CQ - Patient Centredness

Introduction

End-of-life (EOL) care in care homes includes patients experiencing "ordinary dying" from dementia or frailty, alongside those with chronic diseases and cancer. Recognizing non-specific decline is complex. The One Weston Care Home Hub (CHH) implements comprehensive EOL care, achieving 95% of deaths in the preferred place and prioritising a "good death". Whilst "Just in Case" (JIC) injectable medications are commonly prescribed, a broader understanding of prescribing patterns is useful for learning about medicines waste and recognition of dying. This study investigates the prevalence of common prescriptions and explores the need to re-evaluate anticipatory medications for care home residents.

Method

A qualitative audit evaluated EOL care prescribing practices in 100 care home deaths by examining medication management in patient notes. Data were collected retrospectively on parameters including the completion of palliative drug charts, issuing JIC medications, and the timeline from prescribing JIC medications to death. Information on medications administered within the last two weeks of life and the cause of death was also recorded.

Results

34% received no additional medications. Antibiotics were the most commonly issued medications; 31% patients received them, half in liquid form. Other prescriptions included oral or topical analgesia (21%), laxatives (9%), benzodiazepines (8%), and oral steroids (5%). Liquid preparations comprised half of the issued medications. 74% of patients had JIC medications issued a median of 23 days before death (range: 1-1244 days).

Discussion

The use of antibiotics in this cohort is complex: are they prescribed for successful treatment, or could braver decisions be made not to prescribe when recovery chances are limited? Injectable JIC medications are a timely proxy for recognizing the terminal phase, but 26% of patients who died did not have these in place. Further study is required to determine if they were indeed not needed and how many of those prescribed were used.

Background: Language is a social determinant of health, as constituted by the World Health Organisation (WHO) back in 1948. UK migration rates have risen exponentially recently, and with it the inability for patients to speak functional English is a growing concern. Poorer health information and avoidance of service use creates fundamental health inequity within this demographic. The UK’s ever-changing sociodemographic landscape necessitates a growing focus on health outcomes within non-English speaking patients.

Aim: To explore the barriers towards interpreter service use within South Yorkshire and how to improve communication with non-English speaking patients.

Method: Data was collected in a mixed quantitative-qualitative approach. A yes/no approach was adopted to answer the study objectives (ie., whether family members had translated on behalf of relatives or if interpreter service use was documented). Observational comments from the notes were used to contextualise the data for further discussion. This was compared to available UK guidelines.

Findings: There was a widespread reliance on family members to interpret on patients’ behalf, seen in 75% of non-English speaking patients on the sampled wards. Only 50% of these patients had documented use of interpreter phone lines across the wards, significantly below the audit’s standards.

Discussion: Barriers to interpreter services may be attributed to inefficiencies within its online nature, including queues and connectivity issues. This discourages its uptake, especially in the face of increasing hospital pressures. The high reliance on family members requires ethical considerations. These include issues with confidentiality, poor safety netting and disjointed communication of diagnoses when family members are used to translate. Ultimately, reliance on family members should be actively discouraged. This project recommends a language assessment tool and identification charts to guide NHS staff to appropriate interpreter services, preventing care delays.

Introduction: Total Laparoscopic Hysterectomies (TLHs) are one of the most common gynaecological surgical interventions in the ageing population. Whilst co-morbidities have huge influence on the perceived patient suitability for surgery, patient factors like age ought to be considered in the pre-operative stage. Clinicians must counsel patients on individualised risks to enable informed decisions.This audit looked to identify the impact of age on the likelihood of operative complications in TLHs, guiding specific counselling for older patients considering this procedure.

Methods: Extensive data was collected retrospectively using electronic care records and operative notes regarding patients undergoing TLH by a single surgeon at a UK cancer centre between 2008-2020 (N=593). Complications were intra-operative (bladder injury, bowel injury and bleeding >500ml) or post-operative (bleeding, infection, readmission, return to theatre and GAU attendance). Patients were grouped according to their age. Complication rates (intra-operatively and post-operatively) were compared between groups and differences tested for statistical significance (p<.05).

Results: intra-operatively complication rates increased with age. significant differences were found between most age groups (>50yrs p=0.001, >60yrs p=0.021, >70yrs p=0.04). A significant difference in post-operative complication rates was found >50yrs (p=0.011).

Conclusions: With significant differences in TLH complication rates between different age groups, pre-operative assessment of patient factors becomes increasingly important. Not only for patient education purposes, but also for their suitability for surgery. Whilst co-morbidities are more pertinent in the ageing population which could account for this significant difference, age alone is a factor that should not be overlooked. It is a simple measure that is easily conceptualised to patients to stratify risk in the decision making progress.

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed :- 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312(68.7%) Female, median age 86 years. 157(34.6%) patients had a femoral fracture and 300(65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206(68.7%) being discharged same day. Overall, admission was avoided in 207(45.3%) patients and 247(54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

Introduction: Frailty presents significant challenges to healthcare systems, particularly in Thurrock, Essex, where 14% of residents are aged 65 or older. This demographic shift, combined with socioeconomic factors, highlights the need for patient-centred, clinically effective, and tailored healthcare services that prioritise patient safety. 

Aim: To improve frailty management for elderly patients in Thurrock by integrating pharmacist support within a nurse-led service. The initiative focuses on improving medication management, alleviating workload pressures, and providing holistic care to enhance patient outcomes and reduce hospital admissions. 

Method: A 12-week pilot involved patients aged 65+ undergoing joint reviews with a frailty nurse and pharmacist. Participants had a Rockwood Frailty Score of 5-7 and at least one long-term condition. The reviews encompassed an evaluation of physical observations, medication regimen, functional and fall risk assessment, nutritional status, fracture risk, and analysis of pertinent blood test results. The management phase focused on reviewing long-term chronic conditions, deprescribing, medication dose adjustments, and addressing health metrics such as postural hypotension, bradycardia, bone protection, and fall risk. Regular follow-ups ensured coordinated care between the nurse and pharmacist, focusing on patient-centred outcomes and patient safety. 

Results: A total of 37 patients (mean age: 84) participated from April 4^th to June 28^th, 2024. Comprehensive assessments led to 155 interventions (averaging 4.07 per patient). Medication management improved significantly, with 88 drugs deprescribed, including 55 Falls Risk Increasing Drugs (FRIDs), resulting in a 14.39% reduction in FRIDs and a 23.03% reduction in polypharmacy. These interventions led to £6,252.18 in annual drug savings and a 974.09 kg reduction in CO₂ emissions. Key outcomes included 57 health and social interventions and 38 new medications prescribed. Financial analysis suggested savings of £63,450 from preventable hospital admissions, with a return on investment (ROI) of 1655.4%.

Conclusion: The pilot demonstrated the clinical effectiveness of pharmacist-nurse collaboration in improving medication management, chronic condition control, reducing fall risk, and preventing hospital admissions. It underscores the value of skill mixing between professions for enhanced patient-centred care, safety, and clinical outcomes.

Background 

Specialist, hyperacute management of a transient ischemic attack (TIA) is necessary to decrease subsequent stroke. As part of a local Quality Improvement (QI) initiative, we implemented a new TIA pathway in our hospital to maximise efficiency, encourage an ambulatory approach, and improve global TIA management in line with the 2023 UK and Ireland Clinical Guidelines for Stroke. 

Method 

We completed a retrospective cohort study of patients who attended our hospital between April 1, 2024, and June 30, 2024. Patients with a primary diagnosis of TIA were identified through the Hospital In-Patient Enquiry (HIPE). Each diagnosis was verified with electronic records review, with exploration of key investigations and management parameters. 

Result 

28 patients were coded as TIA. 28.5% were seen directly via Acute Medical Unit (AMU), increased from 10.1% pre-TIA pathway, with the rest attending ED initially. The median length of Stay (LoS) in hospital was 0.65 days, down from 1.08 days pre-TIA pathway for those managed directly in AMU. 35.7% were managed within 24 hours, vs 28.2% prior to new pathway initiation. Most patients were admitted under the AMU (35% vs 33% pre-pathway) or Stroke service (42.9% vs 26% pre-pathway), with a shorter LoS if the patient was admitted under these services. 27 (96.4%) patients underwent neuroimaging; 89.3% underwent CT Brain vs 94.8% pre-pathway, 7% underwent MRI Brain without preceding CT in keeping with National Clinical Guideline for Stroke for the UK and Ireland recommendations. 96.4% were reviewed by a stroke specialist vs 82.1% pre-pathway. Utilisation of inpatient echocardiograms and 24-hour holter monitors were reduced to 35.7% and 21.4% respectively, down from 42.9% pre-pathway. 

Conclusion 

This re-audit has shown improved neuroimaging utilisation, increased numbers of patients being reviewed by stroke specialist clinicians, increased use of ambulatory services, and reduced length of stay.

Introduction: In winter 23/24, the NHSCT tested an anticipatory care model in residential care homes. The model included a pharmacist medication review and pharmacy education element. 

Method: Across four residential homes the lead care homes pharmacist completed patient-centred, medication optimisation reviews, and carried out education sessions for senior carers. The number of recommendations/interventions made by the pharmacist was calculated. The number of recommendations/interventions relating to falls prevention, was also calculated. The clinical significance of each medicine optimisation recommendation/intervention made by the pharmacist was graded using the Eadon1 criteria. Eadon graded interventions were then assigned a monetary value using The Sheffield Centre for Health and Related Research (Sheffield University) Economic Model (ScHARR)2. Additionally a qualitative review of the service was carried out via questionnaires. 

Results: In total 92 residents had their medications reviewed. A total of 322 recommendations/interventions were made, an average of 3.5 per resident. Of the 322 recommendations/interventions 115 (36%) were in relation to falls prevention, an average of 1.3 per resident. Interventions of note included antihypertensives being stopped or dose reduced for 20 residents (22%), and bone protection being reviewed, commenced or altered for 31 residents (34%). The views of a capable residents, next of kins and senior carers were sought via questionnaire. Responses were all positive. 

Conclusion: Results demonstrate the positive impact and value of medicines optimisation by a pharmacist in the residential care home setting. 

References: 1. Eadon, H. (1992). Assessing the quality of ward pharmacists’ interventions. International Journal of Pharmacy Practice, 1(3), pp. 145-147. https://doi.org/10.1111/j.2042-7174.1992.tb00556.x. 2. Karnon, J., McIntosh, A., Dean, J., Bath, P., Hutchinson, A., Oakley, J., Thomas, N., Pratt, P., Freeman-Parry, L., Karsh, B. T., Gandhi, T., & Tappenden, P. (2008). Modelling the expected net benefits of interventions to reduce the burden of medication errors. Journal of Health Services Research and Policy, 13(2), pp. 85-91. https://doi.org/10.1258/jhsrp.2007.007011.

Introduction
Observations of the acute medical take suggested that patients who sustained a fall were affected by long delays and wait times to see both A+E and medical doctors. We felt that analgesia prescribing in these patients, many of whom sustained injury, was done poorly and some were being left without any analgesia leading to a negatively perceived patient journey. Our aim was to assess analgesia prescribing practices for patients following a fall with a view to improving experience.
Method
We completed three rounds of data collection, with 20 patients in each. We included patients coded as having a fall on admission and excluded patients under 70. We manually reviewed the case notes to see if patients had a pain assessment on admission and whether they were prescribed analgesia by the A+E team, the medical admissions team or on the post-take ward round. Our intervention was a presentation and education session to the acute medicine and geriatrics departments following each cycle, with the aim of involving both junior and senior decision makers with prescribing privileges.
Results
We reviewed 68 patients across all three data cycles and found that 40% of patients were not prescribed any analgesia by the A+E team. We found that the number of patients with regular or PRN analgesia prescribed rose to 70% once the medical and post-take had seen them. The proportion of patients that had no regular/PRN/stat analgesia prescribed throughout their entire acute patient journey fell from 28% to 16%.
Conclusion
Despite intervention, prescribing practices remained static. 1/3rd of patients did not receive regular or PRN analgesia following their admission injury despite seeing multiple clinicians. There was a modest reduction in patients who never received any analgesia at all following intervention.

Introduction: Care home residents are often multi-morbid with both physical and cognitive impairments. An average care home resident takes 7.2 medications per day. Older people are more likely to experience adverse effects from polypharmacy due to pharmacokinetic and pharmacodynamic changes associated with age. Polypharmacy and anti-cholinergic burden (ACB) not only increase the risk of adverse drug reactions but also can increase the number of falls, hospital admissions and mortality. 

Method: Retrospective analysis in October 2024 of all patients at a residential home who had an initial Comprehensive Geriatric Assessment (CGA) which included a medication review since Enhanced Health in Care Home (EHCH) team started in March 2022 up until September 2024. The number of medications a patient was on at initial CGA alongside their ACB burden was analysed pre and post CGA. 

Results: 65 residents had an initial CGA within this time period with an average of 6 medications and ACB score of 2. Post CGA, the average number of medications per resident was reduced to 5 with an ACB score of 1. 68% of patients had polypharmacy (≥5 medications) prior to initial CGA and this was reduced to 58% post. 12% had ≥10 medications (excessive polypharmacy) prior to CGA and 8% (5) post. Pre CGA, 26% of residents had a high ACB score ≥3 which reduced to 15% post. There were 59 medications prescribed with an anti-cholinergic score of ≥1 which were reduced overall by 24% following the CGAs. 

Conclusion: The overall degree of polypharmacy and anti-cholinergic burden in care home residents can be reduced through a medication review as part of a CGA