Clinical Quality

There is unequivocal evidence to support Perioperative care for the Older Person Undergoing Surgery (POPS) services. However, POPS services are not available in all Trusts offering surgery, including Royal Surrey Foundation Trust (RSFT). The necessity for POPS services will continue to grow with increasing numbers of older people undergoing elective and emergency surgery due to: changing demographics, surgical and anaesthetic advancements, shifts in culture and patients’ expectation of healthcare (1). A RSFT POPS steering group was convened to explore the current orthopaedic elective pathway, the what-why-how of implementing a POPS service and ultimately write a business case to submit to the board to request funding for a formal POPS service. Unfortunately, ahead of submitting we were informed a business case would unlikely secure funding due to the current financial climate. To continue to evidence the need for this service, over the course of a year, Geriatricians used their Supporting Professional Activities (SPA) time to provide informal POPS Comprehensive Geriatric Assessment (CGA) reviews to patients aged ≥65 with a CFS ≥5 on the elective waiting list for knee/hip operations. The average age of patients seen was 82 years (range 67-92). The average Clinical Frailty Score calculated was 7 (range 4-7) with the average number of frailty markers identified being 4 (range 1-7). Following CGA, 75% of patients decided not to proceed with operative management. 88% either initiated or completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We now have both local and national data to support the need for a POPS service at RSFT. When financial support is not available to invest in and develop new services, alternate methods such as staff re-distribution can be considered with the aim of both providing a service as well as collating invaluable evidence to support a business case and secure funding.

Introduction:

As awareness of hospital-associated deconditioning increases, services to prevent hospital admissions and provide discharge support for older adults are expanding, aiming to reduce admissions and the risks associated with prolonged hospital stays. A Welsh Government IQS titled “Older People and People Living with Frailty” published in January 2024 identifies a need to shift our health and social care system from prioritising reactive crisis management to a ‘place-based’, community-focused approach that emphasises proactive identification and management of frailty. The CTMUHB @Home Service (AHS) was instituted in 2017 to provide domiciliary and community-based care to patients at risk of hospital admission, covering Rhondda, Cynon, Taff Ely and Merthyr Tydfil.

Methods:

A retrospective review of patients discharged from the AHS between February and May 2024 was completed (n=345). Reasons for referral, diagnostic journey details, and patient outcomes were recorded. Alongside this, the IV Antibiotics Service register for the same period was analysed (n=48) to calculate the number of Bed Days saved and its associated cost effectiveness.

Results:

57% of referrals are related to patients’ risk of or recent falls, followed by 16% of patients with increased frailty who are approaching crisis. 8% of patients have been referred for the specialised services of the AHS, such as COPD reviews, discharge support, pharmacological optimisation, or follow-up blood tests. Most referrals originate from GPs, with other sources including facilitated discharges or WAST. Bed day costs saved from the IV Antibiotics Service are estimated to be £358,000.

Conclusion:

We now have a better understanding of the AHS’ monthly patient in and outflow. Although the substantial cost savings seem positive, it is still uncertain whether this conclusively measures the AHS’ cost-effectiveness. This understanding will help pave the next steps towards increasing awareness about the functions of the AHS as a hospital avoidance team focused on frailty.

Abstract Content - 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 from WPH established a baseline of 4-AT usage across trust. Post-intervention, 60 patient records were reviewed to reassess 4AT usage. Interventions included In-person Training sessions in completing 4AT Informative posters-placed at ED and Medical wards 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 but 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 optimize delirium assessment practices.

Introduction

In 2021, the Welsh Government launched the “All Wales Dementia Care Pathway of Standards”, which the Cardiff and Vale University Health Board (CVUHB) Memory Assessment Service (MAS) works under (1. Welsh Government, 2021). This service evaluation aims to evaluate the CVUHB MAS diagnostic pathway against these standards.

Method

This retrospective review analysed 299 referrals to the CVUHB MAS from August 2020-2023. Data was collected via referral and clinic letters, focusing on demographics, referral sources, diagnostic timelines and clinical outcomes.

Results

Patients had a mean age of 78.2 years (n=299), with 86.0% (n=257/299) referred by General Practitioners. The average Charlson Comorbidity Index (CCI) was 4.93 (n=299) and the median Clinical Frailty Scale (CFS) score was 4 (n=299). Patients were on an average of 6.5 (n=299) medications at referral, with an anticholinergic burden (ACB) score of 1.12 (n=293) and 15.0% (n=44/293) had a high ACB (≥3). The average time from referral to diagnosis was 19.3 weeks, primarily due to pending neuroimaging. Ethnic minorities experienced longer symptom onset to diagnosis, 2.56 (n=16) vs 1.94 (n=263) years average. 59.2% (n=177/299) of patients received a diagnosis of dementia and 36.5% (n=109/299) of cognitive impairment. Medication was initiated in 30.8% (n=92/299). 84.1% (n=244/290) required one clinical appointment to receive a diagnosis.

Conclusions

Results showed the average CCI score was 4.93, indicating significant health burdens. The need for targeted medication reviews in Memory Clinic was highlighted in 15.0% of patients with an ACB ≥3. Addressing ethnic disparities is crucial to the overall reduction of diagnosis times. The CVUHB MAS achieved a high diagnostic rate at first clinical contact (84.1%). 30.4% (n=91/299) received a diagnosis of mild cognitive impairment, a critical cohort for early intervention to manage disease progression. Streamlining the pre-diagnostic pathway, especially performing neuroimaging at referral, is essential to meet the 12-week diagnosis target (1).

Pulmonary embolism (PE) is the third most common among acute cardiovascular diseases, after myocardial infarction and stroke, with a significant mortality rate. At Portsmouth University Hospital's acute medical and respiratory departments, inadequate understanding of pulmonary embolism diagnosis and management, which led to unnecessary investigations and medications putting the patients at risk of the side effects and complications of that, was the main impetus for initiating this audit. The hospital did not adhere to the NICE recommendation of regular interim anticoagulation for patients awaiting imaging for probable PE. A significant number of patients unnecessarily admitted to the hospital due to PE could have benefited from outpatient treatment. We collected data for eight weeks both before and after the implementation of the new hospital PE pathway, following a baseline audit and PDSA-based problem-solving, which underscores the significance of accurately utilising the Wells Score and PE rule out criteria (PERC). We obtained PE diagnosis criteria from NICE standards for comparison. The new hospital PE pathway was a result of the initial audit. The results from the re-audit showed an improvement in documentation and calculation of the Wells score from 16.1% to 66.1%, the PERC score from 9.1% to 58.3%, and the PE severity index (sPESI) score increased from 9.1% to 58.3%, as well as an increase in the number of junior doctors who initiated the PE pathway from 19.6% to 41.9%. Additionally, the proportion of inappropriately requested investigations, such as D-dimer and CTPA, was reduced. Also, the number of CTPAs requested in line with the guidelines increased from 11.11% to 52.27%, and the diagnostic yield of PE on CTPAs increased from 36.08% to 64.85%. A simple diagnostic pathway resulted in a decrease in unnecessary investigations and an increase in the diagnostic yield of PE.

Introduction

Patients living with dementia are more likely to experience delirium and adverse outcomes when admitted to hospital (Dementia UK, 2022). The General Surgery directorate at Cardiff and Vale University Health Board secured funding for a Memory Link Worker (MLW) in the emergency stream. The aim of the MLW is to improve the hospital experience for patients living with cognitive impairment or anyone experiencing delirium. The MLW should also increase awareness and completion rates of “Read About Me” (RAM).

Method

Eligible patients are identified by ward staff or the Perioperative care of Older People undergoing Surgery (POPS) team and referred. The MLW reviews patients, offers activities, contacts families/ carers and completes the RAM. We used dementia care mapping (DCM), an observational tool to objectively measure the impact of interventions on patient wellbeing and improve care for people living with dementia. Patient, relative and staff feedback was collected via a short survey.

Results

During the first 2 years the MLW has seen 107 and 141 patients respectively. DCM demonstrated a positive impact on patient well-being, mood and engagement. Very few patients were able to self-entertain in the absence of the MLW and those that did were using tools supplied by the MLW. A small survey of patients and relatives (n=9) found MLW support to be ‘extremely helpful’ and if readmitted would want MLW support again. A larger staff survey (n=52) showed most felt their ward had benefitted from MLW input, and felt that other wards with cognitively impaired patients would benefit from similar, as well as showing good awareness of the role.

Conclusion

The DCM process aligned with survey findings of a positive impact of the MLW role on patient experiences in secondary care setting.

Introduction

A good discharge summary for a patient is an important clinical record that narrates and communicates clinical information about the patient's entire hospitalisation. Discharge communications between healthcare facilities play a pivotal role in the coordination of patient care. As geriatric patients’ physical health is intricately woven into their social circumstances, mobility, and available care facilities, the mention of these parameters becomes quite important as it informs the community medical team of the patient’s condition more comprehensively. Crafting a good summary is challenging and we noted insufficient documentation of geriatric domains.

Methods

A discharge summary QIP was run in the geriatric wards at the Royal Gwent Hospital for 5 cycles. In these 5 cycles, we introduced a poster, electronic MDT, teaching sessions, and discharge summary checklist respectively as our chosen intervention. We collected data prospectively and calculated the percentages of presenting complaints, diagnosis, comorbidities, history, examination findings, investigations, management, mobility, care needs, discharge destination, cognition, resuscitation and escalation plan, whether were documented or not in the summaries.

Results

A total of 20-30 patients’ discharges were included in each cycle. Overall, there was good documentation in general medical domains (95-100%). A remarkable rise in the documentation of care needs (65%), mobility (80%), and discharge destination (50%) amongst other parameters was noted. However, there was minimal improvement in cognition, resuscitation and escalation plans as some of them do not apply to all patients. The improvement is progressing as the physicians are now frequently referring to the checklist for writing the summaries.

Conclusion

These interventional measures showed the quality of discharge summaries has improved dramatically. Hence, we uploaded the discharge checklist to our health board intranet and included it in the induction booklet. We hope to include it in our yearly induction sessions to maintain the level of improvement.

Introduction:

Polypharmacy is commonly defined as the concomitant use of five or more medications. This is a common problem in frail elderly patients and more so on the surgical inpatients where it is not regularly reviewed by the surgical team.

Methods:

We reviewed retrospectively the data on vascular inpatients from 2015-2016 and after the set-up of the perioperative services in 2022-23. Patients above 65 years of age with a clinical frailty score of 4 or more or with two or more co-morbidities were selected from both groups. In total 130 patients were selected from each group and their notes were reviewed in terms of polypharmacy review, before and after the introduction of the perioperative service in the trust.

Results:

Average age of the patients in both groups combined was 75 years. Average polypharmacy number per patient before and after the perioperative service were 6.8 and 10.7, respectively. In 2022-23, all the 130 patients had a polypharmacy review by a Consultant Geriatrician. In 2015-16, polypharmacy was reviewed only if there was an adverse effect to the drug, for example bradycardia caused by beta blockers. There was no routine review of polypharmacy. 0.06 Medications were stopped per patient in 2015-16, in contrast to 1.7 per patient in 2022-23. Most common causes of discontinuation of medications were falls, confusion, postural hypotension, drowsiness, electrolyte imbalance or medication no longer needed.

Conclusions:

Polypharmacy optimisation should routinely be practised in frail vascular surgical patients as it leads to avoidance of undesirable side-effects, improves patient compliance to medications, and has a huge financial benefit from deprescribing.

People from ethnic minorities face additional challenges in hospital. These contribute to poorer progress and outcomes. We set out to develop an online resource to help hip fracture teams provide answers to questions commonly posed by people presenting with hip fracture, and to address inequalities in patients’ and their families’ access to information. Method In 2021 we surveyed all 167 hospitals in England, Wales, and Northern Ireland which look after people with hip fracture – to identify which provided printed or digital information, and which made this available in languages appropriate to their local population. Results Most hospitals (70%) claimed that they routinely provided printed information about injury, surgery and recovery, but only 26% could say that they provided this in languages appropriate to their local population. The equivalent figures for digital forms of information were 23% and just 10%. We produced, piloted and finalised an English language template in discussion with people attending our hospital. Initial Google translations of this were circulated to clinicians within our department who were familiar with this patient group and able to read, edit and sign off versions in other languages. We surveyed these editors and 71% described the final document as highly useful. However, nearly two-thirds had identified limitations in the Google draft and 50% reported needing to modify technical elements of the text. One-third (36%) spent more than two hours editing the text to a form they felt would be accessible to patients. Conclusion We would recommend this approach to those working with other conditions and other patient groups, as there is clearly a need for information to meet the needs of the patient. We plan to extend our portfolio of 19 languages (the first languages of >3 million people in the UK alone) in collaboration with clinicians fluent in other languages.

Abstract Content - 'The number of patients being diagnosed with Heart Failure (HF) on a global scale continues to rise, placing a huge strain on the National Health Service (NHS). Caring for patients with HF comes with huge cost implications and exacerbates an already growing economic burden for healthcare systems. HF care needs to be standardised and integrated if we are to provide optimal care. Evidence shows that there is potential to improve the detection, diagnosis and management of HF care through innovative care pathways when delivered consistently through strong leadership and collaborative working. A care pathway for clinical nurse assessors was developed and implemented to guide and steer HF care within an 'Out of Hospital' clinical team; create a streamlined process to move patients with HF from one service to another; and encourage collaborative working amongst HF services. In addition, weekly HF MDT meetings were introduced in an attempt to reduce hospital admissions.

The Model for Improvement Framework was used to provide structure and support the change management, along with the RE-AIM Framework which facilitated the implementation of this pathway and supported the translation of this project into practice. 

Following the introduction of the care pathway, comparative data was analysed and the results showed that first line steps in the diagnostic pathway were being carried out quicker in patients presenting with HF symptoms, the time taken to refer on to cardiology services was significantly quicker, and all patients presenting with HF symptoms had a BNP blood test carried out on initial assessment. In addition, the length of time patients remained on the 'Out of Hospital' caseload and the number of hospital admissions were significantly reduced. The results also showed that the majority of patients on the pathway were treated in the comfort of their own homes and the number of patients referred to cardiac rehabilitation had vastly improved.  

To conclude - integrated care pathways together with high level government strategies are vital in the re-organisation of HF care and the standardisation of interconnected guideline-based care and management. Implementing a HF care pathway not only streamlined care for patients diagnosed with HF within the community setting but it had a positive impact on patient outcomes, quality of life and hospital admission rates. The pathway provided clinical nurse assessors within the 'Out of Hospital' team with a structured and standardised approach to HF care and having regular HF MDT meetings significantly improved the outcomes of people living with HF, as complex cases could be managed quicker and more effectively and hospital admissions could be avoided. Communication channels and relationship building between specialist services were also enhanced as a result of the pathway.