CQ - Clinical Effectiveness

Introduction 

Delirium is a common presentation in geriatric medicine. Improvement in delirium assessment and management should improve identification of these patients and improve their outcomes. This Quality Improvement Project, completed by a group of Health Care for Older People (HCOP) resident doctors, aimed to improve delirium assessment and management for patients admitted to the five HCOP wards at Good Hope Hospital, Sutton Coldfield. 

Methods 

Patients with documented confusion were selected and delirium assessment/management was compared to current NICE Guidance. This included whether delirium screening was done, which screening tool was used, and how delirium was managed. Data was collected retrospectively from electronic patient records, anonymised, and recorded using an online form. Data from 85 randomly-selected patients admitted to HCOP wards in Good Hope Hospital during September 2024 was collected. Interventions of departmental teaching for all HCOP doctors and informative posters in common areas were implemented. Data collection was then repeated with 77 patients admitted during November 2024. 

Results 

Screening for delirium increased from 55.3% to 71.4% (+16.1%). Use of the NICE recommended 4AT tool increased from 30% to 43.9% (+13.9%). Implementation of non-pharmacological techniques (such as re-orientation) rose from 2.4% to 16.9% (+14.5%), and treating an identified cause rose from 75.6% to 94.8% (+19.2%). 

Conclusion 

Departmental teaching and educational posters were successful in improving delirium assessment and management. The largest improvements were in using a screening tool and treating an identified cause, which are largely undertaken by doctors. To improve further, educational efforts could be extended to the entire multi-disciplinary team. This may have resulted in more frequent use of non-pharmacological interventions. To implement long-lasting change, the posters have been provided to the department and delirium will continue to be taught in departmental teaching for future rotations of resident doctors.

Introduction

There are approximately 600 patients in the Pembrokeshire Movement disorder service, of whom, around 10% are either housebound or live in placements.   There is concern these patients struggle to access follow up due to difficulties in attending face to face clinics.  NICE and Parkinson’s UK recommend that people with Parkinson’s should be seen by a specialist healthcare professional every 6 to 12 months.

Method

A retrospective case note analysis was carried out for 55 patients that were identified as being either housebound or living in residential or nursing homes.  Data were collected on time since last clinic visit and last letter, hospital admissions in the past 2 years, number of prescribed medications and DNACPR status on Welsh Clinical Portal.

Results

The mean time since last clinic visit was 15.3 months, with the longest 81 months.  Housebound patients had a mean time since last clinic visit of 15.5 months and those in placements had a mean time of 15.3 months.   The time since last letter was lower, however those patients still in their own homes had a longer interval than those in placement.   53% of patients had a DNACPR decision recorded on Welsh Clinical Portal.  When isolating   housebound patients this dropped to 29%.  72% of those in placements had a DNACPR decision.

Conclusions

The requirement to see patients with Parkinson’s every 6 to 12 months is not being met.  This is likely due to practical difficulties of attending face to face clinics.   It is proposed to create a regular virtual clinic to discuss these patients, in combination with their relatives or carers and patient reported outcome measure questionnaires.  This will be brought to the health board Parkinson’s meeting in order to facilitate change.  Once the change has been implemented data can be recollected to establish the effect of the change.

Introduction Delirium is a common, reversible condition with significant morbidity. Guidelines facilitate diagnosis and management (NICE Delirium Guidelines [CG103]). Previous audits in an acute frailty ward identified areas for improvement in assessment of delirium. In this cycle, a novel admission proforma was implemented to promote adherence to current guidelines. Methods This is a continuation of a previous quality improvement project representing cycles three and four. An admission proforma was co-developed with patients and the multidisciplinary team (MDT), primarily to prompt staff to complete delirium assessments. Adherence was audited and the proforma was modified based on feedback. An equivalent audit was then conducted on the updated proforma. The audit period occurred over several resident doctor changeovers. Primary outcomes; completion of delirium assessments, positive diagnosis of delirium and use of the new proforma. Secondary outcomes; completion of resuscitation and clinical frailty score (CFS) forms and the relationship between length of stay (LOS) and delirium or CFS. Results  The initial admission proforma was used in 86% of admissions. After its introduction, 53% of patients had completed delirium assessments and the prevalence of delirium was 25%. Resuscitation forms were completed in 86% of patients, 60% of patients had completed CFS. Diagnoses of delirium were associated with increased LOS. CFS of 6/7 was associated with an increased LOS and a diagnosis of delirium. The modified proforma was used in 94% of admissions. Completion of delirium assessments improved to 79% and diagnoses of delirium to 43%. Completion of resuscitation forms and CFS improved to 93% and 79% respectively. The difference in LOS between patients with and without delirium was statistically significant. Conclusion This study shows the efficacy of an admission proforma, as low-cost MDT-based intervention, improving and sustaining adherence to guidelines and improving documentation and assessment of other elements of a comprehensive geriatric assessment. 

Care of the elderly simulation-based teaching for the multidisciplinary team

Introduction

Geriatric medicine is inherently complex and requires multi-disciplinary integration. Simulation-based training has been recognised by the Joint Royal Colleges of Physicians’ Training Board and the Royal College of Nursing as a method to enhance learning and improve patient outcomes. This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional clinical practice that takes place on geriatric hospital wards.

Methods

A total of ten half-day simulation sessions have been run across two sites in two years. The scenarios cover frailty, orthogeriatric post-operative complications, acute delirium, Parkinson’s disease, thrombolysis and end of life care.

The sessions were attended by 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates. Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation as a learning tool.

Results

Both pre- and post- simulation, candidates had the most confidence in managing end of life situations, and least confidence in managing acutely unwell patients with Parkinson’s disease. Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the simulation session. Thematic analysis highlighted the importance of collaboration within a team to enhance a sense of belonging, and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.

Conclusions

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the multi-disciplinary team looking after geriatric patients through exposing candidates to complex situations and increasing awareness of the roles within the team.

The simulation sessions have highlighted clinical areas that require further education within the Trust, such as thrombolysis.

Future development of the simulation will aim to adapt the scenarios for use of the wider multidisciplinary team, incorporating therapists and pharmacists.

Introduction: Treatment Escalation Planning (TEP) ensures timely clinical decision-making and appropriate responses to patient deterioration. This project aims to assess compliance with TEP documentation in the acute respiratory ward, identify gaps, and implement strategies for effective documentation. 

Methods: 3 PDSA cycles were completed using a quality improvement strategy, each for 5 days. Data was collected retrospectively using the patient’s electronic records, assessing key metrics such as TEP presence in patient’s notes and TEP TAB, DNACPR documentation, and time from admission to TEP completion. An intervention followed each cycle. The first cycle focused on awareness to consider TEP completion on admission, second cycle focused on educational sessions highlighting the importance of TEP discussion and documentation in a timely manner. 

Results: The results show steady improvement in TEP documentation across all cycles. TEP in patient's note completion increased by 11.5% in Cycle 2 and 15.3% in Cycle 3, reaching 61.5%. However, TEP in TEP TAB completion drops by 10.1% in Cycle 2 but recovers with a 24.7% increase in Cycle 3, reaching 26.1%. DNACPR documentation improves by 14.4% in Cycle 2 but decreases slightly by 1.6% in Cycle 3. The average time to TEP completion decreases by 2.6 days in Cycle 2 and 0.7 days in Cycle 3, reaching 1.5 days. These findings indicate significant progress but highlight areas needing attention. 

Conclusions & Recommendations: Ensuring the completion of both TEP in notes and TEP TAB is crucial for effective patient management. To improve compliance, the implementation of a ward-round documentation template is recommended to prompt TEP status when seeing new patients with the Consultant on-call. Additionally, TEP status should be considered during patient clerking to ensure early documentation and prompt discussions should take place if a patient’s clinical condition deteriorates. Sustained improvements can be achieved through structured documentation workflows and ongoing clinician training.

Introduction 

We were wanting to better understand the population of older people accessing a district hospital emergency department, to identify how a front door frailty team could be utilized and estimate the potential impact this could have for the hospital. 

Method 

All patients over the age of 65 who were within the Emergency department on 4 consecutive Thursdays between 8am and 4pm were assessed and proposed a potential intervention from a front door frailty team (either to be streamed to an SDEC or community service, receive a review in ED, ward follow up, or no intervention at all). All patients’ notes were then followed up including ED disposal, inpatient notes if admitted, length of stay and their 7 and 30 day outcomes. 

Results

Of the 121 patients I was able to review and follow up, I believed 48 would have benefitted from intervention from a dedicated frailty team. Of these 48 patients, 28 were admitted to the hospital and totaled 161 bed days. On review of the notes many patients were deemed to be medically fir for a number of days prior to discharge (61 in total), which we know has a huge impact on a patients’ welfare, risk of hospital acquired harms as well as the impact on patient flow and hospital resources. Unfortunately, one patient deemed medically fit was unable to have an essential D2A to facilitate discharge, and he deteriorated and subsequently died in hospital. His preferred place of death was his own home. Conclusions I believe every emergency department would benefit from a dedicated front door frailty service, which would not only serve to improve patient care and allow a comprehensive geriatric assessment, but also serve the hospital to improve flow, reduce admissions and the associated complex discharges from hospital wards back to community care. 

Introduction 

There is a drive for same day emergency care (SDEC) assessments of older frail patients attending hospitals. Multiple documents suggest how frailty SDEC services could work. 

Methods 

A trial of a mobile frailty SDEC, the Frailty Intervention Team (FIT) took place for 4 weeks in October 2020.. Data were collected manually but most of the presented data was indirect, such as length of stay of all older frail patients, rather than directly related to who FIT had seen. As FIT developed it was clear that data collection required automation. This was achieved through use of specific “Clinical Data Capture” (CDC) forms on the Trust’s Electronic Patient Record (EPR). Utilising a combination of emergency care and admitted patient datasets, a bespoke dashboard has been produced which visualises the data using Statistical Process Control methodology. A CDC form was developed that enabled identification of patients assessed by FIT. 

Results 

Initially the success depended on where the patient was when the CDC form was completed with 135 patients identified a month from ED dropping to 73 after the establishment of a SDEC unit (non significanton SPC) and 51 identified a month among inpatients, with 160 after the SDEC unit opened (p<.05 on spc) . through collaborative working, adjustments were made to how the data was extracted and transformed for reporting. there no significan diferenceinthenumbersofin november 2024, 284 patients seen with 260 cdc forms. of these 250 recognized by developed dataset (96%). 

Conclusion 

Collaborative working between analyst & fit clinical lead has led bespoke dashboard allow demonstrate value system trust board. work is ongoing generate reports demonstrating levels compliance girft standards aligned model hospital sets benchmarking.

Introduction: Osteoporosis causes significant deterioration of bone health predisposing individuals to an increased risk of fractures. Hip fractures in particular lead to increased mortality, morbidity and substantial economic burden on the healthcare system. Early identification of high-risk individuals is crucial to improve patient-related outcomes and significantly reduce the burden on our healthcare system. The objective of this quality improvement project (QIP) is to promote osteoporosis risk assessment in the frailty unit at North Manchester General Hospital (NMGH), by introducing a Comprehensive Geriatric Assessment (CGA) inclusive of a bone health risk evaluation. Methods: CGA, including a formal bone health assessment (as per NICE guidelines April 2023) was implemented in our frailty unit. This QIP was carried out in two cycles. Baseline data was collected (N = 33) retrospectively in January 2023 before CGA implementation followed by data collection in May 2023, to evaluate CGA with bone health assessment inclusion as an intervention (N=31). At the end of cycle one the results were presented to staff including education on CGA and bone health. Cycle two, conducted in June 2024 assessed compliance (N=30). Results: Bone health assessment compliance improved from 15% at baseline to 55% after cycle one and 83% after cycle two. When evaluated for inclusion of a bone health treatment plan, the baseline value was 31% which improved to 84% and 90% in cycles one and two, respectively. Conclusion: Implementing CGA with the bone health assessment standardised interventions to improve patient’s bone health admitted to the frailty unit at NMGH. CGA also helped identify people at risk of fractures and to initiate prompt management. This QIP helped our frailty unit to adhere to NICE guidance, thereby improving the quality of care offered at NMGH.

Introduction: 

Urgent Community Response (UCR) teams need innovative solutions to deliver timely and effective care to frail older adults. This project explores the combined impact of remote assessment, continuous monitoring, and AI scribes to enhance UCR service delivery, aiming to improve patient care, staff efficiency, and resource utilisation.

Methods: 

This service initiative integrates three key remote technological interventions within a UCR frailty service:

• Assessment: Digital examination devices (TytoCare) were used by Clinical Support Workers for remote clinician assessment. Data from 74 remote examinations conducted between April and September 2022 were analysed.
• Monitoring: Biobeat chest and wrist monitors were piloted with 20 patients within a Frailty Virtual Ward for four months. Data was collected to assess the impact on clinical decision-making, patient care, and system efficiency.
• AI Scribes: An AI scribe (Heidi) was introduced to the frailty team, to evaluate its impact on note-taking efficiency and documentation quality. Usage data from 419 sessions were collected and analysed.

Results:

• Assessment: Remote examinations using digital devices allowed clinicians to avoid hospital admissions in 70.3% of cases. The use of Clinical Support Workers saved between £13 and £78 per hour, equating to a potential yearly saving of up to £13,853.
• Monitoring: Continuous monitoring improved clinical decision-making and facilitated safe discharge to the patient's usual residence (91% with monitoring vs. 69% without).
• AI Scribes: Within the UCR workstream, the use of the AI scribe reduced time spent on documentation, with some areas experiencing time savings of 15-20 minutes per patient. Note quality improved and the AI scribe also decreased administrative burden.

Conclusion: 

This service initiative demonstrates the potential of combining remote assessment, continuous monitoring, and AI scribes to transform urgent community response for frailty enabling more efficient use of resources, improved patient outcomes, and enhancing note quality in the UCR workstream. This warrants further development.

Introduction:

It is important to identify delirium on admission as delirium increases patient mortality and also is linked to an increased length of hospital admission (1). Delirium is identified through a scoring system such as 4AT (2) and should be done on all patients over 65, with new confusion, or reduced mobility (3) as per NICE guidelines. The aim of the QIP is therefore to bring the department in line with NICE guidelines and increase the number of patients in the over 65 cohort having a cognitive assessment, and in particular looking at those with confusion and falls as these can be presenting symptoms of delirium(3).

NICE guidelines state that all over 65s should have a cognition screen on admission to identify delirium and particularly those with symptoms of delirium (3).

This completed two cycle QIP aimed to improve the proportion of patients over 65 who presented with a fall, new confusion, or both fall and new confusion, who had a documented completed cognition screen on admission to CDU from Eastbourne ED.

Method:

From a random 2 week interval of CDU admissions, we identified those aged over 65. Using their clerking documentation we identified those presenting with fall, new confusion, or both. We assessed if they had an accepted completed cognition screen (MMSE, MOCA, 4AT, AMTS, SQuID) documented in their clerking. This required reading through the entirety of the clerking as there was no dedicated place for a cognition screen to be documented. This was repeated post intervention.

For cycle 1, a 4AT box with the four questions which generated a score was added to the electronic clerking proforma. For cycle 2 we organised and delivered in person teaching sessions for the junior doctors within the department. Juniors were recruited to act as 'delirium champions' and encourage a culture of delirium awareness through discussion at board rounds and within the department on a daily basis. The high turnover of A&E staff and the highly varied rota's posed a challenge to the efficacy of in person teaching sessions. To ensure the educational element was delivered to all, we created posters to educate on the presenting symptoms of delirium, the importance of early identification, and screening tools to use such as the 4AT box.

Results:

For CDU admissions for all over 65s, the percentage with a completed cognition screen increased from 0.02% to 5.10% after cycle 1, and increased further to 11.25% after cycle 2. For those admitted to CDU aged >65 with new confusion only (no falls), the percentage with completed cognition screen increased from 9.09% to 25.00% in cycle 1 and to 66.67% in cycle 2. For those aged >65 presenting with fall only (no confusion), the percentage increased from 0.00% to 4.35% in cycle 1 and to 26.32% in cycle 2. For those aged >65 with both fall and new confusion, the percentage increased from 0.00% to 11.76% in cycle 1 and to 33.33% in cycle 2.

Conclusion:

Including a 4AT prompt on the clerking proforma improved cognition screening for those with symptoms of delirium. However, clerking proforma changes alone are insufficient and much greater improvement was achieved through the combination of proforma changes (4AT box) and departmental educational initiatives. It is additionally important to consider a variety of educational initiatives in a department such as A&E with high staff turnover and varied rota's which can limit engagement with traditional in person teaching sessions.

References:

1. Anand, A. et al. (2022). Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and Home Time: Two-centre study of 82,770 emergency admissions. Age and Ageing, 51(3). Available at: https://doi.org/10.1093/ageing/afac051.
2. Jeong, E., Park, J. and Lee, J. (2020). Diagnostic test accuracy of the 4AT for delirium detection: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(20), p. 7515. doi:10.3390/ijerph17207515.
3. NICE (2010). Recommendations: Delirium: Prevention, diagnosis and management in hospital and long-term care: Guidance (2010) NICE. Available at: https://www.nice.org.uk/guidance/cg103/chapter/Recommendations#assessment-and-diagnosis (Accessed: 07 January 2024). Last updated: 18 January 2023