Clinical Quality

Venous thromboembolism (VTE) prophylaxis is commonly administered to patients across many hospital settings; however, it can be more challenging to address in frailty patients. These patients are more likely to have contraindications to anticoagulation and be “delayed discharges” (medically fit for discharge and at baseline mobility), at which point VTE prophylaxis may not be indicated. 

Method: This quality improvement project was carried out in the acute geriatric ward at St John’s Hospital. With the aim to improve VTE prophylaxis (appropriately prescribed and deprescribed when delayed discharge) in frailty inpatients by December 2024, through education of medical staff and by creating a Trak proforma. Teaching was provided to ward medical staff and a new delayed discharge Trak proforma was created. This prompted a review of VTE prophylaxis deprescribing when patients were medically fit for discharge. A simultaneous QI project created an admissions proforma which prompted a review of VTE prophylaxis prescribing when a patient was first admitted to the ward. 

Results: Before the intervention, only 58% of patients in Ward 8 had VTE prophylaxis correctly prescribed on admission. Many patients (40%) remained on VTE prophylaxis despite being delayed discharges. A staff survey revealed a higher confidence level around prescribing VTE prophylaxis than deprescribing. Only 44% of staff regularly considered stopping VTE prophylaxis once a patient was a delayed discharge. After the intervention, an increased number of patients (74%) had correct VTE prescriptions on Ward 8 admission (28% improvement). Only 16% of delayed discharge patients remained on VTE prophylaxis (60% improvement). 

Conclusion: This project improved rates of VTE prescribing in patients admitted to an acute frailty ward and deprescription rates in patients where VTE prophylaxis was no longer indicated by prompting regular reviews of these prescriptions. This intervention could be utilised in other departments

Introduction
Observations of the acute medical take suggested that patients who sustained a fall were affected by long delays and wait times to see both A+E and medical doctors. We felt that analgesia prescribing in these patients, many of whom sustained injury, was done poorly and some were being left without any analgesia leading to a negatively perceived patient journey. Our aim was to assess analgesia prescribing practices for patients following a fall with a view to improving experience.
Method
We completed three rounds of data collection, with 20 patients in each. We included patients coded as having a fall on admission and excluded patients under 70. We manually reviewed the case notes to see if patients had a pain assessment on admission and whether they were prescribed analgesia by the A+E team, the medical admissions team or on the post-take ward round. Our intervention was a presentation and education session to the acute medicine and geriatrics departments following each cycle, with the aim of involving both junior and senior decision makers with prescribing privileges.
Results
We reviewed 68 patients across all three data cycles and found that 40% of patients were not prescribed any analgesia by the A+E team. We found that the number of patients with regular or PRN analgesia prescribed rose to 70% once the medical and post-take had seen them. The proportion of patients that had no regular/PRN/stat analgesia prescribed throughout their entire acute patient journey fell from 28% to 16%.
Conclusion
Despite intervention, prescribing practices remained static. 1/3rd of patients did not receive regular or PRN analgesia following their admission injury despite seeing multiple clinicians. There was a modest reduction in patients who never received any analgesia at all following intervention.

Introduction

The timely administration of Parkinson’s Disease (PD) medications is essential for better motor symptom control, leading to improved patient outcomes. The NICE Guidelines and Parkinson’s UK recommend all hospital in-patients with PD should get their PD medications on time – within 30 minutes of their prescribed administration time. This audit aimed to assess the adherence of timely administration of PD medications amongst in-patients at South Tyneside and Sunderland NHS Foundation Trust, and to compare this pre- and post-interventions. 

Methods 

A two-cycle retrospective audit was conducted on November 2023 (pre-intervention) and July 2024 data (post-intervention). Data on all doses of PD medications administered in the trust, and whether they were given on time, was collected via our trust’s data warehouse application. On analysis, the percentage of PD medication doses given on time was calculated according to location. From this, six lower-performing wards were identified, and interventions for them (surveys, education and training) were carried out in April-May 2024. 

Results 

In November 2023, the trustwide percentage of PD medications given on time was 83.46% (n=2920), increasing to 88.32% (n=4024) in July 2024. Pre-intervention, the percentage of PD medications given on time across in-patient locations within the trust was varied, ranging from 0-100%. Post-intervention, there was more consistency – ranging from 50-100%, this evidenced improved performance achieved trustwide. All wards where interventions took place showed improved results, seeing 7.5-95.4% increases from their previous rates. New lower-performing wards which would benefit from interventions in future cycles of this audit were also identified. 

Conclusion

Over the two cycles, South Tyneside and Sunderland NHS Foundation Trust showed improvement in the percentage of in-patients receiving their PD medications on time. The post-intervention data also illustrates the positive impact of our interventions. Our work has been recognised as a best practice case study by Parkinson’s UK.

Introduction 

Delirium is a common presentation in geriatric medicine. Improvement in delirium assessment and management should improve identification of these patients and improve their outcomes. This Quality Improvement Project, completed by a group of Health Care for Older People (HCOP) resident doctors, aimed to improve delirium assessment and management for patients admitted to the five HCOP wards at Good Hope Hospital, Sutton Coldfield. 

Methods 

Patients with documented confusion were selected and delirium assessment/management was compared to current NICE Guidance. This included whether delirium screening was done, which screening tool was used, and how delirium was managed. Data was collected retrospectively from electronic patient records, anonymised, and recorded using an online form. Data from 85 randomly-selected patients admitted to HCOP wards in Good Hope Hospital during September 2024 was collected. Interventions of departmental teaching for all HCOP doctors and informative posters in common areas were implemented. Data collection was then repeated with 77 patients admitted during November 2024. 

Results 

Screening for delirium increased from 55.3% to 71.4% (+16.1%). Use of the NICE recommended 4AT tool increased from 30% to 43.9% (+13.9%). Implementation of non-pharmacological techniques (such as re-orientation) rose from 2.4% to 16.9% (+14.5%), and treating an identified cause rose from 75.6% to 94.8% (+19.2%). 

Conclusion 

Departmental teaching and educational posters were successful in improving delirium assessment and management. The largest improvements were in using a screening tool and treating an identified cause, which are largely undertaken by doctors. To improve further, educational efforts could be extended to the entire multi-disciplinary team. This may have resulted in more frequent use of non-pharmacological interventions. To implement long-lasting change, the posters have been provided to the department and delirium will continue to be taught in departmental teaching for future rotations of resident doctors.

Introduction: 1 in 37 adults in the UK are diagnosed with Parkinson’s Disease (PD). The varied nature and specific symptom management of the condition requires a person-centred multi-disciplinary approach to care. 

Methods: On a care-of-the-elderly ward at Bristol Royal Infirmary, 3 cycles of a quality improvement project were conducted to upskill knowledge and confidence of the staff caring for PD patients. In cycle 1, baseline knowledge and confidence of staff were gathered using a data collection survey. 5 teaching sessions were organised addressing topics in PD such as medication, palliative care and communication. The survey was then repeated. In cycle 2, another 3 teaching sessions were run on swallowing, physiotherapy and occupational therapy in PD. An easy-to-read information board on PD was also created on the ward. After a month, the staff were re-surveyed. In cycle 3, information was gathered from PD patients and their carers on what topics they thought were important and a 3 further teaching sessions were run on physiotherapy, medication and an overview of PD. A final data collection survey was distributed after 6 months of the initial baseline survey being conducted 

Results: Within the knowledge questions there was a 5 out of 8 higher correct answer rate across most parameters except medications, after the teaching sessions. This was also mirrored in the confidence questions with higher confidence rankings in 4 out 5 parameters being questioned. 

Conclusion: To continue the teaching programme with a wider range of care providers and having repeat teaching sessions on topics highlighted by PD patients and their carers. There should be a focus on further medication teaching, which has also been widely requested by staff members. Additionally, this teaching could be recorded for staff who cannot attend in person.

Introduction: Care home residents are often multi-morbid with both physical and cognitive impairments. An average care home resident takes 7.2 medications per day. Older people are more likely to experience adverse effects from polypharmacy due to pharmacokinetic and pharmacodynamic changes associated with age. Polypharmacy and anti-cholinergic burden (ACB) not only increase the risk of adverse drug reactions but also can increase the number of falls, hospital admissions and mortality. 

Method: Retrospective analysis in October 2024 of all patients at a residential home who had an initial Comprehensive Geriatric Assessment (CGA) which included a medication review since Enhanced Health in Care Home (EHCH) team started in March 2022 up until September 2024. The number of medications a patient was on at initial CGA alongside their ACB burden was analysed pre and post CGA. 

Results: 65 residents had an initial CGA within this time period with an average of 6 medications and ACB score of 2. Post CGA, the average number of medications per resident was reduced to 5 with an ACB score of 1. 68% of patients had polypharmacy (≥5 medications) prior to initial CGA and this was reduced to 58% post. 12% had ≥10 medications (excessive polypharmacy) prior to CGA and 8% (5) post. Pre CGA, 26% of residents had a high ACB score ≥3 which reduced to 15% post. There were 59 medications prescribed with an anti-cholinergic score of ≥1 which were reduced overall by 24% following the CGAs. 

Conclusion: The overall degree of polypharmacy and anti-cholinergic burden in care home residents can be reduced through a medication review as part of a CGA

Introduction 

According to the GMC’s Good Medical Practice, medical professionals have a responsibility to be considerate and compassionate to those close to a patient through giving support and information. For those lacking capacity, clinicians can assume that patients would want those close to them to be kept up to date with their condition. NHS digital data last year showed that 17.1% of written complaints are linked with communication. The primary aim of this project was to increase the percentage of surgical patients aged 65 or over receiving a next of kin (NOK) update. The secondary aim was to decrease the time to NOK update for this patient group to under 48 hours.   

Method  

QI methodology and 2 PDSA cycle loops were used. Using the electronic patient record surgical patients aged 65 years or over on two surgical wards were identified. Medical records were checked for documentation of a NOK update. Where a NOK update was documented, time to update from surgical team decision to admit was noted. In those without a documented NOK update, time from clerking was recorded. The percentage of patients receiving an update and mean time to update was calculated. Following the implementation of posters prompting NOK updates, data was recollected. Following a teaching session a third data analysis was undertaken. 

Results  

Following the initial intervention the time to NOK update decreased by 78% from 232 hours to 50 hours. The data post second intervention saw an increase in the percentage of NOK updates from 62% pre-interventions to 70% and time to update decreased by a further 5% to 40 hours. 

 
Conclusion 

Implementation of a poster prompt and undertaking a teaching session, highlighting the importance of communication with NOKs, demonstrated improvement in percentage and mean time to NOK updates for our patient cohort on surgical wards. 

Introduction . DVT is a common complication post stroke. Clinically evident DVT can occur in 2-10% after an acute stroke. DVT can develop as early as Day 2 after acute stroke; Risk peaks between Days 2 and 7. Untreated proximal DVT has a 6-15% mortality risk. Intermittent pneumatic compression (IPC) of the legs is recommended to reduce the risk of DVT in non-ambulatory stroke patients. Methods Criteria = All new stroke admissions to Stroke ward should have IPC applied by the time they were seen by the consultant on the post-take ward round – Unless contraindicated. Initial Audit = 100 admissions from June-July 2024. Intervention = Posters placed in doctors' offices and nursing bases (three locations) to remind both nursing and medical staff to prescribe and apply IPC on time. Post-intervention Audit = 100 admissions from August-September 2024. Results Initial Audit = 21.6% of patients did not have their IPC applied on time. Post- intervention audit = 18.1% of patients did not have IPC applied on time, reflecting a 3.5% improvement. Patients not receiving IPC by Post-take ward round reduced by 3.5% post-intervention. The reduction was mainly due to more timely IPC prescriptions by medical staff (improved by 5.9%) but compliance in IPC application by nursing staff worsened (by 2.2%). Conclusion The intervention successfully improved timely IPC prescription rates but did not fully address the delay in application by nursing staff. Targeted reminders can improve compliance, but additional strategies may be necessary for sustainability. Second cycle being planned to include: More targeted posters. Larger pool of patients to be audited (150). Request for ideas for interventions from nursing staff/resident doctors. Data will be collected on incidence of VTE in affected patient group.

Introduction: Frailty is a clinically recognized condition characterized by increased vulnerability due to age-related decline across various physiological systems, leading to reduced ability to cope with daily and acute stressors . Managing frailty requires a person-centred approach, involving patients, families, and caregivers, and utilizing evidence-based practices such as Comprehensive Geriatric Assessment (CGA), delivered by specialist multidisciplinary (MDT) teams. Research indicates that older individuals receiving CGA are more likely to be alive and living independently at home six months after an acute illness. To support the development of Older People’s Services, a review of the service model was conducted to deliver a rapid access service for patients referred by general practitioners (GPs). This service aims to avoid emergency department (ED) visits while providing necessary CGA assessments. Method: The initiative involved creating a direct referral option within the GP’s electronic referral system (Clinical Commissioning Group), developing a standard operating procedure for the triage process, establishing an education process for staff to clarify roles and responsibilities including data collection, and scheduling MDT members for triage support. Results: Following the implementation of the agreed procedures, there was a notable improvement in scheduling urgent GP referrals within three days. A daily referral system with live triaging was established, along with daily post-clinic MDT meetings. The backlog of urgent GP referrals was cleared. This successful system was replicated using Plan-Do-Study-Act (PDSA) cycles to integrate ED referrals. Conclusion: Collaborating with a team whose values aligned with Health and Social Care (HSC) principles—working together, striving for excellence, openness, honesty, and compassion—was a rewarding experience. The project provided valuable learning opportunities in team-building and service development. The success of the GP referral system was also leveraged to expand the service to other areas, such as ED referrals, demonstrating effective duplication of successful strategies.

Introduction: 

Following the publication of ‘Call to action: A Five nations consensus on the use of intravenous zoledronate after hip fracture,’ Craigavon Area Hospital began offering IV Zoledronic acid (IV Zol) to patients with a fragility neck of femur (NOF) fracture. However, the administration of IV Zol is based on the bone health assessment, vitamin D level, and requires ongoing post-discharge care. An oral bisphosphonate should be started one year after IV Zol administration. This study aimed to analyse whether discharges from Craigavon Area hospital following a NOF fracture had clear instructions for post-discharge care.

Methodology: 

Discharge letters of patients with a NOF fracture from the Trauma Ward between 4/11/24 and 22/12/24 were divided into three groups:

A (Bone health, IV Zoledronic acid and post discharge instructions), B (Bone health and IV Zoledronic acid mentioned but no post discharge instructions given)

C (Bone health, IV Zoledronic acid and post discharge instructions not mentioned). 

These groups were then analysed for potential interventions to improve future discharge letters. The second stage assessed the 4 week period between 14/1/25 and 18/2/25 with the same methodology.

Discussion: 

Only 38% (16) of the 42 discharge letters were included in group A and 37.5% of these contained ambiguous instructions. There were 13 discharge letters in group B and C of which 15% and 38% were discharged during outside of normal working hours respectively. Standardised wording and poster reminders were implemented and the impact reassessed. In the second stage 96% of discharge letters contained a full bone health assessment with follow up instructions.

Conclusion:

This study has highlighted the importance of adequate post discharge care for patients who have received IV Zoledronic acid. Unfortunately, many discharges did not mention the necessary information for GPs so proposals were made to improve ongoing care. The impact has been significant with 96% of letters containing the required information and so these changes will be introduced permanently.