CQ - Patient Centredness

Introduction

At Epsom and St Helier, a dedicated Frailty service exists during daytime hours, and not weekends, nights or Bank Holidays. During these hours, patients are reviewed primarily by a cohort of “frailty-naïve” medical junior doctors. We aimed to compare the management plans, patient outcomes, rates of discharge, documentation and care delivered by medical junior doctors to that of an established frailty service.

Methodology

Data on presenting complaint, demographics, degree of frailty, postcode was collected on all patients over the age of 65, presenting to A&E at Epsom and St Helier Hospitals with a Frailty Syndrome. Patients who presented with symptoms or signs outside of the frailty syndrome criteria were excluded. The Medical Service was compared to the Frailty Service on rates of discharged and whether or not a resuscitation status, an escalation plan, baseline functional assessment, vision and hearing assessment, home set-up assessment, cognitive status, the elicitation of patient preferences and a medication assessment were performed.

Results

In 202 patients, average age was 85.2 years and consisted of 85 men and 117 women. Unwitnessed falls were responsible for 143 presentations. 127 patients were Caucasian and from the least deprived deciles. 109 patients (54%%) were seen directly by Frailty, and another 93 (46%) seen as referrals to the Medical Doctors. 33(16%) of patients were discharged by Frailty within 24 hours of admission, compared to 15(7.4%) by the Medical Team. The Frailty Service was more proficient in assessing patient baseline status (OR1.71), property (OR1.64), cognition (OR1.43), medications (OR1.28) and patient preferences (OR21.95).

Conclusion

Frailty reviews at an early stage in patient presentation to hospital was twice as likely to result in discharge within 24 hours of admission. Additionally, patients were more likely to have a thorough, comprehensive frailty assessment, and were significantly more likely to be empowered in their decision-making process.

Introduction:

Chronic limb-threatening ischemia (CLTI) is defined by presence of peripheral artery disease, rest pain, and/or gangrene or ulceration.1 Management of CLTI often involves a major amputation which has a 30-day in-hospital mortality of 6.6%. Despite improvements in secondary risk management, 5-year mortality remains high.1 Understanding how comorbidity affects amputation survival may help support patient optimisation and shared decision-making.

Methods:

This audit assessed the outcomes of patients who were reviewed by the POPS team using a comprehensive geriatric assessment (CGA) before undergoing a major lower limb amputation. We retrospectively analysed electronic records from 60 patients with CLTI who were admitted in an emergency setting, reviewed by the POPS team, and underwent a major lower limb amputation during 2022. The primary outcome measure was death following surgery. Data was collected from the patient records and analysed using the Chi square test.

Results:

In this group of 60 patients the 30-day mortality was 5% (3 patients) and 1-year mortality 43% (26 patients), with the average age at time of death being 77 years. Age (p=0.022) and co-morbidity (p = 0.021) were the strongest prognostic factors for mortality. Other factors like clinical frailty score (CFS), albumin concentration and length of hospital stay showed non-significant correlations with mortality in patients who underwent lower limb amputation.

Conclusion:

This study highlighted prognostic factors that could enable doctors to identify high-risk patients who may benefit from optimisation and detailed shared decision-making prior to undergoing a major lower limb amputation. As mortality is not necessarily modifiable, even in the context of a CGA in this group, it also highlights the need for advanced care planning before discharge.

References 1. Waton S, Johal A, Birmpili P, et al. National Vascular Registry: 2022 Annual Report. London: The Royal College of Surgeons of England.

Introduction

Authoritative medical organisations including the Resuscitation Council UK, NHS and BMA all state that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions should only be relevant to CPR and should not impact other decisions about care and treatment. We set out to examine the reality of decision making in clinical practice.

Methods

We circulated a clinical scenario of a patient deteriorating with COVID-19 after hip fracture to 128 members of the consultant and trainee geriatrician WhatsApp groups in Wales. Recipients were blindly randomised to one of two versions; differing only in whether or not they included the words “She has a DNACPR in place”. Recipients were unaware of the survey’s purpose. We surveyed individuals’ management decisions using a multiple-choice Likert scale questionnaire.

Results

A total of 47 (37%) clinicians responded. Those who addressed the scenario without a DNACPR decision were more likely to consider non-invasive ventilation (91% vs 67%, P<0.05), and more likely to consider escalation to intensive care (26% vs 21%).

Decisions in respect of ward level care were also affected. In the absence of a DNACPR decision, clinicians were more active in providing naloxone for a potential opioid toxicity (57% vs 29%).

Conclusion

Patients’ concern that a DNACPR decision might reduce the intensity of care they might receive do not appear to be unfounded. We believe that this study demonstrates the reality of clinical decision making in acute patient care.

These clinicians will have been aware that DNACPR status should have no influence on other clinical decision making, but unconscious bias clearly has substantial influence despite this. We do not believe that training to reinforce such knowledge will ever fully compensate for such unconscious bias.

Clinicians need to consider how DNACPR decisions are made, recorded and communicated given this risk of unforeseen consequences for other aspects of care.

Introduction

In today's healthcare practice, many patients live longer with multiple health issues, often in a frail or terminally ill state. Their quality of life doesn't necessarily improve. These patients require optimal supportive care that respects their dignity. Advanced Care Plans (ACPs) are crucial here, facilitating person-centered discussions about future care preferences while the patients have the mental capacity for meaningful participation. We aim in this study to assess how many patients in General Internal Medicine department would benefit from ACP and compare that to our current practice in implementing ACPs

Method

This cross-sectional retrospective study was done in 2 instances, 1 month apart from 29/03/23 to 01/05/23. The Sample size was 300 patients. The eligibility criteria were life expectancy of 12 months or less, age of 80 years and above, Clinical Frailty Scale (CFS) 8 or more, advanced dementia, and end-stage disease.

Result

33 patients (11%) met the eligibility criteria for ACP. 8 patients (24.2%) were above the age of 85. 25 patients (75.8%) had a Clinical Frailty Scale score higher than 7. 12 patients (36%) had terminal cancer. ACP was done for only 6% of the cases that meet the eligibility criteria. Within three months, 90% of these cases passed away. It is important to mention that in 57.6% of the cases, ACP was discussed with the patient and the next of kin (NOK) but was not formally documented.

Conclusion

Our findings revealed that only 6% of the eligible cases had evidence of ACP. This aligns with the study “advanced care planning in patients referred to the hospital for acute medical care: Results of a National Day of Care survey” which showed 4.8% had an ACP. The absence of ACP in the vast majority of re-admitted patients represents a significant missed opportunity to improve care.

INTRODUCTION: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Pain management is essential for quality care in all inpatient settings, where pain may stem from trauma, acute medical conditions, or surgery. Patients with cancer or chronic pain often experience acute exacerbations or may develop acute pain related problems.

This audit aimed to assess adherence to best practices in pain management for hospitalized patients and compare current pain management services in UK.

We conducted an 8-week audit at Derriford Hospital, Plymouth, using patient records from seeEHR. We assessed the effectiveness, safety, and immediacy of pain relief actions and whether patients with complex pain were referred to the Integrated Pain Service (IPS). We also examined if discharge summaries detailed the analgesia provided. Additionally, we surveyed medical staff (doctors and nurses) on their pain management knowledge.

The audit included 50 patients: 32 (64%) from geriatric wards, 10 (20%) from oncology, and 8 (16%) from haematology wards. Patients on at least step 2 of the pain ladder were included. Results showed that analgesia was 74% effective and 26% ineffective. Analgesia was 100% safe, with no antidote used. Immediate action was taken in 96% of cases and a delayed action in  4% cases.

However, none of the discharge summaries (0/50) mentioned pain relief provided, and no patients (0/50) were referred to IPS. The medical staff survey revealed that 50% were unsure when to refer to pain teams. All doctors knew the pain ladder.

The audit indicates timely, effective, and safe pain relief but highlights the need for improved referral practices to IPS for complex pain and detailed analgesia records in discharge summaries. Educating staff on hospital pain management protocols is crucial.

This project is significant for all healthcare professionals and enhances patient care quality. Recommendations were made after the first cycle, and data collection for the second cycle is ongoing.

Introduction

This project aims to explore the diagnostic experiences of people with Parkinson’s disease (PD) and compares this with the experiences of healthcare professionals diagnosing PD, to inform areas of improvement to increase patient satisfaction.

Method

A quality improvement project conducted using two surveys, one aimed at clinicians, and one aimed at people with PD, which were distributed via email and in person, to allow insights to be gained from conversation.

Results

31 patients and 24 professionals completed the surveys.

63% of patients were happy with the diagnosis communication, and 83% felt they received adequate information. This aligns with clinician perspectives, with 66% feeling that they meet the needs of patients well when diagnosing PD.

60% of patients want comprehensive information about PD at diagnosis, with focus on disease progression. In contrast clinicians were more likely to focus on the DVLA, with follow up information given one month after diagnosis. Patients were most likely to use the internet as their primary source of information on PD. Although this was rated as being useful, it relies on internet access and computer literacy. In contrast, the majority of clinicians would recommend follow up with a PD nurse specialist for patients to gain information. 63% of patients want to learn more about PD, again with emphasis on disease progression (78%) and treatment options (56%), including curative research.

Both patients and clinicians would prefer face-to-face informative sessions, ideally in a one-to-one setting.

Conclusion

Patient satisfaction can be increased by giving patients a comprehensive amount of information at diagnosis, with emphasis on the progression of the disease, followed up by accessible information to be read at home. Informative sessions should be long enough to allow time for both patient and clinicians differing priorities, and should be face to face, in a one-to-one session.

Introduction: Orthostatic hypotension is very common and increases with age, affecting about 20% of community-dwelling older adults and it increases up to 50% in long-term care units. Measuring lying and standing blood pressure (LSBP) is an important and simple bedside clinical test needed to diagnose the condition. The regulation of blood pressure depends on the baroreflexes, normal blood volume, and defenses against excessive venous pooling. These mechanisms are altered in older adults that lead to increased incidence of OH. Orthostatic hypotension leads to symptoms of dizziness, syncope, cognitive decline, impaired mobility and falls if it is left untreated.

Objective:

1. The primary aim is to standardize the approach to falls assessment on long term care units amongst all members of the multi-disciplinary team. We plan to address this by focusing on OH.

2. To educate all the multi-disciplinary team and increase knowledge of OH.

3. To improve accuracy in recording and documentation of LSBP to proactively screen patients and plan the clinical management accordingly.

Method: The study adopted an educational approach to orthostatic hypotension assessment in long term care. We did survey questionnaire before and after the study to check the understanding of MDT about the OH. We have undertaken two rounds of data collection with orthostatic hypotension related variables in each cycle. After round one, we did a PDSA that involved small group education sessions by physicians, pharmacists and physiotherapists to raise awareness of orthostatic hypotension.

Results: The study developed a standardized approach to measure LSBP in all long-term care units. It also improved the accuracy in assessment and recording of LSBP and it helped to raise awareness of OH among the MDT in long term care units. The knowledge domain improved to 90% from 10% in MDT. The documentation of LSBP improved to 85% on Long Term Care.

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.

Background

Loneliness is increasingly impacting older people in the UK and associated with poor health. The “Campaign to end loneliness” estimates that 1.2 million people are lonely. Age UK states that 2 million people will be lonely by 2026. For half of people aged >65, their main source of company is TV or pets.

Our objectives are to identify the prevalence of loneliness in the population presenting to Leighton Frailty Unit, develop a social prescribing tool to reduce this and highlight community services.

Methods

During September 2023- February 2024 we gathered baseline data on loneliness by encouraging staff to provide our questionnaire, based on the UCLA 3-item loneliness scale and Age UK guidance on direct loneliness questioning, to patients in chair spaces at Leighton Frailty Unit. We developed a social prescribing leaflet with activities in the local area using LiveWell Cheshire East. We re-contacted patients from cycle 1, repeated the questionnaire and asked if they had utilised the intervention leaflet.

Results

From Cycle 1, 53% of patients experienced loneliness, with 23% reporting “often” feeling lonely. From Cycle 2 when assessing the impact of the social prescribing leaflet, 37% of patients experienced loneliness, with 19% reporting “often” feeling lonely. Patients did not use the social prescribing leaflet, citing being unable to attend activities as a reason.

Conclusions

We are increasingly identifying and assessing loneliness as part of a CGA and raising awareness of services. Rates of loneliness may have reduced due to simply talking openly about it. However, engagement with the intervention was poor. Loneliness differs from social isolation, it is complex and multi- factorial. Community care connectors are an under used resource and could help support the issue of accessibility. We will ask them to deliver teaching to the Frailty Unit about their services and which patients would be suitable.