CQ - Efficiency and Value for Money

Implementation of Advanced Clinical Practitioners as part of developing a ‘front door’ frailty service at Weston General Hospital. 

Weston General Hospital (WGH) site, within University Hospitals Bristol and Weston is developing its front door frailty services with the aim of becoming a centre of excellence for frailty. With up to 55% of admissions resulting in deconditioning (1) and geriatric medicine being the largest specialty in general medicine, there is a clear need for an advanced practitioners. 21.4% of Weston-Super-Mare’s population is aged >65 (2); suboptimal management of this demographic of people costs the NHS approximately 5.8 billion a year (3). The development of a front door frailty service will encompass the Geriatric Emergency Medicine (GEMS) service, Same Day Emergency Care (SDEC) and the Older Persons Assessment Unit (OPAU) to provide ‘front door’ patient-centred reviews of older patients.

The recruitment of two ACPs will play an integral part of the front door frailty service as they will cover each ‘front door’ area to ensure equity between locations. ED and SDEC is expanding to include specific frailty sections aligned with the SAMEDAY (4) and FRAIL (5) strategies enabling gold standard patient care and encompassing Comprehensive Geriatric Assessments (6).

Although the project is in its infancy, two tACP’s have been recruited, are in post and have been focusing on OPAU initially where the key performance indicator is the patients length of stay has been reduced. Figure 1 highlights the length of stay for patients who were reviewed on OPAU as part of their admission. It is to be noted that most patients were admitted for between 1 and 5 days.

The initial benefit is visible. As an aspiring centre of excellence for older adult care, the expansion of ED and SDEC are a priority to widen the capacity of the frailty service alongside further upskilling of staff through in-house teaching which is in process. Although there is not enough evidence to prove causation, the reduction in length of admission is noted in correlation with the tACP recruitment.

References:
1) British Geriatrics Society (2020) Sit up, get dressed and keep moving. Available from: https://www.bgs.org.uk/policy-and-media/%E2%80%98sit-up-get-dressed-and-keep-moving%E2%80%99 
2) Office for National Statistics (2021) Weston-Super-Mare. Available from: https://www.ons.gov.uk/visualisations/customprofiles/build/#E14001038 
3) British Geriatrics Society (2022) 8 key issues for older peoples health care. Available from: https://www.bgs.org.uk/InvestInCare 
4) NHS England (2024) SAMEDAY strategy. Available from: https://www.england.nhs.uk/long-read/sameday-strategy/ 
5) NHS England (2024) FRAIL strategy. Available from: https://www.england.nhs.uk/long-read/frail-strategy/ 
6) 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.

Introduction: Emergency departments are increasingly seeing more older adults living with frailty. Between 5% and 10% of all those attending EDs and 30% of acute medical units are older adults living with frailty. The consequences of this on the system manifests as increased patient length of stay, poorer patient experience and clinical outcomes, such as mortality and morbidity, are measurably worse.

Aim: The Acute Frailty team aimed to move and expand its resource to provide a service to frail, older adults in both the Acute Medical Unit and the Emergency Department. This aligns with a key National objective that recommends all type 1 EDs have 70 hours access to a Acute Frailty Service. The team are a liaison service and therefore work alongside the ED and medical teams.

Method: Quality improvement methodology was applied utilising multiple PDSA cycles. An incremental increase in provision of an Acute Frailty service within the ED. A stakeholder group was set up, KPIs were set. The team worked alongside the ED team to improve early CFS scoring for over 65s and embedded the Nationally agreed same day frailty criteria of CFS/4AT, EWS and the presence of a frailty syndrome to identify appropriate patients for the service within the ED. The CGA was initiated in parallel with the ED assessment.

Results: Time between admission and CGA decreased by an average of 30 hours, Time between CGA and dc from hospital decreased by an average of 1.6 days. The Acute Frailty team activity increased in the ED and decreased in the AMU and there was no increase in re-admission rate.

Conclusion: A CGA initiated in the Emergency Department had a positive impact on length of stay and the earlier dc did not increase readmission rates.

Introduction

East Kent Frailty H@H provides an alternative to admission to an acute hospital for frail people who are acutely unwell. Treatment at home is often the preferred option for people living with frailty and prevents some of the complications associated with hospitalisation such as environmental delirium, loss of function, isolation from usual contacts and infection. However, it was not known whether H@H also reduced the workload of the acute hospital. 

Method

Frail people who are acutely unwell are offered treatment in H@H instead of admission to an acute hospital. Referrals were made by community clinician eg Primary care, community nurse, Single point of access, paramedics etc. Interventions include CGA based assessment, point-of-care blood tests, ultrasound, urgent outpatient x-ray, CT and MRI scans, Intravenous therapies etc. Data were collected using electronic patient records for the community and hospital services. The data collection period was April 22-Dec 23 Patients of 69 and over were included. SPA charts were generated for results.

Results

Before the introduction of H@H the number of non-elective admissions plus the corridor activity closely matched the predicted number of admissions. Since the introduction of the H@H there is a significant drop in the number of non-elective admissions plus the corridor activity compared to predicted admissions. This number (~400 per month) is similar to the number admitted to H@H. 

Conclusion

H@H Data validated by NHS England has demonstrated that for every 1.03 patients treated 1 non-elective admission to the acute hospital was avoided.

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 Surgical interventions for older adults are increasing as the population ages. This demographic has a higher perioperative risk. Perioperative care through virtual wards (VWs) is a new service, allowing patients to remain at home. We compared operational and clinical metrics between two age groups (65+ and <65 years) receiving surgical inpatient care through a VW service to evaluate safety and efficacy.

Methods The VW service at Wrightington Wigan and Leigh (WWL) NHS Foundation Trust cared for patients at home using the Current Health (CH) platform for medical and surgical inpatients. Patients wore a device that transmitted vital signs, allowing VW staff to monitor real-time data. Patients in this service would have otherwise been hospitalized; bed days saved were estimated based on clinical judgment. De-identified and aggregated data from January 14, 2022, to January 31, 2024, were analysed to evaluate differences between older (65+ years) and younger (<65 years) patients. Fisher’s exact, t-tests and Mann-Whitney tests compared outcomes.

Results There were 75 younger patient admissions (mean age 47.5 ± 11.1 years, 57% female) and 30 older patient admissions (mean age 72.7 ± 6.0, 53% female). Both groups had a similar VW length of stay (mean 9.3, SD 5.4 days), bed days saved (median 7, IQR 5-7 days), and adherence (median 92%, IQR 87-96%). Median alarms per patient-day were 2.9 (IQR 1.4-5.4). In total, seven patients (6.7% of admissions) returned to the hospital. Of those, four patients presented to A&E out of hours from the VW (2 per group). There were no escalations to community services or adverse events.

Conclusion The VW service has successfully managed surgical inpatients from their homes, demonstrating good adherence, bed days saved, minimal hospital returns, and no adverse outcomes in both older and younger patients. There were no statistical differences in operational or clinical outcomes between groups.

Introduction Hospital-acquired deconditioning (HAD) leads to functional decline, extended hospital stays, increased fall risk, and higher readmission rates, resulting in a significant cost burden on the NHS. Preventing HAD through early and regular physical rehabilitation is crucial for improving patient outcomes and reducing healthcare costs. This Quality improvement project , conducted in a ward, aimed to evaluate and enhance the implementation and effectiveness of physical rehabilitation programs to prevent HAD. Method The project began with administering questionnaires to both staff and patients to assess their knowledge about HAD, its significance, and the importance of physical rehabilitation. Following the initial data collection, educational leaflets and teaching sessions were provided to both groups to raise awareness and improve understanding. Post-intervention data were collected using the same questionnaires to evaluate changes in awareness and practices. Results The post-intervention data showed significant improvements. Staff awareness of deconditioning risks increased (3.8x post-intervention vs. 1.4x pre-intervention), and the time spent mobilizing patients increased (4.7 hours per shift vs. 3.5 hours per shift). Patients showed a better understanding of the importance of sitting out (9.0 to 9.6/10) and engaging with physiotherapy (5.6 to 9.7/10), along with heightened awareness of the dangers of bed rest (8.5 to 9.5/10). These outcomes indicate that the intervention effectively enhanced both staff and patient awareness and practices regarding physical rehabilitation. Conclusion This intervention significantly improved staff and patient awareness, mobilization efforts, and understanding of rehabilitation's importance, effectively reducing the risk of HAD in the ward. Sustaining these improvements requires ongoing staff training, regular audits, and continuous education for both patients and healthcare providers. By preventing HAD, these efforts enhance patient outcomes and reduce the NHS's financial burden due to readmissions and prolonged hospital stays. The study highlights the crucial role of education and structured rehabilitation programs in combating hospital-acquired deconditioning.

Introduction: More than 50% of patients undergoing emergency general surgery are > 65
years. The Emergency Laparotomy and Frailty (ELF) study showed strong associations
between frailty (CFS ≥ 5) and increased mortality, risks of complications, and length of
hospital stay.

Methods: For nearly 10 years, we have had geriatric liaison input for general surgery and
colorectal patients in a tertiary teaching centre. This has transformed into a fully embedded
service involving consultant geriatrician, registrars and senior house offices, providing 3-day
a week medical input. NELA best practice tariff (BPT) April 2023 emphasises perioperative
Geriatric team involvement in frail patients aged 65 and above. The main metrics include
CFS, an MDT-based risk assessment, treatment escalation decision making and
perioperative geriatrician involvement.

Results: The service has previously demonstrated significant improvement in patient care
and holistic management including reducing the length of stay in hospital (average decrease
of 5.5 days). Simple job planning, use of current resources and efficiency can mean Trusts
can incorporate geriatricians with essential skills to improve patient management and reach
NELA BPT.

Conclusion: Changes in NELA BPT emphasise the importance of comprehensive geriatric
assessment in the management of older laparotomy patients. Introducing a
multidisciplinary geriatric liaison service into the general surgical department can achieve
high levels of compliance with national guidelines, resulting in better outcomes for patients
as well as financial benefits for Trusts. This is particularly pertinent given the financial
constraints on many services across the NHS, this is an opportunity to increase revenue and
build a geriatric workforce.

Background

Perioperative services must adapt to the needs of an increasingly older surgical population. Perioperative medicine for Older People undergoing Surgery (POPS) services integrate geriatric medicine teams into surgical pathways to provide quality and cost-effective medical care. This project aims to examine value-based outcomes (clinical and financial impact) of embedding a POPS service at a district general hospital.

Methods

Following a period of implementation on an acute Trauma and Orthopaedic (T&O) ward, a two-week pilot was undertaken. All emergency fragility fracture admissions aged over 65 years with Clinical Frailty Scores (CFS) of ≥5 were included. Patients with hip fractures were excluded. The POPS service provided medical consultation, medicine rationalisation, proactive treatment escalation planning and shared decision making, as well as leading multidisciplinary team meetings. Outcome metrics: geriatric medicine consults, medical emergency team (MET)/cardiac arrest calls, staff/patient satisfaction and clinical coding. The REDUCE trial cost calculator was used to estimate savings.

Results

35 patients were included, mean age 84 years, mean CFS score 7. Ward MET calls and cardiac arrest calls were reduced from a weekly average of 2.5 to 0, and weekly referrals to geriatric medicine reduced from 3 to 0. Experience-based design surveys identified thematic improvements relating to leadership, communication, dignity and respect. Improved quality of documentation resulted in the comorbidity score tariff increasing from £3325 to £6096 per patient. For services introduced by POPS including Comprehensive Geriatric Assessment and delirium assessments, the REDUCE trial cost calculator estimated an additional saving of £2926 per patient totalling hospital savings of £2 million per year (for an estimated 700 patients per year).

Conclusion

Implementation of a POPS service at a district general hospital can lead to cost savings, improved patient and staff experience, and improved clinical outcomes within a sustainable workforce model.

Introduction

Prevalence of malnutrition in care homes is high and oral nutritional supplements (ONS) often prescribed. Prescription and monitoring of ONS use varies considerably within residential settings. Locally dietetics are not funded to visit care homes and input is limited. This project explored dietetic ONS prescribing within care homes in one primary care network within Devon, recording the potential impact on costs.

Methods

All patients prescribed ONS (n=50) across 16 care homes were reviewed, alongside referrals to dietetics (n=39) from November 2022-March 2023. Supplements were switched to first-line formulary supplements where possible, stopped where unnecessary according to dietetic assessment, and a “food first” approach encouraged within homes. Cost of supplements prescribed pre-dietetic assessment, cost of new prescriptions, dietetic staff time and mileage costs were recorded. Supplement cost was calculated from the local formulary and staff cost from NHS oncosts.

Results

Patients seen represented 20% of all residents (89/436) within the 16 care homes, suggesting high suspected clinical need. Mean age was 90 years, ranging from 73-103 years. Female patients accounted for the majority (n=68). Addressing inappropriate prescribing saved £57.62 per day in prescriptions through stopping or changing ONS. Cost of dietetic staff time and milage totalled £3105.80 over the five-month period meaning that after 54 days the dietetic review service was saving money. Patients often preferred first line powder-based supplements, and these were either similar or more appropriate in nutrient content than initially prescribed ONS. For example, one patient affected by pressure ulcers was prescribed a fat emulsion supplement. It contained no protein or micronutrients to promote skin healing (cost £3.15) whilst first-line supplements provided macronutrient and micronutrient needs (cost 52p each and £1.04 total prescription).

Discussion

Dedicated dietetic input for care home residents appears to save costs on ONS prescribing whilst providing specialist nutritional expertise.

Effect of Early Intervention By Physiotherapy And Occupational Therapy On Older Inpatient Population

S Kotak¹, C Miller ²

¹ Senior Physiotherapist, University Hospitals of Leicester NHS Trust

²Consultant Geriatrician, University Hospitals of Leicester NHS Trust

Background: Currently, on inpatient medical wards at University Hospitals of Leicester NHS Trust, the first contact by therapy teams (physiotherapy and occupational therapy) is made when patients become medically optimised for discharge. This is due to a number of reasons such as staffing and resource shortages.

Aim: Analyse the effects of early intervention by therapy on patients on a geriatric medicine inpatient ward at a large, teaching hospital. It is hypothesised that earlier intervention can improve patient and service outcomes.

Method: A data sheet was created to capture baseline information including mobility/care needs prior to admission, date of initial contact by therapy, mobility/care on discharge, length of stay and discharge destination. Data was collected over two phases; initial therapy contact at point of patient being medically optimised for discharge, and then with the planned intervention of proactive therapy input early in a patient’s admission.

Results: The data shows an improvement in all measured patient outcomes in the intervention group. The average time from admission to therapy first contact reduced from 6.4 days to 2 days. The average length of stay reduced from 16.3 days to 7.4 days in the intervention group. 70% of patients left the hospital with a reduction in their mobility status in the control group, whereas only 32% of patients left with worse mobility in the intervention group. 41% of patients in the control group left with new or increased care provision compared to 36% in the intervention group. The data also showed that a higher proportion of patients were mobilised by ward staff and less patient were discharged to 24 hour care settings in the intervention group.

Conclusion: Therapy (with the help of the wider multi-disciplinary team) should proactively identify patients in need of therapy input as soon as safely possible during an inpatient journey. This shows that adopting this approach leads to improvements for both our patients and our service.