CQ - Clinical Effectiveness

Introduction: A large proportion of Morriston Hospital’s acute medical take consists of elderly patients admitted with falls. Postural hypotension is a cause of syncope and fall which contributes to morbidity, disability and death in cases of injury in the frail and elderly population¹. Hence, diagnosing and treating postural hypotension is crucial. It is important that the measurement of lying-standing blood pressure (LSBP) is consistent to ensure reliability of results as this would affect patients’ management. The aim of this project is to assess how postural hypotension is diagnosed in various clinical areas and assess the quality of detection.

Methods: We designed a survey to identify baseline variation in method and accuracy in measuring postural hypotension and compared it against National Audit in-patient Falls RCP “Falls and fragility Fracture Audit Programme”¹. The survey was distributed across acute and general clinical areas involving staff nurses, healthcare assistants and junior doctors. We collected and analysed the data, implemented outcomes and re-conducted the second PDSA. Grand Round presentation and worked-based tutorial sessions based on the above was our intervention.

Results: 57 staff members (acute medical, surgical wards and emergency department) participated. PDSA2 showed improvement of >25% of participants allowing patients to rest before initial BP measurement compared to PDSA1. There is an improvement of approximately 7% in repositioning the patient. 47% measured standing BP between 1-3mins at PDSA1 and this has doubled in PDSA2.

Conclusions: This study showed the importance in ensuring consistency in measuring LSBP. There was significant variation in timing and measurements which have impacted the results and interpretation of postural hypotension. The education sessions had positive impact and is also a sustainable practice.

References: 1. Royal College of Physicians, Falls and Fragility Prevention Programme. (FFFAP)

Introduction

Heart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol.

Methods

We developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management.


Results

ACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels.


Conclusions

Through introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.

Background Polypharmacy is a recognised burden on patients with frailty. Medication reviews as part of comprehensive geriatric assessment (CGA) ensure appropriate prescribing and minimise harms. This project aimed to develop and initiate a pharmacist delivered frailty medication review tool to enhance existing CGA within our acute frailty service. Methods A structured in-patient medication review tool was developed based on the STOPIT and STOPPFRAIL tools for patients with a clinical frailty score (CFS) of >4. Initial work tested this on 20 patients in our frailty ward evaluating usability and efficacy. A sample of patients seen by the acute frailty team were audited against this tool. Data was collected on falls risk medications, Anticholinergic Burden (ACB), medications stopped, medications to review and cost savings. On identifying the potential benefits, this tool was trialled by pharmacists on all elderly care wards with similar outcomes collected. Results. Twelve acute frailty inpatients’ CGAs were audited against the tool. Five had some evidence of a polypharmacy review but no FRAX or ACB scores were completed. 58% of patients were on 3 or more 'falls medications. Overall, 19 medications should have been stopped, 5 medications could have been reduced and 14 medications highlighted for review in primary care, with a potential cost saving of £956.35/year. After initiating pharmacist reviews with the tool, 34 of 34 patients had a review, 80% of FRAX scores were documented, ACB score was completed for all patients. All patients were taking medications that increased risk of falls (average 3.5/patient) with 16 patients on ≥4. Eighty-five medications were stopped, 10 medications reduced and 33 medications highlighted for review in primary care, with a cost saving of £2755.29/year. Conclusions This project developed a pharmacist delivered acute frailty polypharmacy tool which enhanced existing frailty medication reviews with potential cost savings.

Background: Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Our aims: improve delirium detection using the 4AT screening tool as a validated approach, Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Methodology: Plan Do Study Act (PDSA) methodology was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results: Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion: Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway.Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.

Introduction: Syncope is a common clinical problem with a lifetime prevalence of 20%.¹ Syncope shares clinical features with other disorders including seizures, metabolic disturbances and sleep disorders.² The assessment and management of syncope can be challenging.

The syncope service at the QEUH is run by geriatricians and cardiologists with an interest in syncope. Although MDTs are recognised key components in contemporary patient care in areas such as heart failure and cancer management, there is no guidance on MDT working in syncope management.^3/4 In November 2017, a syncope MDT was introduced at the QEUH involving cardiologists, geriatricians, a neurologist and cardiac physiologists. This in-person MDT occurs monthly with outcomes recorded on electronic medical records in addition to a database. The aim of this review was to understand the potential impact of the MDT on diagnostic yield and time to further investigation or management.

Method: A retrospective case note analysis was performed for patients reviewed at the Syncope MDT between November 2017 and December 2021.

Results: 103 patients were discussed with an average age of 64 years. The main reason for referral was cardiology specialist advice (65%), neurology specialist advice (19.4%) and complex case review (13.6%). After MDT discussion, the percentage of patients with unexplained TLoC reduced from 26.2% to 14.6% without requirement for additional investigations. 8.7% of patients were started on anti-epileptic medication prior to outpatient neurology review after a diagnosis of seizure disorder was established and 23.1% of patients were streamlined for pacemaker or ILR insertion.

Conclusion: Introduction of a syncope MDT reduces unexplained syncope rates in complex patients, streamlines investigations, reduces the need for multi-speciality outpatient reviews and allows earlier introduction of anti-epileptic medication for those with a new seizure disorder. These benefits improve the patient experience by reducing time to diagnosis and treatment.

1. Introduction

Delirium is a very common and treatable condition, and approximately 20-30% of older patients in medical wards in hospitals presented with delirium. Hence it is important to do timely assessment and correct management of delirium. This QIP was carried out to improve adherence to the trust’s clinical guideline for delirium and to improve the communication with patients, relatives, and primary care doctors.

2. Method

40 patients’ notes were randomly reviewed in the geriatric wards of the Addenbrooke’s hospital as baseline, then 20 patients’ notes were reviewed again after PDSA intervention. As an intervention, we introduced new discharge template to ensure better communication with the GP and we did departmental teaching session to promote awareness of delirium assessment and management. Patients on End-of-Life care were excluded.

3. Results

Compliance of delirium screening tests (4AT or CAM) markedly increased from 37.5% to 80% and documentation of delirium diagnosis in the discharge letter was improved from 70% to 100%. Doing cognitive assessment increased from 32.5% to 40% while performing confusion screening bloods raised from 57.5% to 75% and CXR from 85% to 90%. Taking collateral history was noted to be less complied with 75% after intervention from 85%. Performing urine culture/analysis dropped from 55% to 20%. Assessing delirium screening tool within 24 hours of admission, documenting delirium trigger factors and updating delirium in the problem lists were also analysed.

4. Conclusion

This QIP has shown improvement in delirium assessment and management, but some areas were identified for further progress. It is recommended to continue promoting awareness of delirium (diagnosis, assessment, investigations, and discharge letter template) within department.

Introduction

Back pain is a common presentation in general practice and a significant cause of morbidity in the elderly population. While the majority of cases are secondary to chronic degenerative changes, a number of sinister pathologies may prompt referral beyond primary care. This project assesses whether RADAR is the appropriate service to refer elderly patients with back pain through analysis of patient demographics and NICE guidance.

Methods

A total of 373 RADAR appointments from October 2020 until April 2022 were screened for record of “Back”/”Spinal” pain. Of the 104 appointments found, 41 patients were selected for further analysis with back pain as a significant presenting complaint. Data categories collected on each patient included comorbidity scoring using cumulative illness rating score (CIRS-G), NICE red flag symptoms, diagnoses, referral locations and waiting times between referral and visit.

Results

Patients had multiple comorbidities with a mean average of 6 organ systems affected by disease in addition to their back pain. Median average waiting times from referral to clinic was 2 days. All patients were over 50, satisfying NICE criteria for at least one cancer red flag. 65.8% also contained other NICE cancer red flags, with 14.6% of patients presenting with a combination of cancer and neurological red flag symptoms. Diagnoses included degenerative spinal disease (24.3%), vertebral fracture (22.0%), spinal stenosis (12.2%) and tumours (9.7%). 78% of patients avoided admission.

Conclusion

RADAR addresses elderly, comorbid patients with worrying yet cryptic sinister presentations in a holistic manner. Patients are seen far more quickly than a standard 2 week wait referral enabling rapid diagnosis and management, with the majority of patients being managed as an outpatient. It also enables complex older patients to be seen who do not fit urgent criteria for other existing back pain pathways.