Clinical Quality

Introduction: 

Urgent Community Response (UCR) teams need innovative solutions to deliver timely and effective care to frail older adults. This project explores the combined impact of remote assessment, continuous monitoring, and AI scribes to enhance UCR service delivery, aiming to improve patient care, staff efficiency, and resource utilisation.

Methods: 

This service initiative integrates three key remote technological interventions within a UCR frailty service:

• Assessment: Digital examination devices (TytoCare) were used by Clinical Support Workers for remote clinician assessment. Data from 74 remote examinations conducted between April and September 2022 were analysed.
• Monitoring: Biobeat chest and wrist monitors were piloted with 20 patients within a Frailty Virtual Ward for four months. Data was collected to assess the impact on clinical decision-making, patient care, and system efficiency.
• AI Scribes: An AI scribe (Heidi) was introduced to the frailty team, to evaluate its impact on note-taking efficiency and documentation quality. Usage data from 419 sessions were collected and analysed.

Results:

• Assessment: Remote examinations using digital devices allowed clinicians to avoid hospital admissions in 70.3% of cases. The use of Clinical Support Workers saved between £13 and £78 per hour, equating to a potential yearly saving of up to £13,853.
• Monitoring: Continuous monitoring improved clinical decision-making and facilitated safe discharge to the patient's usual residence (91% with monitoring vs. 69% without).
• AI Scribes: Within the UCR workstream, the use of the AI scribe reduced time spent on documentation, with some areas experiencing time savings of 15-20 minutes per patient. Note quality improved and the AI scribe also decreased administrative burden.

Conclusion: 

This service initiative demonstrates the potential of combining remote assessment, continuous monitoring, and AI scribes to transform urgent community response for frailty enabling more efficient use of resources, improved patient outcomes, and enhancing note quality in the UCR workstream. This warrants further development.

Introduction: The Frailty Same Day Emergency Care (SDEC) unit at Fairfield General Hospital provides same day Comprehensive Geriatric Assessments (CGA). Bone health is an integral part of CGA, however recognition and management of osteoporosis is often not prioritised in acute hospital settings. We noticed that bone health was an area that was often overlooked within our CGAs. Our goal was to increase the number of bone health assessments performed and improve access to appropriate treatment for patients in the Frailty SDEC. The aim of this project was to increase the number of appropriately managed FRAX scores by 40% within 12 weeks in high-risk patients. 

Method: Baseline data was collected on all patients attending Frailty SDEC 2 days per week over an 8 week period. We measured how many patients were having FRAX scores calculated. Analysis of the baseline data indicated that patients presenting with falls were not having FRAX scores completed. Our change idea was implementing a bone health pathway which was displayed on the Frailty SDEC unit. This helped guide and remind clinicians when to calculate a FRAX score. 

Results: Bone health assessment in patients presenting with falls to Frailty SDEC was improved from 40% pre-intervention, to 80% post-intervention. Of those who were identified as needing treatment for osteoporosis, all patients had an appropriately assessed treatment plan and none were untreated who had been deemed appropriate for treatment. 

Conclusion: The implementation of a bone protection pathway has led to an improvement in the amount of FRAX scores calculated for patients attending with a fall. Our pathway was implemented across the Northern Care Alliance as part of a Quick Reference Guide for Frail Fallers Attending Frailty SDEC.

Introduction and Aims
The Older People’s Same Day Emergency Care (OSDEC) unit at Portsmouth Hospitals University NHS Trust accepts admissions for older patients referred by South Central Ambulance Services (SCAS), aiming to deliver early patient reviews and reduce emergency department (ED) waits. Timely blood test results are critical for decision-making and early discharge. NHS England SDEC protocols recommend pathology access comparable to ED processes, though no national standards exist for pathology turnaround times.
This quality improvement project aimed to implement targeted interventions to improve patient admission processes in OSDEC and to assess the sustainability and long-term impact of these improvements.

Methods
Data were collected for 88 SCAS direct attendances to OSDEC from February to September 2024. Patient arrival times, time of pathology request, laboratory receipt and blood results availability were recorded. Analysis focused on the average times from arrival on OSDEC to blood sample collection and laboratory receipt.

Results
Baseline data showed an average sample receipt time of 91 minutes and time to first results of 147 minutes. Improvement interventions were introduced to include printing of blood forms on receipt of referral and identification of staff to obtain blood sample on patient arrival. In May, sample receipt times were reduced by 7 minutes (8%), and time to results improved by 26 minutes (18%). By July, sample receipt times decreased further by 35 minutes (38%), and time to results improved by 35 minutes (24%) from baseline.

Although times increased in July and September (to 124–165 minutes), consistency improved, with fewer delays. Additional interventions included daily checklists to ensure stock levels for phlebotomy supplies and enabling senior nurses to request appropriate pathology investigations based on common frailty presentations.

Conclusion
Implementation of several interventions using a Plan-Do-Study-Act method improved availability of blood tests results that is important to enable prompt decision-making.

Introduction:

It is important to identify delirium on admission as delirium increases patient mortality and also is linked to an increased length of hospital admission (1). Delirium is identified through a scoring system such as 4AT (2) and should be done on all patients over 65, with new confusion, or reduced mobility (3) as per NICE guidelines. The aim of the QIP is therefore to bring the department in line with NICE guidelines and increase the number of patients in the over 65 cohort having a cognitive assessment, and in particular looking at those with confusion and falls as these can be presenting symptoms of delirium(3).

NICE guidelines state that all over 65s should have a cognition screen on admission to identify delirium and particularly those with symptoms of delirium (3).

This completed two cycle QIP aimed to improve the proportion of patients over 65 who presented with a fall, new confusion, or both fall and new confusion, who had a documented completed cognition screen on admission to CDU from Eastbourne ED.

Method:

From a random 2 week interval of CDU admissions, we identified those aged over 65. Using their clerking documentation we identified those presenting with fall, new confusion, or both. We assessed if they had an accepted completed cognition screen (MMSE, MOCA, 4AT, AMTS, SQuID) documented in their clerking. This required reading through the entirety of the clerking as there was no dedicated place for a cognition screen to be documented. This was repeated post intervention.

For cycle 1, a 4AT box with the four questions which generated a score was added to the electronic clerking proforma. For cycle 2 we organised and delivered in person teaching sessions for the junior doctors within the department. Juniors were recruited to act as 'delirium champions' and encourage a culture of delirium awareness through discussion at board rounds and within the department on a daily basis. The high turnover of A&E staff and the highly varied rota's posed a challenge to the efficacy of in person teaching sessions. To ensure the educational element was delivered to all, we created posters to educate on the presenting symptoms of delirium, the importance of early identification, and screening tools to use such as the 4AT box.

Results:

For CDU admissions for all over 65s, the percentage with a completed cognition screen increased from 0.02% to 5.10% after cycle 1, and increased further to 11.25% after cycle 2. For those admitted to CDU aged >65 with new confusion only (no falls), the percentage with completed cognition screen increased from 9.09% to 25.00% in cycle 1 and to 66.67% in cycle 2. For those aged >65 presenting with fall only (no confusion), the percentage increased from 0.00% to 4.35% in cycle 1 and to 26.32% in cycle 2. For those aged >65 with both fall and new confusion, the percentage increased from 0.00% to 11.76% in cycle 1 and to 33.33% in cycle 2.

Conclusion:

Including a 4AT prompt on the clerking proforma improved cognition screening for those with symptoms of delirium. However, clerking proforma changes alone are insufficient and much greater improvement was achieved through the combination of proforma changes (4AT box) and departmental educational initiatives. It is additionally important to consider a variety of educational initiatives in a department such as A&E with high staff turnover and varied rota's which can limit engagement with traditional in person teaching sessions.

References:

1. Anand, A. et al. (2022). Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and Home Time: Two-centre study of 82,770 emergency admissions. Age and Ageing, 51(3). Available at: https://doi.org/10.1093/ageing/afac051.
2. Jeong, E., Park, J. and Lee, J. (2020). Diagnostic test accuracy of the 4AT for delirium detection: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(20), p. 7515. doi:10.3390/ijerph17207515.
3. NICE (2010). Recommendations: Delirium: Prevention, diagnosis and management in hospital and long-term care: Guidance (2010) NICE. Available at: https://www.nice.org.uk/guidance/cg103/chapter/Recommendations#assessment-and-diagnosis (Accessed: 07 January 2024). Last updated: 18 January 2023

Introduction: Urgent Care Response (UCR) provides a rapid assessment, diagnostic and treatment service to prevent hospital admission. Occasionally, patients under the UCR team require acute hospital admission. Patients were experiencing long waits in the Emergency Department (ED), despite being referred directly from the UCR team due to the ED triage system. National Institute for Health and Care Excellence (NICE) recommends ensuring coordinated and patient-centred transfer of care from one healthcare team to another. We created an electronic alert icon to notify UCR referred patients to the ED triage team. 

Method: All patients reviewed by UCR from 1st January to 29th September 2024 requiring hospital admission were included. An electronic alert notifying the triage nurse that a patient has been assessed by UCR was created on 15th July. The time taken from patient arrival to Emergency Department (ED), ED team assessment, specialist team assessment and treatment initiation was recorded before and after the electronic alert was implemented. The readmission and mortality rates were recorded for this cohort of patients. 

Results: 47 patients assessed by UCR were seen in ED prior to the implementation of the electronic alert. 26 patients were seen in ED after the electronic alert. Average patient waiting times reduced by 47 minutes for ED review, reduced by 2 hours 2 minutes for specialty review and reduced by 1 hour for treatment initiation, after electronic alert implementation. 26/47 and 20/47 patients were readmitted and died respectively prior to electronic alert. 9/26 and 3/26 patients were readmitted and died respectively post electronic alert. 

Conclusion: The introduction of the electronic alert significantly improved time to ED team review, specialist team review and treatment initiation. Readmission and patient mortality within 12 months were recorded for the patient cohort. Post electronic alert, patient readmission reduced by 21% and patient mortality reduced by 31%.

Introduction 

The development of specialist acute frailty services is well recognised as crucial to meet the needs of our ageing population and is recommended by the NHS England Long Term plan. At the same time, same day emergency care (SDEC) services are rapidly expanding as an alternative to ED However, to date there is a limited evidence base for specialist frailty SDEC units. 

Methods 

We ran a 6-week pilot of a 7-day specialist frailty SDEC open from 8am-6pm. The unit was staffed by consultant geriatricians, frailty ACPs, specialist nurses, junior doctors, a therapy team and resident pharmacists. Patients were accepted both directly from the community (GPs, ambulance crews community frailty teams) and from ED. Criteria were loosely defined by Clinical Frailty Score (CFS 5 or above) and NEWS <3. 

Results 

A total of 256 patients were reviewed in the frailty SDEC over the 6 week pilot period. 166/256 (65%) of patients stayed <24 hours and a further 48 (19%) had a short stay of between 24-72 hours. 7-day ED re-attendance rates remained low at 6% (16/256) and 10% (26/256) of patients were re-admitted to hospital within 30 days of discharge (compared to 17.9% England national average for 2023-2024). 

Conclusions 

Frailty SDEC provides a safe, effective environment for rapid comprehensive geriatric assessment of patients living with frailty. Through close links with community teams we facilitate admission avoidance and person centred care in the right place, first time.

Ensuring Consultant Geriatrician reviews for patients on the Older Persons Assessment Unit.

Weston General Hospital (WGH) is working towards becoming a centre of excellence for frailty in keeping with its demographic. As part of this, there is a purpose-built Older Persons Assessment Unit (OPAU) compromising of 14 beds and Geriatric Emergency Medicine (GEM) unit compromising of 3 beds. Our OPAU medical team alongside the therapy team strive to ensure that each patient is reviewed by a Consultant Geriatrician during their admission, in addition to the routine medical and therapy teams to ensure expert oversight is sought to enhance patient care and subsequent outcomes as part of a gold standard Comprehensive Geriatric Assessment (CGA)(2,4).  The standard worked towards is that every patient admitted to the OPAU is reviewed by a Consultant Geriatrician to reduce length of stay and optimise their outcomes.

A retrospective audit was conducted of the patients admitted to OPAU in the months of August and December 2024. Notes were reviewed to ascertain if patients had a consultant Geriatrician review during their stay on OPAU. Data is captured on a spreadsheet to be reviewed and fed back to the wider teams to discuss current workings and any further work that is needed.

In December 90% of patients admitted to OPAU were reviewed by a Consultant Geriatrician during their admission. The 10% of patients that are not reviewed by a Consultant Geriatrician are reviewed by other specialties such as a Consultant Cardiologist or Oncologist; but still an expert in the patients complaining condition.

The majority of patients are reviewed by a consultant geriatrician, as part of the MDT for a CGA review on the OPAU which have further enabled more holistic care and successful discharges as well as a reduction in length of admissions and further readmissions. Those who were not reviewed by a geriatrician mostly presented at weekends; we aim to strive to 7 day consultant geriatrician cover in the future.

References: 
1 ) Hosoi, Tatsuya et al. Association between comprehensive geriatric assessment and short-term outcomes among older adult patients with stroke: A nationwide retrospective cohort study using propensity score and instrumental variable methods eClinicalMedicine, Volume 23, 100411 
2) Allen S, Bartlett T, Ventham J, McCubbin C, Williams A. Benefits of an older persons' assessment and liaison team in acute admissions areas of a general hospital. Pragmat Obs Res. 2010 Aug 21;1:1-6. doi: 10.2147/POR.S13355. PMID: 27774002; PMCID: PMC5044994. 
3) Ellis G, Whitehead M A, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials BMJ 2011; 343 :d6553 doi:10.1136/bmj.d6553 
4) Chen, Z., Ding, Z., Chen, C. et al. Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials. BMC Geriatr 21, 377 (2021). https://doi.org/10.1186/s12877-021-02319-2

Implementation of Advanced Clinical Practitioners as part of developing a ‘front door’ frailty service at Weston General Hospital. 

Weston General Hospital (WGH) site, within University Hospitals Bristol and Weston is developing its front door frailty services with the aim of becoming a centre of excellence for frailty. With up to 55% of admissions resulting in deconditioning (1) and geriatric medicine being the largest specialty in general medicine, there is a clear need for an advanced practitioners. 21.4% of Weston-Super-Mare’s population is aged >65 (2); suboptimal management of this demographic of people costs the NHS approximately 5.8 billion a year (3). The development of a front door frailty service will encompass the Geriatric Emergency Medicine (GEMS) service, Same Day Emergency Care (SDEC) and the Older Persons Assessment Unit (OPAU) to provide ‘front door’ patient-centred reviews of older patients.

The recruitment of two ACPs will play an integral part of the front door frailty service as they will cover each ‘front door’ area to ensure equity between locations. ED and SDEC is expanding to include specific frailty sections aligned with the SAMEDAY (4) and FRAIL (5) strategies enabling gold standard patient care and encompassing Comprehensive Geriatric Assessments (6).

Although the project is in its infancy, two tACP’s have been recruited, are in post and have been focusing on OPAU initially where the key performance indicator is the patients length of stay has been reduced. Figure 1 highlights the length of stay for patients who were reviewed on OPAU as part of their admission. It is to be noted that most patients were admitted for between 1 and 5 days.

The initial benefit is visible. As an aspiring centre of excellence for older adult care, the expansion of ED and SDEC are a priority to widen the capacity of the frailty service alongside further upskilling of staff through in-house teaching which is in process. Although there is not enough evidence to prove causation, the reduction in length of admission is noted in correlation with the tACP recruitment.

References:
1) British Geriatrics Society (2020) Sit up, get dressed and keep moving. Available from: https://www.bgs.org.uk/policy-and-media/%E2%80%98sit-up-get-dressed-and-keep-moving%E2%80%99 
2) Office for National Statistics (2021) Weston-Super-Mare. Available from: https://www.ons.gov.uk/visualisations/customprofiles/build/#E14001038 
3) British Geriatrics Society (2022) 8 key issues for older peoples health care. Available from: https://www.bgs.org.uk/InvestInCare 
4) NHS England (2024) SAMEDAY strategy. Available from: https://www.england.nhs.uk/long-read/sameday-strategy/ 
5) NHS England (2024) FRAIL strategy. Available from: https://www.england.nhs.uk/long-read/frail-strategy/ 
6) Ellis G, Whitehead M A, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials BMJ 2011; 343 :d6553 doi:10.1136/bmj.

Introduction 

Malaysia is transitioning from an ageing to an aged nation. According to the Department of Statistics Malaysia (DOSM), 7.4% of Malaysia's population was aged 65 years or older in 2023, projected to exceed 15% by 2030. Frailty is increasingly prevalent, affecting 11% of adults aged 50–59 years and escalating to 51% among those aged 90 years or older, based on global data. A local pilot study in March 2024 in general medical wards highlighted common frailty-related issues, including deconditioning (36%), delirium (17%), and a 12-month readmission rate of 46%. 

Objectives 

To introduce a user-friendly, standardized frailty care bundle to support non-geriatric-trained healthcare personnel in detecting common issues related to frailty syndrome early and implementing appropriate interventions. 

Methods 

A multidisciplinary team comprising geriatricians, medical practitioners, pharmacists, nurses, therapists, dieticians, and medical social workers developed a care bundle focusing on three key components: (1) screening tools for identifying acute functional decline, sarcopenia, and delirium; (2) protocolized management pathways; and (3) a discharge planning checklist. The bundle is designed for ease of use in general medical wards by non-geriatric-trained personnel. 

Results 

The care bundle will be piloted in 2025 across general medical wards. Nurses and doctors will screen patients aged 65 and older for deconditioning and delirium upon admission, notifying geriatrician as needed. Early physiotherapist referrals will address deconditioning, and a structured delirium checklist will guide targeted management. The discharge checklist includes caregiver identification, discharge planning, medication reconciliation, equipment assessment, and welfare support. 

Conclusion 

Frailty amidst an ageing population poses significant clinical and economic burdens, including higher readmission rates and healthcare costs. A standardized frailty care bundle offers a systematic approach to optimizing elderly care, improving outcomes, and addressing ageing challenges. Future audits will assess its effectiveness in reducing readmissions, functional decline, and healthcare costs.

Introduction: 

With an aging population of major trauma patients admitted to the Southwest Major Trauma Centre, a dedicated team of medics, nurses, and therapists launched a pilot aimed at enhancing the care of frail major trauma patients in a Major Trauma Centre (MTC). This initiative - the Frailty and Trauma Liaison Team (FTLT), focuses on ensuring continuity and quality of care for this vulnerable population in major trauma. 

Methods: 

It targeted the completion of comprehensive geriatric assessments (CGA) within 72 hours for patients with a Clinical Frailty Scale (CFS) score greater than 4 and traumatic injuries. Key components included standardised frailty screening tools to identify at-risk patients upon admission, followed by individualized care planning that integrates geriatric principles with trauma care underpinned by the HECTOR daily assessment. Every morning, 3 to 4 patients from the major trauma ward round were selected based on their CFS, length of stay (LOS), and location. Priority was given to those not located in a Health Care of the Elderly (HCE) ward. 

Results: 

The average CFS of the patient reviewed was 5.18% with 70% overall having CFS 5 or above. The findings from this pilot indicate that the FTLT were successful in identifying early factors affecting patients including pain management, bowel and bladder care, hydration / nutrition and cognitive / delirium screening that all required interventions to mitigate negative patient outcomes on the ward. 

Conclusion: 

This multidisciplinary approach fosters collaboration among healthcare providers, patients, and families, ensuring tailored interventions that address specific needs of the frail older patient. Data collection will be crucial in assessing patient outcomes, allowing for continuous improvement of the FTLT model. By implementing this comprehensive framework, it aims to enhance the care and outcomes for frail patients in the major trauma population, contributing to improved standards and outcomes of geriatric trauma