Clinical Quality

Improving Advance Care Planning Within Residential Homes

Introduction:

As care home residents are living with advancing frailty and multi-morbidity, it is important to initiate advance care planning as part of the comprehensive geriatric assessment and create universal care plans (UCPs). There is evidence that it can reduce inappropriate escalations of care, reduce hospital admissions, increase the proportion of residents dying in their preferred place and improve both resident and relative satisfaction.

Method:

Retrospective audit in June 2024 of residents within the five residential homes covered by the newly formed enhanced health in care home (EHCH) team who had an initial comprehensive geriatric assessment (CGA) between March 2022-May 2024 to review if they had a universal care plan in place (UCP).

Further sub-analysis to review whether they had an existing UCP prior to EHCH review or this was created/edited by the EHCH team. Both the CGA and UCP would have either been completed by the EHCH matron or consultant geriatrician.

Results:

There was an average increase from 26% to 89% in the number of residents with a UCP following an EHCH CGA. We have created/edited a total of 117 UCPs across the care homes in addition to those already in place across the 177 CGAs completed over this time period.

Conclusions:

Advance care planning is a vital part of a comprehensive geriatric assessment and it is often not completed for many reasons including its time-consuming nature, lack of awareness and apprehension in having these discussions both amongst residents, relatives and staff and a lack of training and education.

As an EHCH team, we have managed to improve the number of residents with UCPs to 89%. We hope this will mean a greater proportion of residents receive appropriate personalised care according to their wishes in their chosen place as well as dying in their place of preference.

Introduction

The UCNH model is being implemented across Sussex to reduce ED pressures. Based at the Polegate Make Ready Centre, the UCNH launched in mid-November 2024 to provide alternative pathways for 999 callers. The UCNH operates as a multidisciplinary team of up to eight clinicians, including an Urgent Community Response Trainee Advanced Care Practitioner and a Consultant in Frailty, two Advanced Paramedic Practitioners, two Computer-Aided Dispatch drivers, and two remote consultation paramedics.

Method

The team triages calls, manages acute cases, and works collaboratively with ambulance crews and community services to avoid unnecessary ED attendance by offering interventions, referrals, or home-based management.

Results

Between 11 November and 31 December 2024, the hub operated on 33 weekdays, managing 554 contacts (16.8 per day). Their average age was 75 years. Of these, 184 were handled before dispatch, and 370 involved on-scene crews. The service avoided 121 ambulances (3.7 per day) and 339 ED conveyances (10.3 per day), significantly reducing unnecessary hospital visits.

Referral pathways included 254 patients directed to acute services, such as Same Day Emergency Care (SDEC) and specialist assessment units, and 139 patients referred to community services, with 4.2 supported at home daily.

Cost savings were substantial, totalling approximately £2395 per day (£1760 from avoided ambulances and £635 from ED avoidance), equating to £79,000 over this period.

Conclusions

The UCNH demonstrates significant benefit, reducing ambulance utilisation and ED conveyances while enhancing patient outcomes through community and home-based care. These results highlight its potential to improve ambulance response times and hospital handovers, although further data is needed to confirm this. Reinvestment of savings into SDEC and community services could enhance care pathways further. By preventing inappropriate ED attendances and facilitating access to suitable care services, the hub delivers both financial benefits and meaningful improvements to individual patient care.

Topic

We identified a deficiency in the identification and treatment of bone health in the Day Rehabilitation Unit. DRU is an Out-patient clinic where older people with falls or reduced mobility receive comprehensive geriatric assessment. We aimed to improve early screening for osteoporosis, prompting targeted investigation and intervention to improve patient outcomes.

Intervention

Our first intervention was consultant teaching specifically to the junior doctors working in clinic. This was followed up by the introduction of a Medical Assessment Proforma to include osteoporosis risk assessment. Finally we had departmental wide teaching on bone health assessment.

We hypothesised that a combination of clinical education and prompts in the proforma would improve our practice.

A total of 205 patients where audited across an 18 month period from Sept 20 to Feb 22. We reviewed the electronic care record of patients seen in clinic to determine if bone health had been considered. A spreadsheet was designed in accordance with the NICE⁽¹⁾ guidelines to record data. This included what supplements were prescribed, if a FRAX score had been recorded and the outcome of this.

Improvement

We noted an improvement in supplements prescribed (from 27% to 83%), FRAX score recorded (from 0% to 100%). Routine bloods including serum calcium remained unchanged (100%). Recording of Rockwood score also saw an improvement (from 0% to 49%).

Discussion

Increased use of a structured screening tool, supported by targeted education improves recognition and intervention of bone health. 54% of people who had a FRAX score done required a DEXA as per guidelines, of these 26% have osteoporosis. This early intervention helps to prevent osteoporotic fractures, therefore improving the quality of life of our elderly population.

References

1. Nice.org.uk. (2017). Osteoporosis: assessing the risk of fragility fracture | Guidelines| NICE. [Online] Available at: https://www.nice.org.uk/guidance/cg146

Introduction

Age is a risk factor for digital exclusion, but many older people have excellent access to digital services. Frailty may offer a clearer mechanism of exclusion. The aim of this study was to assess the association between living with frailty and digital exclusion from video consultation.

Methods

We undertook a multicentre cross-sectional study across primary care, interface, and secondary care services in South-West England. Patients were enrolled between 21st February and 12th April 2022. The primary outcome was complete digital exclusion from video consultation (defined as the no access for the individual and no option for help from their support network). A secondary analysis looked at digital exclusion of the individual only. Frailty was measured using the Clinical Frailty Scale. Outcomes were analysed with logistic regression.

Results

255 patients were included of which 39% were living with frailty. Only one person not living with frailty (CFS 1-3) experienced complete digital exclusion compared to 10.7% living with frailty (CFS ≥4). Frailty was not associated with complete digital exclusion, but was associated with individual digital exclusion: compared to CFS 1-3, CFS 4-5 aOR=36.5 (95%CI 4.40-304.9) and CFS 6-8 aOR=65.4 (95%CI 6.63-645.9). The imprecise estimates were caused by only one person not living with frailty digitally excluded.

Conclusion

Frailty was associated with individual digital exclusion. However, when considering a person living with frailty’s support network digital exclusion from video consultation was rare. To improve access to video consultation for people living with frailty their support network should be explored when booking appointments.

Background

Sarcopenia, defined as age-related loss of muscle function and strength, has a reported prevalence of up to 40.4% in the older adult. Despite its association with frailty, disability and mortality, it is underdiagnosed among hospitalized older patients. Exercise interventions have also been shown to improve fall risk scores for sarcopenic patients.

Objective

A QI initiative was started by a team comprising doctors and physiotherapists. Our aim was to enhance detection of possible sarcopenia and reduce time to delivery of targeted physiotherapy interventions to 1 working day from admission in patients aged 65 admitted to our ward. Interventions were grouped into three main categories – strength training, balance and gait stability training. A pilot study of 12 patients showed that no sarcopenia assessments were carried out and mean time to PT review was 2.16 days from admission, with an average of 1.08 interventions performed per patient.

Methodology

Fishbone analysis and Pareto chart were conducted to identify and prioritise factors behind low screening rates of sarcopenia, before driver diagram was performed to develop solutions. Our team established that education of junior doctors on sarcopenia and implementation of SARC-CAIF screening were the most appropriate interventions to achieve our objective.

Results

A total of 26 patients were identified, with an average age of 76.7 [6.7] years old. The mean SARC-F and SARC-CaIF scores were 4.51 [3.5] and 14.6 [2.4] respectively. 50% (13/26) of patients were admitted for falls. After implementation of SARC-CaIF screening, mean time to PT review was shortened to 1.38 days from admission, with an increase in PT interventions to 2.23 per patient.

Discussion and Conclusions

The prevalence of possible sarcopenia is high inpatient. More can be done to enhance its detection among frail hospitalized older patients, so as to deliver targeted physiotherapy interventions. Doctor education and SARC-CaIF screen are simple and practical tools that can be utilised.

Introduction

Treatment escalation plans (TEP) guide level of life sustaining therapeutic interventions that should occur for each patient admitted to hospital and can prevent inappropriate and undignified interventions. However, implementation of TEP in routine clinical practise has been ad hoc partly due to the paucity of literature on their benefits. Our aim was to systematically review the literature to ascertain the use and benefits of TEP in adults.

Methods

A systematic search for studies reporting TEP use were performed in the databases OVID Medline, Embase, Scopus and Web of Science. Search terms were ‘Treatment Escalation Plan’ Treatment Limitation, ‘Therapy Escalation’, ‘Escalation of Care’, ‘Palliative’, End of Life’, ‘Advanced Care Plan’. Exclusion criteria included studies prior to 2007, systematic reviews, case reports and letters.

Results

468 records were retrieved, 117 duplicates removed, 351 records were screened. 302 were excluded by date or relevance. Of 49 eligible records, 39 were excluded by criteria or unavailability of full text articles. 10 Studies using case control and quality improvement methodology conducted between 2010-2022 involving 1614 patients were subject to a narrative review. 8 different TEP proformas were used. All studies reported an increase in TEP use across all clinical settings and after each PDSA intervention ranging from 78%-100%. TEP reduced the frequency of non-beneficial interventions and was associated with an average saving of £220 per patient.

Conclusions

TEP lead to more frequent and proactive discussions with patients on ceilings of care and provide clear guidance to clinical staff out of hours, facilitate patient handover over successive shifts and enable proactive discussions with critical care. We identified the need for TEP to be successfully implemented in a unified manner across all healthcare facilities in order to improve patient care, reduce the burden of non-beneficial interventions and align with the NHS Long Term Plan.

Introduction:

Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national Irish Health Service Executive (HSE) guidelines after education sessions in a Model 3 Hospital.

Methods:

A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants.

Results:

Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%.

Discussion:

This audit elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. We posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan.

Conclusion:

Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.

Introduction At Wrightington, Wigan and Leigh we admitted over 400 patients with hip fracture diagnosis in 2023. As part of ortho-geriatric review, denosumab treatment would be utilised in a cohort of patients where this is appropriate, in line with NOGG guidelines. Traditional model of delivering first dose after outpatient appointment led to delays in treatment initiation and did not address the significant risk of “imminent fracture” which was recognised in the latest NOGG guidelines. The aim of this project was to reduce delays in denosumab treatment initiation by introducing consenting process during hospital stay led by ortho-geriatric Advanced Clinical Practitioner.

Method Utilising hospital electronic records, a sample of patients was selected from patients admitted in 2022 (19 patients), 2023 (19 patients) and 2024 (6 patients). Time of decision to treat with denosumab to time of first dose administered was used as the outcome measure. Alongside this, analysis of time to outpatient appointment was completed which was where the pre-intervention consent was taken. Intervention of inpatient consent being taken was implemented in September 2023.

Results The average length of time from clinical decision being made to first dose of denosumab being administered was 187 days in 2022 sample, 76 days in 2023 sample and 27 days in 2024 sample. The governance around consent process was established and adopted by the whole ortho-geriatric team. Waiting times for outpatient bone health clinic were on average 240 days in 2022, 164 days in 2023 and unknown in 2024 cohort.

Conclusion(s). Introduction of ward-based consent process for patients who are suitable for denosumab led to significant decrease in delays in time to first dose. This ensures that patients benefit from bone protection in a timely manner, as their risk of refracture is greatest in the first 6 months post index fracture.

Introduction: Emergency departments are increasingly seeing more older adults living with frailty. Between 5% and 10% of all those attending EDs and 30% of acute medical units are older adults living with frailty. The consequences of this on the system manifests as increased patient length of stay, poorer patient experience and clinical outcomes, such as mortality and morbidity, are measurably worse.

Aim: The Acute Frailty team aimed to move and expand its resource to provide a service to frail, older adults in both the Acute Medical Unit and the Emergency Department. This aligns with a key National objective that recommends all type 1 EDs have 70 hours access to a Acute Frailty Service. The team are a liaison service and therefore work alongside the ED and medical teams.

Method: Quality improvement methodology was applied utilising multiple PDSA cycles. An incremental increase in provision of an Acute Frailty service within the ED. A stakeholder group was set up, KPIs were set. The team worked alongside the ED team to improve early CFS scoring for over 65s and embedded the Nationally agreed same day frailty criteria of CFS/4AT, EWS and the presence of a frailty syndrome to identify appropriate patients for the service within the ED. The CGA was initiated in parallel with the ED assessment.

Results: Time between admission and CGA decreased by an average of 30 hours, Time between CGA and dc from hospital decreased by an average of 1.6 days. The Acute Frailty team activity increased in the ED and decreased in the AMU and there was no increase in re-admission rate.

Conclusion: A CGA initiated in the Emergency Department had a positive impact on length of stay and the earlier dc did not increase readmission rates.

Introduction

In conjunction with Roche, a 18 month project was proposed to facilitate a more holistic approach in managing this patient cohort post-diagnosis and in turn improve outcomes, reduce length of stay and improve patient experience.

Method

The aim of the project was to design the MDT, ensure there is sufficient clinician capacity for implementation as well as develop accompanying pathways. The patient cohort was all patients with a diagnosis of Non-Hodgkin’s Lymphoma over the age of 65. Whilst all patients meeting these criteria would potentially be eligible to be reviewed by the MDT, the patients would first complete a comprehensive frailty assessment at the end of which the clinician will assign a clinical frailty score (CFS). Any patient scoring 4 or above with a clinical concern will be added to the MDT for review. The MDT itself will aim to address all aspects of the patient’s health care journey post diagnosis. To this end, the roles that have been defined as critical are: Haematologist, Geriatrician, Pharmacist, Physiotherapist/Occupational Therapist, Dietician, Clinical Nurse Specialist and Support Worker.

Results

Currently over 90 patients assessed. Over 60 discussed in MDT, with over 170 total reviews. Further qualitative TBC.

Conclusions

Currently at UHS there is limited provision of frailty services. This unmet need manifests as e.g. reduced rates of treatment completion or increased treatment modifications, increased length of stay for post treatment episodes, missed appointments and non-elective admissions. All of which subsequently impact the patient's prognosis and NHS resources. Evidence shows centres with a geriatric oncology service have seen increased success in completion of treatment for patients and length of stay reduced by an average of 4.5 days. This pilot has enabled the Trust to collate evidence of this being the case locally, ultimately facilitating improved patient experience, better patient outcomes and reduced