Clinical Quality

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.

Introduction

Music therapy (MT) can alleviate the behavioural and psychiatric symptoms of dementia (BPSD) but it is not a standard intervention. NICE recommends MT to improve wellbeing in patients with dementia. On our Care of the Elderly (COE) wards, MT is carried out by a qualified music therapist once a week, in groups, individual sessions, or both. This quality improvement project (QIP) aimed to establish what, if any impact, MT, as it was currently provided, had on BPSD, in the setting of a general district hospital ward, thereby also potentially setting new standards which could be used to further optimise the provision of MT to patients. 

Method 

Patients with either a diagnosis of dementia or delirium were identified at the start of the day. MT was delivered in groups, individually, as well as both in some cases. Patients were interviewed by the music therapist both before and after MT, using the Neuropsychiatric Inventory Questionnaire (NPIQ), which was introduced and edited for this project. Patients’ engagement with MT was observed by the therapist and recorded as routinely done, unbeknown to the therapist to later be included in the project. Data was collected on a weekly basis. 

Results 

Over the course of 9 Mondays, 37 patients were scored on the NPIQ pre and post MT. Nine had a score of 0 both pre and post intervention. From the remaining 28 participants, 20, i.e. 71% had an improvement in their NPIQ score. Engagement levels were extracted from the therapist’s narrative on the day and 94 % (32/34) were positively engaged. One patient had five sessions of MT. In his case, MT reduced the need for anti-psychotics. 

Conclusions 

Music therapy improves the wellbeing of patients with dementia and delirium and should therefore be a standard resource on a COE ward. 

Frailty is a growing concern, particularly for older adults attending Emergency Departments (EDs). Frailty accounts for 5-10% of all ED visits and up to 30% of acute admissions. The NHS mandates that hospitals with Type 1 EDs provide a minimum of 70 hours of Acute Frailty Services per week to address this challenge. At Salford Royal Foundation Trust (SRFT), a Frailty Same Day Emergency Care (SDEC) service was introduced to deliver rapid assessment and care for frail older adults, aiming to reduce hospital admissions and improve patient outcomes. This service operates five days per week and is staffed by a multidisciplinary team. Methods: A mixed-methods approach was used to evaluate the Frailty SDEC service. Data was collected through paper surveys distributed to patients aged 65 years or older with a Clinical Frailty Score (CFS) >5 and their relatives or carers during their admission to the SDEC service. The survey included both closed-ended and open-ended questions. Quantitative data was analyzed using descriptive statistics and qualitative data was analyzed using thematic analysis. Results: A total of 32 responses were collected over a two-month period in 2024. The results showed high levels of patient and family satisfaction (97%) with the Frailty SDEC service. Participants particularly valued the compassionate and personalized care, clear and professional communication, and the efficient and timely service delivery. Areas for improvement included upgrading the physical environment and providing clearer communication about waiting times and procedures. Conclusion: The Frailty SDEC service at SRFT demonstrates high levels of patient satisfaction and effectiveness in delivering care for frail older adults. This evaluation provides valuable insights for enhancing patient-centered care and highlights the importance of further research to explore long-term outcomes and compare different models of SDEC services for older adults.

Introduction

This quality improvement project (QIP) aimed to determine whether the acute admission of patients with Parkinson’s Disease (PD) is meeting the current NICE guidelines in the appropriate prescription and timely administration of anti-parkinsonian medications (APM). The project evaluated the accuracy of prescriptions, quantified delays in medication administration, and established the causative factors for delays. 

Methods

This QIP was a retrospective study with two cycles analysed over a one-year period. Following consent and approval, notes for eligible patients meeting the inclusion criteria of a PD diagnosis being treated with APM’s, were retrieved. The records were analysed and reviewed against a data collection tool. Two criteria were established with a targeted compliance of 100% without exception: the first outlined that patients should have their APM administered on time without a delay of more than 30 minutes (criteria 1); the second appraised the accuracy of the prescription on drug charts (criteria 2).

Results

The combined cycles included sixty-five patients which were analysed based on the QIP objectives. In the first cycle, the compliance of criteria 1 was 21%, and criteria 2 was 58.6%. Following these results, key interventions were implemented in the trust: regular teaching on APM’s, commencement of mandatory PD training, posters created and displayed, stocks of APM kept in the emergency department, new guidelines for PD management published, and ‘Give it on Time’ stickers clearly placed on patient notes with a diagnosis of PD. Following the intervention, the second cycle’s compliance of criteria 1 improved to 65% and criteria 2 increased to 88.5%. Notably, after interventions, more patients (36%) were empowered to self-administer their medications. 

Conclusions

Overall, this QIP identified a low compliance with the standards set by NICE guidelines in the first cycle. Following the key interventions, the compliance improved significantly and this subsequently enhanced patient safety and outcomes.  

1.           Introduction

At Wrightington, Wigan and Leigh 412 patients were admitted with hip fracture diagnoses in 2024.  As part of the orthogeriatric review, bone health medications zoledronic acid and denosumab were utilised in this cohort of patients, where appropriate, to address the significant risk of “imminent fracture” in line with NOGG guidelines. The aim was to review January to June of 2024; 118 patients were evaluated, reviewing delays in initiation of these treatments to improve services and patient care.

2.           Method

Utilising hospital electronic records, a sample of patients were selected from those admitted in 2024 (118 patients). These were split into treatment choices zoledronic acid (59 patients) and denosumab (59 patients) to better evaluate the pathways for each treatment. An intervention to consent and initiate treatments before discharge in patients presenting with a hip fracture was implemented at WWL in September 2023. The results reviewed the number of patients receiving treatments before discharge, the date range variation between first doses and why these were so varied.

3.           Results

The average length of time for first dose denosumab was 62 days, improved greatly since 2022 (187 days) and 2023 (76 days). The average length of time for first dose zoledronate was 72 days with no comparative data. Further analysis shows how zoledronate delays in 91% of patients was due to the practice of not administering bisphosphonate medications within 14 days of surgery, a practice that has now changed. Furthermore, 64% of denosumab patients and 75% of zoledronate patients were delayed due to replacement of vitamin D.

4.           Conclusion(s).

Implementation of inpatient consent has been shown to expediate first dose denosumab greatly. Analysis of data will be required to review the first dose administration of zoledronate; stopping limitations such an administering within the 14 days of surgery should reduce delays further.

Introduction 
In-situ simulation has been shown to improve professional skills, team working and clinical care via social learning theories, benefiting all of the wider multi-disciplinary team – including nursing, physician associate and administrative colleagues – in addition to medical staff, by building camaraderie and a sense of belonging. Thus, a novel in-situ simulation training programme was created within the Department of Medicine for the Elderly at Broomfield Hospital; additionally forming part of an ongoing quality improvement project in medical education. 

Method 
Cycle 1: 30-minutes long sessions held on frailty ward on ad-hoc basis. 
Cycle 2: 30-minutes long sessions held on base ward of doctors on an ad-hoc basis, with select equipment provided. 
Pre- and post-teaching questionnaires were circulated to participants, with data scored via Likert scales assessing pre- and post-teaching confidence in reviewing an acutely unwell patient, familiarity with ward staff and equipment, and confidence in escalating patients, and handover. Each cycle ran over 4 months, with new participants per cycle. 

Results 
Significant improvements in key metrics were noted following attendance at a simulation session. Following the first cycle (n=20), 75% of participants were confident above neutral midpoint in reviewing an acutely unwell patient post-attendance, compared to 20% pre-teaching. Confidence in escalation of unwell patients rose from 65% to 95%, and confidence in handovers increased from 45% to 85%. Following the second cycle (n=23), confidence above neutral midpoint in reviewing an acutely unwell patient rose from 13% to 69%. Confidence in escalation of unwell patients increased from 52% to 65%, and confidence in handover rose from 30% to 65%. 

Conclusion 
The implementation of in-situ simulation has been shown to improve confidence in reviewing an acutely unwell patient, along with other metrics related to patient care and communication, highlighting the need for high fidelity simulation in medical education within hospital settings.

Introduction: In winter 23/24, the NHSCT tested an anticipatory care model in residential care homes. The model included a pharmacist medication review and pharmacy education element. 

Method: Across four residential homes the lead care homes pharmacist completed patient-centred, medication optimisation reviews, and carried out education sessions for senior carers. The number of recommendations/interventions made by the pharmacist was calculated. The number of recommendations/interventions relating to falls prevention, was also calculated. The clinical significance of each medicine optimisation recommendation/intervention made by the pharmacist was graded using the Eadon1 criteria. Eadon graded interventions were then assigned a monetary value using The Sheffield Centre for Health and Related Research (Sheffield University) Economic Model (ScHARR)2. Additionally a qualitative review of the service was carried out via questionnaires. 

Results: In total 92 residents had their medications reviewed. A total of 322 recommendations/interventions were made, an average of 3.5 per resident. Of the 322 recommendations/interventions 115 (36%) were in relation to falls prevention, an average of 1.3 per resident. Interventions of note included antihypertensives being stopped or dose reduced for 20 residents (22%), and bone protection being reviewed, commenced or altered for 31 residents (34%). The views of a capable residents, next of kins and senior carers were sought via questionnaire. Responses were all positive. 

Conclusion: Results demonstrate the positive impact and value of medicines optimisation by a pharmacist in the residential care home setting. 

References: 1. Eadon, H. (1992). Assessing the quality of ward pharmacists’ interventions. International Journal of Pharmacy Practice, 1(3), pp. 145-147. https://doi.org/10.1111/j.2042-7174.1992.tb00556.x. 2. Karnon, J., McIntosh, A., Dean, J., Bath, P., Hutchinson, A., Oakley, J., Thomas, N., Pratt, P., Freeman-Parry, L., Karsh, B. T., Gandhi, T., & Tappenden, P. (2008). Modelling the expected net benefits of interventions to reduce the burden of medication errors. Journal of Health Services Research and Policy, 13(2), pp. 85-91. https://doi.org/10.1258/jhsrp.2007.007011.