CQ - Clinical Effectiveness

Background

Older people account for >40% of acute hospital admissions. Delivering alternatives to hospital admission and community-integrated care closer to home are increasing priorities. We aimed to develop an Emergency Department (ED) Frailty MDT to provide rapid assessment, early Comprehensive Geriatric Assessment (CGA), and reduce inpatient admission rates for frail older people.

Methods

From November 2023 to April 2024, a newly formed Royal Infirmary of Edinburgh ED Frailty team delivered CGA for older adults aged ≥75 (≥65 if care home resident) with Clinical Frailty Scores ≥5 in the ED. The ED Frailty Team consists of an Emergency Medicine Consultant with an interest in Frailty, a Consultant Geriatrician, two Frailty Advanced Nurse Practitioners, an Occupational Therapy Advanced Practitioner, Occupational Therapists and a HomeFirst Social worker. We prioritised patients who were most likely to achieve same-day discharge. We built on strong integrated community pathways including Hospital @ Home, Rapid Access Day Hospital, and Discharge2Assess. We evaluated efficacy and safety using readmission and mortality rates.

Results

We reviewed 344 patients and discharged 209/344 (60.7%) of frail older patients who were awaiting medical beds. We discharged 114/209 (54.5%) with Hospital @ Home; 49/209 (23.4%) with rapid access Day Hospital; 21/209 (10%) home with GP follow-up; 18/209 (8.6%) home with no follow-up; 5/209 (2.3%) home with other community follow-up; and 2/209 (1%) home with ambulatory care. Discharged patients had a 19.4% 30-day representation rate and a 5.8% 30-day mortality rate. Admissions from ED amongst Edinburgh city residents reduced from 60% to 43% in 75-85 year olds and from 52% to 46% in the 85+ age group.

Conclusion

ED Frailty MDTs can effectively deliver CGA in an Emergency Department setting, facilitating admission avoidance and delivery of integrated care closer to home that is effective and safe.

Introduction

Acute kidney injury (AKI) and hyponatraemia are common causes for hospital admission for frail, elderly people. Some patients could be managed at home using the Virtual Ward model, reducing risk of healthcare related adverse events. We aimed to show plausibility for this treatment model.

Methods

We produced guidance for managing patients with AKI/hyponatraemia on the Frailty Virtual Ward (FVW). We then collected data from patients treated for AKI (N=12) and hyponatraemia (sodium 126mmolL (N=9) and compared with a similar inpatient cohort (AKI N=14, hyponatraemia N=16). FVW patients received remote vital signs monitoring, telephone consultations and blood tests.

Results

AKI: FVW patients had creatinine rise 30-101%, and pre-renal AKI. They had fewer adverse events and none died. None required intravenous therapy or Renal input. Most fully recovered by discharge, whilst some established a new creatinine baseline, and had community follow-up. Inpatients had more severe AKI and frailty contributing to higher mortality and adverse events.

Hyponatraemia: FVW patients had asymptomatic/chronic moderately-severe hyponatraemia (sodium 120-126mmol/L). The most common cause was SIADH. They were less likely to undergo hyponatraemia investigations, but more likely to receive an explanation for hyponatraemia. They had fewer healthcare associated adverse events, readmissions, or deaths. Inpatients were more severely unwell. Three FVW patients received Endocrine opinions. Most FWV patients recovered (sodium >125mmol/L), except one who was admitted (sodium 120mmol/L) and one who had a follow-up plan for sodium 124mmol/L.

Conclusion

Mild AKI and moderately severe chronic/asymptomatic hyponatraemia can be managed under the Frailty Virtual Ward model with few adverse events compared with inpatient care. Underlying causes often require minimal medical intervention, such as medication review or fluid restriction. Specialist input is still possible. Work is needed to ensure FVW patients receive the same level of investigation as inpatients, and have a clear follow-up plan.

Introduction:

The Trauma Audit and Research Network report “Major Trauma in Older People” highlighted the need to recognise falls in older patients as a mechanism leading to potentially life-threatening injuries. Reasons behind falls can be equally serious and must be addressed concurrently. A Frail Trauma Pathway was introduced in the Emergency Department (ED) of a Major Trauma Centre (MTC) and subsequent audit revealed it was underutilised. We relaunched the Frail Trauma Pathway incorporating a checklist with the aim of improving patient care.

Method:

Retrospective data was collected over one week, including patients over 65 years with a Clinical Frailty Score ≥5, a low velocity trauma and multiple injuries or isolated head injury. We then updated the Frail Trauma Pathway incorporating a checklist, re-distributed it throughout the ED, sent staff email reminders and held teaching sessions. An educational “Advent Calendar” was circulated daily in December. Following this we repeated data collection.

Results:

20 patients pre and 18 post-intervention fitted inclusion criteria. There was a reduction in admission rates, improvement in ED senior doctor review for primary survey, increase in timely administration of Parkinson’s disease medication and venous thromboembolism assessment. However, there was a decline in other parameters measured. Due to the small patient cohort, it is difficult to assess if changes in results post-intervention are statistically significant.

Conclusion:

Several aspects of the frailty pathway showed improvement, notably admission reduction. This QIP demonstrates the difficulties of instigating change in an MTC, where numerous pathways result in ‘information overload’ and staff numbers are large and constantly changing. By focusing on the frail trauma checklist and incorporating it into our electronic records system we hope to improve compliance with the pathway. Further research on a national level is required to determine how to best care for this expanding cohort of patients.

Introduction: At Warrington hospital, a small district general, the orthogeriatric team adheres to national guidelines by conducting bone health assessments for inpatients with neck-of- femur (NOF) fractures and commencing suitable secondary prevention measures. However, there is a noticeable gap in secondary prevention for patients with non-NOF fractures requiring admission (such as tibial or humeral fractures). This predisposes patients to a future increased risk of disability, morbidity and mortality following discharge.

Method: A Quality Improvement initiative was launched, introducing various interventions such as educational sessions for doctors and pharmacists, E-learning modules and a flow chart poster guiding bone health assessment. Bone health teaching and all interventions were shared and at each doctors changeover inductions, to reinforce and sustain change.

Results: Preliminary data in January 2023 identified that 0% of patients with non-NOF fractures received secondary prevention and only 7% had bone health mentioned in the discharge summary. The results of teaching alone from May 2023, indicated improved clinician knowledge and confidence, but only modest clinical improvement. However, by December 2023, the combined interventions demonstrated significant progress; 92% of patients had bone health bloods performed, 57% of patients were identified as requiring treatment and 70% of those received appropriate management. Additionally, 82% of patients had bone health mentioned on their discharge summary.

Conclusion: The interventions enhanced the identification of patients requiring further investigation and management, underscoring the importance of a multimodal approach for tangible change. To further solidify these improvements, a checklist was created for medically fit patients and is utilised by the ward manager to guide the daily multidisciplinary board round. Furthermore, an order set within our ICE system was created to streamline requesting bone health blood tests. Whilst the outcomes of these interventions are outstanding and to be collected in May 2024, we anticipate greater improvements in outcomes.

Background

Evidence suggests 30-40% of patients with a neck of femur fracture (NOF#) develop oropharyngeal dysphagia (OPD) during the perioperative period.1-2 Our data, collected over two months, shows our Speech and Language Therapy Team (SLT) identified only 12% of cases. Given the importance of nutrition and medication in the perioperative period, early identification of OPD is critical. We launched a new dysphagia screening tool for all patients admitted to our hospital with a NOF#.

Methods

A retrospective review of patient notes allowed collection of data regarding age, hip injury, frailty score, comorbidities, and staff compliance with tool. Patients with a completed screening tool had outcomes recorded (low, medium, high risk), timeliness of referral to SLT if appropriate, and if OPD was present on assessment. Balancing measures included length of time kept nil by mouth. We completed four PDSA cycles over 5 months.

Results

During this period, 157 patients were admitted with a NOF# and 58 had a completed screening tool. By producing a training pack and expanding into the emergency department, compliance improved by 33% over the 4 cycles. 19 of the 58 patients with a completed screening tool had OPD; 79% had mild, 14% moderate and 7% severe. The screen was adjusted during each cycle improving the suitability of SLT referrals from a 25% identification rate in cycle 1 to 100% in cycle 4. No patients were kept nil by mouth.

Conclusions

The screening tool has increased OPD identification by 21%. However, this requires staff training and high compliance rates to be effective. Next steps include adding the tool to the NOF# proforma, creating a training pack for the wider MDT, and improving the specificity of the tool.

References

1. Love et al. Age and Ageing, 2013. 42(6):782-5. 2. Mateos-Nozal J et al. Age and Ageing, 2021. 28;50(4):1416-1421.

Background
An important modifiable risk factor associated with falling is the use of falls-risk inducing drugs (FRIDs). The World Falls Guidelines identified this as a key domain and recommended that a validated tool should be used in medication reviews targeted to falls prevention in older adults (1).
A proforma was created based on the STOPPFall Tool (2) to aid doctors in performing structured medication reviews in patients with falls. The research question was ‘in older adult inpatients with falls, does use of the STOPPFall screening tool increase deprescribing of FRIDs?’

Methods
The project was carried out on Geriatric Medicine wards. Patients were included if they were inpatients and had been admitted with a fall, had a history of recurrent falls and/or had an inpatient fall. FRID classes were identified using STOPPFall, and FRIDs prescribed on admission and discharge were determined using discharge letters. The primary outcome was the number of FRIDs stopped or dose reduced on discharge. An online survey assessed HCOP doctors’ confidence in deprescribing.

Results
102 patients were reviewed at baseline. The percentage of patients prescribed at least 1 FRID was reduced from 84.3% on admission to 65.7% on discharge. A total of 162 FRIDs were prescribed on admission; 73 (45.1%) of these were stopped and 12 (7.4%) were dose reduced.
19 prescribers responded to the online survey, and self-assessment of confidence in deprescribing averaged at 7.74 (1-10 - ‘not confident at all’ to ‘very confident’). Confidence increased with seniority; average confidence ranged from 6.5 in foundation doctors to 9.0 in consultants. 

Conclusion
52.5% of FRIDs prescribed in older adult inpatients with falls were stopped or reduced. Introduction of a STOPPFall proforma shows potential in encouraging deprescribing of FRIDs.

Introduction: In 2021, there were 38,839 adults >65 years living in Brighton and Hove, 13% of the local population, compared to 18% in England. However, 56% of emergency laparotomy procedures in the UK are in the > 65s. At the Royal Sussex County Hospital, a consultant geriatrician was appointed to lead a Frailty Liaison Service to respond to the needs of frail older patients undergoing general surgery (GS). No process was in place for the early identification of these patients, so intervention decisions were being made without GS Frailty Liaison input, potentially leading to unnecessary procedures and adverse outcomes such as deconditioning, which could potentially be reduced by timely clinical frailty scoring (CFS) and comprehensive geriatric assessment. This quality improvement project sought to identify all appropriate frail older patients over 70 within 1 week of admission to be seen by the Frailty Liaison Team on the general surgical ward.

Methods: We used the Model for Improvement and diagnostic tools (fishbone; stakeholder mapping; driver diagrams) and PDSA cycles to test the impact of junior doctor education on CFS scoring and awareness raising primarily through a newsletter; measured by the number of frailty scores given to patients pre-intervention, remeasured at 3 months after the initial data set. We captured feedback following the education sessions to assess usefulness.

Results and conclusion: Results showed 100% of participants felt more confident in identifying frailty in GS patients. The average number of days from admission to identification and first review decreased from 8.29 to 6.36, possibly reducing adverse outcomes. The proportion of appropriate referrals increased, releasing time to care for those who needed it most. Moving forward, we plan to promote the use of a CFS column on the handover list and continue our education sessions, incorporating real patient cases as requested in feedback.

Abstract Content - Introduction The Irish Hip Fracture Database (IHFD) is a national clinical audit managed by the National Office of Clinical Audit, that measures the quality of care and outcomes of hip fracture patients aged over 60 years. Annually there are 4000 hip fractures, the median age of a patient is 81 and 66% are female. 84% are admitted from home, 12% from a nursing home and 95% are caused by a low trauma fall. Methodology Data is collected through the Hospital In-patient Enquiry (HIPE) system. Care is measured against 7 clinical standards and two data quality standards and since the IHFD 2018 those have been linked to a Best Practice Tariff payment. The hospital with the highest compliance in the standards is awarded the ‘Golden Hip Award’. Results To date the IHFD has reported on 11 years of data. There have been statistically significant improvements in all standards between 2013-2023. In 2023 the data showed that 29% were admitted through ED within 4 hours, 75% had surgery within 48 hours, 4% developed a pressure injury, 83% were seen by geriatrician or Advanced Nurse Practitioner, 87% had bone health assessment, 83% specialist falls assessment and 87% were mobilised on the day after surgery (87%). Other data shows that 82% get a pre-op nerve block, 71% have a nutritional screen, 49% had a delirium screen day 1, 24% achieved independent mobility, 25% were discharged home directly, 38% went to rehabilitation and the median length of stay was 12 days. This data has led to the development of a national hip fracture bypass pathway, orthogeriatric services in each hospital and quality improvement is embedded in each hospital through their hip fracture governance committee. The IHFD is an exemplar of how to get care right for older adults. 

Introduction: Non-pharmacological de-escalation techniques are effective in managing agitated patients with delirium, yet are often overlooked in favour of pharmacological management. Sedatives are prescribed despite increased falls and extrapyramidal side effects. We used quality improvement methodology with the aim of reducing sedative use in older adults with delirium in an acute UK hospital. 

Methods: Utilising inpatient electronic prescribing records, we collected data on all patients aged ≥65 prescribed a sedative acutely during May 2022 in a 575-bedded acute district general hospital. Based on best-practice guidelines, formulated standards were: <10 cases of sedatives prescribed monthly, and in individuals with sedatives prescribed 100% screened for delirium, 90% have non-pharmacological delirium management methods trialled first, 100% have rationale for sedative prescription documented, and 100% of sedative prescriptions reviewed within 24 hours. Of cases prescribed a benzodiazepine, 100% should have contraindication to haloperidol documented. We conducted one Plan-Do-Study-Act (PDSA) cycle, focussing on hospital-wide education and the implementation of aide-memoires, and repeated our audit in May 2024. 

Results: Total sedatives prescribed declined significantly at re-audit (42 vs 72), with 28 individuals meeting inclusion criteria (vs 36 at baseline). Rates of delirium screening remained static (93%) while documentation of non-pharmacological methods improved by 16%. Where sedatives were used, 21% of prescriptions lacked documentation of rationale (vs 14% at baseline), no instances of contraindication to haloperidol were recorded (vs 6%), and only 68% of prescriptions were reviewed within 24 hours (vs 75%). Sedation for a scan reduced by the largest margin (18% of prescriptions vs 34%). 

Conclusions: The total number of sedatives prescribed decreased through education initiatives. Where prescribed, fewer standards were met, including fewer documentations of rationale and medication reviews. Future work will be to implement an electronic prescribing sedative care plan to encourage non-pharmacological de-escalation techniques prior to consideration of appropriate, time-limited sedative prescriptions.