Clinical Quality

Introduction

As the prevalence of dementia continues to increase across the UK, understanding the lived experience of patients and carers affected by dementia becomes paramount. There is an established dementia pathway in Sussex for people living with dementia (PLWD) and their carers. To improve care and inform future commissioning priorities, the Brighton and Hove Health Watch (BHHW- a community interest company) surveyed the opinions of a group of PLWD and their carers around initial diagnosis and subsequent support.

Methods

PLWD and their carers receiving social support and willing to provide feedback were included in this survey. Using a topic guide, BHHW volunteers conducted a telephone interview with this group exploring their experience with their general practitioner (GP), and the memory assessment service (MAS) in relation to diagnosis, and post-diagnosis support. Transcribed interviews were analysed using qualitative thematic analysis (inductively and deductively) using Braun and Clarke’s method.

Results

Forty-five participants were interviewed, 37 carers and 6 PLWD (average age 78.2 range 64-95 years) between December 2022 and May 2023. Thirty-nine participants (86%) were of white-British ethnicity. Participants reported a range of different experiences with no consistent pattern by age, gender or location. Participants were generally satisfied with the initial GP care they received. The waiting time to access MAS was six weeks on average, an acceptable timeframe for the group. Some participants reported waiting as long as two years since the initial GP consultation before a dementia diagnosis was eventually made. Participants were generally satisfied by the thorough MAS review. Most participants felt that the information material they immediately received after dementia diagnosis was complex and overwhelming. Social support offered post-diagnosis was commendable.

Conclusion

The lived experience of PLWD and their carers in Sussex was generally positive. However, a tailored approach to post-diagnosis information provision is required.

Introduction:

CGA is the gold-standard intervention for older adults living with frailty. A challenge is providing person-centred, time-efficient CGA. The CGA-questionnaire (CGA-Q) aims to facilitate person-centred CGA, allowing patients/carers to highlight concerns. We describe a two-site multi-cycle QIP implementing the CGA-Q.

Methods:

CGA-Q is a 19-item questionnaire covering seven CGA domains. It was adapted from the validated CGA-GOLD questionnaire. Between March 2023-June 2024, CGA-Q was established in a London and Scottish NHS Trust using ‘Plan-Do-Study-Act’ methodology. Cycle 1-3 involved designing and establishing CGA-Q at one London geriatric clinic. Cycle 4 assessed feasibility in multiple London geriatric clinics. Cycle 5 examined implementation of CGA-Q in a Scottish day-hospital. Person-centredness refers to inclusion of person-selected concerns in clinic letters, and not including person-excluded concerns.

Results:

Across cycles, cohorts were comparable in age, sex, frailty and cognitive status. In cycles 1-3 (n=174), CGA-Q completion rates improved from 39% to 83%. More CGA-Q questions were addressed especially cognition, mood, continence and falls. Inclusion of person-selected concerns increased from 60% to 70%; exclusion of person-excluded concerns remained ~70%. In cycle 4, completion rates varied by clinic: renal-CGA 100% (12/12); CGA 42% (13/31); bone-health 14% (10/60). >50% of questionnaires were completed by patients, except in bone-health where two-thirds were completed by staff. Staff feedback highlights CGA-Q is a useful discussion prompt. In cycle 5 (n=41), a similar breadth of CGA-Q questions were addressed among respondents compared to baseline. With CGA-Q, continence and pain were addressed more frequently. Inclusion of person-selected concerns was 62%; exclusion of person-excluded concerns was 71%.

Conclusion:

CGA-Q has been successfully implemented across multiple sites and clinics. It can improve person-centeredness and breadth of CGA, but early results vary across subspecialty geriatric medicine clinics with their unique processes. Ongoing work will determine the experience of patients and carers of this approach.

Introduction: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.

Introduction
The Assessment and Rehabilitation Centre (ARC) in Edinburgh sees around 600 new patients a year who are beginning to demonstrate signs of frailty, principally around mobility and balance. When taking a comprehensive geriatric assessment, we commonly identify concerns around cognition. We noted in some cases people were already waiting to be seen by the Memory Clinic Services, the current wait for which is approximately 10 months. We decided to see what ARC could do to help.
Method
From within existing resources, alongside the Psychiatry of Older Age (POA) Team, the ARC multi-disciplinary team coproduced a pathway that involved an initial assessment comprising identification of potentially cognitively frail patients, taking a corroborative history, performing cognitive and imaging investigations. Each step was added to a shared spreadsheet enabling us to chart progress of diagnostic information steps.
Then once assessment complete, a POA colleague reviewed the evidence and made a diagnosis with treatment recommendations.  The ARC team then discusses the outcome with the patient and their family, arranges a medication tolerance follow-up in ARC, then refers onward for ongoing community support.
Results
Between March 2023 and 2024, 52 patients completed the Memory MDT process, 34 (65%) of which were diagnosed with a dementia, 20 (33%) of which were started on dementia medication. 16 were removed from the Memory service waiting list (2.5%) and a further 18 avoided the need to be referred.
Conclusion
We identified a group of patients with a common underlying pathology that had resulted in them being referred to multiple specialities.  By arranging our services around this vulnerable patient group rather than the other way around, we reduced their need for multiple hospital attendances and freed up resource in the memory service. Work is underway to spread and scale up.

Introduction

Physical and cognitive frailty combined with unfamiliar surroundings in hospitals puts elderly patients at high risk of falls. It has been demonstrated that patient-centred, non-clinical stimulating activities in hospital have been found to reduce agitation, improve affect and engagement, relieve pressure on nursing staff and reduce falls. In the Medicine of the Elderly (MOE) wards of an urban teaching hospital, after a successful pilot, a Meaningful Activity Team (MAT) was implemented. The effect of this change to patient and staff well-being was assessed, as was the frequency of falls on the wards.

Methods

The MAT was implemented by July 2023. In November 2023, questionnaires were distributed to staff across the MOE department to collect quantitative (Likert scales) and qualitative data on potential benefits and limitations. As part of our Quality Programme, prevalence of patients admitted to MOE wards with a diagnosis of dementia/delirium is regularly measured, as are patient falls, which are recorded via DATIX and collated on ward-based run charts. We interrogated these charts for any significant changes.

Results

The current prevalence of patients with delirium/dementia across the MOE 152 bed footprint is 69%. 49 staff questionnaires were completed, 47 of which had comments. 100% of respondents agreed or strongly agreed that the MAT benefited patient well-being. 87.8% agreed or strongly agreed that the MAT benefited staff well-being (figures 1, 2). Common themes regarding patient well-being were patients being happier, brighter and more sociable. Common themes regarding staff well-being included less stress and increased time for clinical tasks. The frequency of falls has reduced with some wards seeing maintained shifts in median number.

Conclusion

Implementation of the MAT across our MOE wards has improved patient and staff well-being. Reductions noted in frequency of falls have been maintained.

Background Royal Bolton Hospital is a district general hospital in Greater Manchester. In 2023, a Cardiogeriatrics service was introduced to deliver comprehensive geriatric assessment for older cardiology inpatients with frailty.

Introduction

Our aim was to evaluate the Cardiogeriatrics service with respect to the impact on end of life care for older cardiology inpatients.

Methods

Audit standards were defined using metrics for quality in end of life care. All patients between the year 2021 and 2024 aged 75 and over who died as an inpatient or within 30 days of discharge were included. Patients who died following procedural interventions were excluded. Patient’s casenotes were audited and compared before and after the initiation of the service.

Results

Casenotes for 88 inpatient deaths were audited (66 prior to introduction of the Cardiogeriatric service, 22 following). The Cardiogeriatrician initiated end of life care in 31.6% of inpatient deaths. This corresponded with a reduction in unexpected deaths from 26% to 14%, and a reduction in patients initiated on end of life care by the on-call team, from 31.8% to 10.5%. Junior doctors on Cardiology began to initiate resuscitation conversations with patients. Casenotes for 44 deaths within 30 days of discharge were audited, however no meaningful insight could be gained as there were only 6 outpatient deaths after the Cardiogeriatric service began.

Conclusion

After introduction of the Cardiogeriatrics service, there was improved recognition of patients who were approaching end of life, and more proactive management of this. As many patients audited were not seen directly by the Cardiogeriatrician, we believe the service has contributed to a cultural change in the Cardiology team more widely towards more proactive recognition and management of end of life issues in older Cardiology patients.

Introduction

Delirium has a significant impact on morbidity and mortality. It is also associated with an increased level of institutionalisation at discharge and increased length of stay. Therefore, a diagnosis of delirium should always be considered with an assessment of risk factors. The aim of this project was to ensure 100% of patients on Geriatric wards have a diagnosis of delirium considered via the 4AT as per NICE guidelines.

Methods

A Plan-Do-Study-Act methodology was utilised with an initial audit exploring identification and documentation of delirium diagnosis. A Lanyard Prompt Card was then distributed to all physicians with the 4AT score illustrated. A departmental teaching session about Delirium was delivered to all juniors. A re-audit was conducted to assess impact.
 

Results

Of the 41 patients evaluated initially, 50.7% (21) were suspected to be delirious. Of these, 9.5% (2) had been assessed for delirium on the same day delirium was suspected. Of 38 patients, post-intervention audit revealed 36% (14) were suspected to be delirious and of these patients, 43% (6) had a 4AT score on the same day.

Key conclusions

This project revealed 4AT assessments were approximately tripled in patients suspected to be delirious post-interventions. There remains scope for improvement in confidence and skill of documenting assessments to meet the NICE recommendations and potential to explore barriers. Ultimately, we aim to expand across all medical and surgical wards to upskill all MDT members on identification and management of delirium

Introduction: Hip fractures, predominantly affecting older adults, represent a significant health concern due to high morbidity, mortality, and healthcare resource utilisation. This ongoing Quality Improvement Project within Forth Valley Royal Hospital aims to enhance adherence to recommendations from the 2023 and 2024 Scottish Hip Fracture Audit. It specifically focusses on the timely administration of Vitamin D and IV Zoledronic Acid to frail patients with hip fractures.

Method: A retrospective and prospective cohort study design was employed, analysing the records of 165 inpatients under orthogeriatric care from November 2023 to May 2024. Initial data analysis indicated low rates of IV zoledronic acid and vitamin D administration, primarily due to clinician unfamiliarity and process inefficiencies. Subsequent interventions included staff education sessions, process standardisation, and the introduction of tracking tools such as Bone Health stickers and whiteboards. Formal referral pathways and decision-making protocols were implemented to ensure comprehensive and timely patient care.

Results: The interventions led to substantial improvements in adherence rates. Between November 2023 and March 2024 vitamin D administration rates increased from 14.71% to 100%, and IV Zoledronic Acid administration rose from 12.12% to 95.45%. These improvements were achieved through systematic tracking, enhanced clinician education, and standardised care processes. Despite these gains, challenges remain in achieving 100% adherence to IV Zoledronic Acid administration and addressing initial data capture inaccuracies due to inconsistent use of referral systems.

Conclusion: The project demonstrates that targeted interventions and standardized care pathways substantially improve adherence to national guidelines for hip fracture patients. Sustained efforts in education, process refinement, and collaboration with the Hip Fracture Audit Team are essential to maintain these improvements. Future proposals include integrating Vitamin D and Adcal-D3 doses into an electronic prescribing protocol and conducting detailed statistical analyses to identify further areas for improvement.  

Introduction

University Hospitals Dorset (UHD) wants to provide hospital level care to patients with frailty, in their own home. Our frailty virtual ward (VW) team consists of a consultant geriatrician, lead nurse, pharmacist, advanced nurse practitioner, nurses and therapists. We have a capacity of 20 patients across Bournemouth, Christchurch and Poole localities. Our patients receive care at home for acute medical conditions supported by remote monitoring, blood testing, face to face assessments and daily Geriatrician input. We are collaboratively working with our community partners seeking to provide complete CGA in the patient’s home.

Methods

Establishing the service was non-linear and required multiple improvement cycles. Our VW fits alongside our frailty SDEC, day hospital and interim care team. We developed a SOP, a patient flow pathway and processes for medication prescribing and delivery supported by the Royal Voluntary Service. We screened our frailty wards for suitable patients and in May 2023 we tested by taking our first patient home. Subsequently our processes have developed around the patient’s needs. Through multiple PDSA cycles we tested various screening techniques, 7 day Geriatrician input, nurse recruitment, remote monitoring and used patient feedback to guide further service development and improvement.

Results

We are an established frailty virtual ward with 20 beds.

Conclusion

The UHD Frailty VW has developed out of a need for an early supported discharge and admission avoidance for our older patients. Through multiple PDSA cycles, we have established a virtual model that we feel is providing safe, hospital level care for patients with acute medical presentations. We hope to expand through recruitment and funding with an aim to deliver excellent quality care to patients with frailty in their in their own home. Our ambition includes closely working with South West Ambulance Service for further admission avoidance and developing a home IV pathway.

Introduction Serum procalcitonin levels increase in response to bacterial infections and decrease with successful treatment. Procalcitonin can, therefore, inform decisions around antibiotic use. For adults with suspected infection, using procalcitonin to start antimicrobials is not advocated but serial testing is suggested to aid with the decision to discontinue therapy. Methods A retrospective study was performed of adults over the age of 80 years admitted on a medical ward whom had a serum procalcitonin completed between November 2022 and April 2023. Their electronic patient records were reviewed, with data collated and analysed using Microsoft Excel. Results Of 160 patients studied, median age was 85 with a median clinical frailty score of 6. The suspected sources of infection for the patients were chest (65%), unknown source (22.5%), urine (5%), cellulitis (3%), biliary (1.3%), osteomyelitis (1.25%), abdomen (0.63%) and infected haematoma (0.63%). Confirmed viral respiratory infection was present in 76 (47.5%) patients. Of all patients, only 62% were taking antibiotics at the time the procalcitonin was taken. Only 4 patients (2.5%) had serial procalcitonin testing (24-48 hours apart). Conclusion Procalcitonin was more likely to be used for suspected respiratory tract infection than other suspected infections. The majority of patient were taking antibiotics at the time the test was performed, which would indicate the tests being used to support a diagnosis of bacterial infection. Only a minority of patients (2.5%) had more than one procalcitonin result indicating that the clinical utility of this blood test to aid decision making in altering antimicrobial therapy was not occurring. Therefore, procalcitonin testing within an older adult population is being used in an inappropriate manner in the context of infection. Given a cost of £39.50 per test we anticipate that in its current use procalcitonin testing is not being used in a cost effective or clinically effective manner.