CQ - Patient Centredness

 Introduction: The pandemic has shown how vital patient-centred treatment escalation planning (TEP) is for older people. Locally we have seen inappropriate transfer of dying patients to acute hospitals from rehabilitation units. Mortality review found a lack of useful TEPs in these cases. Baseline data in our rehabilitation hospital showed 54% of patients had a TEP and 16% a decision made about repatriation during acute illness. We aimed to increase the proportion of patients in this setting with a TEP to 80% over six months.

Methods: A multidisciplinary team of doctors, ANPs and senior nurses worked together. We conducted stakeholder engagement to understand the factors that result in transfer of patients and found that completion of TEPs was felt to be an effective way to improve communication out of hours. Our first test of change involved an ANP raising the CPR status and TEP for all new patients at the weekly MDT. We measured the process of what decisions were made once a fortnight. Outcome data on the overall completion of TEPs and repatriation decisions was collected each month.

Results: New decisions were made at each MDT – for example, on one date two new DNACPRs and six new TEPs were completed. Overall TEP completion rate varies however since our first intervention we have seen a sustained increase in the number of TEPs which include consideration of repatriation – from 16% to 60%. Ongoing conversation with doctors in training reveals challenges with ward staff awareness of TEP content and their ability to guide unexpected events out of hours.

Conclusion: Involvement of motivated permanent staff across disciplines has allowed us to ensure escalation plans are being made each week and begin to see improvements. 

Background  

University Hospital Southampton (UHS) partnered with Saints Foundation (SF), to test the feasibility and acceptability of a non-registered Exercise Practitioner (EP) to work alongside the therapy team to promote physical activity (PA) of hospitalised older people. Our aim was to collect trust level data to review the impact the EP had on outcomes such as length of stay (LOS) and discharge destination (DD) and identify and address any additional challenges that arose. 

Methods  

The EP delivered twice weekly gym-based group interventions as well as regular 1:1 rehabilitation and education sessions to hospitalised older patients. Interventions were ward based or within the acute therapy gym.  

Results  

Between June and August 2023 the EP reviewed 82 patients, mean age of 88 years. 15 (18%) patients underwent 1:1 rehabilitation whereas 67 (82%) patients underwent gym-based rehabilitation sessions. Median LOS for patients reviewed by the EP was 15 days compared with average departmental LOS of 8 days. 53 (65%) patients were able to either maintain or improve their predicted to actual discharge destination, compared with 10 (12%) patients whose physical capability declined. Of those remaining, 1 patient died and 18 others had not yet been discharged. High patient satisfaction levels continued to be reported.  

Conclusion  

Intervention by a non-registered EP appears to have an impact on patients’ ability to maintain or improve level of function and physical dependency during acute hospital stay.  Factors such as outbreaks of infectious illness and staffing challenges prevented more frequent EP led intervention. Next steps include introducing daily class-based interventions. Participants will be encouraged to attend at least three classes. Anticipated benefits include improvement in patients’ functional levels and reductions in physical dependency on discharge.  Additional data will be collected on fear of falling and confidence in function as well as uptake of post discharge activity and readmission. 

Introduction:

Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national Irish Health Service Executive (HSE) guidelines after education sessions in a Model 3 Hospital.

Methods:

A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants.

Results:

Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%.

Discussion:

This audit elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. We posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan.

Conclusion:

Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.

Introduction

There are multiple national drivers promoting person-centered healthcare. In the face of competing pressures, patient experience is often compromised. 

Aim: To increase the percentage of service users in our orthogeriatric rehabilitation ward rating experience as more than 6/10 to 90% by June 2024.

Methods

A multidisciplinary project using quality improvement methodology.  Patients and carers were involved throughout. Patient, staff and carer interviews shaped improvement themes and change ideas. Broad themes identified:

•             Communication

•             Provision, and facilitation of, ward activities 

•             Environment

Several, cost neutral, tests of change were studied: weekly exercise class, mobile library, ‘activities trolley’, music concerts, volunteer recruitment, improved signposting and coordinating weekly relative update.

Run and SPC charts were used to study impact. Measures used:

•             Outcome: Patient and carer satisfaction using 10-point Likert scale (1=poor, 10=excellent) in weekly, random cohort (P-chart). Mapping themes over time.

•             Process: Minutes of physiotherapy delivered/week. Number of patients participating in activity other than PT/OT (C-chart). Percentage of relatives updated by MDT/week

•             Balancing: Length of Stay (LOS). Readmission within 1-month. Staff Feedback. Inpatient falls.

Results

•             The % of patients scoring experience >6/10 increased over the project but did not meet ‘special cause’                criteria. Feedback themes shifted positively.

•             The median percentage of relatives receiving a weekly update increased (45% to 78%).

•             Participation in activities improved, with special cause variation observed. The amount of physiotherapy delivered each week increased by 3 hours due to exercise classes.

•             There was no significant change to falls, readmissions or LOS.

•             Staffing, covid outbreaks and workload impacted negatively during the project. 

Conclusions

‘Experience’ is individually unique and cannot be improved with a unilateral approach.

Using continuous feedback from patients and carers, we tested multiple interventions across several areas, demonstrating positive changes.

Patient experience is challenging to measure quantitatively but should not deter improvement work in this area

Introduction

As the prevalence of dementia continues to increase across the UK, understanding the lived experience of patients and carers affected by dementia becomes paramount. There is an established dementia pathway in Sussex for people living with dementia (PLWD) and their carers. To improve care and inform future commissioning priorities, the Brighton and Hove Health Watch (BHHW- a community interest company) surveyed the opinions of a group of PLWD and their carers around initial diagnosis and subsequent support.

Methods

PLWD and their carers receiving social support and willing to provide feedback were included in this survey. Using a topic guide, BHHW volunteers conducted a telephone interview with this group exploring their experience with their general practitioner (GP), and the memory assessment service (MAS) in relation to diagnosis, and post-diagnosis support. Transcribed interviews were analysed using qualitative thematic analysis (inductively and deductively) using Braun and Clarke’s method.

Results

Forty-five participants were interviewed, 37 carers and 6 PLWD (average age 78.2 range 64-95 years) between December 2022 and May 2023. Thirty-nine participants (86%) were of white-British ethnicity. Participants reported a range of different experiences with no consistent pattern by age, gender or location. Participants were generally satisfied with the initial GP care they received. The waiting time to access MAS was six weeks on average, an acceptable timeframe for the group. Some participants reported waiting as long as two years since the initial GP consultation before a dementia diagnosis was eventually made. Participants were generally satisfied by the thorough MAS review. Most participants felt that the information material they immediately received after dementia diagnosis was complex and overwhelming. Social support offered post-diagnosis was commendable.

Conclusion

The lived experience of PLWD and their carers in Sussex was generally positive. However, a tailored approach to post-diagnosis information provision is required.

Introduction:

CGA is the gold-standard intervention for older adults living with frailty. A challenge is providing person-centred, time-efficient CGA. The CGA-questionnaire (CGA-Q) aims to facilitate person-centred CGA, allowing patients/carers to highlight concerns. We describe a two-site multi-cycle QIP implementing the CGA-Q.

Methods:

CGA-Q is a 19-item questionnaire covering seven CGA domains. It was adapted from the validated CGA-GOLD questionnaire. Between March 2023-June 2024, CGA-Q was established in a London and Scottish NHS Trust using ‘Plan-Do-Study-Act’ methodology. Cycle 1-3 involved designing and establishing CGA-Q at one London geriatric clinic. Cycle 4 assessed feasibility in multiple London geriatric clinics. Cycle 5 examined implementation of CGA-Q in a Scottish day-hospital. Person-centredness refers to inclusion of person-selected concerns in clinic letters, and not including person-excluded concerns.

Results:

Across cycles, cohorts were comparable in age, sex, frailty and cognitive status. In cycles 1-3 (n=174), CGA-Q completion rates improved from 39% to 83%. More CGA-Q questions were addressed especially cognition, mood, continence and falls. Inclusion of person-selected concerns increased from 60% to 70%; exclusion of person-excluded concerns remained ~70%. In cycle 4, completion rates varied by clinic: renal-CGA 100% (12/12); CGA 42% (13/31); bone-health 14% (10/60). >50% of questionnaires were completed by patients, except in bone-health where two-thirds were completed by staff. Staff feedback highlights CGA-Q is a useful discussion prompt. In cycle 5 (n=41), a similar breadth of CGA-Q questions were addressed among respondents compared to baseline. With CGA-Q, continence and pain were addressed more frequently. Inclusion of person-selected concerns was 62%; exclusion of person-excluded concerns was 71%.

Conclusion:

CGA-Q has been successfully implemented across multiple sites and clinics. It can improve person-centeredness and breadth of CGA, but early results vary across subspecialty geriatric medicine clinics with their unique processes. Ongoing work will determine the experience of patients and carers of this approach.

Background Royal Bolton Hospital is a district general hospital in Greater Manchester. In 2023, a Cardiogeriatrics service was introduced to deliver comprehensive geriatric assessment for older cardiology inpatients with frailty.

Introduction

Our aim was to evaluate the Cardiogeriatrics service with respect to the impact on end of life care for older cardiology inpatients.

Methods

Audit standards were defined using metrics for quality in end of life care. All patients between the year 2021 and 2024 aged 75 and over who died as an inpatient or within 30 days of discharge were included. Patients who died following procedural interventions were excluded. Patient’s casenotes were audited and compared before and after the initiation of the service.

Results

Casenotes for 88 inpatient deaths were audited (66 prior to introduction of the Cardiogeriatric service, 22 following). The Cardiogeriatrician initiated end of life care in 31.6% of inpatient deaths. This corresponded with a reduction in unexpected deaths from 26% to 14%, and a reduction in patients initiated on end of life care by the on-call team, from 31.8% to 10.5%. Junior doctors on Cardiology began to initiate resuscitation conversations with patients. Casenotes for 44 deaths within 30 days of discharge were audited, however no meaningful insight could be gained as there were only 6 outpatient deaths after the Cardiogeriatric service began.

Conclusion

After introduction of the Cardiogeriatrics service, there was improved recognition of patients who were approaching end of life, and more proactive management of this. As many patients audited were not seen directly by the Cardiogeriatrician, we believe the service has contributed to a cultural change in the Cardiology team more widely towards more proactive recognition and management of end of life issues in older Cardiology patients.

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.

Introduction:

The Gloucestershire Frailty Virtual Ward (FVW) is a novel multidisciplinary collaborative project which seeks to improve care for frail older patients. We describe our experience, reflect on lessons learnt and plans for future service development.

Methods:

The Gloucestershire FVW was started in early 2023. It arose from an understanding that the needs of frail patients can often be better met in their own homes, by utilising a combination of digital technology combined with improved working across organisational boundaries at the primary/secondary care interface. We reviewed data from all patients admitted onto our FVW between October 2023 and March 2024.

Results:

66 patients were included. The majority of patients were ‘step-down’, having been in hospital prior to FVW admission. The minority were ‘step-up’, having been referred from community colleagues. Clinical frailty scores ranged from 2-8, with a mean of 6. During this period, our FVW managed a range of different clinical problems. The most common reason for FVW admission was infection, then heart failure, delirium and acute kidney injury. Most patients were admitted for the management of a single problem (58%), although a significant proportion had 2 or more problems (42%). Our FVW conducted a variety of interventions, including blood tests, face-to-face reviews, amending medications including antimicrobials, diuretics and analgesia. Our FVW was also involved in decisions around the withdrawal of active care and initiation of a palliative approach.

Conclusions:

Our FVW has helped facilitate early discharge and avoid hospital admission, with associated benefits to both patients and the acute trust. As a new service which aims to sit between primary and secondary care, we have encountered logistical and governance challenges associated with working across organisational boundaries. Additionally, we have found that the use of digital technology can cause anxiety for patients and place additional strain on carers.

Background: NICE Quality Standard (QS) 164 – QS1 states; Adults with Parkinson's have a point of contact with specialist services. This will facilitate continuity of care and access to information, advice, care and support when they need it. QS4 states; Adults with Parkinson's disease in hospital or a care home should take levodopa within 30 minutes of their individually prescribed administration time.

Introduction: To increase opportunities in meeting NICE QS’s consistently, Parkinson’s Specialist Nurses introduced Parkinson’s Champions. Individual studies consistently find that champions are important positive influences on implementation effectiveness. Over half of people with Parkinson’s don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death.

Method

Supportive structures that enabled the development and maintenance of our Champions Network:-

Clear Role Profile and Measurable Objectives

Provision of Resources/Tools

Ongoing Education/Training

Peer Support/Networking

Recognition/Appreciation 

PDNS leadership/support

Energy & Perseverance

Results: The Get it On Time Audit (GIOT) looked at Parkinson’s medications given more than 30 minutes early, on time and more than 30 minutes late. Following multiple interventions including promoting leadership and education within each dept, input to medicines policy, incident reporting and development of a learning module, On time medication administration improved from 58% to 80.05% compliance.

Champions were not experts in Parkinson’s when we started, through the process of undertaking the role, they have gained expertise and serve as an ongoing resource to their peers.

Conclusion: Our aim of having champions who enhance staff’s knowledge and skills so care delivered to persons with Parkinson’s is consistently safe and effective is being realised.

Investment in them, as demonstrated by audit results, is rewarded with more consistent meeting of NICE QS 164 and thus improved patient outcomes.

Our Champions network model will be shared with the Parkinson’s Excellence Network.