Clinical Quality

Background 

Frailty Same Day Emergency Care (FSDEC) is a service designed to identify and manage frail older people at the hospital front door with a view to provide early Comprehensive Geriatric Assessment, implement management and where appropriate support a same day discharge home. 

Introduction 

In September 2023 the FSDEC service opened with 6 assessment spaces adjacent to A&E. This project aimed to quantify the rate of re-admission for patients seen in FSDEC and explore approaches to improve performance.  

Methods 

This QIP utilised a PDSA approach. Baseline re-admission data was collected from a 2 week period in October 2023. Notes were reviewed for all patients seen in FSDEC during this timeframe and reviewed for evidence of any 30 day emergency re-attendances. Cases were then reviewed to identify any links between the 2 attendances and any preventative measures that could have been taken. Following PDSA cycle 1 frailty nurse telephone follow up was implemented. PDSA cycle 2 was a stress test of this (limited) service during winter pressures. PDSA cycle 3 followed expansion of Community Integrated Response Hub (CIRH) and discharged patients being able to self-refer for support once discharged. 

Results 

FSDEC 7 day re-attendance reduced from 10% to 5% after introduction of frailty nurse follow up. This was not sustained over challenging winter months with variable staff availability but did recover in Summer 24. There has also been a gradual improvement in 30 day re-admission by PDSA cycle 3 following roll out of self-referral to CIRH. 

Conclusion 

Emergency re-admissions have reduced following implementation of frailty nurse telephone follow up and expansion of community services including patient access to CIRH for help following discharge from FSDEC. Addressing staffing model could allow for a more consistent follow up service. There is scope to trial this approach on geriatric ward discharges.  

Introduction

We proactively reviewed nursing home residents using a multidisciplinary team (MDT) approach within a Primary Care Network (PCN). We aimed to enhance care coordination, reduce inappropriate medication use and ensure all residents had current advanced care plans in place.

Method

An MDT comprising a geriatrician, prescribing pharmacist, general practitioner, and nurse reviewed residents proactively. This involved reviewing the residents' current health and care needs, falls risk, medication regimens and advance care plans. We then performed medication reviews, reviewed advanced care plans, and identified the need for further interventions. When we repeated the process, we used a proforma that could be pre-populated prior to the meeting by the pharmacist and geriatrician to improve efficiency of the discussion.

Results

The initiative was piloted in two residential nursing homes with a total of 65 residents reviewed, of which 86% (n=56) received interventions. There was a 47% (n=29) increase in completed advanced care plans. 62% (n=40) of residents had medicines optimised, with polypharmacy being reduced in 46% (n=30) by an average of 2 medications per resident. 8% (n=5) were referred to additional services and 8% (n=5) required further investigations.

Conclusion(s)

This proactive MDT model effectively addressed the needs of residents whilst demonstrating immediate positive outcomes. Key facilitators to good practice were teamwork, clarifying the objectives of the MDT, prior reviews of patient records, and ensuring staff who knew the residents well were present. We will use this approach with other nursing homes within the PCN and share our results with colleagues. This has the potential to reduce costs of medications and hospital admissions, as well as improve quality.

Introduction:

The Gloucestershire Frailty Virtual Ward (FVW) is a novel multidisciplinary collaborative project which seeks to improve care for frail older patients. We describe our experience, reflect on lessons learnt and plans for future service development.

Methods:

The Gloucestershire FVW was started in early 2023. It arose from an understanding that the needs of frail patients can often be better met in their own homes, by utilising a combination of digital technology combined with improved working across organisational boundaries at the primary/secondary care interface. We reviewed data from all patients admitted onto our FVW between October 2023 and March 2024.

Results:

66 patients were included. The majority of patients were ‘step-down’, having been in hospital prior to FVW admission. The minority were ‘step-up’, having been referred from community colleagues. Clinical frailty scores ranged from 2-8, with a mean of 6. During this period, our FVW managed a range of different clinical problems. The most common reason for FVW admission was infection, then heart failure, delirium and acute kidney injury. Most patients were admitted for the management of a single problem (58%), although a significant proportion had 2 or more problems (42%). Our FVW conducted a variety of interventions, including blood tests, face-to-face reviews, amending medications including antimicrobials, diuretics and analgesia. Our FVW was also involved in decisions around the withdrawal of active care and initiation of a palliative approach.

Conclusions:

Our FVW has helped facilitate early discharge and avoid hospital admission, with associated benefits to both patients and the acute trust. As a new service which aims to sit between primary and secondary care, we have encountered logistical and governance challenges associated with working across organisational boundaries. Additionally, we have found that the use of digital technology can cause anxiety for patients and place additional strain on carers.

INTRODUCTION

Polypharmacy represents a significant challenge in the vulnerable elderly population, where concurrent use of multiple medications increases the risk of interactions and adverse reactions, often precipitating acute events and complicated hospital stays. This necessitates thorough medication reviews to mitigate these risks; a hospital admission allows for such opportunities.

METHODS

This project aimed to evaluate and address the medication burden among elderly patients, following WHO's Global Patient Safety Challenge: Medication Without Harm. 50 patient’s medications were reviewed on a elderly care ward over the space of 3 months. A ward pharmacist and a senior member of the medical team critically evaluated inpatient charts on a twice weekly basis. Any changes made to the medication regimens were documented; additionally, the general practitioner was informed of any changes.

RESULTS

Initial data indicated that 66% of patients were on five or more medications, with a high incidence of falls and a notable anticholinergic burden. On review of the 50 patients a total number of 36 drugs were de-prescribed, 38.9% were inappropriate anti-hypertensives, 13.8% vitamins amongst others.

CONCLUSIONS

This project has been an enlightening endeavour, teaching us the critical nature of addressing polypharmacy. We have learned that interdisciplinary collaboration, regular medication reviews, and patient education are key to managing this complexity. To ensure long-term sustainability, we plan to institutionalize pharmacy board rounds and implement mandatory medication reviews. We aim to work closely with primary care to maintain continuity post-discharge. These efforts are expected to foster a culture of mindful prescribing and medication safety.

Background: NICE Quality Standard (QS) 164 – QS1 states; Adults with Parkinson's have a point of contact with specialist services. This will facilitate continuity of care and access to information, advice, care and support when they need it. QS4 states; Adults with Parkinson's disease in hospital or a care home should take levodopa within 30 minutes of their individually prescribed administration time.

Introduction: To increase opportunities in meeting NICE QS’s consistently, Parkinson’s Specialist Nurses introduced Parkinson’s Champions. Individual studies consistently find that champions are important positive influences on implementation effectiveness. Over half of people with Parkinson’s don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death.

Method

Supportive structures that enabled the development and maintenance of our Champions Network:-

Clear Role Profile and Measurable Objectives

Provision of Resources/Tools

Ongoing Education/Training

Peer Support/Networking

Recognition/Appreciation 

PDNS leadership/support

Energy & Perseverance

Results: The Get it On Time Audit (GIOT) looked at Parkinson’s medications given more than 30 minutes early, on time and more than 30 minutes late. Following multiple interventions including promoting leadership and education within each dept, input to medicines policy, incident reporting and development of a learning module, On time medication administration improved from 58% to 80.05% compliance.

Champions were not experts in Parkinson’s when we started, through the process of undertaking the role, they have gained expertise and serve as an ongoing resource to their peers.

Conclusion: Our aim of having champions who enhance staff’s knowledge and skills so care delivered to persons with Parkinson’s is consistently safe and effective is being realised.

Investment in them, as demonstrated by audit results, is rewarded with more consistent meeting of NICE QS 164 and thus improved patient outcomes.

Our Champions network model will be shared with the Parkinson’s Excellence Network.

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Introduction:

The geriatric population has a high incidence of dementia, delirium and frailty meaning often these patients cannot give comprehensive histories themselves. We are left with missing pieces of the puzzle; we might not know their ‘normal’ and frequently ask: ‘Are they always like this?’.

A collateral history becomes a valuable tool, contributing to a Comprehensive Geriatric Assessment and assisting the whole MDT to make informed decisions for patient-centred care.

The primary aim of this project was to improve the quality of collateral histories taken for patients admitted to the geriatric wards, with content measured against 8 domains. A secondary aim was to encourage timely collateral histories within 48 hours of admission to the ward.

Method:

Using PDSA methodology, collateral histories were analysed before and after implementation of a poster and teaching session.

Results:

At baseline each domain was covered a mean of 40.5% of the time (range 9% - 81%). Following intervention this increased by 22% to 62.5% (range 18% - 89%), demonstrating a significant improvement (paired t-test, P<0.05).

It was already common practice to take collateral histories within 48 hours of admission to the ward (91%) which was sustained post-intervention (88%).

Conclusion:

Use of a poster as a prompt, and delivering teaching, led to more thorough collateral histories. This suggests two barriers are knowing what to ask and perceived importance; elements which could be integrated into early postgraduate education. The impact on patient care has the potential to be significant and multidimensional but further work would be needed to understand this.

Background: This project is based in the geriatric department of Wye Valley NHS trust which serves Herefordshire and mid-Powys.

Introduction : In frail, older patients, cardiopulmonary(CPR) resuscitation has low rates of success. Lack of appropriately completed ReSPECT forms leads to futile attempts of CPR, repeated readmissions and patient harm. This project aims to improve patient centred advance care planning (ACP), and the quality of their documentation in the ‘clinician recommendations’ section in ReSPECT forms through development of new educational tools.

Methods: The Supportive and Palliative Care Indicator Tool (SPICT) was used to identify patients benefitting from ACP in the department. Data was collected on how many patients had ReSPECT forms and how well they were completed against standards adapted from the Resuscitation Council guidelines. Plan-Do-Study-Act(PDSA) cycle 1 was completed developing an aide-memoire (ReSPECT tool), and an interactive workshop. PDSA cycle 2 lead to design of the project poster titled ‘Revamp your ReSPECT discussions’ which was displayed on the wards, and shared on social media. PDSA cycle 3 was conducted to measure response and aid direction. Results: PDSA 1 showed 71% patients meeting SPICT criteria had ReSPECT forms. This improved to 82% by PDSA 3. PDSA cycle 1 revealed that only 32% of ReSPECT forms were completed to audit standards, by PDSA 3 this improved to 43%. The project received engagement from the wider healthcare community on Twitter/X where the project poster garnered over 36,600 views and has been shared in the trusts latest issue of safety bites.

Conclusions: Our work led to an improvement in the quality of documentation and illustrated a novel approach to communicating the standards expected when delivering patient-centred ACP. The interest received via social media highlighted the importance of sharing this experience. We plan on building on this success through wider communication of the standards.

Introduction

The Frailty Network, initiated in November 2023, aims to enhance care for frail patients through multidisciplinary collaboration across acute and community settings. By fostering partnerships with Health and Social Care teams, GPs, district nurses, and third sector organisations, the Network strives to provide realistic and patient-centric improvements in Lanarkshire. The initiative focuses on proactive, personalised, and coordinated support to help frail older adults maintain independence and well-being.

Methods

The Frailty Network is supporting multiple teams to implement new pathways to streamline care and improve outcomes. The aim is to understand our systems and have a focus on the data impacting our older adults. Stakeholder Engagement Table was utilised to show project success so far. Quantitative methodology such as LOS, number of referrals will be used to show impact. With a progress / Driver Diagram to show Quality Improvement Journey thus far. As the Network is a large piece of work, many aims are long term.

Results

The implementation of the Frailty Network has resulted in notable improvements in communication, engagement, collaboration and innovation. There has been reduced LOS in the frailty wards, improved transfers to community hospitals and more pathways to keep people at home. There are structures now imbedded to encourage multi system working from all settings.

Conclusion

The Frailty Network's innovative design has begun to successfully improve care for frail older adults in Lanarkshire. The collaboration between acute and community teams, combined with proactive interventions and the use of digital technology, has started the journey to a more sustainable future. Continued focus on integrated leadership and shared goals will further refine and sustain these improvements, setting a gold standard for frailty care in the region. Further research is required to assess long-term impacts.

Background

Evidence shows that CGA based in Frailty units is better for patient care (Fox 2012, Ellis 2011). University Hospital Wishaw (UHW) is the only acute site in NHS Lanarkshire that does not have a frailty assessment unit as part of the admission/receiving pathway. Patients are currently admitted to the Medical Assessment Unit (MAU) and seen by either Geriatrician or Medical consultant depending on the time of admission. UHW is working towards a frailty unit but has been limited by space and resource. Instead we have been on a journey of step-wise improvements to establish one.

Methods

Over the course of 5 days, we developed a Rapid Access Frailty Team (RAFT) in a cohort of 10 beds within the existing MAU. Patients were over 65 and had a CFS ≥5. Patients were reviewed by a Geriatrician in morning and afternoon, and had MDT input from Physiotherapy, Occupational Therapy and a Nurse specialist.

Results

Over the 5 days 28 patients were admitted to RAFT beds. 9/28 (32%) were discharged from RAFT. Length of stay was 32 hours. Patients either went home or moved to a downstream ward if needed. Medical and AHP staff feedback was positive, but nursing staff in MAU voiced it was onerous having all frail adults in one area.

Conclusions

Development of frailty area within a medical assessment unit is possible and appears to lead to improved outcomes and discharge rates compared to non-cohorted areas. We are now looking for an area where we can apply our RAFT principles and have more staff support.