Clinical Quality

Introduction

Frail adults should be offered comprehensive geriatric assessment. Falls are the most common reason for conveyance to hospital for Nursing Home (NH) residents in SBUHB and are associated with mortality, morbidity and are a significant burden on Welsh Ambulance Service (WAST) and the Emergency Department (ED). Older people are often subject to long ambulance waits and offload delays. By using a collaborative approach, we aim to reduce hospital conveyance rates and adverse patient outcomes.

Methods

Phase 1 - WAST calls analysed January 2020 – February 2022 from Swansea Bay UHB NH concerning Falls/ Potential Falls where an Emergency vehicle attended the scene. Education provided about post-fall management in Swansea NH’s in March 2022. Phase 2- Development of a referral pathway with Acute-GP unit (AGPU) and Advanced Practice Paramedic (APP) colleagues who review the WAST “live stack” allowing calls to be diverted to Older Person’s Assessment Service (OPAS). OPAS also offer same-day assessment for NH residents (and others) directly.

Results

March-July 2022, 980 calls from SBUHB NH, 195 falls (19.9%), additional 228 potential falls (22.67%). There was significant change in conveyance (p <0.05) with no change in call nature or call frequency (p >0.05). Per month, the mean conveyance reduction was 20 patients. In addition, OPAS review 8 (mean) patients from NH directly each month, bypassing WAST.

Conclusions

Falls remain a significant burden on ED and WAST and we have shown education plus collaboration between AGPU, WAST and OPAS shows significant conveyance reduction, ultimately delivering a better patient experience and system efficiency. Each call-out has a cost per hour of £101.34, with average offload for those >65 years old being 406 minutes, saving a minimum of £25000 a month. Future directions include expanding post-fall education to NH in Neath/Post Talbot and WAST first responders and piloting a rapid-response vehicle

Aim:

There been several studies validating the Hospital Frailty Risk Score (HFRS) to identify frailty. (1),(2). We proposed that it could identify patients in the Emergency Department (ED) who would benefit from the Older Persons Assessment Service (OPAS).

Methods:

OPAS is an ED service which accepts patients on frailty criteria (aged >70 years, falls, confusion, care dependence, polypharmacy and poor mobility). A retrospective analysis of the OPAS databank was conducted using HFRS to divide patients in High/Intermediate and Low Frailty Risk. We considered Age, Clinical Frailty Score (CFS), Post-code with Deprivation Index and death within a year of attendance.

Results:

700 admissions: 400 High/Intermediate HFRS and 300 Low HFRS. High/Intermediate HFRS: 170 (42.5%) male, mean age 83.69 years, CFS 5.7. Low HFRS: 102 (34%) male, mean age 81.46 years, CFS 4.5. High HFRS vs Low HFRS had similar deaths (p=0.2) but a significant difference in CFS (p<0.05). HFRS was significant at detecting frailty in those <75 years old (p<0.01) but not at >76 (p=0.08). There was no association between the Welsh index of multiple deprivation with Frailty or Death. The HFRS Sensitivity is 0.44, Specificity 0.83, Positive Predictive Value 0.66, Negative Predictive value 0.34, Area under the curve 0.39 vs CFS.

Conclusion:

The HFRS identified 57% of the retrospective OPAS cohort, with the addition of >80yrs of age, the modified score identifies >85% of service users. We found that controlling for socio-economic status, quality of discharge summaries and coding had no relationship to the efficacy of HFRS as a screening tool. We have developed an electronic, automated Frailty Flag that operates in real-time to signpost appropriate patients who would benefit from OPAS, Orthogeriatric or POPs services (this facilitates patients to be ‘flagged’ for review as stated within NELA.) The Frailty flag is currently being tested in clinical practice.

Introduction: Most stroke patients fail the swallowing assessment, hence the need to have NGT. Sometimes, it is impossible to get an aspirate from these NGTs, other times, the pH of the aspirate is quite high. As such times, to confirm NGT position, in line with the National patient safety agency an Xray is used. Recently, incidents in the trust (UHCW) have been documented regarding NGT Xray interpretation, thus the need to undertake this audit

Methods: Patients (n=15) who had NGT in the stroke ward (24th March to 20th June,2022) were reviewed against University of Coventry and Warwickshire Trust guidelines. The following were assessed: date and time Xray was requested, how it was interpreted, clear instructions regarding action, interpreter’s grade and use of NGT stickers. Data was analysed using percentages and illustrated with bar charts. These were compared with data from the first audit.

Results: The adherence to the assessed variables (date and time Xray was requested, how it was interpreted, clear instructions regarding action, interpreter’s grade and use of NGT stickers) were 77%, 46%, 73%,70% and 40% accordingly.

Conclusion: There was an improvement in documentation of date and time of requested Xray a well use of NG Tube stickers by doctors in the stroke ward, this is in contrast to documentation of the 4 point check and clear plan instructions.

Introduction:

Suprapubic catheter (SPC) insertion is recognised as an alternative to urethral catheterisation to enable urinary drainage or continence control. This audit aims to establish the 1 and 2 year mortality associated with SPC insertion and to identify factors that may be linked with mortality.

Methods:

Data were collected for demographics, medical co-morbidities, indication for procedure and mortality from 1st February 2018 to 1st February 2020 across three NHS trusts. Multivariate regression analysis was undertaken to assess correlation between mortality and collected data.

Results:

48, 12 and 8 (total 68) SPC insertions were identified at the respective trusts. Two patients were excluded owing to a lack of mortality and cognitive data. Total mortality was 10.4% (7/67 patients) at 1 year and 16.4% (11/67 patients) at 2 years. Two-year mortality for those with a clinical frailty score (CFS) ≥3 and <3 was 21% (6/28) and 13% (5/39), p>0.05. Two-year mortality in those aged over and under 71 was 21.6% and 10.3% respectively. Other collected risk factors were not associated with increased mortality.

Conclusion:

Our study has demonstrated increased mortality rates in both the moderately to severely frail population and in elderly patients. These results have triggered the entry of SPC insertion onto the Model Hospital dashboard which states a national 1 year mortality rate of 15.4%. Clinicians should continue to be judicious when considering patients for this procedure.

• Listen to “What Matters Most” to the individual however it is expressed.
• A gap persists for people with advancing frailty, dementia, neurodegenerative conditions whose end-of-life needs are NOT recognized NOR appropriately met but nonetheless have no acute specialist palliative needs. End of life is harder to recognize with slowly deteriorating trajectory. Challenge indiscriminate use of single condition protocols as underlying frailty becomes increasingly irreversible at this stage.
• Identification: CFS 7 – 9 registered with a local GP on acute frailty unit, other medical and surgical wards. From community referred to Rapid Response Team experiencing frailty crisis. Exclude if EOLC needs require hospital or hospice level input.
• GeriPall interventions: “Tender conversations” mainly listening. Review history from all sources. Explain including uncertainties of outcomes to patient and family. Whatever else is needed—accurate and appropriate Fast Track completion, Urgent (Advance) Care Plan both online and paper copies
• Extensive medication review particularly deprescribing of items no longer of net benefit. Prescribe as required for symptom management.
• Harness existing pathways including ward discharge coordinators, D2A, community therapy, 2 hour urgent care MDT response
• In community: advise patient’s own GP and selectively use Palliative Care Coordination Hub, specialist palliative care, Care Home Support Team, district nursing, SALT, social care… (voluntary sector)
• Post discharge, Consistent phone follow up as soon as possible and sometimes visited. Ability to prescribe, review situation. Away from the large institution it is easier for death to become a social phenomenon as much as a medical one. 
• Survey post-bereavement. Very limited due to admin staff shortage but individual feedback from relatives positive. One Datix from discharge team fully investigated for learning purposes. 
• Outcome measures. 72 patients in 4 months, mostly from acute hospital. 19 RIP to end of March 2022. Average no of days for 10 sample patients: in index admission prior to GeriPall intervention =17.3, after GeriPall  =3.1, previous 12 months in hospital =11, Days out of hospital under GeriPall=40
• Funded by winter pressures money 2021-22 and being sought for this winter.
• Shortlisted for HSJ Patient Safety Awards Care of the Older Person
• Hopes for future: funding, multidisciplinary staffing, systematic patient identification and referral. Data collection, MDT review post discharge and development and learning opportunities.