Clinical Quality

East Kent has 38,101 people over 80 years, 39, 021 living with moderate or severe frailty and 304 care homes. This population have high levels of unplanned admissions which can put them at risk of long hospital stays, reduced mobility and increased delirium.

East Kent Ambulance services (SECAMB), Acute hospitals (EKHUFT) and Community Services (KCHFT) have piloted a single-point of access consisting of an ED consultant, community frailty clinician, Urgent care senior nurse, advanced paramedic practitioners. They sit together at the ambulance bases, 10am-6pm Monday to Fridays. This team reviews all patients awaiting ambulances to assess whether there are alternative services to ED which would meet the individuals' needs.

Method

The MDT assesses all patients listed as awaiting an emergency ambulance. Clinical records can be accessed from all services including GP records. If patients would benefit from treatment by alternative services, rather than conveyance, the paramedics are asked to call the MDT. This allows clinical assessment, history and investigation results to be taken into account in planning care. Patients and Carers are involved in deciding how they would like to receive medical care via a video or phone link with clinicians.

Results

Conveyance to hospital pre pilot - 62% post pilot less than 50%

Ashford catchment: admissions save weekly 27.3, bed days saved weekly 179.2

Thanet Catchment: admissions saved weekly 19.1, bed days save weekly 106.9

Conclusion

Many people can be treated effectively without conveyance to hospital through pre-hospital triage, consultation and planning by senior clinicians in a multi-disciplinary team.

Introduction

Incidents and complains are an important form of learning for healthcare institutions. The learning is often shared via huddles, handovers, emails and learning alert bulletins. In the older persons medicine (OPM) department at James Cook University Hospital, we identified that there may be a role for whole team in-situ sim to not only facilitate learning around important and highly relevant topics but also improve the education provision for nurses and healthcare assistants who have less access to education compared to their doctor colleagues and improve whole team communication.

Methods

Initially a working group including a consultant, advanced clinical practitioner, SIM training facilitator, liaison psychiatry nurse, teaching fellow and ward manager was set up to organise a pilot session. Following the success of this session the training was initially organised to be monthly, arranged by the advanced clinical practitioners, facilitated by the sim technicians. The ward managers fully supported the training and facilitated the attendance of the ward staff. The clinical director identified topics for learning from incidents and complaints and there was support from the OPM registrars and teaching fellow. It quickly became so popular amongst staff that the session frequency was increased first to fortnightly and is now run weekly.

Results

The feedback was excellent. From the attendees, to the sim trainers who said that the OPM department had been the most enthusiastic about ward-based training. The anonymised and entirely positive feedback from the sessions was that they were interesting, informative, and relevant to clinical practice.

Conclusion

Using in-situ simulation training on the older persons medicine wards to share learning from incidents and complaints is not only practical, but incredibly well received by staff of all disciplines.

 1. Introduction. Advance care planning (ACP) allows patients to prepare for their future and articulate their care preferences. Despite it being a major policy focus there are significant barriers that affect ACP delivery, including paperwork burden and information sharing difficulties. Electronic Health Records (EHRs) are fundamental to how ACP conversations are recorded and communicated. We present data from inpatient geriatric medicine unit during a change in trust-wide EHR (namely, EPIC) and a contemporaneous ACP educational drive.

2. Methods. Clinical notes for all patients on three geriatric wards were analysed on a single day in July 2023 and April 2024. EPIC was rolled out in October 2023.Demographics including age, admission and discharge destination, clinical frailty score (CFS) and social circumstances were retrieved and notes were reviewed for ACP decisions. Teaching took the form of regular small group seminars for ward teams, and departmental sessions to build confidence and optimise ACP documentation using the new software.

3. Results. 83 and 85 patients were identified in July 23 and April 24 respectively. Demographic data were similar between groups including mean age (82; 84), CFS of ≥6 (67%; 61%). In July cohort, one patient had an ACP . In April, 20 patients had an ACP and 8 patients had a Universal Care Plan.

4. Conclusion(s). Significant improvements were noted in ACP delivery and documentation. Following the launch of EPIC alongside targeted teaching to staff members, the proportion of patients with an ACP increased by 23% and UCP by 10% over a 9-month period. EPIC includes improved ability to search for relevant information and dedicated space to document ACP plans, both of which may have contributed to these results. Future work aims to expand this learning into GSTT community services and across other trusts, capitalising on the potential of improved EHR technology in the NHS. 

Introduction

16% of adults over the age of 75 years old have a diabetes diagnosis¹ and 1 in 6 hospital beds in the UK is occupied by someone with diabetes². Keeping diabetic patients safe during hospital stays is a priority, and in 2023 the Joint British Diabetes Societies (JBDS-IP) published guidance on managing Diabetes in Frail inpatients³. An audit at our hospital later that year found that 70% of Capillary Blood Glucose (CBG) testing was non-compliant with guidelines resulting in unnecessary patient intervention, use of staff time and consumption of non-recyclable resources. The main aim of our project was to improve compliance with these guidelines and establish potential time and cost saving resulting from this.

Method

Focus on medical education with teaching sessions, information cards for lanyards and prompt posters around the inpatient ward areas. Worked with electronic prescribing team to establish use of an order-set for CBG testing to allow medical team to accurately communicate with nursing colleagues.  In addition, engaged nursing staff via ward bulletins and observed CBG testing on ward.  

Results

There was a reduction in CBG frequency for all diabetic patients of 27.9%. We identified that those patients with diet-controlled diabetes were commonly over tested, and in this sub-group the number of CBG tests performed was reduced by 51.9%. Average time for CBG testing was 147 seconds with anticipated cost savings from staff time and equipment use.

Conclusions

The use of default four times a day CBG testing results in unnecessary intervention in our frail inpatients. Through education and use of electronic systems we can reduce these interventions based on national guidelines, but more work needs to be done. Reducing CBG testing reduces use of healthcare assistant time, costly non-recyclable materials and overall reduces unnecessary patient intervention.

References

1. NHS England (2023) Health Survey for England, 2021 Part 2 < https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-diabetes#:~:text=Prevalence%20of%20doctor%2Ddiagnosed%20diabetes%2C%20by%20age%20and%20sex&text=Prevalence%20increased%20with%20age%2C%20from,adults%20aged%2075%20and%20over.> Accessed 8/11/24
2. Watts.E, Rayman. G (2018) Diabetes UK: Making Hospitals safe for people with diabetes. Available at < https://www.diabetes.org.uk/resources-s3/2018-12/Making%20Hospitals%20safe%20for%20people%20with%20diabetes_FINAL%20%28002%29.pd> Accessed 24/07/2024
3. JPDS-IP 2023: Inpatient care of the Frail Older Adult with Diabetes. Available at <JBDS_15_Inpatient_Care_of_the Frail_Older_Adult_with_Diabetes_with_QR_code_February_2023.pdf (abcd.care)>

Introduction: Sarcopenia is common in hospitalised older people and is associated with unfavourable health consequences. Identification of sarcopenia risk with the offer of resistance exercise are key to improving outcomes and recommended in clinical practice guidelines.

Previously, there was no sarcopenia testing on Older People’s Medicine (OPM) wards highlighting a need for local improvement. This project seeks to translate and implement best practice to determine the possibility for physiotherapy staff working in OPM to offer a sarcopenia intervention as part of discharge planning. Improving sarcopenia care can help an ageing population maintain health and independence.

Project aim: Within 3 months, to achieve a 50% increase in the number of patients offered sarcopenia assessment.

Methods: Using the ‘Plan-Do-Study-Act’ approach, a sarcopenia assessment and therapy intervention was developed and introduced as part of the discharge process on an OPM ward. Measures: The weekly number of patients with a documented offer for sarcopenia assessment was collected over 13 weeks and evaluated on a run chart. Cohort data were also recorded and described using descriptive statistics.

Results: At baseline, 0 patients were offered sarcopenia assessment, this improved to 59/87 (68%). The mean age was 82 years (range 66-97) and 53 (90%) consented to be tested for sarcopenia; grip strength was measured in 51 (96%) and standardised 5*sit-to-stand in 5 (9%), with the latter typically not measured without upper limb support. There was a high prevalence of probable sarcopenia, (49 [92%]); 47 (96%) of those engaged with the exercise plan offered.

Conclusions: Physiotherapy staff can identify sarcopenia and offer therapy, as part of discharge planning of older people from hospital. Resources are necessary for sustainable and scalable application. Implementation could help older people to recondition after hospitalisation and improve clinical outcomes, benefiting patients and the healthcare system.

Introduction

Vertebral fragility fractures (VFFs) are the most prevalent form of osteoporotic fracture, with an incidence of >20% in women >70 years old. While often clinically silent in isolation, VFFs are associated with future osteoporotic fractures, decreased quality of life and an 8-fold increase in age-adjusted mortality.

Radiologists may facilitate early diagnosis of VFFs, allowing for more cost-effective intervention with greater patient outcomes. However, a national audit in 2019 demonstrated widespread failings in the radiological recognition and reporting of VFFs, according to criteria outlined by the Royal Osteoporosis Society. Crucially, only 2% of reports in patients with moderate-severe VFFs recommended referral to Fracture Liaison Services (FLS), compared to the national target of 100%.

Here, we evaluate local VFF recognition and reporting performance, relative to the Royal College of Radiologists (RCR) targets.

Methods:

Single-centre retrospective analysis of all CT thorax, abdomen and pelvis scans in >50-year-olds. Two cycles were completed, with implementation of educational posters and a quick-code reporting alert between cycles. The proportion of reports meeting best practice criteria were measured.

The criteria included: assessment of bony integrity (target 100%), correct identification of moderate-severe VFFs (target 90%), use of correct terminology in reports (target 100%), referral of moderate-severe VFFs to the FLS (target 100%).

Results:

Bony integrity was assessed in 100% in both cycles. Identification of moderate-severe VFFs improved from 37% to 64% between cycles. Correct terminology was used in 63% and 56% of reports in the first and second cycles respectively. 0% of patients were recommended for FLS referral in both cycles.

Conclusion:

This audit demonstrates local shortcomings in VFF recognition and reporting. While there was an improvement in identification of VFFs between cycles, RCR targets were still not met post-intervention. This reflects a nation-wide issue in the under-diagnosis.

Introduction

Global estimates indicate over half of individuals aged 85 and older are frail (1), costing the UK healthcare system approximately £5.8 billion annually(2). Locally, over 6,500 patients aged 65+ are admitted to West Middlesex University Hospital (WMUH) every six months. The proposed frailty team aims to implement early comprehensive geriatric assessments (CGAs) through a multidisciplinary approach. Timely CGAs can increase the likelihood of patients remaining in their own homes at 6 and 12 months(3), reduce length of stay (LoS), and lower healthcare costs, contingent upon available community infrastructure. WMUH serves multiple boroughs, necessitating coordination with various community services to support discharges. These services include Hospital at Home and Integrated Care Response Services.

Objective

To gather baseline data on frail patients admitted before the introduction of a 'Front Door Frailty' team.

Methods

Data were collected for all medical admissions to WMUH from 1st to 14th July 2022, including:

• Patients aged ≥65 years

• Numbers with a frailty syndrome

• Clinical Frailty Score (CFS)

• Admissions in the previous year

• Length of stay

• Mortality at 5, 9, and 12 months

Results

From 459 admissions over 2 weeks, 278 patients (61%) were ≥65 years old. Among these patients:

• 54% had a CFS ≥ 6

• 44% presented with a frailty syndrome

• 83%, 72%, and 67% were alive at 5, 9, and 12 months respectively

• Mean LoS was 11.0 days

• 37% had ≥1 admission in the following 6 months

• Of those with a CFS ≥ 6, 63% had ≥1 admission in the previous year

Conclusions

A high percentage of acute admissions at our hospital are characterised by frailty. Through early identification, multidisciplinary management, and improved links with local community services, the new acute frailty team aims to decrease length of stay and improve patient experience.

Telemedicine uses communications technology for remote healthcare. Unreadiness includes difficulties with hearing, speaking, cognitive issues, vision problems, lack of internet-enabled devices, or no recent use of digital communication. Telehealth can enhance access and convenience, especially for rural patients, but faces challenges such as technology issues and impacts on patient-provider relationships, examination quality, care quality, and patient satisfaction. The COVID-19 pandemic has accelerated telemedicine adoption to protect medical personnel and patients, with significant promotion of video visits for home-based care.

This study aims to evaluate telemedicine unreadiness in an older, frail population at a geriatric clinic. Patients were contacted from February 1st to March 14th, 2021, during Ireland's COVID-19 "third wave," with up to three contact attempts made. Statistical analysis was conducted using STATA 14. 84 patients attended the Geriatric clinic, with 33 excluded for various reasons, leaving 51 participants (67%) who completed the survey. The mean age was 81.7 years, with 49% female. Most referrals were for cognitive issues (59%), followed by BPSD (13%), weight loss (9%), and falls (7%). The median Clinical Frailty Score was 4, indicating moderate to severe frailty. Regarding mobility, 77% were independent, 21% used an aid, and 2% were immobile. Cognitive assessments revealed 25% had normal cognition, 18% had mild impairment, and 57% had dementia.

Only 10% of patients were ideal for teleconsultations, while 90% faced significant barriers, such as environmental impairments (26), sensory impairments (2), and both (18). Additionally, 25% lacked computer, and only 10% used the internet regularly. Despite 59% having family assistance, overall, 82% had some form of environmental impairment. Sensory impairments were common, with 29% using hearing aids but 37% still experiencing issues. Visual impairments were better managed, with 76% wearing glasses.

Telemedicine adoption has accelerated due to COVID-19, but significant barriers for geriatric patients highlight the need for better support.

Abstract Content - Introduction

We wished to improve the knowledge of care home staff in Leeds in identifying frailty and managing frailty related problems

Method

We developed a frailty education course (www.leedsfrailtyeducation.co.uk) which was then refined and modified to target care home staff. We engaged key stakeholders at the council and the ICB to help develop and promote the course. The course was delivered across 4 venues in Leeds by geriatricians, a pharmacist and a community nurse.

Results

We had 128 attendees across the four days. From the feedback taken immediately after the study day (n=69): -100% of attendees found that the content was useful and well delivered. -97% of attendees improved their knowledge of frailty and 100% improved knowledge of CGA. -CGA, assessing delirium and positive approaches to managing dementia were the 3 most common things attendees intended to take away for their future practice. From the follow-up feedback (n=19): - 95% (18/19) ‘extremely agree’ with the statements “Attending the training day has improved my understanding of frailty” and “I would recommend my colleagues attend this course” -42% (8/19) have implemented frailty assessments as part of standard care in some form Attendees also valued the multi-sector, multi-professional expert presenters alongside the opportunity to meet and interact in-person.

Conclusion(s)

A dedicated study day for care home staff was well received by attendees and feedback received demonstrated self-reported lasting change to practice. Key enablers to the success of the course were: the reputation of the course locally which had been piloted and delivered in different formats previously, tailoring the material to the audience, and delivering the course in several different locations. More regular frailty teaching days can be implemented to capture more care home staff and ultimately improve care for residents.

Introduction: Hospital-Associated Deconditioning Syndrome (HADS) can lead to prolonged length of stay (LOS). Evidence indicates that early intervention may reduce HADS and LOS. (British Geriatrics Society, Deconditioning, Healthy Ageing, 11 May 2017, Dr Amit Arora, NHS England, 24 January 2017, Time to Move). The Acute Frailty Team (AFT) at Eastbourne District General Hospital piloted a Frailty Early Discharge Scheme (FEDS) in the Frailty Unit for 8 weeks between May-June 2023 with the aim of providing early mobilisation and discharge planning to reduce LOS.

Methods: Patients were admitted to either FEDS or Non-FEDS (NFEDS) beds depending on the bed availability. FEDS patients were provided with additional early assessments and interventions including discharge plans from day 1 after admission, offering early, continuous and active mobilisation by a trained FEDS team of a registered Nurse and Health Care Assistant. The FEDS team worked in conjunction with the medical team to actively promote discharge planning while patients were still receiving acute medical treatment, before patients becoming medically fit for discharge (MFFD). NFEDS followed the standard care plan, usually initiated after patients were declared MFFD. Data was collected for all patients, comparing FEDS 12 beds with NFEDS 12 beds.

Results: 83 patients were enrolled 45 FEDS, 38 NFEDS Discharged within 48hrs FEDS 11.11%, NFEDS 2.63% Discharged within 7 days FEDS 44.44%, NFEDS 28.94% LOS 8.07 days FEDS, 11.36 days NFEDS (30 day trim point).

Conclusions: 1. Increased rate of discharge within 48 hrs and 7 days. 2. Reduced LOS within 30 days. 3. The benefit is mostly noticed within the first 7 days indicating the need to apply the intervention early 4. The adoption of a FEDS-project in all frailty wards could be beneficial for elderly patients.