaluate delirium assessment using the 4AT. Initially, data from 59 patients 49 at FPH and 10 at WPH established a baseline of 4-AT usage across the trust. Post-intervention, 60 patient records were reviewed to reassess 4AT usage. Interventions included: 1. In-person Training sessions in completing 4AT 2. Informative posters placed in ED and Medical wards (AMU and Elderly-care) 3. Continuous reminders to enhance early detection.

Results:

Before the intervention, only 6.8% of patients were assessed using the 4AT tool, 55.9% with the AMT, and 37.2% without assessment. Post-intervention, the overall assessment rate rose to 62.7%, significantly increasing 4AT usage. Among 28 delirium-diagnosed patients, only 14.3% were screened with the 4AT, indicating room for further improvement. Discussion and

Conclusion:

The increased use of the 4AT tool post-intervention highlights the effectiveness of educational initiatives in improving delirium screening. Early detection through the 4AT facilitates timely interventions and better patient outcomes. However, the small sample size and underutilization among diagnosed patients suggest the need for ongoing efforts to improve its usage.

Background: Patients triaged as routine, discharged home from Intermediate Care Units (ICUs) in areas of West Sussex wait  approximately 4 weeks or more until rehabilitation continues by the Community Therapy Team (CTT).

Introduction NHS England (2023a) and NHS England (2023b) call for minimal delays, effective coordination processes and sharing of information for timely rehabilitation in intermediate care settings. Local patient feedback indicated poor patient satisfaction and increased clinicians anxiety regarding risk of deterioration due to long waits (Lewis A., 2018).

Aim To improve average wait times for routine ICU patients’ discharge, for ongoing community therapy input, to within 1 week by July 2024, while maintaining patient safety and improving patient satisfaction.

Methodology: Quality improvement methodology, using stakeholder engagement was used to determine the cause for long wait times for home therapy. PDSA cycles were engaged to determine if improvements could be made without a loss of quality of care, or impacting patient safety, while improving patient experience. These involved formal communication channels between teams and using a therapy assistant for an initial home assessment where assessments had already been undertaken by registered therapists on the ICUs. Patient satisfaction surveys were undertaken to understand the experience of transition home.

Results: Baseline data indicated that waiting time for home therapy varied between 18 - 59 days, from discharge. After the initial PDSA cycle, waiting time reduced to between 4 - 10 days, and after the second cycle waits reduced further to between 3 - 7 days. Patients’ satisfaction improved significantly with shorter waiting times for therapy once home.

Conclusion: Therapy assistant initial visits at home reduced waiting times to within a week, and patients’ satisfaction improved with shorter waiting times. Patient safety was not compromised as there were clear protocols for appropriate escalations for unregistered staff.

East Kent has 38,101 people over 80 years, 39, 021 living with moderate or severe frailty and 304 care homes. This population have high levels of unplanned admissions which can put them at risk of long hospital stays, reduced mobility and increased delirium.

East Kent Ambulance services (SECAMB), Acute hospitals (EKHUFT) and Community Services (KCHFT) have piloted a single-point of access consisting of an ED consultant, community frailty clinician, Urgent care senior nurse, advanced paramedic practitioners. They sit together at the ambulance bases, 10am-6pm Monday to Fridays. This team reviews all patients awaiting ambulances to assess whether there are alternative services to ED which would meet the individuals' needs.

Method

The MDT assesses all patients listed as awaiting an emergency ambulance. Clinical records can be accessed from all services including GP records. If patients would benefit from treatment by alternative services, rather than conveyance, the paramedics are asked to call the MDT. This allows clinical assessment, history and investigation results to be taken into account in planning care. Patients and Carers are involved in deciding how they would like to receive medical care via a video or phone link with clinicians.

Results

Conveyance to hospital pre pilot - 62% post pilot less than 50%

Ashford catchment: admissions save weekly 27.3, bed days saved weekly 179.2

Thanet Catchment: admissions saved weekly 19.1, bed days save weekly 106.9

Conclusion

Many people can be treated effectively without conveyance to hospital through pre-hospital triage, consultation and planning by senior clinicians in a multi-disciplinary team.

Introduction

Incidents and complains are an important form of learning for healthcare institutions. The learning is often shared via huddles, handovers, emails and learning alert bulletins. In the older persons medicine (OPM) department at James Cook University Hospital, we identified that there may be a role for whole team in-situ sim to not only facilitate learning around important and highly relevant topics but also improve the education provision for nurses and healthcare assistants who have less access to education compared to their doctor colleagues and improve whole team communication.

Methods

Initially a working group including a consultant, advanced clinical practitioner, SIM training facilitator, liaison psychiatry nurse, teaching fellow and ward manager was set up to organise a pilot session. Following the success of this session the training was initially organised to be monthly, arranged by the advanced clinical practitioners, facilitated by the sim technicians. The ward managers fully supported the training and facilitated the attendance of the ward staff. The clinical director identified topics for learning from incidents and complaints and there was support from the OPM registrars and teaching fellow. It quickly became so popular amongst staff that the session frequency was increased first to fortnightly and is now run weekly.

Results

The feedback was excellent. From the attendees, to the sim trainers who said that the OPM department had been the most enthusiastic about ward-based training. The anonymised and entirely positive feedback from the sessions was that they were interesting, informative, and relevant to clinical practice.

Conclusion

Using in-situ simulation training on the older persons medicine wards to share learning from incidents and complaints is not only practical, but incredibly well received by staff of all disciplines.

 1. Introduction. Advance care planning (ACP) allows patients to prepare for their future and articulate their care preferences. Despite it being a major policy focus there are significant barriers that affect ACP delivery, including paperwork burden and information sharing difficulties. Electronic Health Records (EHRs) are fundamental to how ACP conversations are recorded and communicated. We present data from inpatient geriatric medicine unit during a change in trust-wide EHR (namely, EPIC) and a contemporaneous ACP educational drive.

2. Methods. Clinical notes for all patients on three geriatric wards were analysed on a single day in July 2023 and April 2024. EPIC was rolled out in October 2023.Demographics including age, admission and discharge destination, clinical frailty score (CFS) and social circumstances were retrieved and notes were reviewed for ACP decisions. Teaching took the form of regular small group seminars for ward teams, and departmental sessions to build confidence and optimise ACP documentation using the new software.

3. Results. 83 and 85 patients were identified in July 23 and April 24 respectively. Demographic data were similar between groups including mean age (82; 84), CFS of ≥6 (67%; 61%). In July cohort, one patient had an ACP . In April, 20 patients had an ACP and 8 patients had a Universal Care Plan.

4. Conclusion(s). Significant improvements were noted in ACP delivery and documentation. Following the launch of EPIC alongside targeted teaching to staff members, the proportion of patients with an ACP increased by 23% and UCP by 10% over a 9-month period. EPIC includes improved ability to search for relevant information and dedicated space to document ACP plans, both of which may have contributed to these results. Future work aims to expand this learning into GSTT community services and across other trusts, capitalising on the potential of improved EHR technology in the NHS. 

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)>