Clinical Quality

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.

Introduction: The Acute Frailty Team (AFT) review all acute admissions referred to Medicine for the Elderly within our organisation. Our team is comprised of a consultant, AHPs and a specialist clinical pharmacist. The Clinical Frailty Scale Score (CFS) was used to quantify frailty within our patient population. Recognising that older patients are at increased risk of medicine related harm, medication reviews are undertaken as part of the comprehensive geriatric assessment. The aim of this project was to determine the number of documented Level 3 medication reviews on discharge including number of medication interventions and determine any correlation with CFS. 

Methods: For a 5 month period, all patients reviewed by AFT (Monday to Friday) had a documented CFS score on admission. A retrospective review was then undertaken with data collected on CFS score, patient demographics and number of Level 3 medication reviews documented on discharge. Data was then collated to indicate medication interventions and the most common medication changes.

Results:  212 patients were reviewed during the study period. Range of CFS score was 2 to 8 and 81.2% were classified as CFS ≥5. 101 patients had a documented Level 3 medication review accounting for 380 medication interventions; 210 medications were stopped and 82 medications were started. 36.6% of the patient group were deceased within 1 year of review.

Conclusion(s):

In order to optimise effective prescribing and minimise harm in older, frail people, this data will be used locally to promote the importance of medication reviews during an acute admission and ensure this is reliably communicated on discharge. Deprescribing accounted for 55.3% of changes. Since 1/3 of patients are deceased within one year, a targeted medication review is essential and should influence our prescribing practice going forward.

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed :- 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312(68.7%) Female, median age 86 years. 157(34.6%) patients had a femoral fracture and 300(65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206(68.7%) being discharged same day. Overall, admission was avoided in 207(45.3%) patients and 247(54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

Background
An important modifiable risk factor associated with falling is the use of falls-risk inducing drugs (FRIDs). The World Falls Guidelines identified this as a key domain and recommended that a validated tool should be used in medication reviews targeted to falls prevention in older adults (1).
A proforma was created based on the STOPPFall Tool (2) to aid doctors in performing structured medication reviews in patients with falls. The research question was ‘in older adult inpatients with falls, does use of the STOPPFall screening tool increase deprescribing of FRIDs?’

Methods
The project was carried out on Geriatric Medicine wards. Patients were included if they were inpatients and had been admitted with a fall, had a history of recurrent falls and/or had an inpatient fall. FRID classes were identified using STOPPFall, and FRIDs prescribed on admission and discharge were determined using discharge letters. The primary outcome was the number of FRIDs stopped or dose reduced on discharge. An online survey assessed HCOP doctors’ confidence in deprescribing.

Results
102 patients were reviewed at baseline. The percentage of patients prescribed at least 1 FRID was reduced from 84.3% on admission to 65.7% on discharge. A total of 162 FRIDs were prescribed on admission; 73 (45.1%) of these were stopped and 12 (7.4%) were dose reduced.
19 prescribers responded to the online survey, and self-assessment of confidence in deprescribing averaged at 7.74 (1-10 - ‘not confident at all’ to ‘very confident’). Confidence increased with seniority; average confidence ranged from 6.5 in foundation doctors to 9.0 in consultants. 

Conclusion
52.5% of FRIDs prescribed in older adult inpatients with falls were stopped or reduced. Introduction of a STOPPFall proforma shows potential in encouraging deprescribing of FRIDs.

Falls and fall related injury are a common problem within our older adult population and are associated with an impact on quality of life and functional independence. The first phase for reducing adverse effects from falls is to identify risk factors that can cause or exacerbate the risk of falling and then act to minimise these risk factors.

Method

A retrospective audit was undertaken to review how falls are assessed in a front door frailty service within the emergency department (ED) and acute medical units (AMU). The notes of each patient who had attended following a fall and was assessed by the OPAL team were reviewed. There are NICE guidelines on how to assess falls in older adults and the risk factors identified were used as a benchmark for the audit.

Results

The audit identified that there is a multidisciplinary approach to falls assessments and that the majority of the risk factors were identified on assessment. There were two domains that were not frequently identified on review - footwear and completion of lying and standing blood pressure measurements. Following completion of the audit, teaching was undertaken to the team and the results distributed with production of a crib sheet for staff to aid future falls assessments to ensure all domains are assessed.

Conclusion

Front door frailty teams often review patients who have presented to ED or AMU following a fall. A standardised approach to identification of risk factors across a multi-disciplinary team ensures patients are receiving appropriate management on risk factors to assist in reducing further falls in line with NICE guidance.

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.

INTRODUCTION

The National End of Life Care (EOLC) Strategy highlighted the need for individualised, accessible, multi-disciplinary care plans for people nearing the end of life. Proformas provide a systematic approach to recording end of life discussions. Our Trust uses an electronic patient record (Cerner), which includes an “End of life care agreement” for people in the last days of life.

An initial staff survey on a Medicine for the Elderly (MFE) ward highlighted a lack of familiarity with required documentation. The aim of this project was to improve end of life care documentation.

METHODS

A Driver Diagram was used to examine the principles underlying excellent EOLC and aided development of change ideas. The Model for Improvement allowed identification of measurable aims. Cerner records of 20 patients were reviewed fortnightly, including patients who had died since the previous intervention.

RESULTS

Three PDSA cycles were completed. The first PDSA cycle involved training for nursing colleagues. Step-by-step teaching on accessing and using Cerner end of life care documentation demonstrated a 15% increase in completed care plans. The second cycle (placing posters around the ward) - detailing how to access and document care plans resulted in a further 5% increase. The third cycle involved education sessions for ward doctors, with a further 25% improvement.

CONCLUSIONS

Comprehensive documentation is key to ensuring good end of life care, as it enables continuity of care and improves MDT communication. Active interventions including face-to-face teaching were more effective than passive (posters) in improving documentation.

Our findings demonstrated consistent improvement in completion of our EOLC agreement. We aim to extend our training interventions to other MFE wards and to integrate documentation training into junior doctor induction. We also plan to use similar methodologies to improve our existing end of life care agreement.

Introduction

The use of cognitive rehabilitation sessions (CRS) in the care of people with neurodegenerative diseases increased following the 2008-2012 Alzheimer's plan in France. Practitioners work with primary carers to optimise care and ensure a better quality of life at home.

Materials and methods

Multicentre, quantitative, descriptive, observational study. We distributed questionnaires from May to November 2023 to the main carers of patients with mild to moderate cognitive impairment who had been prescribed CRSs. Variables were compared using the Kruskal-Wallis test.

Results

We collected 150 questionnaires. Our population had an average age of 81, was predominantly female (55%) and was mainly being followed up for memory (61%) and Alzheimer's disease (58%). The carer was mainly a spouse (74%) or a woman (40%). The majority of patients benefited from a SSIAD (47%) and physiotherapy (34%).  54% of patients benefited from APA. 69% of CRS prescriptions were made by a geriatrician, 19% by a general practitioner. The time taken to prescribe CRSs differed according to the place of follow-up (15 months day hospital vs 26 months GP vs 20 months memory consultation (p=0.03); The average time from prescription to completion of CRS was 3 months.

Concerning the opinion of the main carers: 98% of the main carers considered them beneficial, but in insufficient quantity (67%), 22% did not accept the presence of a team in the home, 21% found the home unsuitable for the sessions

Conclusion

Cognitive rehabilitation sessions should be started as early as possible in the management of cognitive disorders to avoid progression of the disease. Patients treated in HDJ were prescribed cognitive rehabilitation sessions more quickly than patients followed up by their GP or in a memory consultation.

Descriptor

NHS Forth Valley, acute services identified an 122% increase in demand for patients to receive enhanced observations during 2023-2024. The attached chart demonstrates the staff bank requests over the 12 months evidencing the 2 sharp rises during April 23 and November 23. 

Methodology

• Weekly reviews of patients placed on enhanced observation with bedside teaching
• Education programme for nurse leaders (CNM&SCN), nursing workforce and carers
• Ensuring activities are available and accessible
• Scope initiatives being used in other health boards which have proven to reduce demand of enhanced observation
• Gain feedback from patients, staff and carers on improvement ideas

Aims/Objectives

To reduce the requirement of enhanced observations by 50% by May 2025.

A sample review during a two week whole system response to acute site pressures provided intelligence that multiple patients were receiving enhanced observations but there was a lack of adherence to the current NHS Forth Valley Policy1. This highlighted patients were not appropriately risk assessed or regularly reviewed and there was also a lack of evidence that the least restrictive options had been explored. The review also demonstrated patients were not engaged in meaningful activity, cognitive rehabilitation or stimulation, which therefore provided an absence of evidence of the benefit to patient, highlighted a risk of a prolonged length of stay, risk of exacerbating stress and distress and potential increase of physical harm.  In addition, enhanced observation has a significant financial impact due to of supplementary staffing use.

The focus of the improvement work will be to ensure enhanced observations are used appropriately, is the least restrictive option, promotes recovery and benefits the patients in line with national drivers, local guidance and legislation1,2,3.

Results/Outcomes

From the project starting in March 2024 and looking at December 2024 the data confirms a 94% reduction in supplementary hours and staffing requests through the staff bank and an 86% reduction of patient identified on safecare as requiring enhanced observations, see charts attached. Qualitative measures with application of the local policy and the quality of person centred care planning has improved. These improvements combined have lead to no adverse events or complaints raised in relation to appropriate use of enhanced observations. Furthermore, the project has contributed to significant cost reduction in NHS FV nurse staffing.

References

1.NHS Forth Valley, 2022. Nursing Observations and Interventions. NHS Forth Valley. Available at: scottish.sharepoint.com/sites/FV-Guidelines/Guidelines/Forms/AllItems.aspx?id=%2Fsites%2FFV-Guidelines%2FGuidelines%2FEnhanced Nursing Observations%2Epdf&parent=%2Fsites%2FFV-Guidelines%2FGuidelines (Accessed 18 March 2025)

2.NHS Scotland, 2024. Ageing & Frailty Standards in Scotland. NHS Scotland. Available at: https://www.nhsinform.scot (Accessed 18 March 2025)

3.Scottish Government, 2000. Adults with Incapacity (Scotland) Act 2000. Available at:https://www.legislation.gov.uk/asp/2000/4/contents  (Accessed 18 March 2025)

Introduction: Frailty presents significant challenges to healthcare systems, particularly in Thurrock, Essex, where 14% of residents are aged 65 or older. This demographic shift, combined with socioeconomic factors, highlights the need for patient-centred, clinically effective, and tailored healthcare services that prioritise patient safety. 

Aim: To improve frailty management for elderly patients in Thurrock by integrating pharmacist support within a nurse-led service. The initiative focuses on improving medication management, alleviating workload pressures, and providing holistic care to enhance patient outcomes and reduce hospital admissions. 

Method: A 12-week pilot involved patients aged 65+ undergoing joint reviews with a frailty nurse and pharmacist. Participants had a Rockwood Frailty Score of 5-7 and at least one long-term condition. The reviews encompassed an evaluation of physical observations, medication regimen, functional and fall risk assessment, nutritional status, fracture risk, and analysis of pertinent blood test results. The management phase focused on reviewing long-term chronic conditions, deprescribing, medication dose adjustments, and addressing health metrics such as postural hypotension, bradycardia, bone protection, and fall risk. Regular follow-ups ensured coordinated care between the nurse and pharmacist, focusing on patient-centred outcomes and patient safety. 

Results: A total of 37 patients (mean age: 84) participated from April 4^th to June 28^th, 2024. Comprehensive assessments led to 155 interventions (averaging 4.07 per patient). Medication management improved significantly, with 88 drugs deprescribed, including 55 Falls Risk Increasing Drugs (FRIDs), resulting in a 14.39% reduction in FRIDs and a 23.03% reduction in polypharmacy. These interventions led to £6,252.18 in annual drug savings and a 974.09 kg reduction in CO₂ emissions. Key outcomes included 57 health and social interventions and 38 new medications prescribed. Financial analysis suggested savings of £63,450 from preventable hospital admissions, with a return on investment (ROI) of 1655.4%.

Conclusion: The pilot demonstrated the clinical effectiveness of pharmacist-nurse collaboration in improving medication management, chronic condition control, reducing fall risk, and preventing hospital admissions. It underscores the value of skill mixing between professions for enhanced patient-centred care, safety, and clinical outcomes.