CQ - Patient Centredness

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

Introduction:

Loneliness affects nearly a third of adults aged >70. It increases the risk of conditions including depression, coronary artery disease and stroke. Lonely individuals are at increased risk of falls, hospital attendances and prolonged admissions. Following hip fracture, patients are particularly at risk and pre-fracture loneliness is associated with poorer outcomes. An inpatient stay offers the opportunity to screen for and address pre-fracture loneliness.

Method:

Aims: 100% of patients to have a University of California Los Angeles (UCLA) 3-item loneliness score by day 5 post-operatively. A score of 6 or above necessitates referral for befriending services.

Study population: Patients aged >70 admitted with femoral neck fractures to orthogeriatric wards.

Methods: The project followed a PDSA approach. Electronic records were reviewed weekly for documentation of loneliness scores and referral to community befriending.

Interventions: 1. Doctor education session on loneliness and the UCLA 3-item loneliness scoring. 2. Inclusion of the loneliness score in the pre-populated ward round proforma.

Results:

Of 102 patients, 63% of patients were female, mean age 85. At baseline, 0% had a loneliness score documented. This improved to 57% following intervention 1, returning to 0% after 2 weeks. Following intervention 2, this improved to 56% but fell to 25% after 6 weeks. Of 23 patients with completed scores, 5 (22%) had a high loneliness score and 4 patients were referred for befriending services.

Conclusion:

High rates of loneliness were demonstrated, in line with national predictions. Assessment improved following each intervention, but was not sustained. Investigation suggested this was due to rapid turnover of doctors, and successive cohorts were unaware of quality improvement programmes before moving on to their next post. We believe this to be an important finding, with wider implications for research into improving patient care. Further steps include discussion of loneliness in weekly departmental meetings with the wider Multi-Disciplinary Team.

Introduction

Physical and cognitive frailty combined with unfamiliar surroundings in hospitals puts elderly patients at high risk of falls. It has been demonstrated that patient-centred, non-clinical stimulating activities in hospital have been found to reduce agitation, improve affect and engagement, relieve pressure on nursing staff and reduce falls. In the Medicine of the Elderly (MOE) wards of an urban teaching hospital, after a successful pilot, a Meaningful Activity Team (MAT) was implemented. The effect of this change to patient and staff well-being was assessed, as was the frequency of falls on the wards.

Methods

The MAT was implemented by July 2023. In November 2023, questionnaires were distributed to staff across the MOE department to collect quantitative (Likert scales) and qualitative data on potential benefits and limitations. As part of our Quality Programme, prevalence of patients admitted to MOE wards with a diagnosis of dementia/delirium is regularly measured, as are patient falls, which are recorded via DATIX and collated on ward-based run charts. We interrogated these charts for any significant changes.

Results

The current prevalence of patients with delirium/dementia across the MOE 152 bed footprint is 69%. 49 staff questionnaires were completed, 47 of which had comments. 100% of respondents agreed or strongly agreed that the MAT benefited patient well-being. 87.8% agreed or strongly agreed that the MAT benefited staff well-being (figures 1, 2). Common themes regarding patient well-being were patients being happier, brighter and more sociable. Common themes regarding staff well-being included less stress and increased time for clinical tasks. The frequency of falls has reduced with some wards seeing maintained shifts in median number.

Conclusion

Implementation of the MAT across our MOE wards has improved patient and staff well-being. Reductions noted in frequency of falls have been maintained.

1. Introduction

Care home residents have a greater incidence of frailty and co-morbidities. Polypharmacy and inequitable access to integrated healthcare are confounders to positive outcomes in this cohort. Providing proactive care through the Enhanced Health in Care Homes (EHCH) Framework seeks to address these inequalities using multidisciplinary team (MDT) working.

2. Method

A pilot MDT intervention was delivered across eleven older peoples care settings with the most ambulance conveyances in a London borough known for its aging population. MDT members were from general practice (including pharmacist), geriatrics, ambulance service, district nursing, palliative care, psychiatry, social care, integrated care board and senior care home staff. The intervention was refined iteratively over five months via a Plan-Do-Study-Act cycle. The MDT undertook comprehensive geriatric assessments, advance care planning and structured medication reviews. Outcomes were documented in personalised care and support plans (PCSP).

3. Results

Sixty-nine of the most complex patients were selected to receive the intervention. 100% of these patients had a PCSP created post-intervention. A resultant system culture change led to a three-fold increase in the number PCSPs across all care settings. There was a reduction in 999 calls for 57% of MDT patients (across 8 settings) and there was 24% fewer 999 calls and hospital conveyances across the wider patient group in all MDT care settings. MDT professionals and care home staff reported high satisfaction and valued shared learning and clinical decision-making.

4. Conclusion(s)

This intervention addressed health inequalities of care home residents with a clear thread of advocacy for patients. Proactive personalised care planning offered opportunities for earlier diagnoses, treatment, and swifter recognition of the dying phase of life. Primary care interventions within EHCH framework could be augmented by this MDT approach for a more complex cohort of care home residents with severe frailty and greater co-morbidity profile including dementia.

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

National guidance suggests that all patients with neck of femur fractures (NOFF) should be mobilised day one post-operatively (NICE, 2023, QS16). This reduces rates of delirium, pneumonia and length of stay (Sallehuddin & Ong, Age and Ageing, 2021, 50, 356-357). Hypotension is a leading cause of immobilisation post-operatively. National guidance advises appropriate fluid resuscitation and review of polypharmacy when indicated (British Orthopaedic Association, 2007). This quality improvement project aimed to reduce post-operative hypotension and improve day one post-operative mobilisation in NOFF patients.

Method

Three months of NOFF patients were retrospectively reviewed pre-intervention. Those who did not receive surgical intervention were excluded. The proportion of NOFF patients that were unable to mobilise due to post-operative hypotension on day one was identified. We reviewed if intravenous fluids were given pre-operatively and if anti-hypertensives were held. An intervention was then implemented including educational posters and teaching sessions for doctors and nurses to encourage prescription of fluids on admission, holding of antihypertensives pre-operatively and detection and escalation of oliguria or hypotension post-operatively. Data were then re-collected in a three-month period post-intervention to ascertain if there was any change in practice.

Results

70 patients underwent NOFF repair pre-intervention compared to 54 patients post-intervention. There was a decrease in the proportion of patients unable to mobilise day one post-operatively due to hypotension from 15.7% pre-intervention to 9.3% post-intervention. There was an increase in the proportion of patients who received pre-operative intravenous fluids from 64.3% pre-intervention to 77.8% post-intervention. Of those patients who took anti-hypertensive medication, a higher proportion had this suspended pre-operatively, increasing from 82.9% pre-intervention to 88.2% post-intervention.

Conclusion

Simple educational interventions can reduce post-operative hypotension in NOFF patients. Developing local guidelines may facilitate persistent clinical change, as improvements following poster distribution and teaching sessions may be transient.

Background

The Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary tool, designed to promote holistic care of elderly patients and provide a framework for intervention. There is evidence that the CGA reduces mortality and slows progression of frailty. Performing such interventions in the acute setting can be complex and time-consuming.

Introduction

The Older Person’s Assessment Unit (OPAU) at Weston General Hospital allows early identification of frailty and prompt intervention. We aimed to promote elements of the CGA by providing a tool for utilisation throughout the patient’s admission to coordinate patient care.

Methods

This was a prospective pre-post intervention study on OPAU. We reviewed medical records in a 5-day period analysing documentation of elements of the CGA. The primary intervention was introduction of a ward-round proforma prompting delirium screening. Following analysis and re-evaluation, a an updated proforma with an additional bone-health prompt was circulated. The completion of proformas was re-assessed.

Results

Baseline data of 20 patients showed that common presenting complaints were falls and confusion. Only 14% of those who presented with a fall had a documented bone-health screen. 0% of patients with confusion had a delirium screen. After cycle 1, 0% had bone-health screening and 20% had delirium screening. Following cycle 2, 89% of patients who had a fall had completed bone-health screening.

Conclusion

Implementation of a CGA-orientated ward-round proforma encourages consistent documentation. It demonstrated successful increased uptake of delirium and bone-health screening. The future aim is to introduce a full CGA proforma that encourages opportunistic assessment by all members of the multi-disciplinary team.

Introduction:

The geriatric population has a high incidence of dementia, delirium and frailty meaning often these patients cannot give comprehensive histories themselves. We are left with missing pieces of the puzzle; we might not know their ‘normal’ and frequently ask: ‘Are they always like this?’.

A collateral history becomes a valuable tool, contributing to a Comprehensive Geriatric Assessment and assisting the whole MDT to make informed decisions for patient-centred care.

The primary aim of this project was to improve the quality of collateral histories taken for patients admitted to the geriatric wards, with content measured against 8 domains. A secondary aim was to encourage timely collateral histories within 48 hours of admission to the ward.

Method:

Using PDSA methodology, collateral histories were analysed before and after implementation of a poster and teaching session.

Results:

At baseline each domain was covered a mean of 40.5% of the time (range 9% - 81%). Following intervention this increased by 22% to 62.5% (range 18% - 89%), demonstrating a significant improvement (paired t-test, P<0.05).

It was already common practice to take collateral histories within 48 hours of admission to the ward (91%) which was sustained post-intervention (88%).

Conclusion:

Use of a poster as a prompt, and delivering teaching, led to more thorough collateral histories. This suggests two barriers are knowing what to ask and perceived importance; elements which could be integrated into early postgraduate education. The impact on patient care has the potential to be significant and multidimensional but further work would be needed to understand this.

Introduction: Delirium is a common and reversible neurobehavioral condition with significant morbidity and mortality ramifications. Consequentially, clear guidelines exist pertaining to its swift identification and management. However, studies suggest adherence to these guidelines is poor. This audit evaluates compliance to the National Institute for Health and Care Excellence’s (NICE) delirium guidelines in an Acute Senior Health Unit (ASHU) and presents a single centre experience of low-cost ward-based interventions for improving guideline adherence.

Methods: A retrospective observational audit was conducted on patients admitted to ASHU between 01/07/2023 and 30/07/2023. Data on delirium assessments, diagnoses and causes of delirium were obtained through retrospective database searches. Posters and education based multidisciplinary team (MDT) interventions were designed and initiated following grounded thematic literature analysis and ward discussion. A methodically equivalent audit was then conducted between 01/09/2023 and 30/09/23. Data was anonymised and blinded and analysis was performed on SPSS V12.0.

Results: A total of 128 patients were included in the study. Initial audit revealed suboptimal compliance with NICE recommendations. Chi-square test of independence found that patients were statistically more likely to receive a full delirium assessment (1.9% vs. 56.6%, p=0.001) and formal diagnosis (5.8% vs. 27.6%, p=0.002) after the ward-based intervention.

Conclusion: This study provides limited evidence in favour of low-cost MDT based interventions for improving adherence to NICE delirium guidelines and provides a 5-step framework for future studies. This study also explores the potential patient implications of these interventions. A repeat audit should be conducted to ensure lasting and sustainable change is achieved. Trial registration/clinical trial number: AUDI003614