CQ - Patient Centredness

Introduction 

According to the GMC’s Good Medical Practice, medical professionals have a responsibility to be considerate and compassionate to those close to a patient through giving support and information. For those lacking capacity, clinicians can assume that patients would want those close to them to be kept up to date with their condition. NHS digital data last year showed that 17.1% of written complaints are linked with communication. The primary aim of this project was to increase the percentage of surgical patients aged 65 or over receiving a next of kin (NOK) update. The secondary aim was to decrease the time to NOK update for this patient group to under 48 hours.   

Method  

QI methodology and 2 PDSA cycle loops were used. Using the electronic patient record surgical patients aged 65 years or over on two surgical wards were identified. Medical records were checked for documentation of a NOK update. Where a NOK update was documented, time to update from surgical team decision to admit was noted. In those without a documented NOK update, time from clerking was recorded. The percentage of patients receiving an update and mean time to update was calculated. Following the implementation of posters prompting NOK updates, data was recollected. Following a teaching session a third data analysis was undertaken. 

Results  

Following the initial intervention the time to NOK update decreased by 78% from 232 hours to 50 hours. The data post second intervention saw an increase in the percentage of NOK updates from 62% pre-interventions to 70% and time to update decreased by a further 5% to 40 hours. 

 
Conclusion 

Implementation of a poster prompt and undertaking a teaching session, highlighting the importance of communication with NOKs, demonstrated improvement in percentage and mean time to NOK updates for our patient cohort on surgical wards. 

Introduction . DVT is a common complication post stroke. Clinically evident DVT can occur in 2-10% after an acute stroke. DVT can develop as early as Day 2 after acute stroke; Risk peaks between Days 2 and 7. Untreated proximal DVT has a 6-15% mortality risk. Intermittent pneumatic compression (IPC) of the legs is recommended to reduce the risk of DVT in non-ambulatory stroke patients. Methods Criteria = All new stroke admissions to Stroke ward should have IPC applied by the time they were seen by the consultant on the post-take ward round – Unless contraindicated. Initial Audit = 100 admissions from June-July 2024. Intervention = Posters placed in doctors' offices and nursing bases (three locations) to remind both nursing and medical staff to prescribe and apply IPC on time. Post-intervention Audit = 100 admissions from August-September 2024. Results Initial Audit = 21.6% of patients did not have their IPC applied on time. Post- intervention audit = 18.1% of patients did not have IPC applied on time, reflecting a 3.5% improvement. Patients not receiving IPC by Post-take ward round reduced by 3.5% post-intervention. The reduction was mainly due to more timely IPC prescriptions by medical staff (improved by 5.9%) but compliance in IPC application by nursing staff worsened (by 2.2%). Conclusion The intervention successfully improved timely IPC prescription rates but did not fully address the delay in application by nursing staff. Targeted reminders can improve compliance, but additional strategies may be necessary for sustainability. Second cycle being planned to include: More targeted posters. Larger pool of patients to be audited (150). Request for ideas for interventions from nursing staff/resident doctors. Data will be collected on incidence of VTE in affected patient group.

Introduction

Frail older patients with hearing impairments face significant communication challenges in acute care settings such as the Emergency Department (ED) and Same Day Emergency Care (SDEC). These challenges often lead to misdiagnoses, increased anxiety, and diminished patient satisfaction. Improving communication for such patients is critical to enhancing their care experience, maintaining dignity, and improving overall satisfaction and outcomes.

Method

A Quality Improvement Project (QIP) was conducted involving ten participants over 75 years who were identified with hearing impairments and admitted to the SDEC frailty unit from the ED. Baseline communication difficulties were assessed using a pre-designed questionnaire. The AudiMed Communicator 2, a lightweight and ergonomic device with a high-quality amplifier and built-in microphone, was introduced to enhance hearing without requiring traditional hearing aids. Participants provided feedback post-intervention via a follow-up questionnaire, evaluating the device's impact on hearing and communication.

Results

All participants initially relied on alternative communication methods and reported frustration due to impaired hearing. Most did not have functioning hearing aids. Following the implementation of AudiMed, participants' hearing ability scores improved dramatically. All reported a score of 5 on a 1-5 scale, indicating high satisfaction. 100% of participants preferred using AudiMed and highlighted its positive impact on their communication and care experience.

Conclusion

The AudiMed Communicator has significantly enhanced communication, hearing ability, and patient satisfaction among frail older patients in acute care settings. By addressing communication barriers, the device has empowered patients, promoted dignity, and streamlined care delivery, ultimately improving outcomes and quality of life. Recommendations include expanding the use of AudiMed in similar settings, providing staff education for seamless integration, and ensuring ongoing feedback for continued evaluation and improvement.

Introduction: In operative patients, frailty results in increased rates of postoperative morbidity and mortality. The BGS guidelines for perioperative care stipulate that all patients over the age of 65 should have a clinical frailty score (CFS) documented within 72 hours of admission. One benefit of recognising frailty and increased risk of death is timely establishment of a ceiling of care (CoC) for patients undergoing emergency surgery, in line with the NICE guidelines for advanced care planning. In our orthogeriatric department preliminary data suggested that the CFS was almost never routinely calculated, and that clinicians were not always establishing ceilings of care for patients. Methods: Y/N data was recorded for CFS completion and CoC documentation, which included a pre-existing DNACPR and for full active treatment, pre- and post- intervention. Inclusion criteria were patients aged >65yrs on admission, presenting with a neck of femur fracture undergoing operative management. 2 plan-do-study-act (PDSA) cycles were completed, with the aim of improving completion rate of a CFS and establishment of CoC within 72 hours of admission. Intervention: Alteration of the clerking pro-forma to make CFS and consideration of CoC mandatory pre-op assessments, alongside communication to current and incoming resident doctors on the orthogeriatric ward. Results were shared at a clinical governance meeting, initiating discussion between anaesthetic, surgical, and geriatric departments regarding advanced care planning best practice. Results: Following intervention, completion of CFS for patients within 72hrs increased from 4.5% to 41% and documentation of a CoC within 72hrs increased from 68% to 82%. Conclusions: This QIP improved both completion of CFS and consideration of CoC for elderly patients with hip fractures. In discussion at the clinical governance meeting it was agreed that careful consideration and documentation of CoC is always warranted and is an important component of care for this patient cohort.

Introduction: 

With an aging population of major trauma patients admitted to the Southwest Major Trauma Centre, a dedicated team of medics, nurses, and therapists launched a pilot aimed at enhancing the care of frail major trauma patients in a Major Trauma Centre (MTC). This initiative - the Frailty and Trauma Liaison Team (FTLT), focuses on ensuring continuity and quality of care for this vulnerable population in major trauma. 

Methods: 

It targeted the completion of comprehensive geriatric assessments (CGA) within 72 hours for patients with a Clinical Frailty Scale (CFS) score greater than 4 and traumatic injuries. Key components included standardised frailty screening tools to identify at-risk patients upon admission, followed by individualized care planning that integrates geriatric principles with trauma care underpinned by the HECTOR daily assessment. Every morning, 3 to 4 patients from the major trauma ward round were selected based on their CFS, length of stay (LOS), and location. Priority was given to those not located in a Health Care of the Elderly (HCE) ward. 

Results: 

The average CFS of the patient reviewed was 5.18% with 70% overall having CFS 5 or above. The findings from this pilot indicate that the FTLT were successful in identifying early factors affecting patients including pain management, bowel and bladder care, hydration / nutrition and cognitive / delirium screening that all required interventions to mitigate negative patient outcomes on the ward. 

Conclusion: 

This multidisciplinary approach fosters collaboration among healthcare providers, patients, and families, ensuring tailored interventions that address specific needs of the frail older patient. Data collection will be crucial in assessing patient outcomes, allowing for continuous improvement of the FTLT model. By implementing this comprehensive framework, it aims to enhance the care and outcomes for frail patients in the major trauma population, contributing to improved standards and outcomes of geriatric trauma

Introduction

The UCNH model is being implemented across Sussex to reduce ED pressures. Based at the Polegate Make Ready Centre, the UCNH launched in mid-November 2024 to provide alternative pathways for 999 callers. The UCNH operates as a multidisciplinary team of up to eight clinicians, including an Urgent Community Response Trainee Advanced Care Practitioner and a Consultant in Frailty, two Advanced Paramedic Practitioners, two Computer-Aided Dispatch drivers, and two remote consultation paramedics.

Method

The team triages calls, manages acute cases, and works collaboratively with ambulance crews and community services to avoid unnecessary ED attendance by offering interventions, referrals, or home-based management.

Results

Between 11 November and 31 December 2024, the hub operated on 33 weekdays, managing 554 contacts (16.8 per day). Their average age was 75 years. Of these, 184 were handled before dispatch, and 370 involved on-scene crews. The service avoided 121 ambulances (3.7 per day) and 339 ED conveyances (10.3 per day), significantly reducing unnecessary hospital visits.

Referral pathways included 254 patients directed to acute services, such as Same Day Emergency Care (SDEC) and specialist assessment units, and 139 patients referred to community services, with 4.2 supported at home daily.

Cost savings were substantial, totalling approximately £2395 per day (£1760 from avoided ambulances and £635 from ED avoidance), equating to £79,000 over this period.

Conclusions

The UCNH demonstrates significant benefit, reducing ambulance utilisation and ED conveyances while enhancing patient outcomes through community and home-based care. These results highlight its potential to improve ambulance response times and hospital handovers, although further data is needed to confirm this. Reinvestment of savings into SDEC and community services could enhance care pathways further. By preventing inappropriate ED attendances and facilitating access to suitable care services, the hub delivers both financial benefits and meaningful improvements to individual patient care.

Background

Sarcopenia, defined as age-related loss of muscle function and strength, has a reported prevalence of up to 40.4% in the older adult. Despite its association with frailty, disability and mortality, it is underdiagnosed among hospitalized older patients. Exercise interventions have also been shown to improve fall risk scores for sarcopenic patients.

Objective

A QI initiative was started by a team comprising doctors and physiotherapists. Our aim was to enhance detection of possible sarcopenia and reduce time to delivery of targeted physiotherapy interventions to 1 working day from admission in patients aged 65 admitted to our ward. Interventions were grouped into three main categories – strength training, balance and gait stability training. A pilot study of 12 patients showed that no sarcopenia assessments were carried out and mean time to PT review was 2.16 days from admission, with an average of 1.08 interventions performed per patient.

Methodology

Fishbone analysis and Pareto chart were conducted to identify and prioritise factors behind low screening rates of sarcopenia, before driver diagram was performed to develop solutions. Our team established that education of junior doctors on sarcopenia and implementation of SARC-CAIF screening were the most appropriate interventions to achieve our objective.

Results

A total of 26 patients were identified, with an average age of 76.7 [6.7] years old. The mean SARC-F and SARC-CaIF scores were 4.51 [3.5] and 14.6 [2.4] respectively. 50% (13/26) of patients were admitted for falls. After implementation of SARC-CaIF screening, mean time to PT review was shortened to 1.38 days from admission, with an increase in PT interventions to 2.23 per patient.

Discussion and Conclusions

The prevalence of possible sarcopenia is high inpatient. More can be done to enhance its detection among frail hospitalized older patients, so as to deliver targeted physiotherapy interventions. Doctor education and SARC-CaIF screen are simple and practical tools that can be utilised.

Introduction:

Traumatic Brain Injury (TBI) is the most common fall-related injury among adults 65 and older, despite the high incidence there is a paucity of research to guide management of older adult TBI . Simple passive remote home monitoring systems can be used to unobtrusively track markers of health and function in older adults and enhance clinical decision making in community-based care models, such as ‘hospital at home’. There are few studies to-date examining healthcare practitioners (HCPs) views on this technology. We aimed to explore HCPs insights on how to best develop the technology and examined barriers and facilitators to the adoption of passive remote monitoring in the community to track health and function in older adults following TBI.

Method:

This was a multi-center mixed methodology qualitative study. HCPs opinions were explored during and online focus group and individual interviews. Purposive sampling was used to provide balanced representation of healthcare professionals (physicians, nurses and therapists) from both community and acute multidisciplinary teams. Data were analysed using the framework approach.

Results:

The perspectives of 6 HCPs were analysed. Potential barriers to adoption were HCPs lack of familiarity with technology, skepticism over the reliability of technology, the potential for nefarious use of patient’s data and concerns over how data will be managed and interpreted for clinical use. Facilitators were the promotion of safety and independence at home, reduced workload for HCPS, the potential to target appropriate healthcare interventions and flag issues early in cognitively impaired older adults.

Conclusion(s):

HCPs felt that passive remote monitoring holds potential to improve care for older adults following TBI. However, its implementation demands thoughtful planning and clear guidelines for its use and interpretation of data. Iterative development of these systems, incorporating HCPs insights will be key to successful and sustained use in research and clinical practice.

Introduction

Surgical intervention may not be appropriate in frail patients with new or recurrent bladder cancer. To ensure that their care is aligned to the principles of ‘Realistic Medicine’, we developed a structured programme of joint management between our Peri-Operative care of Older People undergoing Surgery (POPS), Anaesthetic and Urology teams. This analysis examines our experience.

Method

Patients listed for surgery and deemed to be frail at initial screening, underwent Comprehensive Geriatric Assessment, an anaesthetic review (if indicated) and surgical evaluations. Validated measures of frailty, cognition and function were used. Each patient had a joint consultation with a bladder cancer and POPS specialist. Patient details, clinical metrics were recorded prospectively on a POPS database, with clinical follow-up records maintained electronically.

Results

From a total of (approximately) 460 suspected or confirmed bladder cancer patients, 100 were reviewed in the joint POPS-bladder cancer specialist clinic between January 2017 and early January 2024. Moderate/severe frailty was noted in 55%. Only 23% of patients proceeded with their intended surgery (GA cystoscopy/TURBT/cystectomy). Most patients opted for no operative intervention instead choosing best supportive care (45%), repeat flexible cystoscopy (17%) or repeat diagnostics (14%). Over the follow up period (median 4 years), of those who opted for no operative intervention, most did not need to change from the recommended plan; 5% of patients required an emergency admission (bladder washouts only).

Conclusions

This novel joint working with POPS and bladder cancer specialists appears to be a safe, comprehensive, and patient-centred approach to the effective and efficient management of frail patients with bladder cancer. It allows various important factors to be carefully considered and balanced including frailty, patient priorities, symptom burden and tumour size/grade/number. This model of care means selected patients could avoid the burden of unnecessary procedures and surveillance.

Introduction

In conjunction with Roche, a 18 month project was proposed to facilitate a more holistic approach in managing this patient cohort post-diagnosis and in turn improve outcomes, reduce length of stay and improve patient experience.

Method

The aim of the project was to design the MDT, ensure there is sufficient clinician capacity for implementation as well as develop accompanying pathways. The patient cohort was all patients with a diagnosis of Non-Hodgkin’s Lymphoma over the age of 65. Whilst all patients meeting these criteria would potentially be eligible to be reviewed by the MDT, the patients would first complete a comprehensive frailty assessment at the end of which the clinician will assign a clinical frailty score (CFS). Any patient scoring 4 or above with a clinical concern will be added to the MDT for review. The MDT itself will aim to address all aspects of the patient’s health care journey post diagnosis. To this end, the roles that have been defined as critical are: Haematologist, Geriatrician, Pharmacist, Physiotherapist/Occupational Therapist, Dietician, Clinical Nurse Specialist and Support Worker.

Results

Currently over 90 patients assessed. Over 60 discussed in MDT, with over 170 total reviews. Further qualitative TBC.

Conclusions

Currently at UHS there is limited provision of frailty services. This unmet need manifests as e.g. reduced rates of treatment completion or increased treatment modifications, increased length of stay for post treatment episodes, missed appointments and non-elective admissions. All of which subsequently impact the patient's prognosis and NHS resources. Evidence shows centres with a geriatric oncology service have seen increased success in completion of treatment for patients and length of stay reduced by an average of 4.5 days. This pilot has enabled the Trust to collate evidence of this being the case locally, ultimately facilitating improved patient experience, better patient outcomes and reduced