Clinical Quality

Care of the elderly simulation-based teaching for the multidisciplinary team

Introduction

Geriatric medicine is inherently complex and requires multi-disciplinary integration. Simulation-based training has been recognised by the Joint Royal Colleges of Physicians’ Training Board and the Royal College of Nursing as a method to enhance learning and improve patient outcomes. This project aimed to develop a multi-professional simulation programme within care of the elderly to mimic the multi-professional clinical practice that takes place on geriatric hospital wards.

Methods

A total of ten half-day simulation sessions have been run across two sites in two years. The scenarios cover frailty, orthogeriatric post-operative complications, acute delirium, Parkinson’s disease, thrombolysis and end of life care.

The sessions were attended by 57 participants, including 24 doctors, 20 nurses, 7 nursing students, 4 healthcare assistants and 2 physician associates. Quantitative and qualitative questionnaires conducted pre- and post- simulation were used to assess confidence levels and attitudes towards simulation as a learning tool.

Results

Both pre- and post- simulation, candidates had the most confidence in managing end of life situations, and least confidence in managing acutely unwell patients with Parkinson’s disease. Confidence levels for managing common geriatric scenarios increased by an average of 21% after candidates participated in the simulation session. Thematic analysis highlighted the importance of collaboration within a team to enhance a sense of belonging, and pro-activeness of staff to highlight deteriorating patients to colleagues and family members.

Conclusions

Simulation that mimics the ward environment is an effective tool in increasing the confidence of the multi-disciplinary team looking after geriatric patients through exposing candidates to complex situations and increasing awareness of the roles within the team.

The simulation sessions have highlighted clinical areas that require further education within the Trust, such as thrombolysis.

Future development of the simulation will aim to adapt the scenarios for use of the wider multidisciplinary team, incorporating therapists and pharmacists.

Introduction: Polypharmacy, multimorbidity, and frailty are closely interlinked. The STOPPFrail (Screening Tool of Older Person’s Prescriptions) criteria offer a structured approach to identifying potentially inappropriate medications (PIMs) in very frail older adults with limited life expectancy. This study evaluates the application of these criteria before and after admission to a specialist geriatric ward in a tertiary care hospital. 

Methodology: Medications were assessed against the STOPPFrail (Version 2) criteria before and after admission. Patients aged ≥65 years were included if they met all three STOPPFrail criteria: dependency in activities of daily living and/or severe chronic disease or terminal illness, severe irreversible frailty, and a clinical expectation of survival of less than 12 months. Data, including demographics, Clinical Frailty Scale (CFS) scores, medical history, and medication lists, were collected prospectively over three months. 

Results : Of 120 patients admitted, 30 met the STOPPFrail criteria (57% female, median age 89.5 years, median CFS 6, median Charlson Comorbidity Index 7). All patients were prescribed one or more PIMs before admission, and 96.7% remained on at least one PIM after admission. Lipid-lowering medications decreased from 36.7% to 16.7%, while antihypertensives were fully discontinued (23.3% to 0%). Vitamin D and calcium supplements decreased from 60% to 43.3%, antipsychotic use increased slightly (10% to 13.3%), and proton pump inhibitor (PPI) use remained unchanged at 30%. Despite deprescribing efforts, the median number of medications increased from 8.5 to 9.5. 

Conclusion: PIMs are prevalent in frail older adults. While deprescribing was focused on lipid-lowering and antihypertensive medications, gaps remain for PPIs and antipsychotics. Structured medication reviews, clinician education, improved documentation, and greater pharmacy involvement are essential to optimize prescribing. Identifying very frail older adults for whom STOPPFrail criteria are appropriate is vital to ensure a person-centred approach to medication management, enhancing safety and appropriateness for this vulnerable population.

Introduction: Treatment Escalation Planning (TEP) ensures timely clinical decision-making and appropriate responses to patient deterioration. This project aims to assess compliance with TEP documentation in the acute respiratory ward, identify gaps, and implement strategies for effective documentation. 

Methods: 3 PDSA cycles were completed using a quality improvement strategy, each for 5 days. Data was collected retrospectively using the patient’s electronic records, assessing key metrics such as TEP presence in patient’s notes and TEP TAB, DNACPR documentation, and time from admission to TEP completion. An intervention followed each cycle. The first cycle focused on awareness to consider TEP completion on admission, second cycle focused on educational sessions highlighting the importance of TEP discussion and documentation in a timely manner. 

Results: The results show steady improvement in TEP documentation across all cycles. TEP in patient's note completion increased by 11.5% in Cycle 2 and 15.3% in Cycle 3, reaching 61.5%. However, TEP in TEP TAB completion drops by 10.1% in Cycle 2 but recovers with a 24.7% increase in Cycle 3, reaching 26.1%. DNACPR documentation improves by 14.4% in Cycle 2 but decreases slightly by 1.6% in Cycle 3. The average time to TEP completion decreases by 2.6 days in Cycle 2 and 0.7 days in Cycle 3, reaching 1.5 days. These findings indicate significant progress but highlight areas needing attention. 

Conclusions & Recommendations: Ensuring the completion of both TEP in notes and TEP TAB is crucial for effective patient management. To improve compliance, the implementation of a ward-round documentation template is recommended to prompt TEP status when seeing new patients with the Consultant on-call. Additionally, TEP status should be considered during patient clerking to ensure early documentation and prompt discussions should take place if a patient’s clinical condition deteriorates. Sustained improvements can be achieved through structured documentation workflows and ongoing clinician training.

Over a 6 month period, all 92 residents were offered the opportunity to have a ReSPECT conversation and 86 accepted the opportunity. In addition to families/legal representatives, advocacy services were used to enable equitable participation. Digitally-facilitated communication tools were also offered.

The vast majority responded positively, and a mutually agreed ReSPECT form was completed. These were stored electronically on NHS systems and shared with the care home in paper format.

However, even when offered all available information some residents chose not to have a ReSPECT placing limitations on their care. Some family members objected strongly to what was being suggested. Case-by-case analysis is ongoing on the impact on unscheduled care use.

Conclusions

Our experiences highlight both the benefits of structured FCP, but also reflect the practical challenges and concerns among the population and those who support them. Empowering staff and family members to advocate in the event of a health deterioration was a powerful consequence. Equally, respecting individual preferences necessitates avoiding blanket approaches. ReSPECT discussions often enabled more timely hospital discharge when an admission occurred. Practical challenges, including the lack of care home access to NHS digital systems can be overcome, but reflect structural barriers to information sharing which integrated systems should avoid.

A Treatment Escalation Plan is a document that records and communicates a patient’s treatment goals and preferences, should their general health or condition worsen. A TEP can include but is not limited to: resus status, preferred place of care or death, if imaging/IVs/venepuncture is appropriate. Treatment Escalation Plans aim to minimise harm from over or under treatment; provide clear continuity of care between healthcare professionals; and prevent futile or burdensome interventions which may be contrary to patient wishes. TEPs can be recorded on the computer system, TRAK. The aim was to introduce TEP recording to the Edinburgh Hospital at Home Team (H@H) and aim for 80% of patients under our care to have a completed TEP. We found that anticipatory care planning and TEP discussions were regularly being had by H@H staff but that these were not being recorded under the TEP tab on TRAK. We increased staff awareness of the importance of TEPs and hosted teaching sessions and created a video on how to create a TEP on TRAK. TEP completion increased from 0% before they were introduced in our team, to a maximum of 78%. The team are reaching an average of 56% of patients having a completed TEP in the first 5 months of use. There does not seem to be a correlation between the number of patients under our care and the number of completed TEPs. We have not yet reached our goal of 80% but there has been a very good response from staff in starting to use the TEP function on TRAK. This data will continue to be monitored and a BOXI report has been created which provides twice weekly data reporting the percentage of patients under H@H care who have a recorded TEP and this will continue to be audited at least biannually.

Introduction 

We were wanting to better understand the population of older people accessing a district hospital emergency department, to identify how a front door frailty team could be utilized and estimate the potential impact this could have for the hospital. 

Method 

All patients over the age of 65 who were within the Emergency department on 4 consecutive Thursdays between 8am and 4pm were assessed and proposed a potential intervention from a front door frailty team (either to be streamed to an SDEC or community service, receive a review in ED, ward follow up, or no intervention at all). All patients’ notes were then followed up including ED disposal, inpatient notes if admitted, length of stay and their 7 and 30 day outcomes. 

Results

Of the 121 patients I was able to review and follow up, I believed 48 would have benefitted from intervention from a dedicated frailty team. Of these 48 patients, 28 were admitted to the hospital and totaled 161 bed days. On review of the notes many patients were deemed to be medically fir for a number of days prior to discharge (61 in total), which we know has a huge impact on a patients’ welfare, risk of hospital acquired harms as well as the impact on patient flow and hospital resources. Unfortunately, one patient deemed medically fit was unable to have an essential D2A to facilitate discharge, and he deteriorated and subsequently died in hospital. His preferred place of death was his own home. Conclusions I believe every emergency department would benefit from a dedicated front door frailty service, which would not only serve to improve patient care and allow a comprehensive geriatric assessment, but also serve the hospital to improve flow, reduce admissions and the associated complex discharges from hospital wards back to community care. 

Introduction 

“Getting it Right First Time – Geriatric Medicine” recommends the Clinical Frailty Scale (CFS) should be completed in patients aged 75+ on arrival in the Emergency Department (ED). Frailty services should focus on patients with a score of 5 or 6. The CFS has been shown to be easily completed in ED, however completion was variable.

 Methods

A Frailty Intervention Team (FIT) based in ED was developed at the Royal Lancaster Infirmary. Around the same time the CFS was embedded into the trust’s electronic Manchester Triage Tool (MTT-CFS) within the Electronic Patient Record, along with a separate CFS Clinical Data Capture form for the frailty team to complete (FIT-CFS). Initially FIT reviewed the notes of all patients 75+, irrespective of MTT-CFS, to identify those suitable for assessment. A FIT Advanced Care Practitioner developed a training program for triage nurses focused on quality completion. FIT moved to a dedicated Same Day Emergency Care unit (FIT SDEC) and changed inclusion criteria to age 75+, MTT-CFS 4+. 

Results 

Completion of MMT-CFS was assessed, with 35.64 patients aged 75+ attending a day, with 32.41 forms completed ( 11.21 scoring 1-3, 21.2 scoring 4+). Comparisons were carried out between MTT-CFS and FIT-CFS, showing that the MTT-CFS scored significantly lower than FIT-CFS (p<0.01) but MMT-CFS of 4+ scored comparably to FIT-CFS 5+ (p=0.2465) Following the move to FIT-SDEC, 38.06 patients aged 75+ attended ED daily, with 36.51 MMT-CFS completed, 8.97 scoring 1-3, 27.57 scoring 4+ (non significant trend for improvement compared to pre FIT-SDEC). 

Conclusion 

Education and embedding the CFS in the MTT led to good compliance in completion however accuracy was poor. A pragmatic approach was to use the MMT-CFS 4+ to identify FIT-CFS 5+. Changing the pathway to include the MMT-CFS of 4+ showed a non-significant trend for improved compliance

Introduction 

Delirium is a common presentation in frail, older, hospitalized patients (approximately 25% of admissions, with 50%+ on surgical wards), with a high mortality (approximately 22% during the hospital stay) with more associated, avoidable deaths than sepsis. Delirium is underdiagnosed. The National Institute for Health and Care Excellence (NICE) recommend using a validated screening tool on all patients at risk or showing evidence of delirium. “Getting it Right First Time, Geriatric Medicine” recommends all patients aged 75 or more, should be assessed using the 4AT tool (a validated delirium screening tool). 

Method 

A delirium pathway was developed in University Hospital Morecambe Bay Trust to embed these recommendations. A program of learning events was devised to target all grades of doctor along with a poster with the byline “Test it, Type it, Treat it”, included in multiple presentations and in trust screensavers. 

Results 

Before the education program, the Frailty Intervention Team (FIT) assessed patients for potential early discharge used the 4AT in 80.85% of patients with a diagnosis of delirium coded in 11.12%. In patients not seen by FIT (nFIT) the 4AT usage was 25.18%, with a delirium diagnosis rate of 9.11% Following the education program FIT 4AT usage was 96.12% with 18.69% diagnosed with delirium. The nFIT cohort completed 4AT in 33.63% of patients with 12.63% diagnosed with delirium. Analysis with Statistical Process Control charts showed that after the education program the use of 4AT by inpatient teams improved (p<0.05), but not in the Emergency Department (ED). 

Conclusion 

FIT assessed and diagnosed more patients than nFIT both before and after the intervention, with both groups showing improvement following the educational package. There is scope for improvement and further education events are planned, especially with ED, engagement of the ward “frailty champions” and possibly mandating the electronic 4AT.

Introduction: Osteoporosis causes significant deterioration of bone health predisposing individuals to an increased risk of fractures. Hip fractures in particular lead to increased mortality, morbidity and substantial economic burden on the healthcare system. Early identification of high-risk individuals is crucial to improve patient-related outcomes and significantly reduce the burden on our healthcare system. The objective of this quality improvement project (QIP) is to promote osteoporosis risk assessment in the frailty unit at North Manchester General Hospital (NMGH), by introducing a Comprehensive Geriatric Assessment (CGA) inclusive of a bone health risk evaluation. Methods: CGA, including a formal bone health assessment (as per NICE guidelines April 2023) was implemented in our frailty unit. This QIP was carried out in two cycles. Baseline data was collected (N = 33) retrospectively in January 2023 before CGA implementation followed by data collection in May 2023, to evaluate CGA with bone health assessment inclusion as an intervention (N=31). At the end of cycle one the results were presented to staff including education on CGA and bone health. Cycle two, conducted in June 2024 assessed compliance (N=30). Results: Bone health assessment compliance improved from 15% at baseline to 55% after cycle one and 83% after cycle two. When evaluated for inclusion of a bone health treatment plan, the baseline value was 31% which improved to 84% and 90% in cycles one and two, respectively. Conclusion: Implementing CGA with the bone health assessment standardised interventions to improve patient’s bone health admitted to the frailty unit at NMGH. CGA also helped identify people at risk of fractures and to initiate prompt management. This QIP helped our frailty unit to adhere to NICE guidance, thereby improving the quality of care offered at NMGH.

The Frailty Hotline is a follow-up service designed to provide ongoing care and support to patients discharged from the frailty service. Patients who have previously been under the care of the frailty team are given a dedicated phone number that allows them to escalate non-urgent concerns regarding their health. This service ensures that patients continue to receive appropriate care and guidance while remaining in their home environment, reducing the need for unnecessary hospital visits.

This quality improvement project sought to evaluate the effectiveness of the Frailty Hotline in reducing avoidable ED visits and improving patient care. The PDSA cycle  was conducted over a 15-day period. During this time, the frailty practitioners at the Royal Preston Hospital responded to a total of 47 phone calls. Details of the calls were recorded using a pro forma to ensure accurate information capture.

The majority of identified concerns centered around queries regarding patient management and issues related to patient symptoms and health. When a problem or concern was identified, actions were typically taken to address it. The majority of the actions involved providing advice to patients and seeking clinical advice from senior practitioners. A significant number of patients were also escalated to the Virtual Frailty Ward.

Out of the 47 phone calls received, 16 (34%) addressed patients' symptoms that could have potentially resulted in Emergency Department (ED) presentations. Of these 16 patients, 9 (19%) were escalated to the Virtual Frailty Ward, potentially preventing hospital admissions. One patient called 999 due to extreme pain and may have presented to the ED. There was no geriatrician available at the time to advise.

This highlights the critical role of the Frailty Hotline service in reducing unnecessary ED visits and hospital admissions. The Frailty Hotline service also played a vital role in improving patient outcomes by addressing a range of queries related to medications, symptoms, and pending investigations, which could have otherwise resulted in unnecessary phone calls to GPs and other services.