CQ - Clinical Effectiveness

Over a 6 month period, all 92 residents were offered the opportunity to have a ReSPECT conversation and 86 accepted the opportunity. In addition to families/legal representatives, advocacy services were used to enable equitable participation. Digitally-facilitated communication tools were also offered.

The vast majority responded positively, and a mutually agreed ReSPECT form was completed. These were stored electronically on NHS systems and shared with the care home in paper format.

However, even when offered all available information some residents chose not to have a ReSPECT placing limitations on their care. Some family members objected strongly to what was being suggested. Case-by-case analysis is ongoing on the impact on unscheduled care use.

Conclusions

Our experiences highlight both the benefits of structured FCP, but also reflect the practical challenges and concerns among the population and those who support them. Empowering staff and family members to advocate in the event of a health deterioration was a powerful consequence. Equally, respecting individual preferences necessitates avoiding blanket approaches. ReSPECT discussions often enabled more timely hospital discharge when an admission occurred. Practical challenges, including the lack of care home access to NHS digital systems can be overcome, but reflect structural barriers to information sharing which integrated systems should avoid.

Introduction 

“Getting it Right First Time – Geriatric Medicine” recommends the Clinical Frailty Scale (CFS) should be completed in patients aged 75+ on arrival in the Emergency Department (ED). Frailty services should focus on patients with a score of 5 or 6. The CFS has been shown to be easily completed in ED, however completion was variable.

 Methods

A Frailty Intervention Team (FIT) based in ED was developed at the Royal Lancaster Infirmary. Around the same time the CFS was embedded into the trust’s electronic Manchester Triage Tool (MTT-CFS) within the Electronic Patient Record, along with a separate CFS Clinical Data Capture form for the frailty team to complete (FIT-CFS). Initially FIT reviewed the notes of all patients 75+, irrespective of MTT-CFS, to identify those suitable for assessment. A FIT Advanced Care Practitioner developed a training program for triage nurses focused on quality completion. FIT moved to a dedicated Same Day Emergency Care unit (FIT SDEC) and changed inclusion criteria to age 75+, MTT-CFS 4+. 

Results 

Completion of MMT-CFS was assessed, with 35.64 patients aged 75+ attending a day, with 32.41 forms completed ( 11.21 scoring 1-3, 21.2 scoring 4+). Comparisons were carried out between MTT-CFS and FIT-CFS, showing that the MTT-CFS scored significantly lower than FIT-CFS (p<0.01) but MMT-CFS of 4+ scored comparably to FIT-CFS 5+ (p=0.2465) Following the move to FIT-SDEC, 38.06 patients aged 75+ attended ED daily, with 36.51 MMT-CFS completed, 8.97 scoring 1-3, 27.57 scoring 4+ (non significant trend for improvement compared to pre FIT-SDEC). 

Conclusion 

Education and embedding the CFS in the MTT led to good compliance in completion however accuracy was poor. A pragmatic approach was to use the MMT-CFS 4+ to identify FIT-CFS 5+. Changing the pathway to include the MMT-CFS of 4+ showed a non-significant trend for improved compliance

Introduction 

Delirium is a common presentation in frail, older, hospitalized patients (approximately 25% of admissions, with 50%+ on surgical wards), with a high mortality (approximately 22% during the hospital stay) with more associated, avoidable deaths than sepsis. Delirium is underdiagnosed. The National Institute for Health and Care Excellence (NICE) recommend using a validated screening tool on all patients at risk or showing evidence of delirium. “Getting it Right First Time, Geriatric Medicine” recommends all patients aged 75 or more, should be assessed using the 4AT tool (a validated delirium screening tool). 

Method 

A delirium pathway was developed in University Hospital Morecambe Bay Trust to embed these recommendations. A program of learning events was devised to target all grades of doctor along with a poster with the byline “Test it, Type it, Treat it”, included in multiple presentations and in trust screensavers. 

Results 

Before the education program, the Frailty Intervention Team (FIT) assessed patients for potential early discharge used the 4AT in 80.85% of patients with a diagnosis of delirium coded in 11.12%. In patients not seen by FIT (nFIT) the 4AT usage was 25.18%, with a delirium diagnosis rate of 9.11% Following the education program FIT 4AT usage was 96.12% with 18.69% diagnosed with delirium. The nFIT cohort completed 4AT in 33.63% of patients with 12.63% diagnosed with delirium. Analysis with Statistical Process Control charts showed that after the education program the use of 4AT by inpatient teams improved (p<0.05), but not in the Emergency Department (ED). 

Conclusion 

FIT assessed and diagnosed more patients than nFIT both before and after the intervention, with both groups showing improvement following the educational package. There is scope for improvement and further education events are planned, especially with ED, engagement of the ward “frailty champions” and possibly mandating the electronic 4AT.

Introduction
Diabetes is a major health concern in the United Kingdom, contributing to both microvascular complications like nephropathy, etinopathy, and neuropathy, and macrovascular issues such as atherosclerosis, which can lead to stroke, myocardial infarction, and peripheral vascular disease. Older  diabetic patients are particularly vulnerable due to frailty and multiple co-morbidities.
Improved prescribing and monitoring could enhance care for this population.
 

Methodology
We conducted a review of older diabetic patients (>75 years) by examining their drug charts and treatment regimes. Blood glucose levels, HbA1c levels, and fall risk assessments were evaluated to determine whether treatment targets were being met. Thirty-one patients met the inclusion criteria, and their treatment was categorized into three groups: insulin only, insulin with other hypoglycaemic agents, and hypoglycaemic agents alone. Diabetic specialist nurse (DSN) involvement was also reviewed.

Results
Of the 31 patients, 14 required a fall risk assessment during admission. Twenty-five patients had an HbA1c within
the target range. However, 29 patients had blood glucose levels outside the target range for their frailty. At discharge, 15 patients achieved the target blood glucose range, while 16 did not.

Conclusion
All patients had blood glucose checks within 48 hours of admission, but fewer than 50% had fall risk assessments. Despite nearly 70% receiving a comprehensive geriatric assessment, 94% had blood glucose levels outside the target range for their frailty. Around 20% had HbA1c levels above 69, and 50% did not meet target blood glucose at discharge. Only 25% were referred to DSNs. Improved glycaemic control may have been achieved with more DSN referrals.

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.

Frailty is prevalent within the local community of the hospital, with long waiting times in ED, the trust has established an FDF service, with a dedicated team based in ED to assess frailty patients, who would have been pended for admission, to ensure they are diverted to appropriate services and discharged to their normal place of residence, as per GRIFT, BGS guidelines and NHS England long term plan.

Method

Data was audited over a 7-month period, all patients who presented to the ED and pended for admission, who were aged over 65, with a Clinical frailty score over 4

Results

The service has seen a total of 1082 patients (8 patients a day), with an average age of 86, with an 84% discharge rate, back to the patient?s normal place of residence.

The most common presentations seen by the team were Falls, (28%), UTI (8%), CAP (5%).  The team noted that there was a low re-presentation to the service, 27 patients (2.54%) within 7 days.  The patients prior to the implementation of the service would have been admitted to the trust with and average length of stay of 17 days.

The potential savings to the. Trust was considered as part of the audit which compared the national and local data for length of stay and costs per day for admission and attendance to ED, which was estimated between £5,600,000 (local) - £6,000,000 (National), and if the same numbers of presentations were looked at over a 12-month period this is estimated as £9,600,000 (local) - £11,310,000 (National)

Conclusion

The service has now enabled the trust to achieve the CQUIN targets, all patients that present to FDF have a CGA started, the patients identified are less likely to be admitted with an overall estimated saving to the trust.

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

Introduction: Older people living with frailty are core users of health and social care. Services attuned to their needs afford better outcomes, help avoid harm and improve the experience for people living with frailty and their carers. These services may also help with flow and capacity. The Glasgow Royal Infirmary (GRI) Team aimed to advance services in order to enhance the quality and provision of care for older people with frailty. 

Methods: As part of the Health Improvement Scotland Focus on Frailty Programme, the GRI Team developed processes for early identification of people living with frailty, using an electronic Frailty Assessment Tool. Processes were designed to streamline patients with frailty to specialist care in order to initiate early Comprehensive Geriatric Assessment (CGA). A Frailty Assessment Proforma was created to promptly identify the priorities, concerns and goals of patients and carers and to gather key collateral information swiftly. Daily CGA Huddles were commenced, which include participants from various acute and community health and social care services. Work is now being done to further develop the Acute Frailty Assessment Area. Rapid Access appointments at the Assessment and Rehabilitation Centres, to support early discharge, have been initiated. 

Results: There has been an improvement in frailty identification. 74% patients 75 years and over, admitted through the Acute Medical Receiving Unit, are being screened for frailty. The proportion of patients with frailty in our Acute Frailty Assessment Area has increased. Collaborative and integrated working has been enhanced, particularly through the CGA Huddles. Length of stay for people with frailty has reduced by 3 days and this has not been coupled with an increase in readmissions at 7 and 30 days. 

Conclusion: Frailty attuned acute services help patients receive person-centred, specialist care. Time in hospital can be reduced, which can contribute to improving flow and capacity.

Background: This Quality Improvement project was undertaken at University Hospitals of Derby and Burton. The team comprised a speciality doctor and improvement fellow previously employed as an operating department practitioner (ODP). Senior sponsors comprised a consultant geriatrician and Divisional Nurse Director.

Introduction: Delirium impacts up to 40% of older hospital inpatients and is associated with mortality, institutionalisation and deconditioning. We aimed to increase diagnosis and management of delirium to reduce complications, length of stay and readmissions.

Method: An initial audit measured delirium prevalence using 4AT in patients aged >65 on arrival to the Surgical Assessment Unit (SAU) and 48 hours later. Staff answered questionnaires relating to delirium awareness and screening. A series of plan-do-study-act (PDSA) cycles then tested small-scale changes to improve delirium practice on SAU. We developed, implemented, and iteratively improved 4AT and delirium sections in care plans. We developed and delivered teaching and supporting materials around the PINCHME acronym to SAU staff. 4AT and delirium care plan completion rates were monitored. Staff knowledge before and after teaching was tested.

Results: 36% of 111 consecutive emergency surgical admissions audited were likely to have delirium based on 4AT. 5% were coded as having delirium and 19% had delirium documented in their notes. Average length of stay was 7, 10 and 5.3 days for the whole cohort, those with and without delirium respectively. These data convinced SAU managers of need for change. Improvements around 4AT screening were associated with a rise in average 4AT completion rate from 40% to 64%. Completion rates were highly dependent on the improvement team, rising as high as 100% after interventions but falling back between these. Knowledge scores improved from 43% to 92% following teaching.

Conclusion: Improvements correlated with higher delirium screening and detection rates, and staff knowledge improved. Interventions were not sustained. We are now exploring delirium champions as a way of sustaining change.

INTRODUCTION:

University Hospital Southampton (UHS) and Saints Foundation (SF) have partnered to test and deliver rehabilitation to hospitalised older adults via a non-registered Exercise Practitioner (EP) to promote physical activity (PA) and address hospital associated deconditioning. Now in its third phase, the project has evolved in response to patient and staff feedback. It delivers regular gym-based exercise classes and additional interventions, which have maintained or improved patients’ dependency levels on discharge.

METHODOLOGY:

From September 2023, the EP has delivered daily gym-based group interventions as well as 1:1 rehabilitation to hospitalised older adults. In addition, exercise prescription education for staff and signposting to community-based interventions is provided. Interventions take place in the acute therapy gym or wards.

RESULTS:

Between October 2023 and February 2024, the EP reviewed 115 patients, with a mean age of 86yrs. 90 (78%) underwent group-based intervention whereas 25 (22%) received 1:1 input. 100 (87%) patients maintained or improved their predicted to actual discharge destination, compared to 13 (11%) whose physical capability declined and 2 (2%) who died. 20 (17%) were readmitted within 30 days of discharge. Elderly Mobility Scores (EMS) improved from a mean of 13.42 to 13.97. Most patients were reviewed twice or more. Most patients (79% after 2 interventions) maintained a 4m gait speed score of >0.8m/s. Patient satisfaction and confidence in function rated high.

CONCLUSION:

Intervention via a non-registered EP continues to have a positive impact on older adults’ ability to maintain or improve function during an acute hospital stay. Factors such as outbreaks of infectious illness, staff absence and vacancies and high patient acuity prevent more frequent EP led intervention. Although overall strength and functional gains are limited, patient confidence in function remains high. Our future aim is to expand the project across UHS and bridge the gap to community rehabilitation services.