CQ - Patient Centredness

Introduction:

In geriatric medicine department of a large tertiary care university hospital, it was observed that multidisciplinary team (MDT) working was not standardised, morning huddles were inefficient, there was a lack of inclusion of all members in MDT meetings and the meetings were too medical focused. The aim of this project was to address these concerns through a multipronged approach.

Methods:

An initial survey was carried out with 34 participants from all disciplines of MDT. Areas needing improvement were identified from the survey and through discussions among doctors, nurses and therapists. A pilot of changes was introduced in the largest ward of the department. A post change survey was carried out, demonstrating improvement across multiple domains.

Results:

Initial Survey

• Are you satisfied with current MDT practices? 52% said they were partly satisfied or not satisfied
• Morning Board Rounds: 68% said it does not happen everyday/attended by most professions
• Feeling valued at MDT meetings / Opinion taken appropriately? 35% said they were not confident they felt valued / opinion taken appropriately
• Are MDT discussions patient centered and effective? 38% said they are not always patient centered/effective
• Do you understand the various concepts and acronyms used in our MDT’s? 30% said they do not understand most concepts/acronyms

Changes implemented

• Structured daily morning board round with all MDT disciplines using a new pro forma
• MDT meetings led by flow-coordinator via a structured format making them more holistic, person-centred and inclusive
• Published a handbook to improve understanding & purpose of MDT’s and terminologies used in meetings

Post change survey results

• 66% said meetings were now more structured and it was easier for them to share their views
• 75% respondents said they now felt more valued
• 76% thought meetings now were more person-centred

• Improved attendance & efficiency of morning huddle (mean time reduced to 10 from 30 minutes)

  These findings were presented and shared in departmental monthly meeting

Conclusion:

The true essence of MDT working lies in all professions coming together to achieve patient-centred care. This can only be achieved if all professions understand and respect each other’s role and responsibilities. Through best practices, we can achieve more holistic care and prevent harm. It results in resources being used more efficiently through reduced duplication, greater productivity and preventative care approaches.

Through a series of changes we demonstrated these in one ward and work is ongoing to implement these changes across the whole department.

Link for published Handbook: 

https://drive.google.com/file/d/1P6Cuz8u1N3cr1FjnG4y9KIwRhkX5qHFM/view?…

Frailty is a growing concern, particularly for older adults attending Emergency Departments (EDs). Frailty accounts for 5-10% of all ED visits and up to 30% of acute admissions. The NHS mandates that hospitals with Type 1 EDs provide a minimum of 70 hours of Acute Frailty Services per week to address this challenge. At Salford Royal Foundation Trust (SRFT), a Frailty Same Day Emergency Care (SDEC) service was introduced to deliver rapid assessment and care for frail older adults, aiming to reduce hospital admissions and improve patient outcomes. This service operates five days per week and is staffed by a multidisciplinary team. Methods: A mixed-methods approach was used to evaluate the Frailty SDEC service. Data was collected through paper surveys distributed to patients aged 65 years or older with a Clinical Frailty Score (CFS) >5 and their relatives or carers during their admission to the SDEC service. The survey included both closed-ended and open-ended questions. Quantitative data was analyzed using descriptive statistics and qualitative data was analyzed using thematic analysis. Results: A total of 32 responses were collected over a two-month period in 2024. The results showed high levels of patient and family satisfaction (97%) with the Frailty SDEC service. Participants particularly valued the compassionate and personalized care, clear and professional communication, and the efficient and timely service delivery. Areas for improvement included upgrading the physical environment and providing clearer communication about waiting times and procedures. Conclusion: The Frailty SDEC service at SRFT demonstrates high levels of patient satisfaction and effectiveness in delivering care for frail older adults. This evaluation provides valuable insights for enhancing patient-centered care and highlights the importance of further research to explore long-term outcomes and compare different models of SDEC services for older adults.

Introduction: Ireland's population aged 65 and older increased by 40% in the last decade. ALONE is a national organisation that enables older people at age at home. The ALONE model is being delivered within the Enhanced Community Care (ECC) programme, which aims to ensure health services work in an integrated way to meet population needs. This presentation, designed using the RE-AIM Framework, presents preliminary effectiveness results from ALONE's national service evaluation. 

Methods: Phone-based surveys using validated measures (Shortened Warwick-Edinburgh Mental Wellbeing Scale, EQ-5D-3L, UCLA Loneliness Scale-3) were conducted with participants at baseline and three months into service. These measures were selected and piloted by the project team, which includes older people and volunteers. 

Results: 272 participants completed the first survey (62.5% were female, 51.5% aged 75-85). Almost all (97%) had at least one chronic illness, 98% identified as white and 95% were not working. Participants had higher levels of loneliness (M= 5.7; SD = 2.2), lower wellbeing (M= 23.81; SD = 4.3), and lower health-related quality of life (M = 59.6, SD =23.6) compared to national studies. Preliminary analysis of data from 212 older people who participated in Time 2 indicated incremental improvements in loneliness (M T1=5.7; M T2=5.5) and self-reported health (M T1= 59.6; M T2 = 64.7). There were some changes in the percentage of people reporting no pain (T1=19.3%; T2 =21.2%) and not feeling anxious or depressed (T1=38.7%; T2=40.1%). Moreover, the average number of GP consultations (T1M = 2.32; T2M=1.93), A&E calls/attendance (T1M=.24; T2M=.09/T1M=.43; T2M=.17), planned (T1M=.30; T2M=.12) and unplanned (T1M=.58; T2M=.24) hospital stays per participant decreased. 

Discussion: These early findings demonstrate modest improvements across several areas within three months of ALONE support. This provides important evidence supporting the effectiveness of community-centred care coordination as part of the wider system.

Introduction

Our district general hospital utilises an unselected medical receiving model where generic admission clerk-ins often miss salient information vital for comprehensive geriatric assessment (CGA). Recent Healthcare Improvement Scotland guidelines outlined people living with frailty that are admitted to an acute hospital are at risk of adverse outcomes. A standardised proforma for admissions to our medicine of the elderly (MOE) ward (clinical frailty score >5 required for admission) would ensure critical information was collated for more effective CGA, decision making and discharge planning. The aim was by November 2024, 90% of inpatients within our acute MOE ward would have had complete admission proformas documented.

Method

We analysed information from generic medical admission notes and identified key items often omitted such as escalation status, medication review and discharge planning goals. We created a standardised MOE admission proforma which was piloted (cycle 1) and then incorporated into the electronic patient record (cycle 2). The outcome measure was the percentage of MOE patients with complete admission proformas. We also reviewed average length of stay data and sought feedback from ward staff.

Results

Baseline data revealed 57.2% of MOE patients had key CGA information documented on admission. Cycle one (July 2024) illustrated an increase to 74.1% meanwhile cycle two (November 2024) increased to 90.8%. There was a 25% reduction in average length of stay from 12.8 days to 9.6 days. Feedback from users of the standardised proforma was universally positive.

Conclusion

This proforma established a standardised patient-centred methodology for initial MOE patient assessment by ensuring medication reconciliation, improved comprehensiveness of clinical documentation and streamlining multidisciplinary team assessment to provide effective continuity of care and discharge planning. This was well received by users and resulted in patients returning home sooner. This proforma will be re-audited in 4 months and applied to other MOE wards.

Introduction: 1 in 37 adults in the UK are diagnosed with Parkinson’s Disease (PD). The varied nature and specific symptom management of the condition requires a person-centred multi-disciplinary approach to care. 

Methods: On a care-of-the-elderly ward at Bristol Royal Infirmary, 3 cycles of a quality improvement project were conducted to upskill knowledge and confidence of the staff caring for PD patients. In cycle 1, baseline knowledge and confidence of staff were gathered using a data collection survey. 5 teaching sessions were organised addressing topics in PD such as medication, palliative care and communication. The survey was then repeated. In cycle 2, another 3 teaching sessions were run on swallowing, physiotherapy and occupational therapy in PD. An easy-to-read information board on PD was also created on the ward. After a month, the staff were re-surveyed. In cycle 3, information was gathered from PD patients and their carers on what topics they thought were important and a 3 further teaching sessions were run on physiotherapy, medication and an overview of PD. A final data collection survey was distributed after 6 months of the initial baseline survey being conducted 

Results: Within the knowledge questions there was a 5 out of 8 higher correct answer rate across most parameters except medications, after the teaching sessions. This was also mirrored in the confidence questions with higher confidence rankings in 4 out 5 parameters being questioned. 

Conclusion: To continue the teaching programme with a wider range of care providers and having repeat teaching sessions on topics highlighted by PD patients and their carers. There should be a focus on further medication teaching, which has also been widely requested by staff members. Additionally, this teaching could be recorded for staff who cannot attend in person.

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