CQ - Patient Centredness

Introduction: Care home residents are often multi-morbid with both physical and cognitive impairments. An average care home resident takes 7.2 medications per day. Older people are more likely to experience adverse effects from polypharmacy due to pharmacokinetic and pharmacodynamic changes associated with age. Polypharmacy and anti-cholinergic burden (ACB) not only increase the risk of adverse drug reactions but also can increase the number of falls, hospital admissions and mortality. 

Method: Retrospective analysis in October 2024 of all patients at a residential home who had an initial Comprehensive Geriatric Assessment (CGA) which included a medication review since Enhanced Health in Care Home (EHCH) team started in March 2022 up until September 2024. The number of medications a patient was on at initial CGA alongside their ACB burden was analysed pre and post CGA. 

Results: 65 residents had an initial CGA within this time period with an average of 6 medications and ACB score of 2. Post CGA, the average number of medications per resident was reduced to 5 with an ACB score of 1. 68% of patients had polypharmacy (≥5 medications) prior to initial CGA and this was reduced to 58% post. 12% had ≥10 medications (excessive polypharmacy) prior to CGA and 8% (5) post. Pre CGA, 26% of residents had a high ACB score ≥3 which reduced to 15% post. There were 59 medications prescribed with an anti-cholinergic score of ≥1 which were reduced overall by 24% following the CGAs. 

Conclusion: The overall degree of polypharmacy and anti-cholinergic burden in care home residents can be reduced through a medication review as part of a CGA

Parkinson’s disease (PD) is a progressive neurological condition which affects approximately 153,000 people in the United Kingdom (1). It classically involves a triad of bradykinesia, rigidity and tremor alongside other significant motor and non-motor features (2). Delayed or missed medications can result in unpleasant motor and non-motor fluctuations (3). Inappropriate management of patient medication has been shown to result in longer length of stay, delayed recovery, and worse overall outcomes (4). Patients with PD have a high risk of complications peri-operatively with evidence showing they are best managed via a multidisciplinary approach (5).​​The PD team at Aintree University Hospital, part of NHS University Hospitals of Liverpool Group (UHLG), noted that referrals for patients undergoing surgery were low. An initial review of data confirmed that patients undergoing surgery at the site were not having the PD team involved in their care. ​The acute management of Parkinson’s disease for inpatients guidelines were updated to include more detailed advice around the management of patients with PD undergoing surgery. The second cycle reviewed patients cared for after the intervention had occurred.​After the guideline was implemented the number of patients reviewed either pre- or post-operatively by the PD team increased from 4 to 47%.​In the initial review there were 640 missed or late doses of PD medications, with only 17% of patients consistently receiving their medications on time. This improved to 56% in the second cohort. ​Cognitive testing via the 4AT was completed for 38% of patients compared to 18% in the initial cohort. ​In the second cohort data was collected to review the number of patients with PD who were put first on the operating list, this occurred in 26% of patients.​ The results show an improvement in all aspects of care that were reviewed. The number of patients seen by the PD team, medications given on time, and cognitive tests performed all improved. Despite this there is still room for improvement; medications are still not being given on time, every time. UHLG has undertaken a trust wide time critical medication quality improvement project which we hope will have a positive impact. Further improvement through education of the surgical and anaesthetic teams and a guideline awareness campaign are planned.

A Treatment Escalation Plan is a document that records and communicates a patient’s treatment goals and preferences, should their general health or condition worsen. A TEP can include but is not limited to: resus status, preferred place of care or death, if imaging/IVs/venepuncture is appropriate. Treatment Escalation Plans aim to minimise harm from over or under treatment; provide clear continuity of care between healthcare professionals; and prevent futile or burdensome interventions which may be contrary to patient wishes. TEPs can be recorded on the computer system, TRAK. The aim was to introduce TEP recording to the Edinburgh Hospital at Home Team (H@H) and aim for 80% of patients under our care to have a completed TEP. We found that anticipatory care planning and TEP discussions were regularly being had by H@H staff but that these were not being recorded under the TEP tab on TRAK. We increased staff awareness of the importance of TEPs and hosted teaching sessions and created a video on how to create a TEP on TRAK. TEP completion increased from 0% before they were introduced in our team, to a maximum of 78%. The team are reaching an average of 56% of patients having a completed TEP in the first 5 months of use. There does not seem to be a correlation between the number of patients under our care and the number of completed TEPs. We have not yet reached our goal of 80% but there has been a very good response from staff in starting to use the TEP function on TRAK. This data will continue to be monitored and a BOXI report has been created which provides twice weekly data reporting the percentage of patients under H@H care who have a recorded TEP and this will continue to be audited at least biannually.

Introduction 

The development of specialist acute frailty services is well recognised as crucial to meet the needs of our ageing population and is recommended by the NHS England Long Term plan. At the same time, same day emergency care (SDEC) services are rapidly expanding as an alternative to ED However, to date there is a limited evidence base for specialist frailty SDEC units. 

Methods 

We ran a 6-week pilot of a 7-day specialist frailty SDEC open from 8am-6pm. The unit was staffed by consultant geriatricians, frailty ACPs, specialist nurses, junior doctors, a therapy team and resident pharmacists. Patients were accepted both directly from the community (GPs, ambulance crews community frailty teams) and from ED. Criteria were loosely defined by Clinical Frailty Score (CFS 5 or above) and NEWS <3. 

Results 

A total of 256 patients were reviewed in the frailty SDEC over the 6 week pilot period. 166/256 (65%) of patients stayed <24 hours and a further 48 (19%) had a short stay of between 24-72 hours. 7-day ED re-attendance rates remained low at 6% (16/256) and 10% (26/256) of patients were re-admitted to hospital within 30 days of discharge (compared to 17.9% England national average for 2023-2024). 

Conclusions 

Frailty SDEC provides a safe, effective environment for rapid comprehensive geriatric assessment of patients living with frailty. Through close links with community teams we facilitate admission avoidance and person centred care in the right place, first time.

Improving Advance Care Planning Within Residential Homes

Introduction:

As care home residents are living with advancing frailty and multi-morbidity, it is important to initiate advance care planning as part of the comprehensive geriatric assessment and create universal care plans (UCPs). There is evidence that it can reduce inappropriate escalations of care, reduce hospital admissions, increase the proportion of residents dying in their preferred place and improve both resident and relative satisfaction.

Method:

Retrospective audit in June 2024 of residents within the five residential homes covered by the newly formed enhanced health in care home (EHCH) team who had an initial comprehensive geriatric assessment (CGA) between March 2022-May 2024 to review if they had a universal care plan in place (UCP).

Further sub-analysis to review whether they had an existing UCP prior to EHCH review or this was created/edited by the EHCH team. Both the CGA and UCP would have either been completed by the EHCH matron or consultant geriatrician.

Results:

There was an average increase from 26% to 89% in the number of residents with a UCP following an EHCH CGA. We have created/edited a total of 117 UCPs across the care homes in addition to those already in place across the 177 CGAs completed over this time period.

Conclusions:

Advance care planning is a vital part of a comprehensive geriatric assessment and it is often not completed for many reasons including its time-consuming nature, lack of awareness and apprehension in having these discussions both amongst residents, relatives and staff and a lack of training and education.

As an EHCH team, we have managed to improve the number of residents with UCPs to 89%. We hope this will mean a greater proportion of residents receive appropriate personalised care according to their wishes in their chosen place as well as dying in their place of preference.

 Introduction: The pandemic has shown how vital patient-centred treatment escalation planning (TEP) is for older people. Locally we have seen inappropriate transfer of dying patients to acute hospitals from rehabilitation units. Mortality review found a lack of useful TEPs in these cases. Baseline data in our rehabilitation hospital showed 54% of patients had a TEP and 16% a decision made about repatriation during acute illness. We aimed to increase the proportion of patients in this setting with a TEP to 80% over six months.

Methods: A multidisciplinary team of doctors, ANPs and senior nurses worked together. We conducted stakeholder engagement to understand the factors that result in transfer of patients and found that completion of TEPs was felt to be an effective way to improve communication out of hours. Our first test of change involved an ANP raising the CPR status and TEP for all new patients at the weekly MDT. We measured the process of what decisions were made once a fortnight. Outcome data on the overall completion of TEPs and repatriation decisions was collected each month.

Results: New decisions were made at each MDT – for example, on one date two new DNACPRs and six new TEPs were completed. Overall TEP completion rate varies however since our first intervention we have seen a sustained increase in the number of TEPs which include consideration of repatriation – from 16% to 60%. Ongoing conversation with doctors in training reveals challenges with ward staff awareness of TEP content and their ability to guide unexpected events out of hours.

Conclusion: Involvement of motivated permanent staff across disciplines has allowed us to ensure escalation plans are being made each week and begin to see improvements. 

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:

Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national Irish Health Service Executive (HSE) guidelines after education sessions in a Model 3 Hospital.

Methods:

A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants.

Results:

Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%.

Discussion:

This audit elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. We posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan.

Conclusion:

Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.

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