Clinical Quality

Introduction 

Fragility Fractures can lead to immediate complications, decline in health status, increase in hospital stay, increased care needs and reduction in the quality of life (Court-Brown C Clement N, Duckworth A, The Bone and Joint Journal, 2014 96-B(3) 366-372). However, the National Osteoporosis Society (2017) reported 80% of non-hip fractures were not offered strength or balance exercises It is estimated that fragility fractures cost the UK £4.4 billion which includes £1.1 billion for social care (Office for Health Improvement & Disparities, 2022). At Sussex Community NHS Foundation Trust, non-weight bearing (NWB) patients have prolonged bed based stays. Complex patients cannot be discharged home when NWB as there is no commissioned social care pathway. These patients are seen as low priority for rehabilitation. The aim of the project was to reduce the length of stay for NWB orthopaedic patients. 

Method: 

Baseline data of 10 inpatients from the Sussex Community NHS Foundation Trust ICU, discharged in April 24 was scrutinised. The team articulated the issues for NWB in a fishbone diagram, and a tailored programme of resistance strengthening and balance exercises was introduced for 8 NWB patients in May and June 2024, as a PDSA cycle. This included leg ankle weights and dumbbells to carry out chair and standing exercises (when appropriate), in addition to routine group physiotherapy sessions. All patients were seen 2-3 times a week. Results: The average length of stay for NWB patients reduced by 14 days. The number of therapy contact sessions reduced to 2.1 post orthopaedic review and patients were weight bearing again. 

Conclusion: 

Providing a tailored strengthening exercise programme that focuses on the non-weight bearing phase of the patient's orthopaedic rehabilitation journey reduced the length of stay on the intermediate care unit, and the physiotherapy interventions once weight bearing.
 

Introduction: In Scotland, more than 18,000 older people are admitted to hospital after a fall each year. One in three people over the age of 65 experience a fall at least once each year (1). Neurological examination is an essential part of the initial assessment of these patients in hospital and can determine the cause of falls such as stroke, peripheral neuropathies and Parkinson’s disease. Local anecdotal evidence suggested that this was often not carried out, with the potential for delayed diagnosis and treatment.

Method: Baseline data was collected from clinical notes of admissions to the care of the elderly (COTE) wards at University Hospital Hairmyres (UHH) over a 1-month period. Multiple departmental education sessions were arranged to highlight to medical staff the importance of neurological examination in patients presenting to hospital following a fall. Following these sessions the data collection cycle was repeated. A poster has now been designed highlighting common causes of falls and in particular emphasising the importance of performing a neurological examination, with a further cycle of data collection planned.

Results: 36.8% of patients admitted to COTE wards in August 2022 were admitted with falls, with only 23% of patients having a neurological exam documented on admission. Following the initial intervention, 30 patients’ notes were reviewed in January 2023. 56.7% of patients were admitted with falls and frequency of documented neurological examination had increased to 58.8%.

Conclusion: Educational sessions resulted in a 156% increase in documented neurological examinations for patients admitted with falls. We hope this improvement will lead to earlier identification of causes of patients’ falls, allowing prompt management. Our project is ongoing, with planned implementation of posters as a secondary intervention, with further data collection in due course.

References: 1. NHS Inform. Why Falls Matter. Available from: https://www.nhsinform.scot/healthyliving/preventing-falls/why-falls-mat… (accessed 27 November 2022)

INTRODUCTION: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Introduction 

Older people living with frailty are often prescribed many medications exposing them to potential medicine-related harm. Pharmacists are a new addition to the East Kent Community Frailty Team, which otherwise consists of doctors and advanced clinical practitioners at various levels of training. Pharmacists are ideally placed to develop medication review processes and support fellow clinicians with deprescribing efforts in frailty. This audit set out to determine current levels of medication review and associated cost-savings through deprescribing. 

Method 

All patients admitted to the frailty team caseloads in the month of May 2023 had their notes manually reviewed for evidence of medication reconciliation, review, and deprescribing. Medicines were assigned a cost price based on the NHSBSA Drug Tariff (May 2023). 

Results 

192 patients were seen in total, 170 of whom were acutely unwell. 62% of patients had their medication documented, taking an average of 8.2 medicines. The majority of omissions were patients with a zero length-of-stay, which include advice calls. 29% of patients had at least one medication stopped, representing an average 0.7 medicines stopped per patient seen. The monthly cost of medications stopped was £690. There were greater levels of deprescribing in the caseloads with MDT board rounds. 

Conclusion 

Rates of deprescribing are low compared to published studies (Ibrahim et al, BMC Geriatr 21, 258 (2021)), although still represent a rolling saving of approximately £8,000 per month on cost of medicines alone, assuming a twelve-month average life expectancy. Lack of standardisation of clinical notes and documentation made data collection difficult and has the potential to lead to transfer-of-care errors. Further work needs to be undertaken to optimise the medication review process and address inappropriate polypharmacy and will be the focus of efforts over the coming year. 

Introduction

The British Geriatrics Society and NHS England recommend that patients aged 65 and over should be screened for frailty when presenting to healthcare services to facilitate early comprehensive geriatric assessment (CGA). Recognition of frailty frequently relies on assessment by FY1s. We sought to assess a) how confident FY1s are in recognising and managing frailty, b) their understanding of CGA, and c) how these change during the year.

Methods

Questionnaires (quantitative and qualitative data) were given to FY1s at induction, 6 months, and 12 months. Teaching sessions on frailty and CGA were delivered. We collated feedback on how frailty recognition and CGA knowledge had altered their assessment of older people.

Results

All FY1 Doctors completed the survey at induction. The 6 months and 12 months surveys were emailed to FY1s. The survey response rate was 100% (31/31), 68% (21/31) and 58% (18/31), respectively. At induction, 23% (7/31) reported they were “quite” or “very” confident in assessing for frailty. This increased to 71% at 6 months and 100% at 12 months. Fifty-two per cent (16/31) of FY1 Doctors were aware of a tool to assess for frailty at baseline, increasing to 100% (18/18) at 12 months. Knowledge of CGA improved less, from 48% (15/31) at baseline to 83% (15/18) at 12 months. There was no association between speciality experience and confidence levels. Feedback from FY1 doctors indicated that frailty recognition allowed identification of patients who may benefit from advanced care planning discussions and triggered early therapy input.

Conclusions

Despite BGS and NHS England recommendations, at induction, FY1s lack confidence in frailty recognition and assessment. Through experiential learning and targeted teaching this improved, not limited to those in geriatric medicine. We recommend final year medical students need increased frailty and CGA specific education to improve their confidence when assessing frail older patients.

Background This quality improvement (QI) work was done at the South Edinburgh Parkinson’s clinic.

Introduction Idiopathic Parkinson’s disease (IPD) is a secondary risk factor for osteoporosis (Torsney KM et al. Journal Neurology Neurosurgery Psychiatry 2014; 85: 1159–1166). The 2022 UK Parkinson’s audit highlighted bone health as an area of QI for IPD (www.Parkinsons.org.uk).

Methods A Plan-Do-Study-Act (PDSA) structure was adopted and project charter created. Baseline data was collected from 20 patients attending the IPD clinic between June- September 2023, reviewing details of assessments in the last three years. The Parkinson’s Excellence network bone health form was used to assess osteoporosis risk (www.Parkinsons.org.uk). Patient records were prospectively assessed pre-annual clinic between June-July 2024. The assessment outcome was documented in the patient’s records to guide discussion. After clinic the form was updated and interventions actioned.

Results From baseline data, only 2 of 20 patients had a bone health assessment as part of recent annual reviews. Using the assessment form, 33 patient notes were reviewed. 22 patients were excluded based on the form’s screening criteria or lack of formal IPD diagnosis. 11 patients had a full assessment completed. Three patients were given lifestyle advice only. 7 patients (63.6%) had a FRAX score for a major osteoporotic fracture >10% and a DEXA scan was suggested for all. 3 of these patients were deemed high risk, ideally to be started on bone health treatment immediately. On average it took 3minutes and 47seconds to complete the form.

Conclusions The assessment forms were straightforward to complete and helped identify IPD patients at increased risk of osteoporosis. The Lothian Parkinson’s service is considering how best to implement this into the structure of annual reviews and will be undertaking further assessments with larger patient numbers. The impact on the service and clinical time needs to be better understood.

Introduction: Bowel health is affected in acutely admitted patients due to illness, change in diet, dehydration, and reduced mobility. Constipation is common and older patients are particularly at risk of constipation due to reduced bowel transit speed. Bowel motion monitoring can help improve bowel health and reduce complications including delirium, which can prolong hospital admission. To increase detection of constipation, a quality improvement project was carried out in the Department of Medicine for the Elderly at Southend Hospital, with aims to increase compliance of daily stool chart entries. Early detection will prompt patient review, investigation, and treatment of constipation, thereby managing symptoms and preventing complications. Methodology: Stool charts of patients across the geriatric wards were reviewed weekly for daily entries up to the last 7 days of their admission. Baseline compliance was determined on day 0 by dividing total days of stool chart entries over total days of admission (up to 7 days). Patients newly admitted or transferred to the ward on the day of stool chart review were excluded from the data. Interventions included verbal reminders to stakeholders (nurses, HCAs, doctors) at morning handovers, an electronic reminder with emails to stakeholders, and lastly a visual reminder with copies of a poster around the ward. The interventions were implemented separately on a weekly basis to quantify their effectiveness on compliance through further stool charts reviews on days 7, 14 and 21, and compared to baseline data. Results: Overall compliance increased by 16.9%, and the largest improvement was in response to the poster strategically placed next to all patient charts. Conclusion: The QIP was time and resource efficient, helping to identify constipation early and flag patients at risk for or for treatment of constipation. It is also easily repeatable and similar principles can be applied across other wards and specialties.

Introduction

In today's healthcare practice, many patients live longer with multiple health issues, often in a frail or terminally ill state. Their quality of life doesn't necessarily improve. These patients require optimal supportive care that respects their dignity. Advanced Care Plans (ACPs) are crucial here, facilitating person-centered discussions about future care preferences while the patients have the mental capacity for meaningful participation. We aim in this study to assess how many patients in General Internal Medicine department would benefit from ACP and compare that to our current practice in implementing ACPs

Method

This cross-sectional retrospective study was done in 2 instances, 1 month apart from 29/03/23 to 01/05/23. The Sample size was 300 patients. The eligibility criteria were life expectancy of 12 months or less, age of 80 years and above, Clinical Frailty Scale (CFS) 8 or more, advanced dementia, and end-stage disease.

Result

33 patients (11%) met the eligibility criteria for ACP. 8 patients (24.2%) were above the age of 85. 25 patients (75.8%) had a Clinical Frailty Scale score higher than 7. 12 patients (36%) had terminal cancer. ACP was done for only 6% of the cases that meet the eligibility criteria. Within three months, 90% of these cases passed away. It is important to mention that in 57.6% of the cases, ACP was discussed with the patient and the next of kin (NOK) but was not formally documented.

Conclusion

Our findings revealed that only 6% of the eligible cases had evidence of ACP. This aligns with the study “advanced care planning in patients referred to the hospital for acute medical care: Results of a National Day of Care survey” which showed 4.8% had an ACP. The absence of ACP in the vast majority of re-admitted patients represents a significant missed opportunity to improve care.

Introduction: At Warrington hospital, a small district general, the orthogeriatric team adheres to national guidelines by conducting bone health assessments for inpatients with neck-of- femur (NOF) fractures and commencing suitable secondary prevention measures. However, there is a noticeable gap in secondary prevention for patients with non-NOF fractures requiring admission (such as tibial or humeral fractures). This predisposes patients to a future increased risk of disability, morbidity and mortality following discharge.

Method: A Quality Improvement initiative was launched, introducing various interventions such as educational sessions for doctors and pharmacists, E-learning modules and a flow chart poster guiding bone health assessment. Bone health teaching and all interventions were shared and at each doctors changeover inductions, to reinforce and sustain change.

Results: Preliminary data in January 2023 identified that 0% of patients with non-NOF fractures received secondary prevention and only 7% had bone health mentioned in the discharge summary. The results of teaching alone from May 2023, indicated improved clinician knowledge and confidence, but only modest clinical improvement. However, by December 2023, the combined interventions demonstrated significant progress; 92% of patients had bone health bloods performed, 57% of patients were identified as requiring treatment and 70% of those received appropriate management. Additionally, 82% of patients had bone health mentioned on their discharge summary.

Conclusion: The interventions enhanced the identification of patients requiring further investigation and management, underscoring the importance of a multimodal approach for tangible change. To further solidify these improvements, a checklist was created for medically fit patients and is utilised by the ward manager to guide the daily multidisciplinary board round. Furthermore, an order set within our ICE system was created to streamline requesting bone health blood tests. Whilst the outcomes of these interventions are outstanding and to be collected in May 2024, we anticipate greater improvements in outcomes.

Introduction 

Dehydration is associated with prolonged hospital admissions and complications. Elderly patients are more susceptible due to physiology, dexterity and cognition. The British Dietetic Association recommends minimum 7 beverages per day whilst The British Nutrition Foundation advises proactive dehydration risk management in hospital. 

This project aimed to reduce the proportion of elderly patients at risk of dehydration in hospital.  
 

Methods  

Staff documented oral hydration over 24 hours for patients on the Care of the Elderly ward. Additional factors obtained retrospectively included demographics, dementia diagnosis, fluid prescriptions and fluid restriction. 

Criteria adapted from a ‘Hydration Care Assessment Tool’ defined risk of dehydration by daily intake as low (>1500mls), medium (800-1500mls), high (400-800mls) or very high (<400mls).  
Approximating each drink as 200mls, we set a daily target of 8 beverages; equating to low risk. Visual hydration trackers were placed at patients' bedsides and junior doctors reminded the multi-disciplinary team each morning. 

Data collection was repeated after 2 weeks.  

Results    

First cycle recruited 13 males, 16 females with mean age 78.5. Over 50% were Very High Risk (5/29) or High Risk (12/29) of dehydration whilst the remainder were Medium Risk (10/29), or Low risk (2/29). 4/5 (80%) at Very High Risk received intravenous fluids. Of the High-Risk group, more than half had a diagnosis of dementia and 3/12 (25%) received fluids intravenously. 

Following intervention, 12 males and 7 females were recruited with mean age 76. Proportion at highest risk was reduced: Very High Risk (5/29 to 0/19; -100%), High Risk (12/29 to 3/19; -61%). Therefore, more were at Medium Risk (10/29 to 13/19; +101%) and Low Risk (2/29 to 3/19; +131%). 

Conclusion 
 
Though improved, few patients meet hydration recommendations. However simple visual reminders are an effective starting point. Further interventions could include oral fluid prescriptions and reflect staff and patient feedback.