Clinical Quality

Introduction:

Clinical frailty scale (CFS) is used to generate a score ranging from 1 (very fit) to 9 (terminally ill) for people aged ≥65 years. A CFS of ≥7 correlates with a one-year mortality rate of ~50%, making it useful for identifying individuals potentially approaching last year of life. NICE recommend this patient group are offered Advance care planning (ACP). ACP is paramount to ensuring individuals receive high-quality, personalised end of life care. We aimed to investigate CFS documentation and frequency of ACP discussions following educational interventions.  

Methods:

We performed a retrospective analysis of all inpatients admitted to an Elderly Medicine department on a given day. Data for demographics, documented CFS score, and ACP discussions was collected. CFS scores were recalculated to assess accuracy. Following formal education sessions on CFS documentation and ACP delivered to the MDT, data was recollected. Subsequently, CFS scores were recorded within electronic “flowsheets” to ensure scores could automatically populate future clinical notes and be extracted for research purposes. 

Results: 

The initial sample included 61 patients with 52 in the repeat sample. 36% of patients had CFS recorded in the initial sample compared to 77% in the repeat. In the initial sample, there was an 18.1% difference in documented and recalculated CFS for patients with a CFS≥7 compared to 7.7% in the repeat, showing improved identification of advanced frailty. In the initial cohort, 18% had pre-existing ACP and 16.4% had inpatient ACP discussion, compared to 21.2% in the repeat with pre-existing ACP and 15.4% having inpatient ACP discussion; demonstrating minimal difference. 

Conclusions: 

CFS documentation improved highlighting effectiveness of education involving the whole MDT to better identify frailty within the inpatient setting. Despite this, ACP discussion rates remained low. Potential barriers include time-pressure and lack of confidence approaching ACP demonstrating a need for further awareness and training.  

Introduction:

The local issue tackled was the suboptimal compliance with the Patient Fall Management Assessment (PFMA) on the Electronic Patient Record (EPR) due to assessments being completed on alternative electronic documents.The goal was to emphasize on this to improve patient safety.

Methods:

Audit data was collected by reviewing incident reports of inpatient falls across various complex care wards over a 12-month period each, with 109 notes reviewed in the first cycle and 204 in the second.

Interventions:

The approach involved conducting repeated training sessions for all grades of training doctors within the trust.

Results:

The first audit cycle revealed fair compliance with the PFMA document (87%), documenting events (94%), examinations (87-96%), further investigations and management (80-86%). However, these were lacking for past medical history (61%), medications, especially anticoagulation/antiplatelets (58%), although antihypertensives/sedative reviews were better (75%).

The interventions led to a small (2%) increase in the use of the PFMA document but a 100% compliance in recording fall events and a 13% improvement in documenting histories. Review of blood thinners and other medications improved by 17% and 8% respectively. Significant improvements were also seen in examinations and developing management plans. Despite these advancements, 14% of patients experienced recurrent falls, indicating a need for ongoing efforts.

Conclusions:

The audit highlighted the effectiveness of continuous training to ensure regular understanding of the importance of completing the PFMA. Given the frequent rotation of junior doctors as well as the increasing variety of allied health care professionals reviewing patients, especially out of hours, this presents a particular challenge. Future efforts will focus on more sustainable methods of increasing awareness of the PFMA such as discussion at multi-disciplinary staff inductions and welcome packs. Sustaining these improvements will involve regular audits and feedback loops as well as feedback on the document itself to assess for future improvements.

Introduction:

Malnutrition is a significant problem in the hospitalised population, particularly in those with cognitive impairment. Malnutrition has been shown to increase rates of infection, pressure sores, length of stay, readmission and morbidity. Malnutrition Universal Screening Tool (MUST) scoring identifies adults at risk of malnutrition and prompts dietetic referrals where appropriate. MUST score recordings across four Complex Medicine Units in the John Radcliffe Hospital were often inaccurate or incomplete, impacting on the identification of malnutrition and timely referral to dietetics. Multi-disciplinary teaching on MUST scores improved identification of malnutrition in this patient population. Further interventions are planned.

Methods:

Electronic patient records for patients >/=75 years of age admitted to the Complex Medical Units at the John Radcliffe Hospital with a diagnosis of cognitive impairment were analysed. The percentage of patients who had either an incomplete or incorrect MUST score were identified. The percentage of patients that did not receive a referral to dietetics due to an underestimated MUST score and the reasons for the underestimation, were determined. Multi-disciplinary teaching interventions focussing on the identification of malnutrition in inpatients were implemented. MUST score recording was re-analysed following intervention.

Results:

71% of MUST scores underestimated risk of malnutrition. 67% of this cohort met criteria for referral to dietetics based on a corrected score, with only 33% of this group receiving the appropriate referral. Failure to identify weight loss in the preceding 3-6 months accounted for 88% of inaccurate scores. Multi-disciplinary teaching interventions improved MUST score accuracy by 14%, indicating improved identification of malnutrition risk.

Conclusion:

Identification of malnutrition is important to improve patient outcomes. Changes to practise will include multi-disciplinary education, improved use of technology to generate accurate MUST scores and the utilisation of transfer boards with integrated weighing scales to ensure all new admissions have an accurate weight.

Introduction The Chandlers Ford, Eastleigh and Southern Parishes Frailty Support Team (FST) identified pockets of high referral rates within independent living facilities. It was hypothesised that this may be because independent living facilities do not have a contractual arrangement for proactive intervention, unlike care homes and nursing homes. This leaves individuals and carers unsure how, when, and where to seek support. In turn, this potentially has a high healthcare burden through unplanned access to GP’s, 999, 111 or admissions to hospital.

Methods: An independent living facility was identified, and participants were invited to have a proactive, holistic review. Medical notes were reviewed for 12 calendar months prior the project and all unplanned contacts recorded. Each participant then received a face-to-face review which identified, addressed and rectified any findings/ concerns. A follow-up review of medical notes and a telephone call to participants was completed 3 months later; 3 months after telephone review medical notes were reviewed to identify incidents of unplanned care.  

Results: This project has decreased unplanned medical contacts by an average of 52% in all participants which equates to an average 6-month gross saving of £431 per person and a 6-month net saving of £383 *Net savings allowed for 3 hours of Agenda for Change 23/24 mid band 7 pay. Trend shows face to face contact has the best impact at reducing unplanned care incidents, however this does not affect the emergency needs secondary to trauma.

Conclusions: The project suggests that in independent living facilities switching from a reactive to a proactive model may allow for better holistic care, in turn reducing the burden on the local health services. It is acknowledged that this is a small sample and therefore may not be representative or generalisable and a larger study is recommended.

Introduction
In older adults, anticholinergic burden (ACB) is associated with serious adverse effects
including delirium, falls, functional decline, cognitive decline and death. We carried out a quality improvement project in a geriatric ward, aiming to reduce the percentage of older adults with high ACB scores on discharge by 15% from a baseline of 48% over a period of 3 months.
 

Method
A pre-interventional analysis of all patients discharged from a single acute geriatric ward in
Changi General Hospital was performed. A pre-intervention survey was conducted to assess awareness among physicians of ACB and tools used. Fish-bone diagram, pareto chart and driver diagram were used to identify root causes, highlight the barriers and to prioritise
interventions. Interventions in the form of educational posters on ACB, non-
pharmacological management of delirium and behavioural symptoms of dementia were made available at the ward. ACB scores were generated for all patients on discharge, using
an online ACB calculator 1 , which combined the use of 2 validated scales: anticholinergic
cognitive burden scale 2 and the German anticholinergic burden scale 3 .

Results
396 patients were included in the analysis. Median percentage of patients with high ACB scores (≥3) on discharge was reduced from 48.4% pre-intervention to 16.1% post- intervention. Out of 14 physicians surveyed pre-intervention, 21.4% was unaware of theterm “ACB” and availability of ACB scoring systems.

Conclusion
An education approach is effective in raising awareness and reducing use of anticholinergic medications in an acute geriatric ward. This highlights the importance of incorporating ACB awareness and the tools into geriatric department teaching programmes.
References
1. ACB Calculator. (n.d.). https://www.acbcalc.com/
2. Boustani M, et al. Ageing Health. 2008. 4(3). 311-320.
3. Kiesel EK, et al. BMC Geriatr. 2018. 18. 239.

Background

This clinical improvement project took place at a community frailty clinic. The primary and secondary care collaboration clinic comprised of an MDT including a physiotherapist, HCA, social prescriber, consultant geriatrician and GPwER in frailty. Older adults with a Rockwood score of 5 or more were assessed using the CGA domains. 

Introduction

Anticholinergic burden (ACB) is defined as the cumulative effect of taking one or more medications with anticholinergic effects (e.g. opioids, antimuscarinics and trycyclics). ACB score is a method of quantifying this. Higher ACB scores (3+) are associated with cognitive decline, risk of admissions with falls/ fractures and increased mortality.

The aim of the study was to quantify reduction in ACB score following structured medication review. The goal was to determine whether the frailty clinic was an appropriate setting for this.

Methods

Over a 5-month period the consultant geriatrician and GPwER calculated each patient’s ACB score. A medication reconciliation within their appointment facilitated deprescribing of high-risk medications. The HCA recorded ACB scores for all patients before and after medication review.

Results

54 patients attended the clinic. 18 patients had an initial ACB score of 0. The remaining 36 patients, had an ACB score of at least 1. Their mean reduction in ACB score was 1.2 points. Most pertinently, of the 19 patients with ACB scores of 3 or more, 12 left the clinic with a lower score and mean reduction was 2.1 points. One patient achieved a drop in score from 9 to 0.  Only 2 patients left with increased anticholinergic burden (in both cases, only increasin by 1 point).

Conclusions

Embedding the ACB score into the frailty clinics medication reviews were easily-achieved. This process is documented in clinic proformas, letters and the MDT discussion. This would be simple to transfer to similar settings.

Background 

Frailty Same Day Emergency Care (FSDEC) is a service designed to identify and manage frail older people at the hospital front door with a view to provide early Comprehensive Geriatric Assessment, implement management and where appropriate support a same day discharge home. 

Introduction 

In September 2023 the FSDEC service opened with 6 assessment spaces adjacent to A&E. This project aimed to quantify the rate of re-admission for patients seen in FSDEC and explore approaches to improve performance.  

Methods 

This QIP utilised a PDSA approach. Baseline re-admission data was collected from a 2 week period in October 2023. Notes were reviewed for all patients seen in FSDEC during this timeframe and reviewed for evidence of any 30 day emergency re-attendances. Cases were then reviewed to identify any links between the 2 attendances and any preventative measures that could have been taken. Following PDSA cycle 1 frailty nurse telephone follow up was implemented. PDSA cycle 2 was a stress test of this (limited) service during winter pressures. PDSA cycle 3 followed expansion of Community Integrated Response Hub (CIRH) and discharged patients being able to self-refer for support once discharged. 

Results 

FSDEC 7 day re-attendance reduced from 10% to 5% after introduction of frailty nurse follow up. This was not sustained over challenging winter months with variable staff availability but did recover in Summer 24. There has also been a gradual improvement in 30 day re-admission by PDSA cycle 3 following roll out of self-referral to CIRH. 

Conclusion 

Emergency re-admissions have reduced following implementation of frailty nurse telephone follow up and expansion of community services including patient access to CIRH for help following discharge from FSDEC. Addressing staffing model could allow for a more consistent follow up service. There is scope to trial this approach on geriatric ward discharges.  

Introduction

We proactively reviewed nursing home residents using a multidisciplinary team (MDT) approach within a Primary Care Network (PCN). We aimed to enhance care coordination, reduce inappropriate medication use and ensure all residents had current advanced care plans in place.

Method

An MDT comprising a geriatrician, prescribing pharmacist, general practitioner, and nurse reviewed residents proactively. This involved reviewing the residents' current health and care needs, falls risk, medication regimens and advance care plans. We then performed medication reviews, reviewed advanced care plans, and identified the need for further interventions. When we repeated the process, we used a proforma that could be pre-populated prior to the meeting by the pharmacist and geriatrician to improve efficiency of the discussion.

Results

The initiative was piloted in two residential nursing homes with a total of 65 residents reviewed, of which 86% (n=56) received interventions. There was a 47% (n=29) increase in completed advanced care plans. 62% (n=40) of residents had medicines optimised, with polypharmacy being reduced in 46% (n=30) by an average of 2 medications per resident. 8% (n=5) were referred to additional services and 8% (n=5) required further investigations.

Conclusion(s)

This proactive MDT model effectively addressed the needs of residents whilst demonstrating immediate positive outcomes. Key facilitators to good practice were teamwork, clarifying the objectives of the MDT, prior reviews of patient records, and ensuring staff who knew the residents well were present. We will use this approach with other nursing homes within the PCN and share our results with colleagues. This has the potential to reduce costs of medications and hospital admissions, as well as improve quality.

Introduction:

The Gloucestershire Frailty Virtual Ward (FVW) is a novel multidisciplinary collaborative project which seeks to improve care for frail older patients. We describe our experience, reflect on lessons learnt and plans for future service development.

Methods:

The Gloucestershire FVW was started in early 2023. It arose from an understanding that the needs of frail patients can often be better met in their own homes, by utilising a combination of digital technology combined with improved working across organisational boundaries at the primary/secondary care interface. We reviewed data from all patients admitted onto our FVW between October 2023 and March 2024.

Results:

66 patients were included. The majority of patients were ‘step-down’, having been in hospital prior to FVW admission. The minority were ‘step-up’, having been referred from community colleagues. Clinical frailty scores ranged from 2-8, with a mean of 6. During this period, our FVW managed a range of different clinical problems. The most common reason for FVW admission was infection, then heart failure, delirium and acute kidney injury. Most patients were admitted for the management of a single problem (58%), although a significant proportion had 2 or more problems (42%). Our FVW conducted a variety of interventions, including blood tests, face-to-face reviews, amending medications including antimicrobials, diuretics and analgesia. Our FVW was also involved in decisions around the withdrawal of active care and initiation of a palliative approach.

Conclusions:

Our FVW has helped facilitate early discharge and avoid hospital admission, with associated benefits to both patients and the acute trust. As a new service which aims to sit between primary and secondary care, we have encountered logistical and governance challenges associated with working across organisational boundaries. Additionally, we have found that the use of digital technology can cause anxiety for patients and place additional strain on carers.

INTRODUCTION

Polypharmacy represents a significant challenge in the vulnerable elderly population, where concurrent use of multiple medications increases the risk of interactions and adverse reactions, often precipitating acute events and complicated hospital stays. This necessitates thorough medication reviews to mitigate these risks; a hospital admission allows for such opportunities.

METHODS

This project aimed to evaluate and address the medication burden among elderly patients, following WHO's Global Patient Safety Challenge: Medication Without Harm. 50 patient’s medications were reviewed on a elderly care ward over the space of 3 months. A ward pharmacist and a senior member of the medical team critically evaluated inpatient charts on a twice weekly basis. Any changes made to the medication regimens were documented; additionally, the general practitioner was informed of any changes.

RESULTS

Initial data indicated that 66% of patients were on five or more medications, with a high incidence of falls and a notable anticholinergic burden. On review of the 50 patients a total number of 36 drugs were de-prescribed, 38.9% were inappropriate anti-hypertensives, 13.8% vitamins amongst others.

CONCLUSIONS

This project has been an enlightening endeavour, teaching us the critical nature of addressing polypharmacy. We have learned that interdisciplinary collaboration, regular medication reviews, and patient education are key to managing this complexity. To ensure long-term sustainability, we plan to institutionalize pharmacy board rounds and implement mandatory medication reviews. We aim to work closely with primary care to maintain continuity post-discharge. These efforts are expected to foster a culture of mindful prescribing and medication safety.