CQ - Patient Centredness

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

Parkinson’s disease (PD) is a progressive neurological condition which affects approximately 153,000 people in the United Kingdom (1). It classically involves a triad of bradykinesia, rigidity and tremor alongside other significant motor and non-motor features (2). Delayed or missed medications can result in unpleasant motor and non-motor fluctuations (3). Inappropriate management of patient medication has been shown to result in longer length of stay, delayed recovery, and worse overall outcomes (4). Patients with PD have a high risk of complications peri-operatively with evidence showing they are best managed via a multidisciplinary approach (5).​​The PD team at Aintree University Hospital, part of NHS University Hospitals of Liverpool Group (UHLG), noted that referrals for patients undergoing surgery were low. An initial review of data confirmed that patients undergoing surgery at the site were not having the PD team involved in their care. ​The acute management of Parkinson’s disease for inpatients guidelines were updated to include more detailed advice around the management of patients with PD undergoing surgery. The second cycle reviewed patients cared for after the intervention had occurred.​After the guideline was implemented the number of patients reviewed either pre- or post-operatively by the PD team increased from 4 to 47%.​In the initial review there were 640 missed or late doses of PD medications, with only 17% of patients consistently receiving their medications on time. This improved to 56% in the second cohort. ​Cognitive testing via the 4AT was completed for 38% of patients compared to 18% in the initial cohort. ​In the second cohort data was collected to review the number of patients with PD who were put first on the operating list, this occurred in 26% of patients.​ The results show an improvement in all aspects of care that were reviewed. The number of patients seen by the PD team, medications given on time, and cognitive tests performed all improved. Despite this there is still room for improvement; medications are still not being given on time, every time. UHLG has undertaken a trust wide time critical medication quality improvement project which we hope will have a positive impact. Further improvement through education of the surgical and anaesthetic teams and a guideline awareness campaign are planned.

A Treatment Escalation Plan is a document that records and communicates a patient’s treatment goals and preferences, should their general health or condition worsen. A TEP can include but is not limited to: resus status, preferred place of care or death, if imaging/IVs/venepuncture is appropriate. Treatment Escalation Plans aim to minimise harm from over or under treatment; provide clear continuity of care between healthcare professionals; and prevent futile or burdensome interventions which may be contrary to patient wishes. TEPs can be recorded on the computer system, TRAK. The aim was to introduce TEP recording to the Edinburgh Hospital at Home Team (H@H) and aim for 80% of patients under our care to have a completed TEP. We found that anticipatory care planning and TEP discussions were regularly being had by H@H staff but that these were not being recorded under the TEP tab on TRAK. We increased staff awareness of the importance of TEPs and hosted teaching sessions and created a video on how to create a TEP on TRAK. TEP completion increased from 0% before they were introduced in our team, to a maximum of 78%. The team are reaching an average of 56% of patients having a completed TEP in the first 5 months of use. There does not seem to be a correlation between the number of patients under our care and the number of completed TEPs. We have not yet reached our goal of 80% but there has been a very good response from staff in starting to use the TEP function on TRAK. This data will continue to be monitored and a BOXI report has been created which provides twice weekly data reporting the percentage of patients under H@H care who have a recorded TEP and this will continue to be audited at least biannually.

Introduction 

The development of specialist acute frailty services is well recognised as crucial to meet the needs of our ageing population and is recommended by the NHS England Long Term plan. At the same time, same day emergency care (SDEC) services are rapidly expanding as an alternative to ED However, to date there is a limited evidence base for specialist frailty SDEC units. 

Methods 

We ran a 6-week pilot of a 7-day specialist frailty SDEC open from 8am-6pm. The unit was staffed by consultant geriatricians, frailty ACPs, specialist nurses, junior doctors, a therapy team and resident pharmacists. Patients were accepted both directly from the community (GPs, ambulance crews community frailty teams) and from ED. Criteria were loosely defined by Clinical Frailty Score (CFS 5 or above) and NEWS <3. 

Results 

A total of 256 patients were reviewed in the frailty SDEC over the 6 week pilot period. 166/256 (65%) of patients stayed <24 hours and a further 48 (19%) had a short stay of between 24-72 hours. 7-day ED re-attendance rates remained low at 6% (16/256) and 10% (26/256) of patients were re-admitted to hospital within 30 days of discharge (compared to 17.9% England national average for 2023-2024). 

Conclusions 

Frailty SDEC provides a safe, effective environment for rapid comprehensive geriatric assessment of patients living with frailty. Through close links with community teams we facilitate admission avoidance and person centred care in the right place, first time.