CQ - Improved Access to Service

University Hospital Plymouth (UHP) provides secondary care to 475,000 people with a wider population of almost 2,000,000 people who can access its specialist services.

COVID pandemic had a significant impact of the outpatient list within the UHP NHS Trust and demonstrated that previously well-established model of Falls clinic was no longer fit for purpose. This resulted in a significant delay in waiting times for patients awaiting a specialist review.

A new model was designed to address issues and reduce waiting times for patients with Falls in the catchment area. The Pilot Multidisciplinary Team (MDT) Falls Clinic was introduced in July 2022 where patients are seen by a Falls Specialist Nurse, Advanced Pharmacist and Advanced Physiotherapist on the same day. All patients then are discussed at weekly virtual MDT meeting with Consultant Geriatrician where a decision is made whether patient could be discharged back to the Primary Care.

117 out of 149 patients have been booked into clinic. Only 57 patients (47%) were referred forward to the 1st Medical clinic. Out of 57 patients 31 have been seen and 10 were discharged back to GP following clinic attendance.

60 patients (51%) were discharged following review at the Pilot MDT Falls Clinic. 7 patients were re-admitted within the next 6 months after been discharged from the Pilot MDT Falls clinic. However, none of the admissions were related to Falls.

The waiting times were reduced by 4 months.

Funding was secured to run the clinic for the 12 months and the next step is to expand the team by employing another Advanced Pharmacist and Physiotherapist. The Pilot MDT Falls clinic demonstrated that a new approach is beneficial to patients. It also supports development of the skills for all team members though sharing expertise, knowledge and skills, and building team rapport.

 Introduction In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes ( 1, 2). Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time. Method An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention. Results There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were > 64 with high CFS and 70% over 80. A 3 month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention. Conclusion Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement. (3

Introduction

It is well recognized frailty is increasing amongst the population and can impact on outcomes for patients when admitted to hospital.  Frail older adults are more vulnerable to developing complications form continued hospital admissions. National recommendations by GIRFT indicate CFS scores ought to be documented in the Emergency Department (ED) to facilitate early recognition of frailty and stream patient to the appropriate pathway and clinician. The aim of this is to ensure the correct Clinician reviews the frailer adult in the most appropriate setting and thereby reduce risk of deterioration and patient harm.  In October 2022. Bolton NHS Trust created a dedicated frailty unit staffed by Geriatricians for older frail adults.  Therefore, a method of identifying and streaming frailer older adults is crucial to effectiveness of the unit. This was embedded into Electronic Patient Record (EPR) system.

Methods

PDSA cycles were implemented. A retrospective audit was performed prior to the implementation of the CFS documentation.

A robust education programme was introduced to all clinical staff in the Emergency Department. Online modules were also available. A second audit as part of PDSA cycle was then performed to assess the intervention.

Results

Pre-intervention and EPR documentation tool only 11% of patients had CFS score. Following the intervention, 88% of medical staff included the CFS score in their assessment prior to a Frailty team referral and review. The frailty team have observed an increase in referrals.

Conclusions

Early recognition and documentation has enabled improved streaming and review of the correct patients to the frailty unit.  This has enabled Gold Standard of Comprehensive Geriatric Assessment for frailer adults to be completed.  Further PDSA cycles to the effectiveness of the unit are ongoing. Initial data indicates with correct identification and recognition of frailty; the average length of stay has reduced.

Background: Geriatrician assessment is associated with improved clinical outcomes for seriously injured older adults. In 2021, the Queen Elizabeth University Hospital opened a dedicated Major Trauma (MT) ward for adults with significant polytrauma. Four Geriatrician sessions were introduced per week, establishing the ‘Frail-T' service. Our aim was to provide specialist review to frail trauma patients within 72 hours of admission. Methods: All patients reviewed were prospectively added to a secure database. Patients >65 years on the MT ward were screened for frailty and reviewed if Clinical Frailty Score (CFS) >4. If medical issues arose in patients CFS ≤4, input was provided upon request. Reviews on Critical Care and surgical wards were provided on referral. Qualitative data collected after service implementation assessed staff satisfaction and service improvements. Our database was compared to analysis from 2019 and cross-referenced with the Scottish Trauma Audit Group (STAG) figures to estimate unmet needs. Results: 220 patients were reviewed between September 2021 and August 2022. Median age was 81. 33.2% of patients were frail. 45% received delirium management intervention. Compared to 2019, median time to Geriatrician input improved in polytrauma patients (5 to 3 days), but head and isolated chest injuries (usually on surgical/medical wards) experienced delays (6 and 5 days respectively). 332 additional patients aged >65 on the STAG database were identified; Geriatrician review was recorded in 38% (n=126). Qualitative feedback deemed the service highly accessible (88%, n=15) with themes of improvement: greater service promotion and educational input. Conclusions: Only a third of patients reviewed by the team were frail, reflecting requirement for medical expertise in trauma care. Cohorting polytrauma in a dedicated ward with proactive screening has improved time to Geriatrician review. Delays remain for isolated head and chest wall injuries. Improvement work will focus on greater identification of patients beyond the MT ward.

Introduction: With the anticipated rise in the annual number of dementia cases in Cardiff and the Vale of Glamorgan (C&V), improvements in dementia diagnosis rates are essential. However, barriers to accessing support still exist, precipitating delays in diagnosis and establishing appropriate interventions. This article aims to highlight potential barriers patients attending the C&V Memory Assessment Service (MAS) may face, as well as ascertain possible delays within diagnostic pathways of cognitively impaired patients.

Methodology: Demographic and primary data analysis was undertaken using a questionnaire. Data was collected in an outpatient setting at two hospitals in C&V. WCP supplemented additional information on patient referrals and memory appointments. Subsequent findings were reviewed.

Results: The C&V MAS received satisfactory feedback from 87.2% of patients, with negative comments surrounding the lack of awareness of support available in the community. 34.5% (n=19)of participants faced difficulties in accessing support. Barriers included stigma, the Covid-19 pandemic, language, delayed GP referrals to the MAS, transport, and parking. The survey discovered an underrepresentation of ethnic minority dementia patients attending the C&V MAS. 94.5% (n=52) of patients were of Caucasian ethnicity. The remaining patients (5.5%) who were from ethnic minority backgrounds reported facing language and/or stigma barriers in obtaining support. The average duration for patients to present to primary care where applicable was 6-12 months from cognitive symptom recognition.

Conclusion: It is evident that the data obtained is not an accurate representation of the overall C&V dementia population, due to sample bias. Educational and strategic interventions need to be implemented to target this issue as well as barriers identified to accessing care.

BACKGROUND

A multidisciplinary (MDT) approach is increasingly recommended as the standard of care for patients with Parkinson’s disease (PD). Research has shown that an MDT approach can lead to better quality of life and improve patient outcomes in a number of domains depending on set up. We established an MDT clinic with a PD specialist physiotherapist and pharmacist to assess how this would improve patient outcomes at a DGH hospital.

METHOD

An MDT clinic led by a consultant geriatrician with a PD specialist pharmacist and a physiotherapist that could assess patients attending the clinic was established once weekly. This run alongside a pre-existing weekly PD clinic with only a consultant geriatrician. We analysed data from both clinics at one year and compared the outcomes regarding:- access to physiotherapy, rates of de-prescribing and medication side effects monitoring, and rates of falls and hospital attendances at six months and one year.

RESULTS

Overall, the results of the project were positive despite a smaller sample size than anticipated due to the covid pandemic. The results showed the presence of a physiotherapist in clinic not only leads to earlier access to physiotherapy, but may also lower the clinician threshold for referral leading to earlier identification of patients at risk. The results also showed a benefit to having a pharmacist in clinic especially in increasing the rates of documented side effect monitoring. Importantly, a chi-squared analysis showed a statistically significant reduction in the number of patients from the MDT clinic having a hospital attendance between 6-12 months. There were also smaller reductions in falls and hospital attendances across both time periods for patients in the MDT clinic. Further cycles are needed to solidify these associations and to analyse the mechanisms by which the effects especially the reduced attendance rates at 6-12 months occur.

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021 (Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit)

Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data).

A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit)

1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data).

A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7.

Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas.

The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007).

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Title: Care of Older People undergoing emergency surgery: meeting the standards of the National Emergency Laparotomy Audit (NELA)

Introduction:

There are well documented in-equalities for outcomes for surgical intervention^1,2,3 associated with Age and Frailty including emergency laparotomy⁴. NELA data has shown over half of such patients are over 65 years old about one fifth are over 80. These patients having significantly higher mortality, longer hospital stays and it has also shown frailty to be an independent marker of poor outcomes.  Through application of key standards these outcomes have improved however input from “consultant geriatrician-led MDT” remains stubbornly low nationally.

Aims:

To improve local Trust performance in meeting the NELA standard: “Peri-operative assessment by a member of the Geriatrician-Led MDT for frail (CFS 5+) patients 65 or older” to >80% (Green: ≥80%, Amber: 50 – 79% Red: <50%) of estimated 100 patients per year.

Methods

1. Proactive case finding with general surgical teams
2. Engagement with Emergency Surgical Committee and NELA leads
3. Improved our own electronic referral system
4. Assist in development of electronic booking system with emergency laparotomy cases

Results:

We showed a significant improved in meeting the NELA standard from the red zone (Mean: 33% range 5% to 35%) into the amber with a of mean 60%  (quartile range 52% to 78%) but still remains below our target with significant quarterly variation seen.

All referrals and assessment remain post-intervention.

Limitations in measures:

• Large variations in Frailty assessment and referral process (prospective Vs retrospective)
• Process rather than a Quality measure
• No balancing measures - Is there Reduced service elsewhere?

Conclusions:

Following a number of change ideas and despite challenging COVID related staffing issues we showed that a combination of key stakeholder engagement, proactive case-finding and improved electronic referral processes we have improved Geriatrician input in frail patients undergoing emergency laparotomy.  We suspect due to the non-systematic assessment of frailty that we may be missing some patients and or seeing late in care pathway.

References:

1. NCEPOD 2010
2. National Service Framework for Older People 2000/2001
3. Parliamentary and Health Service Ombudsman. “Care and compassion” Report of the Health Service Ombudsman on ten investigations into NHS care of older people. 2011.
4. NELA

Introduction

Care home residents can have variable access to eye care services & treatments. We developed a collaborative approach between optometrists, care homes, and primary & secondary care to enable personalised patient-centred care. Objective To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback & hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility & acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity & pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated & are more efficient for residents, health & care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

Introduction

Frail adults should be offered comprehensive geriatric assessment. Falls are the most common reason for conveyance to hospital for Nursing Home (NH) residents in SBUHB and are associated with mortality, morbidity and are a significant burden on Welsh Ambulance Service (WAST) and the Emergency Department (ED). Older people are often subject to long ambulance waits and offload delays. By using a collaborative approach, we aim to reduce hospital conveyance rates and adverse patient outcomes.

Methods

Phase 1 - WAST calls analysed January 2020 – February 2022 from Swansea Bay UHB NH concerning Falls/ Potential Falls where an Emergency vehicle attended the scene. Education provided about post-fall management in Swansea NH’s in March 2022. Phase 2- Development of a referral pathway with Acute-GP unit (AGPU) and Advanced Practice Paramedic (APP) colleagues who review the WAST “live stack” allowing calls to be diverted to Older Person’s Assessment Service (OPAS). OPAS also offer same-day assessment for NH residents (and others) directly.

Results

March-July 2022, 980 calls from SBUHB NH, 195 falls (19.9%), additional 228 potential falls (22.67%). There was significant change in conveyance (p <0.05) with no change in call nature or call frequency (p >0.05). Per month, the mean conveyance reduction was 20 patients. In addition, OPAS review 8 (mean) patients from NH directly each month, bypassing WAST.

Conclusions

Falls remain a significant burden on ED and WAST and we have shown education plus collaboration between AGPU, WAST and OPAS shows significant conveyance reduction, ultimately delivering a better patient experience and system efficiency. Each call-out has a cost per hour of £101.34, with average offload for those >65 years old being 406 minutes, saving a minimum of £25000 a month. Future directions include expanding post-fall education to NH in Neath/Post Talbot and WAST first responders and piloting a rapid-response vehicle