Clinical Quality

Background -

The CQC inspection of the Royal Lancaster Infirmary (RLI) in May 2021 rated the performance of the stroke department unsatisfactory, leading to a number of changes. A retrospective audit was performed to determine the impact of these changes for thrombolysed stroke patients.

Aim –

This retrospective audit assessed the performance of the stroke department at the RLI against the parameters set by the ‘Sentinel Stroke National Audit Program’ (SSNAP), comparing 6-month periods before and after the CQC inspection in May 2021. Method – Using electronic medical records and SSNAP data, we reviewed every thrombolysed stroke patient at the RLI between November 2020 until April 2021 and from May 2021 until November 2021, assessing 10 parameters and comparing the results with SSNAP targets. Since May 2021, changes to practice introduced included opening a new, larger stroke unit located directly opposite the Emergency Department, ring-fencing stroke beds, doubling the number of stroke specialists and stroke consultants reviewing all suspected stroke patients face-to-face within working hours.

Results -

46 patients were thrombolysed with 42 confirmed as having had ischaemic strokes on subsequent MRI imaging. All patients were discussed with a stroke consultant before thrombolysis. Mean time from arrival to CT improved from 51 to 34.5 minutes, admission to stroke unit from 7hr53 to 4hr36 and to thrombolysis from 2hr18 to 1hr22. The number of thrombolysis complications decreased from 5 to 2. Since the changes, the SSNAP grade for stroke unit admission improved from C to A and specialist assessments from E to B.

Conclusion:

The changes implemented following the May 2021 CQC inspection have had a positive impact on the care of thrombolysed stroke patients and overall SSNAP grades at RLI. Improvements are still required and the next steps include improving the efficiency of thrombolysis times and further improving SSNAP grades.

Introduction: NICE guidance recommends that doctors need to identify patients who are approaching their final year of life, through the utilisation of tools such as the Clinical Frailty Score (CFS). The 'Getting it right first time' (GIRFT) document recommended that all local health systems identify older people in the last phase of life and offer them Advanced Care Planning (ACP). Wigan has a large population of frail patients who would benefit from ACP discussions.

Aim: Initiate a strategy for identifying patients with severe frailty and establish a process for implementing ACP.

Method: Retrospective discharge data was used to identify patients aged >65 years, with a CFS of >7, over an 8-week period. The cohort was examined to see if they had been recognised as a patient who would benefit from ACP, or if an aspect of ACP had been completed during their admission. In total, 19 patients were identified, of which 6 were included and 13 were excluded.

Results: Initial data showed that we were poor at identifying and completing ACPs for patients with severe frailty. No advanced care planning decisions (0%) were taken during this period. Education (PDSA cycle 1) on ACPs for the ward doctors led to an improvement regarding ACP discussions. However, we were still poor at identifying severe frailty. Education (PSDA cycle 2) for nursing staff was undertaken, which highlighted inaccuracies with calculating CFS. Further PDSA cycles including a geriatric frailty score assessment, introduction of Electronic Palliative Care Coordination Systems (EPACCS) and frailty posters and cards.

Conclusion: Severe frailty is an end-of-life state and should trigger a healthcare professional to identify and sensitively discuss end of life needs and preferences. ACP should be disseminated to other healthcare professionals to allow them to act in accordance with the patient's wishes or best interests.

Introduction

It is well recognised that patients with Parkinson’s disease (PD) have significant symptom burden in advanced stages of their disease. Integration of movement disorder and palliative care services has been limited by concerns about resource and sustainability. We present our experience of establishing a movement disorders palliative care multidisciplinary meeting. Method In 2019 we established a multidisciplinary virtual bimonthly meeting between movement disorders and palliative care specialists. Referrals were accepted from movement disorder specialists, community Parkinson’s practitioners and palliative care specialists. Referring clinicians all actively applied primary palliative care approaches within their existing services.

Aims of the meeting were to facilitate holistic management of complex needs, support advance care planning (ACP) and consider referral to specialist palliative care services. Result 37 patients in total were discussed over a 2-year period (although the service was limited for a time due to COVID pressures). On average 3 new patients were discussed per meeting. Reasons for referral included motor and non-motor symptoms, support with ACP, medication advice, caregiver concerns and emotional distress.

Meeting outcomes included medication adjustments, expediting reviews, hospice support, carer support, and referral to other services. Since the meetings started 23 (62%) patients have died. Of these, 30% died in hospital compared with the national average of 43.4%. The average between discussion at the meeting and death was 139 days. The meeting has generated education opportunities, triggered joint assessments and a professionals’ framework for the palliative management of patients with a movement disorder.

Conclusions

We present the experience of an MDT embedded within an early integrated palliative care service for movement disorders. The MDT has strengthened partnership working and findings suggest that alongside active primary palliative care, specialist palliative care for PD can be sustainable and resource efficient in a UK setting.

Introduction: Vitamin D deficiency remains an important condition affecting our elderly population, with particular relevance to bone health, frailty syndromes and falls risks. We aimed to improve prescribing practices for deficient patients through the implementation of a prescribing tool and order set on our electronic system.

Methods: We retrospectively analysed data from patients admitted to two of our wards in July (pre-introduction of the order set) and November 2021 (post-introduction) respectively, paying particular attention to whether their vitamin D levels were measured as an inpatient, and then focusing on whether replacement was prescribed as an inpatient, on discharge and in the community, from their Greater Manchester GP Care Record.

Results: After review of a total of 266 patient records, following implementation of the prescribing guideline and order set, improvement was seen in prescribing practices in those identified as having low vitamin D on admission. 96% of deficient patients had a form of vitamin D replacement prescribed as an inpatient (compared with 84.4% pre-implementation), and 100% of patients had a form of vitamin D prescribed on discharge from hospital (compared with 90.7%). Despite seeing an improvement in identification of vitamin D deficient patients, a significant proportion of patients did not have their vitamin D level measured on admission.

Conclusion(s): Despite improvement seen in the initial identification of vitamin D deficiency and consistency of prescribing practices, we are failing to measure vitamin D levels on admission in a significant number of patients. Ways in which we can further develop this project include aiming to raise awareness of the importance of measuring vitamin D levels locally, and promoting continued use of the order set and frailty blood set amongst our junior doctors.

Pressure injury (PI) management is a challenge in dependent patients in acute care wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition). A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long Term Care (LTC) wards and thus may improve outcomes. The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD. After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (19(60 %) were female). All had stage 2-4 PIs (present in 25(83%) on admission to ACW). On transfer to LTC wards, all patients had severe physical dependency with a mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days. PI improvement by >2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (<21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying.

CONCLUSION: These results suggest that an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation has been planned.

Introduction: Neck of femur fractures (NOFFs) are a clinically significant diagnosis, with 10% of patients dying within one month of diagnosis [1]. There is a strong association between earlier surgery and improvement in postoperative outcomes [2]. Taking anticoagulation can cause delays in patients being operated on. At Homerton University Hospital (HUH), no previous guideline existed to aid specifically in the management of patients with NOFFs on anticoagulation. We created a guideline in order to reduce delays to theatre, in keeping with national guidance (<36 hours to operation). Methods: We audited all patients in 2020 admitted to HUH with NOFFs taking anticoagulation. A guideline was then created, reflecting new national guidance [3] on the management of anticoagulation pre-operatively for NOFF patients. Three PDSA cycles were completed, with repeat audit cycles following dissemination and teaching of guideline to relevant clinical groups. Results: Following implementation of our guideline, 56% of patients had surgery within 36 hours of admission, compared to 25% previously. Advice being given to the admitting team regarding timing of the operation was more consistent, and the admitting team needed to ask for advice less often. There was an overall increase in consistency of management. Conclusions: Ensuring NOFFs are operated on promptly reduces the risk of co-morbidity and mortality [2]. There are often incorrect delays to theatre following anticoagulation administration due to perceived risk of bleeding. We created and implemented a new guideline, which successfully reduced time taken for patients on anticoagulation to be taken to theatre for operation. References: [1] NICE. ‘Hip Fracture: Management’. Clinical guideline. Published: 22 June 2011. Accessed at: nice.org.uk/guidance/cg124 [2] Seong YJ, Shin WC, Moon NH, Suh KT. Timing of Hip-fracture Surgery in Elderly Patients. Hip Pelvis. 2020;32(1):11-16. doi:10.5371/hp.2020.32.1.11 [3] Griffiths, R., Babu, S., Dixon, P., Freeman, N., Hurford, D., Kelleher, E., Moppett, I., Ray, ), Guideline for the management of hip fractures 2020. Anaesthesia, 76: 225-237.

Introduction
Dehydration is the most common fluid and electrolyte imbalance in older adults; hospitalised older adults with markers of dehydration have mortality rates of 45% (Hodgkinson B et al, 2003). The current method of measuring fluid intake on wards is to record this hourly on fluid balance charts however this is often poorly documented (Jeyapala S et al, 2015). We wished to improve the accuracy of recording the oral fluid intake of older adults by introducing a simplified bedside chart which could identify those at risk of dehydration.


Methods
Using PDSA methodology, a team of doctors directly observed and recorded the oral fluid intake of patients in a 6-bed bay on an older persons’ ward for 8 continuous hours. The collected data was compared to that recorded on pre-existing fluid balance charts. A new bedside fluid intake chart was then introduced; this laminated chart included example volumes of common drink receptacles and used ‘ticks’ to record each time fluid was consumed. A repeat PDSA cycle was performed with a second observation day. Guided interview qualitative methodology was used to obtain feedback from nursing staff.

Results
The mean difference in observed fluid intake versus charted fluid intake prior to intervention was 287.50ml (SD = 152.27, n = 6) and 95ml post intervention (SD = 94.21, n = 5). Analysis with an unpaired two sample t-test demonstrated a significant difference (p = 0.0367). Qualitative feedback from nursing staff reported it to be easier to use and more likely to be correctly completed.

Conclusion
The redesigned fluid intake chart led to statistically significant improvements in the accuracy of recording fluid intake. A further PDSA cycle across a whole ward will inform feasibility on a larger scale of early identification of dehydration. The tool may also allow assessment of the effectiveness of hydration aids.

Introduction

Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8 week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method

A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results

• 91.5% total health outcomes improved or maintained by average
• FOF reduced by 22.5%
• 180 degree turn improved by 43%
• 60 sec Sit to Stand improved by 14.75%
• Timed Up And Go improved by 15.5%
• Confidence to cope at home improved by 15% 
• Pain / discomfort (self-reported) improved by 18.75% 
• Overall health (self-reported) improved by 8.5%

Conclusion(s).

Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.

Background:

In response to the COVID pandemic when new robust discharge criteria were introduced to facilitate early discharge to optimise hospital capacity, Post Discharge Frailty Support (PDFS) was established. PDFS provides nurse-led telephone follow-up for patients discharged primarily from the Emergency Department (ED) and the Acute Frailty Assessment Unit (AFAU).

Objectives:

We aim to provide continuity of care by following up frail elderly patients at home, reviewing their medical, functional and social progress post discharge and ensuring they received adequate support to avoid hospital re-admission. Methods: The service is overseen by the Lead Frailty Practitioner, supported by Consultant Geriatricians. Calls are made Monday to Friday by a team of Advanced Specialist Nurses. The case load is split up into 3 categories with different levels of priorities – 1: at least weekly calls; 2: Fortnightly calls; 3: Monthly calls. This service engages closely with community partners such as community frailty service, social care, district nurses and general practitioners.

Results:

In year 1 (1/4/2020-31/3/2021), we had 598 patients on this PDFS. 93 patients were referred to therapy team for urgent equipment to maintain safety, 73 patients were referred to community frailty and 112 patients had urgent discussions with GP to avoid hospital admissions. The 30 days readmissions rate was 14%. 547 patients were discharged. In year 2 (1/4/2021 – 31/3/2022), we had 297 patients. 49 patients were referred to therapy team, 32 patients were referred to community frailty team, and 41 patients required input from GP. The 30-day readmission rate was 11%. 224 patients were discharged.

Conclusion:

PDFS is an effective service that has helped to reduce length of stay of frail elderly patients in an acute hospital setting, maintaining patient safety and prevent hospital re-admission, co-ordinated with community services. Our service has been highlighted in the recent GIRFT report on improving clinical practice.

Introduction

NICE Clinical Guideline CG103 states that adults aged 65 and older should be screened for delirium within 48 hours of emergency hospital admission. The Geriatric Medicine Research Collaborative (GeMRC)'s World Delirium Day data from 2019 showed an average screening rate of 27% nationally. After an inpatient fall on the Medical Assessment Unit resulted in hip fracture for a patient who had not been screened for delirium with the recommended 4 A's Test (4AT), we decided to collect data on screening rates and devised a way of improving these.

Method

Baseline data was collected examining patient notes of adults over 65 years currently on the Medical Assessment Unit who had been seen by a doctor. The intervention was a teaching session on delirium for the junior doctors on the ward, focusing on the adverse prognostic features of delirium and importance of clear diagnosis with onward communication to the patient's GP. Repeat data collection was done following this.

Results

55% of all patients on the ward throughout data collection were over 65 years of age. A total of 79 patient notes were examined. The baseline rate of delirium screening with a completed 4AT pre-intervention was 25%. Post-intervention this increased to 41.3%. Without further education this fell to 26.9%. Most of the unscreened patients showed incomplete 4ATs or only the Abbreviated Mental Test (AMT) section completed.

Conclusion

Integrating delirium teaching into departmental teaching on Acute Medical Units can increase the rates at which delirium is diagnosed, which is important for the patient's clinical trajectory and prognosis, both for their inpatient stay and long term. After this data was presented at a clinical governance meeting, the Emergency Department purchased an electronic patient record including mandatory delirium screening in those over 65 presenting to hospital. Future work may include assessing the rate of documented diagnosis out of those who clinically fit the criteria.