Discharge

Background: Older individuals living with frailty face a heightened risk of experiencing significant deterioration in their mental and physical well-being following seemingly minor health challenges. Our aim was to assess and enhance the practice of the Clinical Frailty Scale (CFS) during inpatient assessments within a large teaching hospital.
Methods: We conducted 2 cycles of retrospective data collection within a single centre setting, screening a total of 600 patients focussing on; age ≥65, level of frailty, location of CFS assessment - Emergency Department (ED), Medical Assessment Unit (MAU); and the health-care professionals involved in CFS practice. We compared practices amongst young-old (65-74), middle-old (75-84), and old-old (≥ 85) age groups.  
Results: The CFS documentation rate for eligible patients was 76.7% in the first cycle, involving 240 patients, and 83% in the second cycle which included 247 patients, whereas the rate for the above-mentioned age sub-groups was 13.8%, 67.7%, 98.3% respectively. The prevalence of frailty amongst the age sub-groups was 74.1%, 84.7%, and 93.9% respectively, while male-to-female prevalence was 88.9% and 89.2%. Overall, 72.7% of the CFS assessments were completed in ED. The Frailty Interface Team (FIT) significantly contributed to the CFS assessment by completing 58.1% of overall assessments.
Conclusion: The results underscore the significance of integrating frailty education into core teachings to enhance CFS practice among junior doctors. Identifying inpatient frailty in the 65-74 age group is crucial, as they are frailer than initially perceived and will further decline with aging. Interdisciplinary collaboration is essential, particularly a specialized FIT, proving pivotal in CFS practice within our hospital. Larger studies into inpatient frailty in the young-old age groups are recommended. 

Background

Nationally, the average rate of discharges drops by over a third over the weekend and prioritising these discharges is recognised by NHS England in improving patient care and facilitating the flow of patients through the hospital.(1)

Aims

To assess the documentation of criteria for discharge in Care of the Elderly wards for patients who were identified as having an estimated date of discharge within 72 hours and could be discharged over the weekend.Guidance from NHS England recommends clear plans to be documented in all patients notes detailing social, physiological and functional criteria for discharge.(1)

Methods

We performed a closed loop audit on the documentation of criteria for discharge for all patients on the Care of The Elderly wards identified as having an estimated date of discharge within 72 hours during the Friday morning multidisciplinary team (MDT) meeting.

We looked at whether criteria for discharge were documented, whether to take out medications (TTOs) were prepared and whether patients identified went on to be discharged. 

Intervention

We provided the pre-existing Criteria-Led Discharge Tool to doctors present at the Friday MDT to document criteria for weekend discharge under the supervision of a senior decision maker.

Results

A total of 100 patients were identified as suitable for weekend discharge over the data collection period. Interim results show that following the intervention, documentation of criteria for discharge rose by 34% (31% - 65%). 

References

1. NHS England. Rapid improvement guide to improving weekend discharges. Available from: https://transform.england.nhs.uk/improvement/100-day-discharge-challeng…

Introduction: Older patients are vulnerable to falls after discharge as hospitalization could induce declines in physical function, mobility, and muscle strength. Falls may cause readmissions and subsequent healthcare burden. However, such incidence rates and costs have not been studied. This study aimed to investigate the incidence and costs of fall-related readmissions in older patients.

Method: A population-based retrospective cohort study was conducted among patients aged 65 or over and discharged from public hospitals in Hong Kong from 2007 to 2017. The administrative data for inpatient admission were obtained from the Hospital Authority Data Collaboration Lab. The fall-related readmissions within 12 months following discharge were identified by the International Classification of Diseases code of diagnosis. The incidence rates were calculated in terms of person-years. The costs were computed based on the public ward maintenance fees adopted since 2007.

Results: In total, 611,349 older patients with a mean (SD) age of 75.3(7.6) were analyzed. Within 12 months after discharge, 18,608 patients (3.0%) had 20,666 fall-related readmissions, giving an incidence rate of 35.2 per 1000 person-years. Meanwhile, such rates (per 1000 person-years) were 44.7 for women, 25.5 for men, 20.5 for patients aged 65-74, 41.0 for patients aged 75-84, and 76.2 for patients aged ≥85. The annual cost exceeded HKD 145.6 million (USD PPP 23.9 million in 2018) for older patients, and the mean cost per fall-related readmission was HKD 7,048 (USD PPP 1,158).

Conclusion: The fall-related hospital readmissions were important adverse events during the transitional period and caused a considerable healthcare burden to the patients, family caregivers, and the health system. Health professionals are suggested to implement interventions during hospitalizations or at the early stage after discharge to reduce falls, particularly for women and patients aged ≥75. For instance, increasing physical activity during the hospital stay can be considered for fall prevention.

Introduction

People with Parkinson’s disease (PwP) are more likely to be admitted to hospital and have longer lengths of stay than those without Parkinson’s disease (PD). Parkinson’s UK and NICE have proposed standards of care for inpatients with PD, including that PD specialists are alerted when PwP are admitted to hospital. 66% of UK hospitals don’t have an alert system in place, including King’s Mill Hospital (KMH).

Audit

Over a 6 month period, referrals to the PD service in KMH were audited. 128 referrals were made; 5 per week on average. Hospital-wide, around 12 PwP are admitted weekly. Therefore under 50% are referred for specialist input. 64% of patients had been in hospital over 24 hours before referral. 16 patients were referred to the PD service more than once during admission, reflecting ongoing management difficulties.

Intervention

The digital transformation team completed software changes to create an electronic alert when PwP are admitted to hospital. The local system for recording admission details and electronic prescribing, NerveCentre, can now generate an electronic list showing all inpatient PwP. A multi-disciplinary virtual PD ward round was introduced. Using NerveCentre, all PwP can be remotely reviewed and triaged. Proactive, positive interventions from the specialist PD team include: constipation management, osteoporosis screening, speech and language therapist review, cognitive assessment, issuing dysphagia cards, and advance care planning. NerveCentre enables remote medication reviews and audit of prescribing, ensuring that any breaches of the ‘Get It On Time’ campaign are reported via Datix, with relevant learning shared. The virtual ward round provides training opportunities for specialist registrars, junior doctors, and newly appointed PD specialist nurses.

Conclusion

The electronic flag permits more comprehensive, proactive and timely inpatient reviews of PwP. The interventions from this project enable the Trust to meet Parkinson’s UK recommendations and hopefully improves the inpatient experience of PwP.

Introduction:

Large numbers of geriatric inpatients within acute settings are deemed medically safe for discharge (MSFD) but stranded within the hospital due to a lack of community services and social care packages, leading to increasing length of patient stay and reduced hospital flow. These patients do not require inpatient care and would otherwise be discharged to their home or residential care. This project aimed to identify these patients and rationalise their medical input to mirror a community setting (without routine daily medical reviews).

Methods:

MSFD patient were identified by the multi-disciplinary team (MDT). Patients identified received standard nursing and therapy input, alongside daily MDT discussion at a board round to progress discharge planning. If the MDT expressed concern about a MSFD patient, they would receive a medical review. A sticker placed in the notes identified patients deemed MSFD.

Results:

A 3-week trial on a 19-bedded geriatric ward showed 46% of bed days were occupied by MSFD patients. On average, 8 MSFD patients did not require daily review. 0.6 unplanned reviews/day were needed due to MDT concern, saving an average of 7.4 patient reviews/day, equating to 3.3 hours/day doctor time saved.

Conclusions:

Doctor time saved allowed redistribution of staff to busier wards with more unwell patients, with no detriment to patient care noted. The trust formalised a SOP and the MSFD pathway was introduced across the geriatric medicine department. A MSFD ward has now been opened, to cohort patients awaiting discharge to community pathways. This ward should require minimal doctor input to allow continued redistribution of medical staff across the hospital, as well as facilitating patient flow by admitting patients who reside on the acute frailty unit who require increased community care.