Clinical Quality

Introduction: In 2021, there were 38,839 adults >65 years living in Brighton and Hove, 13% of the local population, compared to 18% in England. However, 56% of emergency laparotomy procedures in the UK are in the > 65s. At the Royal Sussex County Hospital, a consultant geriatrician was appointed to lead a Frailty Liaison Service to respond to the needs of frail older patients undergoing general surgery (GS). No process was in place for the early identification of these patients, so intervention decisions were being made without GS Frailty Liaison input, potentially leading to unnecessary procedures and adverse outcomes such as deconditioning, which could potentially be reduced by timely clinical frailty scoring (CFS) and comprehensive geriatric assessment. This quality improvement project sought to identify all appropriate frail older patients over 70 within 1 week of admission to be seen by the Frailty Liaison Team on the general surgical ward.

Methods: We used the Model for Improvement and diagnostic tools (fishbone; stakeholder mapping; driver diagrams) and PDSA cycles to test the impact of junior doctor education on CFS scoring and awareness raising primarily through a newsletter; measured by the number of frailty scores given to patients pre-intervention, remeasured at 3 months after the initial data set. We captured feedback following the education sessions to assess usefulness.

Results and conclusion: Results showed 100% of participants felt more confident in identifying frailty in GS patients. The average number of days from admission to identification and first review decreased from 8.29 to 6.36, possibly reducing adverse outcomes. The proportion of appropriate referrals increased, releasing time to care for those who needed it most. Moving forward, we plan to promote the use of a CFS column on the handover list and continue our education sessions, incorporating real patient cases as requested in feedback.

Introduction

Inpatient falls are a major cause of avoidable harm in patients on elderly care wards. Delays in identification of fall precipitants and recognition of sustained injuries increases morbidity, mortality and length of stay (Cameron et al, Cochrane Database Syst Rev. 2018 Sep; 2018(9)). Patients sustaining falls are often initially assessed by postgraduate year 1 and 2 doctors independently. We aimed to improve patient outcomes following inpatient falls through standardisation of the assessment and documentation following a fall in hospital.

Methods

Using PDSA methodology, incident reports and documentation of inpatient falls were reviewed retrospectively over three 28-bedded elderly care wards. A post-falls proforma was devised that covered various domains of the post-fall assessment and was distributed to doctors throughout the hospital. Following the intervention, a repeat PDSA cycle was performed prospectively over the same wards and the proportion of assessments fulfilling each domain was compared between the cycles.

Results

Medical assessment of 27 falls from November 2020 to January 2021 was compared to 31 falls occurring between February and May 2022. Use of the proforma in cycle 2 was limited to 8/31 falls following intervention. Post-intervention, the proportion of assessments fulfilling medication review (19% vs 35%, p=0.14) and anticoagulation status (41% vs 55%, p=0.28) was improved. The proportion fulfilling fall circumstances (89% vs 90%, p=0.85), medical precipitant (70% vs 61%, p=0.46) and ordering of appropriate imaging (93% vs 97%, p=0.47) remained high.

Conclusion

Standardisation of post-falls assessment and documentation can improve patient safety outcomes through reducing delay in recognition of medical precipitants of falls and identification and management of sustained injuries. Improved integration of a post-falls proforma into electronic systems is needed to maximise its clinical benefit and would be the target of a further PDSA cycle.

Introduction 

Frailty is associated with an increased risk of perioperative complications, prolonged hospital stay, and functional decline after surgery. Despite the potential advantages of early detection, frailty screening of surgical patients is not standard practice across the UK. Digital questionnaires may offer an effective tool for screening large patient populations; however, there is concern that this is biased when used in frail or elderly patients. The primary aim of this study was to evaluate the effectiveness of digital screening in patients aged 65 and over who are awaiting elective general surgery. 

Method 

We distributed digital questionnaires to 738 patients via text message. Participants were eligible if aged 65 or older and on the waiting list for elective general surgery. Participants had a 7-day period to complete the questionnaire, with a reminder sent 5 weeks later to non-responders. Participants self-assessed frailty using a modified Clinical Frailty Scale (CFS), those who scored above 3 were also asked to complete the Comprehensive Risk Assessment and Needs Evaluation and EQ-5D-3L questionnaire. We analysed response rate, frailty and age. Results 187 (25.34%) patients responded within the initial period. A further 156 (21.14%) responded following the reminder. The overall response rate was 46.48%. The average age of responders was 72. Our data showed that frailer patients were able to complete digital questionnaires either themselves or with support. 

Conclusion 

Early screening can help identify frail patients who would benefit from peri-operative planning and optimisation, including a geriatric review. Our findings suggest that digital questionnaires could be an effective tool for screening older adults and that frail patients are able to participate. This may be due to various factors, including caregivers support. Previous studies have documented response rates ranging from 30% to 50%, which provides a valuable benchmark for the interpretation of our findings.

Background
Current practice for acute delirium presentation is hospital admission whilst the delirium resolves, often including multiple transfers with poor outcomes. This project challenges this practice and allows people to recover at home with a maximum of 6 calls a day and night with carers trained in delirium.

Results
From a previous audit of Pathway 2 beds patients with delirium had poor outcomes, high levels of placement in permanent care and long lengths of stay (21 days).

There have been 192 episodes of care through the Delirium Pathway.80% were from hospital wards and 20% stepped up from community settings.

In 2023, 42% had no ongoing social care support needs and 21% had only the requirement of ongoing domiciliary care needs at home. 2.6% entered long term care with the re-admission rate remaining within the local rate for this cohort of 20-30%. There has been low demand for night care. The average LoS is 15 days.

Delirium symptoms significantly improved at discharge and stayed improved; pre-discharge the median 4AT score was 7, at first pathway assessment (generally within 24 hours of arrival home), the median 4AT score was 2 and at exit of pathway the median 4AT score was 1.

Patients and carers reported that the discharge home felt safe and that home was the best place for recovery: 89% of patients and 76% of carers felt it was safe to return home; 94% of patients; and 93% of carers felt that home was the best place for recovery.

Conclusion
This pathway has demonstrated that discharging patients with an acute delirium with supportive home care is safe, effective, and reduces admissions to long term care

Introduction:

In geriatric medicine department of a large tertiary care university hospital, it was observed that multidisciplinary team (MDT) working was not standardised, morning huddles were inefficient, there was a lack of inclusion of all members in MDT meetings and the meetings were too medical focused. The aim of this project was to address these concerns through a multipronged approach.

Methods:

An initial survey was carried out with 34 participants from all disciplines of MDT. Areas needing improvement were identified from the survey and through discussions among doctors, nurses and therapists. A pilot of changes was introduced in the largest ward of the department. A post change survey was carried out, demonstrating improvement across multiple domains.

Results:

Initial Survey

• Are you satisfied with current MDT practices? 52% said they were partly satisfied or not satisfied
• Morning Board Rounds: 68% said it does not happen everyday/attended by most professions
• Feeling valued at MDT meetings / Opinion taken appropriately? 35% said they were not confident they felt valued / opinion taken appropriately
• Are MDT discussions patient centered and effective? 38% said they are not always patient centered/effective
• Do you understand the various concepts and acronyms used in our MDT’s? 30% said they do not understand most concepts/acronyms

Changes implemented

• Structured daily morning board round with all MDT disciplines using a new pro forma
• MDT meetings led by flow-coordinator via a structured format making them more holistic, person-centred and inclusive
• Published a handbook to improve understanding & purpose of MDT’s and terminologies used in meetings

Post change survey results

• 66% said meetings were now more structured and it was easier for them to share their views
• 75% respondents said they now felt more valued
• 76% thought meetings now were more person-centred

• Improved attendance & efficiency of morning huddle (mean time reduced to 10 from 30 minutes)

  These findings were presented and shared in departmental monthly meeting

Conclusion:

The true essence of MDT working lies in all professions coming together to achieve patient-centred care. This can only be achieved if all professions understand and respect each other’s role and responsibilities. Through best practices, we can achieve more holistic care and prevent harm. It results in resources being used more efficiently through reduced duplication, greater productivity and preventative care approaches.

Through a series of changes we demonstrated these in one ward and work is ongoing to implement these changes across the whole department.

Link for published Handbook: 

https://drive.google.com/file/d/1P6Cuz8u1N3cr1FjnG4y9KIwRhkX5qHFM/view?…

Abstract Content - Background The Major Trauma Audit is a national clinical audit managed by the National Office of Clinical Audit (NOCA), that captures data of patients with life threatening or life changing injuries. It has been publishing annual reports since 2014. Methods; Originally established using the Trauma Audit Research Network (TARN) methodology now entitle National Major Trauma Registry in the UK. Results: In 2024 a focused report from 2017-2021 on older adults was published as this is the largest group of patients in the major trauma population (51%, n=11,145). 56% of patients were female, the median age was 79 and 74% had pre-existing comorbidities. Low falls, of less than 2 metres, were the leading mechanism of injury (82%) and home was the main location of injury (70%). The most common injuries were limbs (27%) & head (25%). One third were allocated to the most severe injury category (injury severity score >15). Older adults are less likely than <65's to be pre-alerted (9% vs. 22%), received by a trauma team (6% vs. 15%), have longer hospital stays (12 vs 7 days), 22% of older adults were discharged to a nursing home and 44% went home. Mortality was 7%. Conclusion In light of the recently published clinical guidance for the care of older adults with major trauma published by the Health Service Executive this data shows that significant improvement is required to create an age friendly healthcare system with prompt and effective care for older adults. Data from the MTA is being used to redesign the trauma system in Ireland into two networks with major trauma centres and trauma units so that the right patient can be brought to the right hospital at the right time.

Introduction 

Effective communication between primary and secondary care teams is essential for providing continuity of care in the community for older people with frailty. Discharge summaries often lack information captured in a comprehensive geriatric assessment (CGA). Junior members of the team, tasked with writing discharge letters, have not been formally taught in this area. This project aimed to incorporate key CGA domains into discharge summaries. 

Methods 

The geriatric medicine department at Broomfield Hospital and community mid virtual frailty team identified 7 core CGA domains for discharge summaries: main diagnosis, DNAR (Do Not Attempt Resuscitation) status, clinical frailty score (CFS), mobility/functional assessment, cognition, psychological concerns, and medications review. The project was piloted on a 26-bed ward, with data collected from patients over 65 years discharged. Audits were conducted across three cycles between October 2023 and November 2024. A total of 42 patients in cycle 1 and 2, and 50 patients in cycle 3 were included, excluding deaths. Initial interventions involved delivering an educational session and placing a poster. For the third cycle, additional measures were introduced: appointing two resident doctors as project champions and displaying an example discharge summary template. Weekly review of discharge summaries for 7 weeks, with weekly feedback was also implemented. 

Results 

Baseline audit showed low compliance with CGA in discharge summaries. By cycle 3, significant improvements were observed: main diagnosis and medications review were fully documented (100%), CFS documentation increased to 75%, and mobility/functional assessment (37%), cognition (38%), and psychological concerns (38%) showed notable progress. However, DNAR status documentation decreased from 81% to 75%. Feedback from doctors was positive, with the new template considered straightforward. 

Conclusion 

The project successfully improved CGA documentation in discharge summaries. Future proposals include expanding the initiative to other wards and integrating a modified template into the electronic discharge system for easier access.

Introduction

The Royal College of Physicians (RCP) introduced guidance on implementing frailty assessment and management in oncology services in November 2023. Frailty-informed care has been demonstrated to improve outcomes. The RCP suggests that where the management of frailty is beyond the skillset of the oncology team, links should be built with local geriatric teams to ensure holistic care, responding to individual needs.

Method

We set up a referral pathway within an existing geriatric clinic at a district general hospital, facilitating referrals initially from oncology colleagues, then expanding to haematology. This was complemented by drop-in sessions and multi-disciplinary teaching sessions on frailty and comprehensive geriatric assessment.

Results

There were 23 referrals between January and November 2024. The median frailty score was 5. Cancer sites included rectal, urological, upper GI, lung and haematological malignancies. The majority of referrals were for polypharmacy (6), pre-treatment optimisation (6) and poor mobility (6). Other categories included falls and advance care planning. Patients waited between 2 and 21 days for an appointment. Outcomes for patients seen included rationalising medications (8); onward specialty team referral and investigations (7); multidisciplinary involvement (4) and advance care planning (2). Through our interventions, assessment of frailty score improved from 0 to 96% of patients in this sample.

Conclusion and next steps

We have demonstrated the feasibility of integrating an onco-geriatrics pathway into an existing geriatrics service and nurturing links between departments through regular teaching sessions. As well as improving access to services for older adults, this provides training opportunities to resident doctors. Patient survey data is currently being collected to look at the impact of this service on patient experience. Whilst outside the scope of the initial project, future work could look into whether the positive impact of this service translates into a reduction in re-admissions in this cohort of patients.